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People from culturally and linguistically diverse (CaLD) backgrounds in Australia generally experience poorer health outcomes, explained in part by low levels of health literacy. We conducted a systematic review to examine the development and evaluation of health education resources designed for CaLD populations. Five electronic databases were searched for English language, peer-reviewed studies published between 1980 and 2020. Thirty-four studies met the inclusion criteria. Twenty-four different health education resources were described and broadly categorized into four types: media campaigns (n = 10), text-based materials (n = 5), films (n = 8) and radio (n = 1). Studies were assessed against domains adapted from a health literacy guideline incorporating: need, collaboration, audience, health literacy, theory, test and process and impact evaluation. All but one study met the majority of the domains. All studies reported positive evaluation outcomes; this may be due to studies involving community early in resource design and including health literacy considerations in their design. Reporting resource design and evaluation against standard practice controls is recommended to build a more robust evidence base for developing effective health education resources for use by audiences from CaLD backgrounds.

Australian HIV notification rates are higher for people born in Northeast Asia, Southeast Asia and sub-Saharan Africa compared to Australian-born people. The Migrant Blood-Borne Virus and Sexual Health Survey represents the first attempt to build the national evidence base regarding HIV knowledge, risk behaviors and testing among migrants in Australia. To inform survey development, preliminary qualitative research was conducted with a convenience sample of n = 23 migrants. A survey was developed with reference to the qualitative data and existing survey instruments. Non-probability sampling of adults born in Northeast Asia, Southeast Asia and sub-Saharan Africa was undertaken (n = 1489), and descriptive and bivariate analyses of data were conducted. Knowledge of pre-exposure prophylaxis was low (15.59%), and condom use at last sexual encounter was reported by 56.63% of respondents engaging in casual sex, and 51.80% of respondents reported multiple sexual partners. Less than one-third (31.33%) of respondents reported testing for any sexually transmitted infection or blood-borne virus in the previous two years and, of these, less than half (45.95%) tested for HIV. Confusion surrounding HIV testing practices was reported. These findings identify policy interventions and service improvements critically needed to reduce widening disparities regarding HIV in Australia.

The objective of this review is to summarize the nature and focus of research that has been conducted into patients' and health care providers' perspectives of sexual and reproductive health access for people with disability.Article 25 of the United Nations Convention on the Rights of People with Disabilities (UNCRPD) requires persons with disability to be provided with equitable access to sexual and reproductive health services. However, there are few scoping or systematic reviews examining the provision of inclusive sexual and reproductive health services to people with disability. Current and planned reviews are either not inclusive of a full range of disabilities or geographical regions, are limited to reproductive health, or focus exclusively on the perspectives of health professionals.Qualitative, quantitative, mixed method studies, and gray literature concerning sexual and reproductive health service access for people with disability will be included. The UNCRPD definition of disability will be adopted, together with a multidimensional conceptualization of "access."The review will be conducted in accordance with JBI methodology. A search strategy has been developed for MEDLINE, Embase, CINAHL, and gray literature. After de-duplication, results will be independently screened against the inclusion criteria by 2 reviewers. There will be no geographical limitations, but non-English-language publications will be excluded. Only literature published after the UNCRPD came into effect (May 3, 2008) will be included. Charting tools will be used for data extraction, and results will be presented in descriptive, diagrammatic and tabular formats.

Past efforts to address endemic rates of sexually transmissible infections amongst young Aboriginal people living in remote/very remote Australian communities have had limited success. Peer educati...

Chronic hepatitis B (CHB) disproportionately affects migrants with low health literacy and help-seeking behaviour living in high-income countries. Evidence of effective interventions is required to increase hepatitis B (HBV) testing, treatment, and monitoring. Available evidence from Medline, Embase, Scopus, Google, and Google Scholar was identified, collated, and synthesised. Inclusion criteria included grey and peer-reviewed literature published in English between January 2012 and December 2021. Systematic reviews and meta-analyses were excluded. Seventeen peer-reviewed articles met the inclusion criteria. Most interventions were conducted at the individual level and were typically outreach testing initiatives. One study was conducted at a structural level. All studies were successful in encouraging HBV screening uptake, and 10 studies demonstrated effective linkage to care. Two studies showed evidence of monitoring participants post-intervention. Most interventions had more female than male participants. Interventions conducted across community and clinical-based settings had more participants engage in screening and/or linkage to care in community settings. Effective interventions to prevent HBV transmission and CHB-related morbidity and mortality were approaches that utilised linguistic-specific and culturally appropriate resources to successfully engage migrants. Community outreach programmes that educate participants about HBV transmission, screening, and treatment can promote community dialogue and understanding to reduce stigma and discrimination.

BACKGROUND Reliable data about sexual behaviors is fundamental in the prevention and control of HIV, hepatitis, and other sexually transmitted infections. Generally, sexual behaviors are regarded as a sociocultural taboo in Africa and Asia, and this results in biased sexual behavior survey data due to social desirability. Various modes of survey delivery, including audio computer-assisted self-interviews (ACASIs), have been investigated to improve data quality. OBJECTIVE This study aimed to review studies that compared the ACASI mode to other survey modes in sexual behavior surveys in Asia and sub-Saharan Africa to ascertain the impact of survey mode on responses to sexual behavior questions. METHODS A systematic literature review was conducted according to the Joanna Briggs Institute Manual for Evidence Synthesis. The review protocol was registered at PROSPERO (International Prospective Register of Systematic Reviews). Six databases were searched. RESULTS A total of 21 papers were included. The face-to-face interview (FTFI) mode was the survey mode most frequently compared to the ACASI mode. Among the most commonly reported outcome variable groups, ACASI participants were more likely to report sexual behaviors, such as “forced sex,” “multiple partners,” “transactional sex,” and “ever had sex,” as compared to FTFI participants. In addition to the survey mode effect, other factors were found to have had an impact on data quality, for example, participant characteristics, social norms, study design, and data collection setting. CONCLUSIONS Use of ACASIs for administering sexual behavior surveys among populations in Asia and sub-Saharan Africa demonstrated higher reports for some sexual behaviors than the use of FTFIs. More studies that compare the ACASI mode to other survey modes would improve our understanding of the usefulness of ACASIs in sexual behavior surveys in these regions.

BACKGROUND Self-administered paper or electronic surveys can create accessibility issues for people with language barriers and limited literacy, whereas face-to-face interviews can create privacy issues and give rise to reporting biases, particularly in the context of sensitive subject matters. An audio computer-assisted self-interview (ACASI) offers an alternative mode of survey administration, and its use has been tested against other survey modes to determine whether the presence of a background narration helps overcome literacy and privacy issues. There are still gaps with the ACASI survey administration because audio narration alone does not assist respondents with limited literacy in choosing response options. To overcome literacy issues, a few studies have used illustrated pictures for a limited number of response options. OBJECTIVE This study aimed to illustrate all the questions and response options in an ACASI application. This research is part of a larger study comparing different modes of survey administration (ACASI, face-to-face interviews, and self-administered paper surveys) to collect data on hepatitis B knowledge, attitudes, and practices among the Myanmar-born community in Perth, Australia. This study describes the 2-phase process of developing a web-based ACASI application using illustrated pictures. METHODS The first phase was the preparation of the ACASI elements, such as questionnaire, pictures, brief descriptions of response options, and audio files. Each element was pretested on 20 participants from the target population. The second phase involved synchronizing all the elements into the web-based ACASI application and adapting the application features, in particular, autoplay audio and illustrated pictures. The preprototype survey application was tested for user acceptance on 5 participants from the target population, resulting in minor adjustments to the display and arrangement of response options. RESULTS After a 12-month development process, the prototype ACASI application with illustrated pictures was fully functional for electronic survey administration and secure data storage and export. CONCLUSIONS Pretesting each element separately was a useful approach because it saved time to reprogram the application at a later stage. Future studies should also consider the participatory development of pictures and visual design of user interfaces. This picture-assisted ACASI survey administration mode can be further developed and used to collect sensitive information from populations that are usually marginalized because of literacy and language barriers.

IntroductionMore research and policy action are needed to improve migrant health in areas such as sexual health and blood-borne viruses (SHBBV). While Knowledge, Attitudes and Practice Surveys (KAPS) can inform planning, there are no SHBBV KAPS suitable for use across culturally and linguistically diverse contexts. This study pretests one instrument among people born in Sub-Saharan Africa, South-East and North-East Asia living in Australia.MethodsEmployees of multicultural organisations were trained to collect data over three rounds using a hybrid qualitative pretesting method. Two researchers independently coded data. Researchers made revisions to survey items after each round. Responses to feedback questions in the final survey were analysed.ResultsSixty-two participants pretested the survey. Issues were identified in all three rounds of pretesting. Of the 77 final survey respondents who responded to a survey experience question, 21% agreed and 3% strongly agreed with the statement ‘I found it hard to understand some questions/words’.ConclusionIt is essential to pretest SHBBV surveys in migrant contexts. We offer the following pretesting guidance: (1) large samples are needed in heterogeneous populations; (2) intersectionality must be considered; (3) it may be necessary to pretest English language surveys in the participants’ first language; (4) bilingual/bicultural workers must be adequately trained to collect data; (5) results need to be interpreted in the context of other factors, including ethics and research aims; and (6) pretesting should occur over multiple rounds.

In this article, we describe the approaches taken to recruit adult migrants living in Australia for a sexual health and blood-borne virus survey (paper and online) and present data detailing the outcomes of these approaches. The purpose was to offer guidance to redress the under-representation of migrants in public health research. Methods of recruitment included directly contacting people in individual/organizational networks, social media posts/advertising, promotion on websites, and face-to-face recruitment at public events/venues. Search query strings were used to provide information about an online referral source, and project officers kept records of activities and outcomes. Descriptive statistical analyses were used to determine respondent demographic characteristics, proportions recruited to complete the paper and online surveys, and sources of referral. Logistic regression analyses were run to predict online participation according to demographic characteristics. The total sample comprised 1454 African and Asian migrants, with 59% identifying as female. Most respondents (72%) were recruited to complete the paper version of the survey. Face-to-face invitations resulted in the highest number of completions. Facebook advertising did not recruit large numbers of respondents. Same-sex attraction and age (40–49 years) were statistically significant predictors of online completion. We encourage more researchers to build the evidence base on ways to produce research that reflects the needs and perspectives of minority populations who often bear the greatest burden of disease.

Sexual health promotion and Relationships and Sexuality Education (RSE) are influenced by interrelated social and cultural factors, particularly in a rural setting. This paper reports on findings f...

Migrant health has been identified as one of the most pressing issues of the 21st century. Migration experiences are influenced by gender and gender norms and have important implications for the sexual health of migrant women. This systematic review explored socioecological factors influencing sexual health experiences and health outcomes of migrant Asian women living in “Western” high-income countries. PRISMA guidelines were followed and this study was registered with PROSPERO. Five academic databases were searched for peer-reviewed articles published between 2000 and 2019. Of 2415 studies retrieved, 17 met the selection criteria: 12 qualitative, 4 quantitative, and 1 mixed-methods study. The four levels of Bronfenbrenner’s socioecological model were applied to examine the individual, interpersonal, institutional, and societal factors of influence. Most studies (n = 13) reported individual level factors, focusing on knowledge and use of contraceptives. At a societal level, host country sociocultural factors, including gender and cultural norms, influenced knowledge, ability to access and utilise contraceptives, and access to health services. Findings suggest that the public health policy, practice, and research to improve the sexual health of migrant women requires greater consideration of the intersecting factors of gender, culture, and the migration process.

Best practice in sex work research advocates for a 'nothing about us without us' methodology. This study employed sex workers as peer researchers to assist in evaluating the sexual health outcomes and well-being of sex workers in Western Australia. All eight peer researchers were invited to reflect on their experiences as peer researchers through semi-structured interviews, and seven peer researchers participated. Giving sex workers a voice and the opportunity to facilitate change for their peers was the primary driver for participation. Some peer researchers from English speaking backgrounds experienced challenges engaging and communicating with study participants for whom English was not their first language. Others experienced role conflict on hearing viewpoints contrary to their own beliefs. Access to support from the project team and other peer researchers was a key enabler for undertaking the peer researcher role. The majority of peer researchers were motivated to participate in the research by the possibility of future changes to sex work-related legislation, and support for sex workers based on the research findings. Research partnerships with peer researchers that offer employment throughout the research process, including co-authorship of journal articles, opportunities for leadership roles and collaboration in research translation activities can increase research impact.

Health literacy is considered by some as a determinant of health. Research suggests that different levels of health literacy may be associated with human immunodeficiency virus (HIV) knowledge and behaviour, including willingness to test. This study assessed the health literacy demands of existing Australia HIV prevention resources available online using a health literacy assessment and content analysis. Two reviewers assessed 66 resources using the Health Literacy INDEX. Sixty-one (92%) scored below 50%, with an average score of 35.5%. A coding frame was developed to conduct a content analysis of the resources excluding videos, multiple webpages and booklets (n = 52). We coded for six categories of knowledge: HIV knowledge (100% of resources), transmission (96%), acquired immune deficiency syndrome (AIDS) knowledge (88%), testing (87%), consequence of infection (85%) and prevention (77%). We found that resources required a reading grade above grade 8, and very few resources considered audience appropriateness. There were missed opportunities to encourage HIV prevention or testing. Some resources used incorrect language to refer towards people living with HIV, and transmission and prevention messages were often inconsistent. Guidelines for developing HIV prevention resources are warranted to improve health literacy, accessibility and appropriateness of resources and ensure consistent messages and framing of HIV risk.

Background Notification rates of gonorrhoea in Australia for heterosexual young adults rose by 63% between 2012 and 2016. In Western Australian major cities, there was a 612% increase among non-Aboriginal females and a 358% increase in non-Aboriginal males in the ten-year period 2007–2016. A qualitative public health investigation was initiated to inform appropriate action. Methods Eighteen semi-structured telephone interviews were conducted with non-Aboriginal heterosexual young adults aged 18–34 years living in Perth, Western Australia, who had recently been notified to the Department of Health with gonorrhoea, to explore the context of their sexual interactions and lifestyles which could have predisposed them to contracting gonorrhoea. Data were thematically analysed. Results Common themes were having several casual sexual partners, limited communication between sexual partners about condom use or sexual history prior to engaging in sexual activity, inconsistent condom use, normalisation of some sexually transmissible infections amongst young people, and poor understandings and assessment of sexually transmissible infection risk. Conclusions The findings support public health interventions that focus on communication between sexual partners and shifting of risk perceptions in sexual health education programs, ensuring accessibility of quality sexual health information, increasing condom accessibility and acceptability, and on strategies for addressing misperceptions of young people in relation to sexually transmitted infections.

Background Aboriginal and Torres Strait Islander people in remote and very remote communities in Australia experience high rates of sexually transmissible infections (STIs), 4- to 29-fold the rates reported for non-Aboriginal people living in remote areas. Young people aged 16–29 years are particularly vulnerable to STIs. The Young Deadly Free (YDF) sexual health youth peer education program was implemented in 15 remote or very remote communities in four Australian jurisdictions in an effort to address endemic STI rates in these communities. The present study sought to evaluate the effect of YDF for Aboriginal young people. Methods: Young people (n = 128) participated in youth peer educator training to deliver peer education sessions on sexual health topics to other young people in their communities. Pre and post surveys were used to examine changes in STI knowledge, attitudes and behavioural intentions of the young people attending the peer education sessions. GHRANITE software extracted deidentified STI testing data for young people attending 13 community health services. Results: Young people (n = 426) attended peer education sessions delivered by trained youth peer educators. Pre and post surveys were completed by 174 and 172 young people respectively (median age 20 years). Gains were reported in STI knowledge, intentions to test (χ2 = 10.58, d.f. = 4, n = 142, P < 0.001) and number of STI tests (50.8% increase from baseline). Feelings of shame associated with STI testing remained high (39.5% post survey). Conclusions: Peer education can enhance the sexual health literacy of young Aboriginal people residing in remote communities. The extent to which knowledge gains result in behaviours that prevent STI transmission requires further evaluation. Normalising STI testing among Aboriginal young people would help reduce feelings of shame.

There has been a growing number of sexual health and blood-borne virus (SHBBV) surveys specifically administered to migrant populations. The purpose of this scoping review is to collate available information about how SHBBV surveys have been administered in migrant populations and the effect that mode of administration has on data quality, reliability and other practical considerations, e.g. response rates (RR) and social desirability bias. A methodological framework for scoping reviews was applied. SHBBV survey studies administered to international migrants published since 2000 were included if they contained some description of mode of administration. Ninety one studies were identified for inclusion from Embase, Medline, Web of Science, Google Scholar and supplementary grey literature. ‘Interview only’ was the most common mode of administration (n = 48), predominately comprising face-to-face interviews. Thirty six studies reported data from ‘self-completed’ surveys only, with pen-and-paper being most common (n = 17). Few studies (n = 7) combined interview and self-completed methods of survey administration. Sixty one studies did not report (or only partially reported) RR or the data necessary to calculate RR. Of the studies that reported RR, most were missing other key information including method of recruitment, consent procedures and whether incentives were offered. Strengths and limitations of all administration modes are summarised. Guidelines to inform future SHBBV survey research in migrant populations are presented.

Background HIV notifications among people born in sub-Saharan Africa and South-East Asia have increased in Australia in the last decade. People born in these regions have the highest rates of HIV diagnosis by region of birth and are overrepresented in late or advanced presentation of HIV infection. Methods This study developed and tested a questionnaire for reliability through test-retest. A cross-sectional survey using intercept and online recruitment of HIV knowledge and use of health services was then undertaken among people born in sub-Saharan Africa and South-East Asia, who had arrived in Australia less than 10 years ago and were living in Western Australia (n = 209). Results were reported on by gender and length of time in Australia. Results Participants had a reasonable knowledge of HIV transmission, but held a number of incorrect beliefs. Two-thirds (65%) of participants reported a barrier to accessing health services in Australia. Just over a third (34%) of participants had ever tested for HIV, despite indicating that they believed HIV testing was important. Conclusions This project indicates a very low rate of HIV testing among this priority population. Further action is required to improve early diagnosis of HIV and reduce onward transmission of HIV infection within these communities. SO WHAT?: We need targeted interventions that extend beyond knowledge to increase HIV testing rates among this population.

Non-invasive prenatal testing (NIPT) for a panel of 25 single gene disorders became available in Western Australia in 2020 and potentially may be able to test for panels of hundreds of disorders as is the case with reproductive carrier screening. How this information would be used by parents in a population screening model is unknown. We used a phenomenological approach to explore retrospectively whether mothers of children with single gene or chromosomal disorders would have wanted to know about their child’s genetic diagnosis prior to delivery. Themes were identified such as having a child with a de novo disorder and effect on pregnancy outcomes in hypothetical situations, impact on family function, the diagnostic journey and personal growth. These themes related to both the concept of expanded NIPT (ENIPT) and the situation of having a child with a de novo genetic disorder that could now hypothetically be detected through ENIPT. Opinions were divided about whether participants would have wanted to know about their affected child’s condition, indicating any expanded NIPT testing panels would need to be offered in the context of an appropriate comprehensive counselling program. How this would be provided on a population screening level and the role of genetic counselling needs further exploration.

In order to explore the impact of potential new technologies in the area of prenatal screening, we conducted a baseline study using qualitative interviews to explore women's attitudes and knowledge regarding current and future prenatal screening technology and methods. Three cohorts were interviewed, including healthy women without children, healthy women with healthy children, and healthy women with children who have de novo genetic disorders. This study aimed to assess the baseline understanding and attitudes of women in Western Australia. Women from each cohort demonstrated adequate knowledge of the differences between screening and diagnostic tests, but were mostly unaware of the conditions for which screening is currently available except Down syndrome. Women who had children with de novo genetic conditions were generally aware of more genetic conditions than women with or without healthy children. Most women recognised the genetic basis for the conditions mentioned. Two thirds of women understood that Down syndrome is a chromosomal condition; just one third recognised that the phenotype is variable. Most women expressed a positive attitude towards Down syndrome. Social acceptance of children with Down syndrome was commonly mentioned as a concern. While the majority of women with children supported screening for Down syndrome, they emphasised that it must be an autonomous choice. General knowledge of genetic conditions illustrated that women are exposed to diverse conditions from lived experience as well as the media.

Australian Aboriginal and Torres Strait Islander people experience disproportionately higher rates of sexually transmissible infections (STIs) and blood borne viruses (BBVs) when compared with the non-Indigenous population. Both incidence and prevalence data for bacterial STIs, such as chlamydia, gonorrhea, trichomonas, and syphilis in remote areas of Australia are reported at rates many times higher than that of non-Indigenous Australians. Similarly, rates of hepatitis B are disproportionately higher for non-Indigenous people in remote communities. The Young Deadly STI and BBV Free project was designed to increase the uptake of STI and BBV testing and treatment in young Aboriginal and Torres Strait Islander people living in remote and very remote areas of South Australia, Western Australia, Queensland, and the Northern Territory. Peer education formed one component of this pilot project and involved training up to 100 young Aboriginal and Torres Strait Islander people across 19 communities in a culturally appropriate and respectful manner on the transmission, testing, and treatment of STIs and BBVs. The trained peer educators were then required to deliver three community education sessions to young people in their respective communities in an effort to raise awareness about STIs and BBVs and encourage testing and treatment uptake. Preliminary evaluation findings, limited to the trained peer educators, revealed the peer educator training program contributed to STI and BBV knowledge gains among the trained peer educators and positively influenced their behavioral intentions and attitudes pertaining to STIs and BBVs. Working with remote Aboriginal and Torres Strait Islander populations on a highly sensitive, stigmatized topic presented many methodological challenges, particularly in terms of ensuring the collection of reliable evaluation data across geographically remote communities. The challenges and strengths associated with the implementation of the peer education training program along with implications for developing culturally inclusive evaluation practices will be discussed.

Migration is a significant risk factor for the acquisition of human immunodeficiency virus (HIV), hepatitis B virus (HBV) and other sexually transmitted infections (STIs). An increasing proportion of these infections in high-income countries, such as Australia, are among migrants moving from low and middle-income countries with a high prevalence of HIV, HBV and other STIs. This systematic review explored the prevention and control of HIV, HBV and other STIs in migrants (>18 years) from Southeast Asia, Northeast Asia and sub-Saharan Africa living in high-income countries with universal health care. This systematic review followed PRISMA guidelines and was registered with PROSPERO. Six academic databases were searched for articles published between 2002 and 2018. Sixteen peer-reviewed articles met the inclusion criteria, consisting of fourteen quantitative and two qualitative studies conducted in Australia, the Netherlands, Canada, Spain, Italy, and Germany. Three levels of interventions were identified: individual, community and structural interventions. Most studies addressed factors at an individual level; interventions were most commonly outreach testing for HIV, HBV and other STIs. Few studies addressed structural factors or demonstrated comprehensive evaluation of interventions. Limited population-specific findings could be determined. To prevent further transmission of HIV, HBV and other STIs, comprehensive public health approaches must consider the complex interactions between migration, health care system determinants, and broader socioeconomic and sociocultural factors.

Early diagnosis is a critical component of the global response to the human immunodeficiency virus (HIV). In Australia, more than two-thirds of women from Southeast Asia are diagnosed late with HIV. There is limited evidence regarding the barriers to HIV testing and which interventions work to increase an uptake among migrants living in high-income countries. This participatory action research (PAR) project will work with women from Indonesia to co-design an intervention to increase HIV testing uptake in Western Australia. The project will involve trained community researchers, representatives from relevant organizations, and community women born in Indonesia. We will conduct three PAR cycles. Phase one will use focus groups to understand enablers for HIV testing among community members. In phase two, data will be presented back to members of the participating communities who will be invited to co-design an intervention to increase HIV testing. The final cycle will focus on implementing and evaluating the resulting intervention. This project will add to the small body of literature on pathways and enablers to HIV testing, and to new insights regarding interventions that work for women from migrant communities and why.

People born in sub-Saharan Africa and Southeast Asia are overrepresented in HIV notifications in Australia. Just under half of all notifications among people from sub-Saharan Africa and Southeast Asia are diagnosed late. Increased HIV testing among these communities is necessary to ensure early diagnosis, better care and reduce likelihood of HIV onward transmission. Recently, Australia has made new HIV testing methods available: rapid HIV testing and self-testing kits. We conducted 11 focus groups with 77 participants with people from sub-Saharan Africa, Southeast Asia and Northeast Asia in four jurisdictions in Australia. Focus groups discussed barriers to HIV testing and the acceptability of new testing methods. Barriers to HIV testing included: cost and eligibility of health services, low visibility of HIV in Australia, HIV-related stigma, and missed opportunities by general practitioners (GPs) for early diagnosis of HIV and linkage into care. Participants had low levels of knowledge on where to test for HIV and the different methods available. Diverse opportunities for testing were considered important. Interventions to increase HIV testing rates among sub-Saharan African, Southeast Asia and Northeast Asian migrants in Australia need to be multi-strategic and aimed at individual, community and policy levels. New methods of HIV testing, including rapid HIV testing and self-testing, present an opportunity to engage with migrants outside of traditional health care settings.

Issue addressed Rates of sexually transmissible infections among young people are high, and there is a need for innovative, youth-focused sexual health promotion programs. This study evaluated the effectiveness of the Sharing Stories youth theatre program, which uses interactive theatre and drama-based strategies to engage and educate multicultural youth on sexual health issues. The effectiveness of using drama-based evaluation methods is also discussed. Methods The youth theatre program participants were 18 multicultural youth from South East Asian, African and Middle Eastern backgrounds aged between 14 and 21 years. Four sexual health drama scenarios and a sexual health questionnaire were used to measure changes in knowledge and attitudes. Results Participants reported being confident talking to and supporting their friends with regards to safe sex messages, improved their sexual health knowledge and demonstrated a positive shift in their attitudes towards sexual health. Drama-based evaluation methods were effective in engaging multicultural youth and worked well across the cultures and age groups. Conclusions Theatre and drama-based sexual health promotion strategies are an effective method for up-skilling young people from multicultural backgrounds to be peer educators and good communicators of sexual health information. Drama-based evaluation methods are engaging for young people and an effective way of collecting data from culturally diverse youth. So what? This study recommends incorporating interactive and arts-based strategies into sexual health promotion programs for multicultural youth. It also provides guidance for health promotion practitioners evaluating an arts-based health promotion program using arts-based data collection methods.

Issue addressed Evidence-informed practice underpinned by ethics is fundamental to developing the science of health promotion. Knowledge and application of ethical principles are competencies required for health promotion practice. However, these competencies are often inconsistently understood and applied. This research explored attitudes, practices, enablers and barriers related to ethics in practice in Western Australian health organisations. Methods Semistructured, in-depth interviews were conducted with 10 health promotion practitioners, purposefully selected to provide a cross-section of government and non-government organisations. Interviews were recorded, transcribed and then themed. Results The majority of participants reported consideration of ethics in their practice; however, only half reported seeking Human Research Ethics Committee (HREC) approval for projects in the past 12 months. Enablers identified as supporting ethics in practice and disseminating findings included: support preparing ethics applications; resources and training about ethical practice; ability to access HRECs for ethics approval; and a supportive organisational culture. Barriers included: limited time; insufficient resourcing and capacity; ethics approval not seen as part of core business; and concerns about academic writing. Conclusion The majority of participants were aware of the importance of ethics in practice and the dissemination of findings. However, participants reported barriers to engaging in formal ethics processes and to publishing findings. So what? Alignment of evidence-informed and ethics-based practice is critical. Resources and information about ethics may be required to support practice and encourage dissemination of findings, including in the peer-reviewed literature. Investigating the role of community-based ethics boards may be valuable to bridging the ethics-evidence gap.

Background:Aboriginal and Torres Strait Islander people in remote and very remote communities in Australia experience high rates of sexually transmissible infections (STIs), 4- to 29-fold the rates reported for non-Aboriginal people living in remote areas. Young people aged 16-29 years are particularly vulnerable to STIs. The Young Deadly Free (YDF) sexual health youth peer education program was implemented in 15 remote or very remote communities in four Australian jurisdictions in an effort to address endemic STI rates in these communities. The present study sought to evaluate the effect of YDF for Aboriginal young people. Methods: Young people (n = 128) participated in youth peer educator training to deliver peer education sessions on sexual health topics to other young people in their communities. Pre and post surveys were used to examine changes in STI knowledge, attitudes and behavioural intentions of the young people attending the peer education sessions. GHRANITE software extracted deidentified STI testing data for young people attending 13 community health services. Results: Young people (n = 426) attended peer education sessions delivered by trained youth peer educators. Pre and post surveys were completed by 174 and 172 young people respectively (median age 20 years). Gains were reported in STI knowledge, intentions to test (χ2 = 10.58, d.f. = 4, n = 142, P < 0.001) and number of STI tests (50.8% increase from baseline). Feelings of shame associated with STI testing remained high (39.5% post survey). Conclusions: Peer education can enhance the sexual health literacy of young Aboriginal people residing in remote communities. The extent to which knowledge gains result in behaviours that prevent STI transmission requires further evaluation. Normalising STI testing among Aboriginal young people would help reduce feelings of shame.

Since the emergence of the HIV pandemic in the 1980s, high rates of condom use for penetrative sex have been reported among sex workers in Australia. The sex industry in Australia and elsewhere has changed over the previous decade with increasing proportions of sex workers working privately and lower proportions of sex workers working in brothels. There has also been some evidence of reductions in condom use, particularly during penetrative oral sex. We therefore decided to investigate sex workers’ use of condoms during penetrative sex with clients. Methods This was a cross-sectional mixed methods study of sex workers in Western Australia. The study involved an environmental scan of the sex industry in Western Australia, visits to brothels and other sexual services premises, a survey of sex workers and in-depth interviews. Results We surveyed 354 male, female and transgender sex workers in Western Australia. We found unexpectedly low rates of reported condom use with clients for all forms of penetrative sex. Of respondents who reported providing this type of service, 33% reported that all clients usedcondom use with clients condoms always during oral sex, 69% during vaginal sex and 59% during anal sex. High levels of client demand for condomless sex was also reported, with 42% of sex workers reporting that all or most clients requested condomless oral sex. Increasing client demand, fear of losing clients and the ability to charge more for condomless sex were reported reasons for providing this service. Conclusions There has been an apparent increase in sex workers reporting condomless penetrative sex with clients in Western Australia compared to a previous cross-sectional study. An increase in private sex work and client demand for condomless sex together with an economic downturn leading to increased competition for clients may be important contributing factors.

Background There is limited information available about the health and wellbeing of male sex workers in Australia and globally. This study therefore was conducted to survey male sex workers in Western Australia as part of a broader study investigating the health and safety of sex workers in Western Australia. Methods:Male sex workers were surveyed using a modified survey instrument that had been used in a study undertaken in 2006. Survey respondents were recruited by word-of-mouth, social media, advertisements in gay press and in person. In-depth interviews with a small number of male sex workers were also conducted. Results:Fifty-eight men responded to the survey. The majority of survey respondents (42/58, 72%) were aged ≤35 years and a high proportion (50/58, 86%) worked privately at least some of the time. Seventy-two per cent (33/46) reported consistently using condoms during anal sex and 22% (11/51) during oral sex with clients. The consistent use of condoms with partners outside of work was associated with consistent use of condoms with clients. Forty per cent (23/58) of respondents reported currently using tobacco and 47% (25/53) reported harmful drinking at least weekly. The majority of respondents reported that sex work enhanced their wellbeing, with negative effects being largely due to stigma and discrimination, and the uncertainty related to not having a steady income. Conclusion:The study findings point to the need for peer outreach and support, interventions to improve the broader health of male sex workers and decriminalisation of sex work in Western Australia.

Rural clinicians in small communities face the pressure of always being 'on duty', and the ethical challenges of overlapping relationships with members of the community and duality of roles. The lead author of this commentary has experience as an insider researcher living within a small rural community, and has navigated the ethical challenges and community pressures of conducting qualitative research within an interconnected network. With appropriate measures and planning, insider research can be conducted rigorously, while maintaining ongoing relationships, confidentiality and anonymity.

The number of migrants has increased globally. This phenomenon has contributed to increasing health problems amongst migrants in high-income countries, including vulnerability for HIV acquisition and other sexual health issues. Adaptation processes in destination countries can present difficulties for migrants to seek help from and gain access to health services. This study examined migrants’ from sub-Saharan Africa (SSA) and South East Asia (SEA) sexual health help-seeking behavior in high-income countries with universal health coverage. The systematic review followed PRISMA guidelines and was registered with PROSPERO. Several databases were searched from 2000 to 2017. Of 2824 studies, 15 met the inclusion criteria. These consisted of 12 qualitative and three quantitative studies conducted in Australia, Spain, the United Kingdom, Belgium, Scotland, Ireland, and Sweden. Migrants experienced a range of difficulties accessing health services, specifically those related to sexual health, in high-income countries. Few studies described sources of sexual health help-seeking or facilitators to help-seeking. Barriers to access were numerous, including: stigma, direct and indirect costs, difficulty navigating health systems in destination countries and lack of cultural competency within health services. More culturally secure health services, increased health service literacy and policy support to mitigate costs, will improve health service access for migrants from SSA and SEA. Addressing the structural drivers for stigma and discrimination remains an ongoing and critical challenge.

BACKGROUND In high-income countries such as Australia, an increasing proportion of HIV cases have been acquired overseas, including among expatriates and travelers. Australia’s national strategies have highlighted the need for public health interventions for priority populations. One approach is to expand efforts to places or spaces where expatriate communities reside. Online settings such as forums used by expatriates and travelers have potential for preventing sexually transmissible infections with those hard to reach through more traditional interventions. OBJECTIVE Our objectives were to (1) identify and describe domains of social interaction and engagement in 1 online forum used by Australian expatriates and travelers living or working in Thailand; and (2) make recommendations to health-promoting organizations and policy makers regarding the role of these forums in public health interventions with mobile populations who may be at risk of acquiring HIV or other sexually transmissible infections. METHODS We identified forums and users in 2 stages. We identified 13 online forums and analyzed them for inclusion criteria. We searched 1 forum that met the required criteria for users who met inclusion criteria (n=5). Discussion threads, rather than individual posts, were units of analysis. For each user, we collected as transcripts the first 100 posts and 10 most recent posts, including the thread in which they were posted. We analyzed and thematically coded each post (n=550). Transcripts and analyses were reviewed and refined by multiple members of the research team to improve rigor. Themes were not totally emergent but explored against symbolic interactionism concepts of presentation of self, meaning, and socialization. RESULTS Key domains were as follows: the forum (characteristics of the space and reasons for use), gaining access (forum hierarchy and rules), identity (presentation of self and role of language), advice, support, and information (sources of information, support provided, influencers, topics of discussion, and receptiveness to advice), and risk (expectations and perceptions). The forum exhibited evidence of unique language, rules and norms, and processes for managing conflict and key influencers. The forum was a substantial source of health information and advice provided to users via confirmation, reassurance, or affirmation of beliefs and experiences. Risk perception and expectations varied. Risk taking, including around sex, appeared to be a key expectation of travel or the experience of being an expatriate or traveler. CONCLUSIONS Australian expatriate and long-term traveler participation in the online forum formed, influenced, and reinforced knowledge, attitudes, interaction, and identity. Such forums can be used by policy makers and health-promoting organizations to provide supplementary sources of support and information to hard-to-reach mobile populations who may be at risk of acquiring HIV or other sexually transmissible infections. This will complement existing engagement with health professionals and other public health interventions.