“That business from before, where parents don’t talk about it, that’s long gone,” says Anne Lennard, Derby based aboriginal health worker, and foot solider in the war against sexually transmitted infection that is raging in the Kimberley. Her message to parents is plain and clear, “why you gotta stay quiet when you should really be talking to your children about those things.”
With an area of 423,517 kilometres squared, think 3 times the size of England, and a population of only 34,794, the people of the Kimberley are spread sparsely across the vast landscape, the making the battle against STI’s a logistical nightmare fraught with culturally sensitive complexity.
The latest Epidemiology & Surveillance Program report issued in February 2014 by the WA Health’s Communicable Disease Control Directorate reveals Chlamydia and Gonorrhea rates in the Kimberley vastly exceeding those of other regions and predominately effecting aboriginal people.
Chlamydia notification crude rates per 100,000 population in the Kimberley are 1669.2 compared to 564.6 in the North Perth metro region and the comparison rates for Gonorrhea are a staggering 1334.4 in the Kimberley against rates of 47.4 in North Perth metro.
With 29 years experience working for Community Health in both Fitzroy Crossing and Derby, and currently part of the Sexual Health team at DAHS, Derby Aboriginal Health Service, Anne Lennard believes that the reasons for high Kimberley STI statistics is that people have a lot of sex and that lifestyle factors such as alcohol use, a desire for young people to try new things and a highly mobile population moving between the surrounding townships of Derby, Broome, Fitzroy Crossing and Looma further the spread of infections.
Lennard regularly sees the same people come into the clinic for a check and treatment, especially men. “Maybe they are used to it,” she says. “We just keep treating them.”
When a person is found positive for an STI, Anne undertakes a process called “Contact Tracing”; all recent sexual partners of the positive person are identified, visited and asked to come into the clinic for a STI health check and treatment. Health Checks, the collection of blood, urine or swabbed sample, can only be undertaken by a registered nurse or doctor. Anne contacts females and her male co-worker does the follow ups with men.
This is the process that is carried out every day across the Kimberley region by aboriginal health workers, nurses and doctors. Lennard points out that health services do a lot screening in the Kimberley and this is explains the high comparison rates. At DAHS, any adult who presents to the clinic for any reason and hasn’t been seen for two years is offered a comprehensive adult health check, which includes a STI screen. The clinic runs annual flu vaccination drives each May, which attract a large volume of people into the clinic and STI screens are offered “opportunistically” as part of this health testing regime.
Derby, located 210kms east of Broome and once the largest town in the Kimberley, attracts a many visitors from outlying communities and a population of homeless, all of whom are targeted for health screens. Positive STI results are referred to their communities for follow-ups and treatment.
In an attempt at early intervention through education, sexual health is part of the curriculum at high schools across the Kimberley. Jessie Hayes, health teacher at Derby District High School says that students from years 8-12 are taught a sexual and reproductive health unit every term. “The students are comfortable enough to ask explicit questions,” she said and made aware of the immediate and long-term implications of STI’s which include infertility for women from tissue scaring due to repeated exposure of infections.
A further 260km ‘up the road’ from Derby heading east is Fitzroy Crossing, where Deborah Carter, an aboriginal health worker at Nindilingarri, contributes to school based sexual health promotion delivering the Mooditj program, a sexual health and positive lifestyle program specifically designed for young indigenous people aged between 11 and 14 years.
Mooditj, meaning ‘deadly’ or ‘the best’, incorporates art and role play as a forum for discussion about relationships and sexuality. Carter says that the challenge in the Fitzroy Valley is that there are 42 remote communities in the area and they are all different; some are very cultural and others are influenced by strong Christian values.
Nindilingarri and Fitzroy Crossing’s dedicated Sexual Health Nurse work together during sports festivals and events such as the annual rodeo which draw a large crowd into Fitzroy Crossing and provide a setting outside the school system for sexual health promotion and opportunistic testing.
The 15-24 year old age group is the hardest to target for sexual health promotion and prevention programs and at 61% were the largest age group to return positive notifications for Chlamydia and 51% for gonorrhea in the Oct-Dec period of 2013.
The use of aboriginal community radio as a means of communicating with the target group has not been cleverly adopted by the WA Health Department, which recently announced that Mary G, The Black Queen of the Kimberley, a well known and highly regarded aboriginal entertainer, will front a short paid radio campaign. Radio station managers across the Kimberley were keen to promote sexual health messages by playing free ‘community service announcements’ and interviews with sexual health workers.
Indigenous stations in Derby, Fitzroy Crossing, Halls Creek and Kununurra missed out on the campaign proper, with only nominal exposure to message as part of the Mary G Show, which is relayed widely around the region. A source close to the campaign said that budget constraints had limited the media buy to the bigger stations in the Kimberley; Goolari Radio in Broome and the PAKAM network, which relays to remote communities in the Pilbara and Kimberley.
In Kununurra, Waringarri Radio, has joined forces with the key stake holders and developed their own sexual health message for radio in a campaign called “Don’t be shame, be game” and in Fitzroy Crossing, station manager for Wangki Radio, Angie Lee Stahl, said she would be willing to develop a radio campaign around sexual health and would fund translation into Kriol.
In Halls Creek, station manager Daniel Akinshola has developed five different scenario’s relating to sexual health promotion which are rotated on a daily basis, as well as a video with Amanda Sibasado.
Based in Broome, Sibosado is the Sexual Health Co-coordinator for the East Kimberley, a huge geographical area extending from Wyndham and Kununurra in the north (an eleven and a hour drive from Broome), east to the NT/WA boarder, Halls Creek (seven and half hours away), Warmun, and the Balgo, Bili Luna and Mulin area as well as the Gibb River Road communities.
Sibosado, works for Kimberley Aboriginal Medical Service (KAMS), a collective that represents four independently incorporated aboriginal health services; the Ord Valley Aboriginal Health Service (OVAHS) in Kununurra, Derby Aboriginal Health Service (DAHS), Yura Yungi Medical Service (YYMS in Halls Creek) and Jurrugk Aboriginal Health Service (JAHS), representing communities along the Gibb River Rd .
Although not a registered nurse, Sibosado worked her way into the position in early 2013 after spending eight years as a regional sexual health worker in the Pilbara and the Goldfields of WA. Last year she spent fifty percent of her time travelling back and forth along the Great Northern highway between Broome and Halls Creek and Balgo. This year Sibosado aims to spend more time reviewing Kimberley wide protocols.
Sibosado co-chairs the Kimberley Sexual Health Network with Katy Crawford, the Acting Senior Public Health Nurse (STI), also based in Broome at the Kimberley Population Health Unit, part of WA Country Health. While the two work closely together, Sibosado says that on the ground, the working relationships between the Aboriginal Medical Services and WACHS are dependent on politics and people at a local level. She would like to see a more formal system in place which relies less on personalities. Another area for which she is advocating is the quality of data they receive. At the moment positive STI notifications are not broken down by postcode in reports. If they were, it would be possible to see rates of testing and positive notifications for each of the postcodes in the Kimberley. According to Sibosado, “it is impossible to evaluate programs without it.” Anne Lennard also called for postcode data but a spokesman for the WA Health Department said postcode level data was not provided for reasons of patient confidentiality and testing data was provided by private pathology providers as a consolidated aggregate of data by region.
Through the course of her research, Sibosado has identified barriers and confusion around opportunistic screening of indigenous men by non-indigenous female clinicians. Herself an indigenous woman, Sibosado does not agree that is it inappropriate for a non-indigenous woman to offer an indigenous man an STI screen. A urine sample is required, which the man can do in private, “it doesn’t require a physical examination, or discussion of symptoms” she says. She sees there is a need for a greater male workforce in the area working as part of a men’s outreach service but low wages and stigma attached to men working in sexual health make it hard to attract candidates into the field.
The Kimberley has adopted a unique way of distributing free condoms throughout the region, enlisting the help of Mother Nature via the Condom Tree program. PVC pipes attached to well known trees around each town in the Kimberley are filled with free condoms, with supplies topped up every other day.
Sibosado said that the issue extended beyond just the scope of condom availability and screening. She is personally passionate about the need to address healthy relationships, communications and negotiation, drug and alcohol use, domestic violence and issues of self esteem; all as part of holistic approach to delivering the sexual health message. It may be the case that a girl doesn’t feel safe to tell a man to put on a condom, or perhaps in a desperate attempt for attention, someone with low self esteem may be a reluctant to stop and negotiate condom use. Sibosado believes that they would see more ‘headway’ if they invested more time working with mental health and drug and alcohol specialists, but says that it is difficult to prioritise activity in those realms against what the powers that be determine to be ‘measureable outcomes’.
Sibosado believes the top down approach to sexual health programs needs reviewing and favors a strategy that educates, engages and consults with senior community elders. Involving the elders will clarify for clinicians what is culturally appropriate and reassure both indigenous and non-indigenous health staff that there will not be a community backlash against sexual health workers. “It’s a long slow process but it’s obviously that what we have been doing for the past thirty years isn’t working, so its time to start thinking outside the square and getting creative”.
Katy Crawford agrees with Sibosado that they will never win the battle against STI’s without addressing the underlying determinates of health such as mental health and domestic violence. “We can go on screening and treating, screening and treating but you won’t see population-wide change,” Crawford said. Crawford supports the concept of stepping back to build community partnership with the support of elders and seeing what young community members want what ideas they generate themselves and build on the strengths of young people; changing the way they deliver health promotion, making it more community driven and less of a paternalistic approach.
Crawford plans to roll out this new strategy on the Dampier Peninsular, which lies north of Broome and in eastern Kununurra, but there are thousands of square kilometers of Kimberley in between these two locations. “We are a small team,” says Crawford. “If you really want to tackle sexual health you need people on the ground.”