Departmental records between 2006

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1 SEXUAL HEALTH Successes in sexual health communications development, programmatic implementation and evaluation in the Torres Strait region 2006 to 2012 Patricia S. Fagan, 1 Heather K. Robertson, 2 Alisa E. Pedrana, 3 Alexandra Raulli, 4 Alan A. Crouch 5 Departmental records between 2006 and 2012 show that the public health unit in Far North Queensland (FNQ) partnered with the Torres and Northern Peninsula Area (T&NPA) District Health Service and communities to develop a program to address high local notifications of bacterial sexually transmitted infections (STIs) and prevent an outbreak of HIV/AIDS. The T&NPA consists of island and mainland communities at the tip of north-eastern Australia with a population of about 9,309 Aboriginal and Torres Strait Islander (Indigenous) people making up 83% of the total T&NPA population in Sixty per cent (5,613) of the T&NPA Indigenous population are aged less than 25 years, with 1,856 aged years. 1 The T&NPA population is younger, has lower levels of education and less access to services, live in more crowded homes 2 and generally have poorer health outcomes than other Australians. 3 Sexual health risk is significant for young people living in remote FNQ due to many factors including: inadequate school-based sexuality and relationships education; 4 low levels of sexual health knowledge and personal risk perception; 5 early age of first sex and frequent partner change; 5 limited access to skilled sexual health services and resources including condoms; 6 and inadequate community engagement around these issues. 7 Unsurprisingly, the burden of STI is Abstract Objective: To evaluate the Indigenous sexual health promotion program in the Torres Strait that culminated in an education-entertainment radio drama, Kasa Por Yarn (KPY). Methods: A mixed methods approach applied to unpublished program documents and program-derived peer-reviewed publications was utilised. Results: Early initiatives established a strong partnership with Torres Strait Islander stakeholders. Significant community engagement throughout ensured a positive process. Telephone survey data (n=100, TSI, years) found: 95% had heard of KPY and 80% listened to 2 or more episodes (reach); 86% recalled storylines/characters (recall); and 54% talked about KPY to family/friends (resonance). There was improvement in sexual health knowledge scores (p) in the year-old Torres Strait Islander population between 2007 and The year-old population exposed to KPY had higher sexual health knowledge scores compared with those unexposed (p=0.02). Conclusions: This is an uncommon comprehensive evaluation of population-based sexual health communications strategies delivered over years in a remote Australian setting. The findings are encouraging but demonstrate that positive shifts take time and are incremental. Implications: In addition to clinical strategies, strategic and sustained investment in sexual health promotion expertise that leads community partnership and program development is required to reduce youth risk and prevent HIV/AIDS in remote populations. Key words: Aboriginal and Torres Strait Islander, sexual health promotion, remote health care, cultural integrity substantial with local data indicating a high prevalence of chlamydia and gonorrhoea among youth and notification rates in the Queensland Indigenous population standing at more than fivefold for chlamydia and tenfold for gonorrhoea and syphilis compared to non-indigenous population rates. 8,9 Bacterial STI enhance the spread of HIV in a population. 10 In the remote T&NPA context, the risk of HIV is heightened by the mobility of youth between the Torres Strait and major population centres in Queensland 11 and the proximity of the region to Papua New Guinea. Due to Treaty arrangements, free movement of Torres Strait and Papua New Guinea residents across this international border 12 is allowed. Papua New Guinea is facing a widespread HIV epidemic characterised by a 1. School of Public Health, Tropical Medicine and Rehabilitation Sciences, James Cook University, Queensland 2. Torres and Cape Hospital and Health Service, Queensland 3. Centre for Population Health, Burnet Institute, Victoria 4. Epidemiology Section, ACT Health 5. Centre for Excellence in Rural Sexual Health, University of Melbourne, Victoria Correspondence to: Dr Patricia S. Fagan, School of Public Health, Tropical Medicine and Rehabilitation Sciences, James Cook University, Cairns, Queensland; trish_fagan@bigpond.com Submitted: August 2014; Revision requested: November 2014; Accepted: November 2014 The authors have stated they have no conflict of interest. Aust NZ J Public Health. 2015; 39:270-6; doi: / Australian and New Zealand Journal of Public Health 2015 vol. 39 no. 3

2 Sexual Health Sexual health program successes in Torres Strait region prevalence >1% as well as high rates of other STIs, and HIV is predominantly transmitted through heterosexual activity. 13 Since the mid-1990s across remote Australia, a screen, treat and contact trace strategy has been implemented in an effort to reduce the burden of STI 14 and, where the investment has been sustained, this approach has shown promise. 15,16 Numerous education projects have also been supported, but only a small number have been formally evaluated (predominantly process evaluations) Recently, evidence that clinical best practice and well-coordinated sexual health promotion activities can reduce STI prevalence in remote Aboriginal populations has been reported 21 and there have been calls for new approaches to STI control and prevention, 22,23 including mass treatment programs and other innovative initiatives. From 2006 in the T&NPA, in addition to innovative testing and treatment programs, 24 a multi-strategic approach to sexual health promotion was pursued (Box 1). In 2010, arising from the learnings of preceding sexual health communication activities (Box 2) and relying on community guidance (overseen by the YARN), 7 a Torres Strait Islander actor/ cultural liaison officer was commissioned to work with a scriptwriter and the community to develop the narrative for a radio drama. This occurred through a documented series of creative workshops (storyline/character and script review workshops) held locally with young people. Kasa Por Yarn (KPY), meaning Just for a Chat, was a story of the dilemmas facing youth in T&NPA about family, love and relationships and the realities of remote area life (see KPY was delivered in Kriol (Yumpla Tok) and all the actors were local Torres Strait Islander and/or Aboriginal people. This paper summarises the evaluation findings of the antecedent projects and the two series of KPY broadcast in the T&NPA in 2010 and Framed as a systematic review based on realist principles, the paper further reports on the processes of KPY development, and its reach (KPY awareness across the population), recall (of characters, storylines and messages), and message resonance (success in creating conversation about sexual health issues with friends or family). The paper also reports changes in aspects of sexual health knowledge among local youth. This program review has been conducted at the request of the Torres Strait-Northern Peninsula Hospital and Health Service, Men s and Women s Health program. It has used (with Queensland Health permission) previously unpublished material produced during and immediately following the development and evaluation of the initiatives. Letters of support for publication have been Box 1: Program of sexual health promotion activities in the Torres and Northern Peninsula Area District Sexual Health Promotion Domain Strategy Comment Community engagement and mobilisation Condom Access: To provide 24/7 community-based private access to condoms from at least one location in each community School-based Sexuality and Reproductive Health education: age appropriate, teacher led, continuous and curriculum based (grades 5-10) Major sexual health communications strategies (See Box 2) Youth and Relationship Networks (YARN groups) External evaluation 7 Engagement with key influential residents and community-based organisations Building condom infrastructure in participating locations; developing condom social marketing strategies e.g. locally branded condoms 6 Engagement of regional education authorities; A cross-sectoral (Education and Health) feasibility study to establish an acceptable mechanism to achieve aims Events based strategies Arts based strategy: Indigenous Hip Hop; External evaluation 27 Radio drama: Kasa Por Yarn 1 (2010) and 2 (2012) Community people meet six weekly in four locations (TI [x1] and NPA [x3]) to discuss youth issues and advise on new projects Ongoing with local government officials, media commentators, sporting club officials, religious leaders Ongoing and accompanied by lobbying of local government and health service agencies Involved engagement of individual school communities in sexual health issues and a partnership with the regional Indigenous School Support Unit World AIDS Day International condom day activities Two series (12 episode and 8 episode) radio drama education-entertainment broadcast 4 times daily across T&NPA supported by press campaign, Facebook, YouTube and SMS. provided by key local health service and community-based organisations. Human Research Ethics Committee approval was obtained for Knowledge, Attitudes and Practices (KAP) surveys in 2007 and 2010 (Cairns and Hinterland Health Service District HREC 2007 #466). Telephone surveys, undertaken as routine monitoring, were performed by a commercial market research agency and conducted in ethical compliance with the Code of Professional Behaviour of the Australian Market Research and Social Research Society. 25 Methods The evaluation used a mixed methods approach applied to the analysis of unpublished program documents and program-derived peer-reviewed publications. Peer reviewed publications and small project findings Published papers describing the community engagement strategy, 7 STI testing and treatment program, 24 condom infrastructure improvement efforts 6 and performingarts-based community awareness-raising initiatives 26,27 were reviewed. Documented findings from four small antecedent campaigns (Box 2: print advertisements and free SMS texting service; chlamydia home testing; 2008 World AIDS Day activities; and a mobile telephone number collection initiative) informed by media consumption surveys, were also reviewed. Document review Sexual health program planning and internal evaluation documents were reviewed to assess the fidelity of the KPY project implementation including the extent and nature of community engagement, cultural appropriateness, suitability of the media mix and adherence to budget and timeline. A complete list of departmental archives accessed by the reviewers can be obtained on request from the authors. Telephone survey reports Confidential telephone surveys were conducted in 2010 and 2012, in the weeks following the final episode of each KPY series. The telephone surveys used a standard approach calling households with landlines seeking an eligible resident. The telephone lists had been supplemented by previously 2015 vol. 39 no. 3 Australian and New Zealand Journal of Public Health 271

3 Fagan et al. Article collected mobile numbers provided by local youth who had consented to being contacted for other purposes. Eligibility for the 2010 survey was a respondent who was a local resident aged over 14 years; for the second survey, eligibility was further restricted to Torres Strait Islander and/or Aboriginal residents aged years. The sampling was reported as purposive and had continued until all telephone lists were exhausted. The telephone survey reports with associated data were re-analysed and used to describe the reach, recall and resonance achieved across the year Indigenous T&NPA population by the two KPY radio series. Assessments of sexual health knowledge The telephone survey following the broadcast of in 2012 included an additional five sexual heath knowledge questions (Box 3) that had also been part of a previous HIV/ STI KAP survey undertaken in FNQ among youth aged years in and 2010 (Queensland Health, unpublished data). The five knowledge questions included in the 2012 telephone survey were pertinent to the themes covered in the KPY drama series. The average number of correct responses (average knowledge score) for the cohort of Indigenous youth aged years and resident in the T&NPA who participated Box 3: Sexual health knowledge questions. Knowledge question If someone with HIV coughs or sneezes near other people, the other people can get the virus A person can get HIV by hugging someone who has it HIV infects only gay men and people who inject drugs A man can have an STI without knowing A woman can have an STI without knowing in the KAP surveys in 2007 and 2010 were compared by gender with the average knowledge score of Indigenous youth of the same age group in the telephone survey following in In addition, a crosssectional analysis of the 2012 telephone survey data (for Indigenous youth aged years) was undertaken to compare (average knowledge) scores of those reporting they were aware of KPY (exposed cohort) compared with those not aware (unexposed cohort). Possible responses Box 2: Sexual health communications campaigns in the Torres and Northern Peninsula Area 2006 to 2012.* Campaign Details / Comments Learnings Lets Get It On week campaign; Youth were unlikely to ask for sexual health information via SMS Print adverts and free SMS texting service to answer sexual health questions no formal evaluation; received 1 SMS query. Pee It, Pack it, Post it 2008 Chlamydia home-based testing (a mainstream Offered for 6 weeks and supported by newspaper adverts; Focus group evaluation with year olds Youth found instructions confusing and the language foreign; The anonymity offered was well-received campaign) World AIDS Day (WAD) activities 2008: WAD information night Addressed by local sexual health nurse, a PLWHA and role play about communicating with youth; Incentive for youth to attend; Questionnaire evaluation (44 attendees) Incentive encourages youth attendance; Involvement of local dignitaries appreciated; PLWHA testimonial well received WAD print advertorial local newspaper Included interviews with mayor, informative articles on sexual health issues, and photos from WAD information night; Influential community members are willing to be involved and local newspaper is an advocate for HIV prevention WAD: Ready for the Football Radio announcements about staying safe ; Overall evaluation of WAD activities 2008 Win an ipod touch competition 2009 To collect mobile phone numbers for future youth communication strategies; Safe Sex No Regrets Campaign Indigenous Hip Hop project: % of 81 interviewees aged were aware of the WAD activities, and 80% could recall messages; 25 entries only; Evaluation by key informant interviews Mainstream sexual health/sti mass media campaign comprising: TV advertisements, a website and posters. The YARN groups modified the campaign developing an FNQ specific poster featuring local Indigenous actors promoting condom use Week-long program in four T&NPA locations in 2010; conducted workshops attracting in-school and out of school youth and adults, culminating in a gala Friday night performance in each location International condom Day: 2011 More than 200 attended Used hip hop performance to attract youth Local health promotion staff and volunteers supported the event. Evaluation: key informant interviews only * other than the Kasa Por Yarn radio drama (see Box 1 and text) The media-mix of radio advertisements, print advertorial in local newspaper provided high reach, and local content and speakers at an incentivised event, was successful Youth are wary of mobile phone scams ; Strategies need to be publicly endorsed by local people of influence; A competition not effective in gathering mobile phone contacts The YARN groups could not endorse the mainstream posters for distribution. No evaluation was carried out. Highly effective in reaching young people at risk; Strengthened partnerships between Health, schools, local Councils and other community organisations; Resource intensive and opportunity costs significant External evaluation 27 Hip Hop engaged audience and allowed conversation about condom use; Need experienced and mature sexual health staff to support such an event; Volunteers recruited by a local person are likely to be very committed 272 Australian and New Zealand Journal of Public Health 2015 vol. 39 no. 3

4 Sexual Health Sexual health program successes in Torres Strait region Data analysis was performed using Stata Version 12 (Stata Corporation, Texas, USA). Univariate analyses were performed using Pearson s chi-squared test and Fisher s exact test where cell counts were less than five. Data was calculated discounting missing values. A significance level of p<0.05 was used. 28,29 Results Sexual health communications initiatives Box 2 summarises the early communication initiatives in the region. These had laid the foundations for a strong partnership with the YARN groups and other stakeholders. Reflections on these initiatives combined with the community knowledge gained over this period informed the development of the radio drama. As a result, the KPY project utilised the talent of local youth, involved influential stakeholders and engaged T&NPA news and media outlets, and used knowledge of media consumption patterns to inform an effective media mix. In addition, the evidence for sexual health risk among local youth presented to and discussed with YARN group members and others over the early years, as well as the projects themselves, had stimulated community awareness and concern, making the idea of a radio drama addressing this sensitive issue more acceptable to community. The KPY process Project documents revealed significant community engagement in the planning, development and implementation phases of KPY 1 and 2. About 80 community members were involved in developing KPY. These ranged from steering group members (the YARNs), young people participating in storyline and script review workshops, local state health and community-based organisation staff, actors and musicians. The KPY cast, songwriter and cultural liaison officers were all Torres Strait Islander people. In addition, project data indicated that more than 500 community members had attended KPY school and/or community launches for both series. Further, the project attracted other influential people to the launch, including the mayor, shire council staff and school principals. The launches included live performances of the KPY theme songs composed by a local Indigenous hip-hop artist. Critical to the success of the project in engaging the community and having meaningful involvement of Indigenous people was the partnership between the project team and community radio and newspaper outlets. In addition to the paid advertising, the producer was able to leverage two front-page articles about KPY in the local newspaper and each episode was aired an additional two times daily on local radio, free of charge to the project. The launches at one location were comanaged by the local radio station with twohour live broadcasts and street performances. The local government health service provided another medium for staff to access KPY by loading episodes onto their intranet site. Local high schools allowed the KPY team to present to students at a school parade to help promote the project and permitted students to participate in a workshop to evaluate and develop storylines for. The strong support from community, in addition to feedback from community stakeholders and comments from telephone survey participants reflected a consensus that although sexual health was not openly discussed, it was appropriate for KPY to encourage conversation about these issues. For example, a Torres Strait Islander stakeholder commented Once dialogue starts it makes it less taboo [we ve] got to put the cultural side down and put this up front ; and a telephone survey participant commented: [We] explained to our nephew what the story was about, [we] would rather break the protocol of culture than risk sickness. Only one community stakeholder was recorded as offering a less-than-positive comment, suggesting that the consultation period could have been longer. Media mix Media consumption survey data confirmed that the media mix of local radio, newspaper and the internet were appropriate to reach the target audience, with two-thirds or more of survey participants reporting that they used radio, newspaper or new media including Facebook, YouTube, SMS on at least a weekly basis. Budget and timelines The KPY series budget ( ) was $325,000 plus salary costs for a part-time producer. The project was completed within budget but delays in community and official approval processes pushed the timeframe from three to almost four years. KPY reach, recall and resonance in the year Torres Strait Islander and Aboriginal population The 2010 telephone survey following achieved a sample of around 300 T&NPA residents. Data analysis was restricted to those 99 Indigenous responders aged years. The 2012 telephone survey following targeted T&NPA youth, achieving a sample of 100 local Indigenous people aged years. In both surveys, there was a reasonable geographic spread of participants reported from the outer islands (2010: 31%; 2012: 19%), NPA (2010 and 2012: 17%) and Thursday Island (2010: 51%; 2012: 64%). The 2012 telephone survey cohort was significantly younger (p=0.03) than the year cohort in 2010 and there was no significant difference in the two year survey samples by gender (p=0.52). Key findings for reach, recall and resonance for the Aboriginal and Torres Strait Islander year population are displayed in Table 1. Table 1 demonstrates that engaged considerable proportions of the Indigenous youth surveyed as measured by its reach, recall and resonance and these increased significantly following the second series () with 86% (up from 48%, p) of those aged years being able to recall characters or storylines and 54% (up from 31%, p) talking about the radio drama to family and/or friends. Changes in sexual health knowledge over time in the year Indigenous population of T&NPA There was a statistically significant improvement in average knowledge scores between 2007 and 2010 in the T&NPA Indigenous year population for females (p) but not for males (p=0.78), whereas the improvement was highly significant between 2010 and 2012 for both females (p) and males (p), see Table 2. A significant difference in average knowledge score was also noted between genders in 2007 (p=0.01), but no difference was observed in 2010 (p=0.71) nor in 2012 (p=0.74). Difference in sexual health knowledge level in the year Indigenous population of T&NPA by KPY exposure In the 2012 telephone survey of the year Indigenous population, 94 reported they were aware of (exposed) and 5 reported 2015 vol. 39 no. 3 Australian and New Zealand Journal of Public Health 273

5 Fagan et al. Article Table 1: Reach, Recall and Resonance of the Kasa Por Yarn radio drama: Findings for the year Torres Strait Islander and Aboriginal population resident in the Torres and Northern Peninsula Area participating in telephone surveys (2010 & 2012) immediately following the broadcast of & age group male female age group male female age group male female Reach Had heard of Kasa Por Yarn 16/19 (84) 19/20 (95) 15/20 (75) 30/35 (86) 31/39 b (79) 49/55 b (89) 16/19 (84) 38/39 (97) 18/18 (100) 23/24 (96) 34/37 (92) 61/63 (97) Reach Listened to two or more episodes 1.0 a 9/19 (47) 1.0 a 5/20 (25) n.a /20 (50) 13/35 (37) 0.19 a 19/39 (49) 0.14 a 18/55 (33) a. Fishers Exact two-tailed probability test available at b. Gender was missing for 5 responders 12/19 (63) 33/39 (85) 15/18 (83) 20/24 (83) 27/37 (73) 53/63 (84) 0.33 Recall Could recall storylines or characters 9/19 (47) 9/20 (45) 0.04 a 10/20 (50) 14/35 (40) /39 (51) 24/55 (44) 14/19 (74) 35/39 (90) 17/18 (94) 20/24 (83) 31/37 (84) 55/63 (87) Resonance Spoke about Kasa Por Yarn to family or friends /19 (37) a 3/20 (15) a 8/20 (40) a 11/35 (31) 15/39 (38) 14/55 (25) 11/19 (58) 17/39 (43) 14/18 (78) 12/24 (50) 25/37 (68) 29/63 (46) a 0.03 a they were not aware (unexposed). Data was missing in one case. The exposed cohort had an average knowledge score of 3.8 correct responses compared with the unexposed cohort with an average knowledge score of 2.8 (p=0.02). Discussion: Current approaches in sexual health promotion suggest that, to be effective, interventions must be implemented at multiple levels (e.g. policy, workforce, societal, social and individual), using multiple strategies (e.g. advocacy, condom social marketing, mass communications, STI testing and treatment strategies, performance art education-entertainment, curriculumbased sexuality and relationships education, community empowerment approaches) in multiple settings and domains (e.g. school, family, recreational spaces, community, cyberspace) with sustained funding commitments. 21,30-33 By this means, raised community consciousness is (ideally) translated into social activism around the disadvantage underlying the high burden of disease, with each stream reinforcing the other. 34 The interventions aim to mobilise young people into conversations on sexual health and relationship issues and also encourage them to access testing and other health services. Embedding them within populationwide sexual health communications strategies and school-centred curriculumbased age-appropriate sexuality and relationships education programs ensures reach and sustainability. 35 Health promotion has also begun to exploit the popularity and interactivity of new social media platforms, 5,36-38 responding to evidence for the utility of such on-line platforms (including social networking sites) as effective tools in sexual health communications due to their popularity, anonymity, affordability and accessibility, particularly among young people This evaluation has been able to assess the process, and the reach, recall and resonance of the two Kasa Por Yarn radio series and to demonstrate a positive shift in sexual health knowledge in T&NPA between 2007 and 2012 among Torres Strait Islander and Aboriginal youth aged years, as well as among the year Indigenous population in 2012, reporting awareness of KPY when compared to those reporting no awareness. The consistent increases in the parameters used to measure reach, recall and resonance following (statistically significant in many instances, see Table 1) demonstrate the value of reinforcing themes and messages using an established and popular vehicle (in this case KPY). The increased knowledge observed among youth over time is Table 2: Comparing selected sexual health knowledge over time in the year Torres Strait Islander and Aboriginal population resident in the Torres and Northern Peninsula Area. Males Females No. participants Average knowledge score encouraging (as is the greater knowledge among those reporting awareness of KPY in 2012) but, at the same time, these findings indicate that the population-level changes that are pre-conditions for risk reduction (e.g. improvement in knowledge) take considerable time and are incremental, requiring sustained investment. The project to improve the availability and effectiveness of school-based sexuality and relationships education remained in its infancy during this time and as such was unlikely to have contributed. 4 In comparison with recent urban sexual health communications campaigns, KPY achieved very high levels of reach, recall and resonance. 22,42,43 While this may be expected due to the geographic specificity of the KPY broadcast zones, the degree of message penetration about such a sensitive issue was highly satisfactory. The authors are of the view that the culturally respectful approach adopted, supported by the involvement of local people in every phase of the development of KPY, was critical. The cultural liaison officer, YARN members, participants in the script review processes and the actors themselves shaped and nurtured KPY as it P value No. participants Average knowledge score KAP survey P value KAP survey KPY survey Australian and New Zealand Journal of Public Health 2015 vol. 39 no. 3

6 Sexual Health Sexual health program successes in Torres Strait region grew from storyline to script to radio drama so that it was able to inoffensively address a sensitive issue. The evident support of community leaders, engagement of local actors and the broadcasts being in Yumpla Tok reinforced the legitimacy of the project and its messages. Reflecting on the factors responsible for the community mobilisation that was fundamental to KPY s success leads one to consider the importance of the following: sustained, high level, health promotion expertise with multi-year access to resources; the commitment of local non-government community organisations, sexual health staff and community people who, once informed of the risk, enthusiastically gave their support to the program; and the genuine partnership with community stakeholders, local schools, media organisations, local health staff and the regional sexual health promotion unit. The multi-determinant nature of sexual health disadvantage suggests that any single intervention will be unlikely to reduce either risk or burden of STI in a given setting. As noted above, evidence from other areas of health promotion indicates that the approaches most likely to result in improved outcomes will be multi-strategic, inter-sectoral and partnership-based, will address multiple domains and will be sustained. The KPY project, embedded as it was within a broader multi-year sexual health communications program and environment-enabling suite of interventions, is an exemplar of such an approach and provides evidence of its effectiveness in a remote Indigenous Australian context. This is even more striking when one considers that the setting is a socially conservative environment within which profound youth sexual health disadvantage continues to exist; and it provides policy evidence for ongoing investments of this kind. The success of the KPY radio drama and the improvements in knowledge are not in themselves evidence of reduction in risk behaviours or STI disease burdens. Although changes in knowledge are considered a necessary precursor for changes in behaviour and subsequent reductions in STI prevalence, measuring change in risk behaviours or STI prevalence was beyond the scope of this review. Furthermore, it is our view that for the small gains evidenced here to be translated into genuine risk reduction for local youth, the investment (which was discontinued after ) would need to be restored. Finally, the learnings from this work in the T&NPA region should be integrated into comprehensive and innovative approaches to sexual health promotion developed in partnership with local communities across remote Australia. Limitations This evaluation has used archival data and has a number of limitations. The paper reports on a service initiative (not a research project) and so there is no control group for comparison. However, the authors were in regular contact with key personnel in this remote region throughout this period and can confidently state that no sexual health promotion campaigns were implemented other than that described here. Education attainment and workforce participation data is available for the 2010 KAP sample, but was not collected in 2007 nor 2012, thus excluding the possibility of further comparison of the three samples (in Table 2). However, the 2010 sample was similar to the wider Torres Strait population with 25% reporting completion of year 12 and 42% working / looking for work. This compares with 28% and 40% reported regionally for the same age group. 44 The population of the Torres Strait is not large and it is not known how many young people may have participated in more than one of the KAP surveys in 2007, 2010 and the telephone surveys of 2010 and The KAP surveys sampled selected areas within the Torres Straits excluding (for logistical reasons) many of the more remote islands, whereas the telephone surveys sampled all young people where access to a mobile or landline phone could be established. The bias here may well be towards a diminution in any detectable improvement in knowledge in 2012; while young people from more remote locations who participated in the 2012 telephone survey had similar access to KPY, they are likely to have had less access to information and resources more generally. Finally, while the wording and the language (English) of the sexual health knowledge questions were identical in both KAP surveys and the 2012 telephone survey, the KAP surveys comprised responses to a written questionnaire whereas the telephone survey was verbal. The impact of these differences is difficult to assess. Conclusion This is one of the few comprehensive evaluations of population-based sexual health promotion strategies delivered in remote Australian settings published to date. Results indicated improvements in knowledge over time among Torres Strait Islander and Aboriginal youth aged years living in T&NPA, and greater levels of knowledge among those reporting awareness of the KPY radio drama compared with those reporting no awareness. It is also important to note that these outcomes rested, not on funding for a series of discrete projects, but on strategic and sustained investment in regional sexual health promotion expertise. This led community partnership development and (given multi-year resources) expertly guided sexual health promotion practice and program (rather than project) development, thus facilitating the clear expression of the Torres Strait Islander voice. Implications In addition to test, treat and contact trace, strategic and sustained sexual health promotion investment such as that described here is required to reduce youth risk and STI disease burdens, and prevent the establishment of HIV/AIDS as (yet another) epidemic of chronic disease in remote Australia. The critical role, observed here, of respectful engagement with communities and the cultural safety afforded participants suggest that a more deliberate inquiry into the elements of health promotion practice that build cultural integrity and can be broadly applied may be useful. Acknowledgements The authors acknowledge the following organisations, agencies and individuals for their support and/or contribution to this evaluation: The Torres Strait-Northern Peninsula Area Hospital and Health Service and its Men s and Women s Health program staff; Queensland Health Tropical Public Health Services; Northern Peninsula Area Family and Community Services (Bamaga Family Resource Centre); Mura Kosker Sorority Incorporated; YARN group members; local government agencies; schools and community radio; and the people of the Torres Strait and Northern Peninsula Area. The KPY radio drama was funded by a grant from Health Promotion Queensland vol. 39 no. 3 Australian and New Zealand Journal of Public Health 275

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