Mapping and Needs Analysis Sexual and Reproductive Health in the HealthWest Catchment

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1 Mapping and Needs Analysis Sexual and Reproductive Health in the HealthWest Catchment 2010 Report Developed by Women s Health West for the Western Region Sexual and Reproductive Health Working Group

2 Acknowledgements HealthWest Sexual & Reproductive Health Working Group: Anna Vu (Women s Health West) Katherine Koesasi (Women s Health West) Corinne Rice (ISIS Primare Care) Carol Preston (ISIS Primary Care, Family Planning Victoria) Donna Froy (Djerriwarrh Health Services) Jane Torney (Maribyrnong City Council) Geraldine Earle (Melbourne City Mission) Rachel Whiffen (HealthWest) Joanna Noesgaard (HealthWest) Nicole Kopel (Western Region Health Centre) The HealthWest Sexual and Reproductive Health Working Group would like to acknowledge the extensive work undertaken by Anna Vu in undertaking the research and collation of the mapping and needs analysis for this report. The Working Group would also like to acknowledge all who gave their time to the mapping and needs analysis, whether it be giving and re-checking information on programs, assisting with general ideas for the project or passing on another s details.

3 Contents List of Acronyms...3 Executive Summary...4 Introduction...6 Sexual and reproductive health: an integrated health promotion priority for HealthWest...6 Definitions and approach to sexual and reproductive health...6 Current Policy Context...7 Needs Analysis...9 Overview: characteristics of the population in the HealthWest catchment...9 Key sexual and reproductive health issues: a literature and data review...12 Mapping Sexual and Reproductive Health Initiatives...23 Background...23 Mapping results Initiatives according to target groups Initiatives and the aspects of sexual and reproductive health that they cover Secondary school nurses...25 The HealthWest Partnership Sexual and Reproductive Health Forum...27 Limitations...28 Needs analysis...28 Mapping...28 Conclusion...29 Findings...29 Recommendations...30 Appendices...32 References

4 List of Acronyms ABS AIDS ATSI CALD CEO DEECD DIAC DHS FPV HIV HPV IDU LGA MSM PLWHA SIECUS SRH SSA STI WHO WMSR Australian Bureau of Statistics Acquired Immunodeficiency Syndrome Aboriginal and Torres Strait Islander Culturally and linguistically diverse Chief Executive Officer Department of Education and Early Childhood Development Department of Immigration and Citizenship Department of Human Services Family Planning Victoria Human Immunodeficiency Virus Human papillomavirus Injecting drug user Local government area Men who have sex with men People living with HIV/AIDS Sexuality Information & Education Council of the United States Sexual and reproductive health Same-sex attracted Sexually transmitted infection World Health Organisation Western Metropolitan Sub-region - 4 -

5 Executive Summary Sexual and reproductive health (SRH) was identified as an emerging priority area for HealthWest in its Integrated Health Promotion Plan. The key task for the first twelve months of this plan was to consider the sexual and reproductive health data and evidence in greater detail, map current services and health promotion initiatives, and identify gaps and areas for improvement in program delivery and organisational capacity. This report presents the results of these tasks, which were carried out between June 2009 and May 2010, and makes recommendations that will inform the selection of target groups and settings for the subsequent two years of the plan for Integrated Sexual and Reproductive Health Promotion in the catchment. The HealthWest catchment (made up of the local government areas of Brimbank, Hobsons Bay, Maribyrnong, Melton and Wyndham) is a diverse area comprised of many population sub-groups. The catchment has comparatively high levels of socioeconomic disadvantage, is home to many culturally and linguistically diverse (CALD) communities and growing numbers of Aboriginal and Torres Strait Islanders (ATSI). These sub-groups (or target groups), among others are known to experience greater levels of sexual and reproductive ill health, and their specific needs must be taken into consideration when planning sexual and reproductive health promotion interventions. This report explores some of the sexual and reproductive health needs of several groups. Mapping carried out by the HealthWest Sexual and Reproductive Health Working Group has found that there are a considerable number of initiatives taking place in the catchment that are either based on or have components that address sexual and reproductive health. The mapping exercise, when compared with information presented in the needs analysis, has led to four main findings: 1. There is limited research that has been done to analyse the sexual and reproductive health status of the catchment s population. 2. There is already strong commitment to sexual and reproductive health in the catchment by various stakeholders. 3. Current sexual and reproductive health initiatives are not equitably spread across target groups. Groups that appear to be under-resourced from a sexual and reproductive health perspective include people in and coming out of prison, Aboriginal and Torres Strait Islanders, same-sex attracted people, sex workers and people living with disability. 4. Responding to the social determinants of sexual and reproductive health is out of the scope of many current initiatives, and further work is required to analyse where - 5 -

6 programs sit on a health promotion continuum, from early intervention to prevention to population health. From these findings, four recommendations have been developed, and it is intended that HealthWest partner agencies will use these recommendations in the development of HealthWest s Integrated Health Promotion Sexual and Reproductive Health Plan The recommendations suggest that resourcing support is sought for: 1. Joint research and data collection, particularly around the experiences of certain population groups (e.g. the ATSI population, SSA people) and their experience of sexual and reproductive health locally. 2. Further analysis of current sexual and reproductive health initiatives in the catchment using HealthWest s Healthy Communities, Healthy Lives Model of Care to determine how effective projects are in tackling the social determinants of health. 3. The design of new programs that are targeted to population groups currently underresourced in the HealthWest catchment with regards to sexual and reproductive health. 4. More support given to workers involved in sexual and reproductive health, such as information sharing opportunities and training. The HealthWest Health Promotion Network endorsed these recommendations from the HealthWest Sexual and Reproductive Health Working Group in May The number of sexual and reproductive health initiatives taking place in the HealthWest catchment is encouraging. This mapping exercise suggests, however, that greater coordination among agencies in the region is required to increase the effectiveness of initiatives in dealing with the social determinants of sexual and reproductive health, and in reaching all key target groups. This mapping and needs analysis exercise is intended to encourage greater coordination in the future

7 Introduction Sexual and reproductive health: an integrated health promotion priority for HealthWest HealthWest is a partnership that provides members with a strategic link to planning for health services in the western suburbs of Melbourne. HealthWest s catchment includes the local government areas of Brimbank, Hobsons Bay, Maribyrnong, Melton and Wyndham and its vision is to lead strategic partnerships that facilitate real improvements in health and wellbeing outcomes in Melbourne s west. Sexual and reproductive health was identified as an emerging priority area for HealthWest in its Integrated Health Promotion Plan, and a sexual and reproductive working group was established in June Working group members are representatives from HealthWest, Women s Health West (lead agency), ISIS Primary Care, Western Region Health Centre, Djerriwarrh Health Services, Maribyrnong City Council and the Braybrook/Maidstone Youth Partnership. The key task for the first twelve months of the working group s plan was to consider the sexual and reproductive health data and evidence in greater detail, map current services and programs and identify gaps and areas for improvement in program delivery and organisational capacity. This report presents the findings of the above tasks, which were carried out between June 2009 and May 2010 and aims to inform the development of the catchment-wide sexual and reproductive health action plan. The report makes recommendations which will inform the selection of target groups and settings for the subsequent two years of the plan for integrated sexual and reproductive health promotion in the catchment. The work of HealthWest focuses on building the capacity of organisations to work with communities to enhance healthy relationships, and achieve good sexual and reproductive health. Issues relating to sexual and reproductive health are interlinked with other HealthWest priorities of mental health and wellbeing, drug and alcohol and the prevention of violence against women. Definitions and approach to sexual and reproductive health HealthWest draws on the definitions provided by the World Health Organisation (WHO) for both reproductive health and sexual health: Reproductive Health: implies that people are able to have a responsible, satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide, if, when and how often to do so. (WHO 2009)

8 Sexual Health: is a state of physical, emotional, mental and social wellbeing in relation to sexuality not merely the absence of disease, dysfunction, or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination, and violence. (WHO 2009b). HealthWest also extends its definition of sexual health to include that provided by the Sexuality Information and Education Council of the United States (SIECUS) (2002): Sexual health incorporates sexual development and reproductive health, as well as the ability to develop and maintain meaningful interpersonal relationships; appreciate ones body; interact with both genders in respectful and appropriate ways; and express affection, love, and intimacy in ways consistent with ones own values. HealthWest considers the work relating to sexual and reproductive health within the context of cultural, social and human-rights approaches, not simply biomedical models and the absence of disease. There are direct links between sexual and reproductive health and the broader determinants of health. To be effective, initiatives must outline how determinants such as socio-economic status, gender, education and experience of violence affect each population group and how they will respond to this. For example, there is evidence that teenage mothers are more likely to be from areas of disadvantage and engage in substance abuse. They are more likely to be victims of domestic violence and sexual abuse and to experience mental health problems (Kirby 2001, Skinner and Hickey 2003 and Williams and Davidson 2004, cited in FPV et al. 2005). The needs analysis section of this report will give more insight into how sexual and reproductive health inequalities are experienced by different population groups, and the section devoted to mapping will give an overview of initiatives already in place in the HealthWest catchment, which population groups they are targeted to and the aspects of sexual and reproductive health that they cover. Current Policy Context Sexual and reproductive health is a relatively recent health promotion priority area for the Victorian State Government (2007). The current context of sexual and reproductive health at local, state and federal levels indicates that HealthWest s prioritisation of sexual and reproductive health is timely, and that sexual and reproductive health requires concerted attention, coordination and action at a range of levels. Australia developed a Sexually Transmissible Infections Strategy for ; however, it lacks a national strategy for sexual and reproductive health, which would provide an overarching framework for policy and program development. A partnership of peak bodies has called for a National Sexual and Reproductive Health Strategy for Australia (O Rourke, 2008). Similarly, there is no comprehensive nationally agreed minimum data set encompassing the overarching issues in sexual and reproductive health. Lack of detailed information (eg: age, - 8 -

9 area and time-specific) on abortions carried out in Australia (and Victoria) makes the determination of priorities for prevention and intervention problematic and can ultimately be subject to bias and uninformed lobbying (FPV, 2009). At the state level, Victoria also lacks a co-ordinated approach to sexual and reproductive health. Hepatitis C and HIV/AIDS strategies exist for as does a Victorian Sexually Transmissible Infections Strategy These strategies have been presented in isolation from other sexual and reproductive or associated health priorities. This fragmented and medically-based approach, which focuses on negative aspects of sexual and reproductive health, also tends to neglect the positive associations with sexuality and sexual desire that can come from a recognition of people s sexual and reproductive rights within a social model of health. In December 2008 the Department of Health (previously Department of Human Services) established a Sexual and Reproductive Health Taskforce, with the aim of providing advice to government on strategies to reduce sexually transmissible infections and unwanted pregnancies, and enhancing health promotion in this priority area. Membership includes CEOs from Family Planning Victoria, Jean Hailes Foundation and the Melbourne Sexual Health Centre, among others. At a more local level, there are currently numerous organisations that deliver programs and services that respond to sexual and reproductive health within the HealthWest catchment. These agencies include community and women s health organisations, the Western Region Indigenous Gathering Place, local governments through the provision of maternal and child health programs and youth services, secondary schools, and the Braybrook/Maidstone Youth Partnership lead by Melbourne City Mission. More information about these services and programs can be found in the mapping section of this report. This report aims to capture a snap-shot of the work of organisations, which can then be used to build on knowledge and experience from these programs to identify strengths and barriers, and enable the capacity of organisations to continue and enhance their work in the area of sexual and reproductive health

10 Needs analysis Overview: characteristics of the population in the HealthWest catchment The HealthWest partnership covers the five local government areas (LGAs) of Brimbank, Hobsons Bay, Maribyrnong, Melton and Wyndham. The estimated resident population of all of these LGAs in June 2007 was 540,634 (about 10.4 percent of Victoria s population at that time), with the highest population density occurring in the inner-west (Maribyrnong, Brimbank, Hobsons Bay) than in the outer areas (Wyndham, Melton) (WHW 2009). Wyndham and Melton are, however, growing at significantly faster rates than the other three LGAs, with Wyndham being the fastest growing LGA in Victoria for the reporting year, and being set to overtake Brimbank as the most populated LGA in the Western Metropolitan Subregion by This growth is and will be largely due to broadhectare housing developments in the area (WHW 2009). Compared to many other parts of metropolitan Melbourne, the HealthWest catchment has relatively high levels of socioeconomic disadvantage. It is home to four of the top ten most disadvantaged LGAs in metropolitan Melbourne, with Brimbank ranked 2 nd, Maribyrnong 3 rd, Hobsons Bay 9 th and Melton 10 th (WHW 2009). As young people (under 25 years old) are often a major target population for sexual and reproductive health information projects and services, it is important to look at the age distribution of the catchment s population. On average in 2007, percent of the catchment s population were aged years, with the highest proportion occurring in Brimbank. Across all HealthWest LGAs, males make up a greater proportion of this age group. While young people are an important target group for programs and services, it is also important to consider the differing needs of each age group when addressing sexual and reproductive health. In 2007, percent of the population were in their young to mid years (25-54), with Maribyrnong having the highest proportion of people in this group, largely concentrated in the age group. It is also interesting to note that in all LGAs across the catchment, there were a greater proportion of women over the age of 70, in comparison with men (WHW 2009). The population across the HealthWest catchment is diverse, with many population groups whose sexual and reproductive health status and needs must be taken into account when planning interventions in the region. In 2006, there were 2,343 people (1,214 male and 1,129 female) in the catchment that identified as Aboriginal or Torres Strait Islander (ATSI), with the age distribution of this population (in comparison to the non-atsi population) heavily weighted to the younger age

11 groups. In Wyndham, for example, which is home to the largest ATSI population in the catchment (702), 59 percent of these people were under the age of 25 in 2006, compared with 37.7 percent of non-atsi people (ABS 2006). After Wyndham, the LGAs with the highest populations of ATSI people are Brimbank and Melton. Many parts of the catchment have long been settlement areas for refugees and migrants, primarily from South East Asia, the Horn of Africa and the Balkans, and therefore the catchment has many culturally and linguistically diverse (CALD) communities. Across the catchment, the LGAs with the highest proportion of females born overseas in countries that are mainly non-english speaking are Brimbank and Maribyrnong. Top languages other than English spoken across the catchment include Vietnamese, Maltese, Chinese languages, Italian, Greek, Macedonian, Croatian, Arabic and Spanish (WHW 2009). These populations have and will continue to change over time according to waves of migration. From January 2006 to January 2009, 3,129 people settled in the HealthWest catchment on humanitarian visas. This equates to 28 percent of all people who settled in Victoria on humanitarian visas during that period, with most settling in Wyndham (1,085 people) and Brimbank (1,073 people) (DIAC 2010). This highlights that recent housing and social trends have led to increased numbers of refugees settling in outer suburban areas than previously. It is important to note that among groups born in mainly non-english speaking countries, levels of proficiency in spoken English differ according to gender. In 2006, across almost all language groups in all LGAs, higher proportions of males than females spoke English very well or well, and higher proportions of women spoke English not very well or not at all (WHW 2009). While there are no statistics on how many people living in the catchment identify as gay, lesbian, bisexual, transgender, queer or intersex, we can draw estimates based on broader Australian figures. In the 2008 Survey of Australian Secondary Students that was carried out nationally with year 10 and year 12 students, 9 percent of students reported that they were not attracted exclusively to the opposite sex, while 1 percent of students reported being attracted exclusively to people of the same sex, 6 percent reported attraction to both sexes and 2 percent were unsure of their sexuality (Smith et al 2009). In another national study, while 97.4 percent of men and 97.7 percent of women identified as heterosexual, reporting of same-sex attraction and experience were more common, which was reported by 8.6 percent of men and 15.1 percent of women (Smith et al 2003). Accurate estimates of people living with a disability in the catchment can be gained by looking at Centrelink s Disability Support Pension Recipients. The following table shows the numbers of people in the catchment receiving a disability support pension from Centrelink as at 12 September

12 Table 1: Disability Support Pension Recipients by LGA Persons Females Males No. No. % No. % Brimbank Hobsons Bay Maribyrnong Melton Wyndham TOTAL 21,637 9, % 11, % Source: Women in Melbourne s West: A Data Book for Program and Service Planning in Health (WHW). The above table shows that the LGA with the highest number of people receiving the disability support pension is Brimbank, and that there is a slightly higher proportion of males as recipients than females in all areas. Victoria s largest women s prison is located within the HealthWest catchment. The Dame Phyllis Frost Centre is a maximum security prison located at Deer Park, and has capacity to hold 260 women. For men, there is Marngoneet Correctional Centre in Lara, with an operational capacity of 306, the Melbourne Remand Centre located in Ravenhall, which holds 663 prisoners, and Port Phillip Prison in Laverton, with accommodation for 33. While it is not possible to gather precise data on the catchment s sex industry, the Resourcing Health and Education in the Sex Industry (Rhed) s website shows that there are ten legal brothels located in the HealthWest catchment (Rhed 2010). This number, while giving us a vague idea of the prevalence of the sex industry in the catchment, does not tell us how many women or men there are in the sex industry, how many illegal brothels there might be in the catchment, how many women or men are operating as street-based sex workers. It is acknowledged that women make up the majority of workers in the sex industry. Another important target group for sexual and reproductive health initiatives is injecting drug users (IDU). As it is impossible to obtain data on how many people in the catchment inject drugs, we can only use anecdotal evidence from service providers in the Western region who work with IDUs. Health Works is part of the Western Region Health Centre and its primary target group is IDUs. Being based in Footscray (Maribyrnong), they are not limited in terms of coverage, however most service users come from the Western region. In 2009 the average number of Health Work s needle and syringe program contacts was 1,500 per month. When planning sexual and reproductive health programs, it is extremely important to take the diversity of the HealthWest catchment into account and consider the needs of each

13 population group in relation to sexual and reproductive health. Some examples of the needs of specific population groups are presented in the following section of the needs analysis. Key sexual and reproductive health issues: a literature and data review This section gives an overview of key sexual and reproductive health issues in Australia, Victoria and (where data is available) the HealthWest catchment, and how they affect specific population groups. Sexual and reproductive health or ill health has a direct relationship to the broader social determinants of health, such as housing, education, income and gender and these determinants differ according to population group. As with broader health issues they affect an individual or community s access to resources and control over their lives. Like other aspects of health, there are population groups in Australia who are disproportionately affected by sexual and reproductive ill health (O Rourke 2008). In addressing sexual and reproductive health inequalities, while consideration must be given to the specific nature of how these issues affect population groups (e.g. stigma and shame when talking about sexuality), consideration must also be given to the underlying causes of health inequalities. This report seeks to give an insight into sexual and reproductive health issues for some key target groups in the HealthWest catchment. Sexual and reproductive health across the lifespan: Sexual and reproductive health issues change as people move through different stages of life. A large number of sexual and reproductive health initiatives in the HealthWest catchment are targeted at young people (see mapping results in the next section), and there has been much research conducted into the sexual and reproductive health status of this population group when compared with other groups. According to the Fourth National Survey of Secondary Students and Sexual Health, which was carried out with year 10 and year 12 students across Australia in 2008, 78 percent of students had experienced some form of sexual activity. More than one quarter of year 10 students had experienced sexual intercourse, as had just over one half of year 12 students. These numbers showed a slight increase compared with 2002 (Smith et al. 2009). Of sexually active students surveyed, 45 percent reported having sex with 3 or more people in the year previous to taking the survey (Smith et al 2009) percent of sexually active students reported always using condoms, 42.6 percent sometimes used condoms and 6.9 percent never used condoms (Smith et al. 2009). In Australia, the teenage fertility rate fell in the period from 1995 to 2005 from 22 to 17 births per 1,000 (FPV 2009). When compared to other metropolitan regions in Victoria, the Western Metropolitan Sub-region (WMSR) (which also includes the LGAs of Moonee Valley and Melbourne), has a slightly higher proportion of births to younger mothers. Around 13.5 percent of all births in the sub-region in 2005 and 2006 were to mothers under 25, while the

14 average percentage of births in this age group for other metropolitan regions was 11 percent (WHW 2009). Melton had the highest percentage of births to women under the age of 20 in the catchment in 2005 and 2006, with 3.3 percent and 3.4 percent of births falling in this age group in respective years. The LGA with the lowest percentage of births to mothers under 20 years of age in the catchment was Maribyrnong, with 1.8 percent and 1.7 percent in 2005 and 2006 respectively (WHW 2009). Young women are particularly vulnerable to sexual violence and abuse, as studies have found that 21.1 percent of women have experienced sexual coercion, most of which occurred when the victims were under the age of 18 (de Visser et al. 2003, cited in Quinn 2009). This is also reflected in the 2008 national secondary school survey, which shows that 38 percent of young women had experienced unwanted sex (Smith et al. 2009). Although there are no accurate statistics on abortion in Australia, it has been estimated that in Victoria 12 percent of all abortions were performed on teenagers (FPV 2005). The HealthWest Partnerships in Safer Sex and Testing (PSST!) project conducted in 2008 explored current knowledge of young people not engaged in mainstream education of sexual and reproductive health services and resources and barriers in accessing these services (the project did not research their sexual behaviours). Focus groups with relevant young people found that knowledge of local services was generally poor. Barriers to accessing services were: A need for more youth friendly GPs and sexual and reproductive health services (services need to be more inviting to young people) Participants had limited knowledge of STIs and safe sex practices Understanding of safe sex was focused primarily on the prevention of pregnancy Cultural sensitivity (HealthWest 2008). It has been recommended that communication with young people about sexual health needs must take diverse population groups into consideration and as such, strategies must be targeted at specific populations and framed in terms of their particular sexual cultures (Keys et al. 2008: 16). While there is sufficient evidence for many sexual and reproductive health resources to be directed at youth, other age groups and their health status must also be taken into consideration. There have been fewer studies carried out on the specific needs of these age groups

15 The age group with the most births in the WMSR is 30-34, with 37.3 percent of births to mothers of this age. This trend is also seen in Victoria s other metropolitan regions (WHW 2009). The WMSR had a lower proportion of older mothers in 2005 and 2006 in comparison to Victoria s other metropolitan regions, while other metropolitan regions averaged 27.2 percent of births in 2005 and 2006 to mothers over 35, the WMSR had only 22.1 percent (WHW 2009). Sexual and reproductive health issues for women in older age groups vary, and include using and choosing when to stop contraception in the lead up to menopause, dealing with menopausal symptoms, changes in libido and body image. In older age groups, men also experience difficulties with their sexual health that can impact on their relationships, including a loss of sexual desire, erectile dysfunction and disorders of ejaculation (Bartlik and Goldstein 2001). Cervical screening rates are collected according to age group, so this gives us an idea of how one type of sexual and reproductive and preventative health behaviour can vary across different age groups of women. Below is a comparison of cervical screening rates across five different age groups in the WMSR in comparison with the whole of Victoria in 2007 and Table 2: Cervical screening participation rates of females in the Western Metropolitan Sub- Region and Victoria Age Group WMSR (% Eligible Women) Victoria (% Eligible Women) These figure show that the WMSR is below the state average in all age groups, with the most notable differences occurring in the and age groups. Given that squamous cell cervical cancer mainly affects women in older age groups (incidence increases for women over the age of 30 and is most common among women in their mid-70s), it is important to consider cervical screening rates for women in the older age groups (Anderson 2007). As can be seen in the above table, 59.9 percent of eligible women in the age group in the WMSR participated in cervical screening in 2007 and 2008, which is lower than the Victorian average of 64.4 percent for this age group (WHW 2009). There are some parts of the HealthWest catchment where this number is significantly lower than the state average. For example, for the suburbs of Mambourin, Mount Cottrell and Wyndham Vale in Wyndham, only 37.6 percent of eligible women aged participated in

16 Cervical screening. For women in this age group in Braybrook (Maribyrnong), only 42.9 percent of eligible women participated (WHW 2009). Some suburbs in the HealthWest catchment that have participation rates for cervical screening lower than state averages in all age groups include Sunshine, Albion, and St Albans in Brimbank, Altona and Altona Meadows in Hobson Bay, Braybrook in Maribyrnong, and Melton and Exford in Melton (WHW 2009). STI rates also differ according to age and gender, and this must be taken into account when designing prevention initiatives. For chlamydia, Victorian statistics show that young people are disproportionately affected, with the majority of cases occurring in people (particularly female) aged years. The following graph, giving figures from 2006, clearly shows this trend. Figure 1: Notified cases and notification rates of chlamydia by age group and sex, Victoria, 2006 Source: Surveillance of notifiable infectious diseases in Victoria In the HealthWest catchment, 1,294 new cases of chlamydia were notified in 2009, which is equal to 9.3 percent of all notifications in Victoria for that year (Department of Health 2010). Distribution of chlamydia across the catchment can be seen in the following graph. It shows that in between 2007 and 2009, all LGAs in the catchment have seen increases in chlamydia notifications and that Brimbank has had many more notifications of the infection than other LGAs

17 Figure 2: Notified cases of chlamydia by LGA, 2007, 2008 and Brimbank Hobsons Bay Maribyrnong Melton Wyndham Source: Surveillance of notifiable infectious diseases in Victoria While gonorrhoea still has its highest prevalence among year olds, there are more cases of the STI found amongst the older age groups in Victoria, when compared with chlamydia, and there are much higher rates of males with gonorrhoea, as can be seen in the following graph: Figure 3: Notified cases and notification rates of gonorrhoea by age group and sex, Victoria, 2006 Source: Surveillance of notifiable infectious diseases in Victoria In 2009, the HealthWest catchment reported 164 new cases of gonorrhoea, 11 percent of all Victorian cases for that year (Department of Health 2010)

18 The following graph shows gonorrhoea notifications in all LGAs in the years 2007, 2008 and 2009, and once again, shows that Brimbank has had the most recent notifications, with sharp increases that have also been seen in Melton. Figure 4: Notified cases of gonorrhoea by LGA, 2007, 2008 and Brimbank Hobsons Bay Maribyrnong Melton Wyndham Source: Surveillance of notifiable infectious diseases in Victoria In Victoria in 2006, syphilis affected an older population group, with the highest rates in 2006 found in the age group and mainly in men. Figure 5: Notified cases and notification rates of syphilis by age group and sex, Victoria, 2006 Source: Surveillance of notifiable infectious diseases in Victoria The HealthWest catchment in 2009 had 110 notifications of syphilis, which was 12.6 percent of all Victoria s notifications (Department of Health 2010)

19 Syphilis prevalence across all LGAs in the catchment is reflected in the following graph. Once again, Brimbank has the highest number of notifications in the catchment, but has seen a slight decrease in these notifications in the past 3 years. From 2008 to 2009, increases in notifications have been seen in Melton and Hobsons Bay. Figure 4: Notified cases of syphilis by LGA, 2007, 2008 and Brimbank Hobsons Bay Maribyrnong Melton Wyndham Source: Surveillance of notifiable infectious diseases in Victoria Given that in all three STIs presented above, Brimbank was the LGA with the highest number of notifications, it is important to note that this is also the most populous LGA in the catchment, a factor which may be greatly influence this data. In 2007, Brimbank s estimated resident population was 176,249, compared with 85,613 in Melton and in Maribyrnong (ABS 2008). Aboriginal and Torres Strait Islanders (ATSI): There is data to suggest that large sexual and reproductive health inequalities lie in the ATSI population, such as: - ATSI communities in Victoria have eight times the prevalence of Chlamydia than in the general population (FPV 2009), and those communities that are geographically isolated have higher rates of Gonorrhoea (FPV 2009) percent of all births to indigenous women in Victoria are to teenagers (FPV et al. 2005). Social disadvantage has been named as a barrier to ATSI having access to sexual and reproductive health information and services (Quinn 2009), and it has been argued that sex education amongst ATSI communities must begin at an early age, be ongoing, culturally sensitive, with particular attention paid to the social position of women in their communities (e.g. the ability of women to negotiate condom use) and relationship dynamics (Senior 2005). It has also been recommended that small-scale targeted campaigns that are developed with input from young Aboriginal people would be of benefit to this group (Keys et al 2008)

20 CALD communities: A resource manual by the Multicultural Health and Support Service highlights the importance of cultural competence when working with CALD communities around issues of sexual and reproductive health, as health beliefs may vary between cultures, such as views on sexuality, risk of contracting STIs and access to treatment and care (MHSS 2008). A study carried out with young people from refugee backgrounds in Melbourne found that this group is often disadvantaged in terms of knowledge and access to services around sexual and reproductive health. The research found that there are key barriers for this population group in accessing information on sexual and reproductive health, including confidentiality concerns, shame, embarrassment, as well as competing demands of settlement. For these people and their families, settling in Australia often presents many challenges (seeking stable housing, for example), and sexual and reproductive health information is not seen as a priority (McMichael and Gifford 2009). While this report groups CALD communities together, it should be remembered that this is an extremely diverse group. Generalisations about people s needs and beliefs based on their cultural background should be avoided. Same-sex-attracted people: Same-sex-attracted (SSA) people are an important target group for sexual and reproductive health interventions, as their information and service needs differ from the general population, and they often have differing sexual and reproductive health outcomes. Compared with the general population of secondary students in Australia, SSA young people are more likely to be sexually active at an earlier age. Writing themselves in again, a 2005 national survey carried out with SSA young people found that they were more likely to have experienced all types of sexual contact (Hillier et al. 2005), with 70 percent of exclusively same sex attracted young men and only 47 percent of exclusively same-sex attracted young women reporting having only had sex with someone of the same sex in the past two years (Hillier et al. 2005). For those engaging in penetrative sex in the year old group, 70 percent reported having used a condom in their last sexual encounter, which is slightly higher than findings in the 2002 national secondary school survey, which surveys the general student population (65 percent). Females that took the Writing themselves in again survey reported less condom use than males. It has also been found that SSA young women in the age group are more likely to have had a sexual encounter that has resulted in a pregnancy (10 percent) compared with students that answered the secondary school survey (8 percent) (Hillier et al. 2005)

21 This national survey also found that 12 percent of SSA young men and 9 percent of SSA young women had been diagnosed with an STI, with the most common infections being reported as warts, gonorrhoea, chlamydia and herpes (Hillier et al. 2005). While there is some evidence of improvement, sex education in schools appears to be more appropriate for those who identify as heterosexual, with 80 percent of SSA young people having found the sex education that they were given at school to be either useless of fairly useless. The internet is seen by many SSA young people to be the most important source of information about homophobia and discrimination, gay and lesbian relationships and gay and lesbian safe sex (Hillier et al. 2005). There are significant barriers for same-sex attracted people in accessing sexual and reproductive health services, with many health professionals in Australia assuming heterosexuality of patients and/or lacking knowledge of SSA people s specific sexual health (McNair 2003). In 2008, following recommendations from the Victoria Law Reform Commission, the Victorian government legislated to allow single and gay women to use reproductive services to conceive. People living with disability: Systemic discrimination against people with disabilities regularly results in them being portrayed or perceived as childlike in terms of their sexuality and capacity to make their own decisions. The fact that they are sexual beings is either ignored or treated as a problem to be managed (Gregory and Wheeler 2005). The position in society of people with disabilities impacts significantly on their reproductive choice. Their desires to parent are seen as unrealistic or wrong. Forced sterilisation and long term use of drugs to inhibit menstruation in women with disabilities and failure to get consent or inform women of the side effects of these drugs are all aspects of this problem (WHW, 2002). Women with disabilities are assaulted, raped and abused at a rate at least two times greater than women without disabilities. The more severe the disability, the higher the risk of abuse or violence. Chenoweth argues that women with disabilities are so devalued they are perceived as asexual and being denied even a sexual identity... enter a state of extreme marginalisation (Chenoweth, 1997 in Howe, 2000). Disability can impact on the sexual health of both men and women, including sexual-esteem and feeling sexually desirable, however this can be positively addressed by health care providers who can assist people living with disability to have a fulfilling sex life (Rosengarten 2005)

22 In consultations for Beyond Symptoms, which was undertaken with women with disabilities in 2002, women reported numerous ways that organisations or service providers fail to meet their needs, including inaccessible examination tables and lack of appropriate equipment (such as hoists and ramps), a focus on the woman s disability rather than health and wellbeing, inadequate time to talk through complex issues, a lack of female service providers who can respond to sensitive sexual and reproductive health difficulties and a lack of appropriate information, education, and promotion of health issues and services. People in Prison: Prisoners in Australia experience inequalities with regards to their sexual and reproductive health. Many female prisoners are victims of abuse prior to their incarceration. Of a sample of women at Dame Phyllis Frost Centre in Deer Park, over half reported childhood or adolescent physical abuse, 68 percent reported emotional abuse and 44 percent reported sexual abuse (Smart Justice 2006). The high rates of women who have experienced sexual abuse is worthy of consideration in relation to strip-searches. When receiving visits from family or community members, prisoners are strip-searched. Given that women in prison often have stronger family ties than men, they receive more visits and are therefore strip-searched more often. It has been argued that the effects of strip-searching female prisoners are highly detrimental, given the high rates of sexual abuse of the population as strip-searches can have a re-traumatising effect (Anti- Discrimination Commission Queensland, 2006). 10 percent of young women at the Dame Phyllis Frost Centre also reported having had a miscarriage in the four weeks leading up to a Prisoner Health Survey (Victorian Aboriginal Legal Service and Victorian Aboriginal Family Violence and Prevention Legal Service 2005). A NSW Survey of Inmate Health in 1996 revealed that male prisoners who were a victim of childhood abuse were more likely to engage in sexual activity while in prison, both consensual and non-consensual, and another of these surveys in 2001 found that even though condoms and dentals dams were available to both male and female prisoners, only 12 percent of males and18 percent of females reported using them (Butler 1997 and Bulter and Milner 2003, cited in Levy 2005). Sex workers: Sex workers are vulnerable to sexual assault, with the stigma attached to their work acting as a barrier to those experiencing sexual violence receiving support and legal assistance (Quinn 2009). There are also links between sex work and child sex abuse, with research finding high rates of women in the sex industry having experienced sexual abuse as a child, when compared to the general population (Child Wise 2004, cited in Quinn 2009)

23 People who inject drugs The sexual and reproductive health needs of people who inject drugs (often termed as injecting drug users IDU) are unique from many other groups that exist in the HealthWest catchment. According to health care workers at HealthWorks in Footscray, some of the main issues that are specific to this group, particularly female IDUs, centre around access to information and specific risk factors. For example, it is acknowledged that some females do opportunistic sex work and engage in sex for drugs. Many women have experiences with assault, domestic violence and mental illness, which impact access and engagement with services. Many IDUs may have had limited education and therefore limited opportunities to access sexual and reproductive health education and also limited knowledge of menstruation, as the use of opiates can impact on their cycles. Capacity Building Needs of Workers in the field When planning sexual and reproductive health initiatives, it is important to take into consideration the support and development needs for workers such as general practitioners, nurses and youth workers in the area. There is little known on these needs, particularly at a local level, and initiatives should take these needs into account, particularly around knowledge and communication methods. While this section has given an overview of key issues in sexual and reproductive health and how they affect specific population groups in Australia, Victoria and (where information is available) Melbourne s West, we must also keep in mind that some of these population groups will overlap, and this can possibly be where higher levels of disadvantage exist. For example some may identify with being same-sex attracted as well as belong to the group classed as culturally and linguistically diverse

24 Mapping Sexual and Reproductive Health Initiatives Background In order to plan HealthWest s initiatives in sexual and reproductive health, it is critical to understand the context of activities already taking place in the west (undertaken by HealthWest partner agencies or other), find out where the gaps are, and what opportunities there are for collaboration and improvement. The previous needs analysis section has given an overview of the population in the HealthWest catchment, and has given a necessary background on which to compare the existing initiatives that take place in the catchment. In order to gather information on existing initiatives, key stakeholders with activities in sexual and reproductive health were identified by the working group, who were then contacted either by telephone, or in person to discuss types of sexual and reproductive health activities being carried out. If programs or services were relevant to this mapping exercise, stakeholders were asked to complete a template answering the following questions: 1. Name of the program/service 2. Aims/objectives of program 3. Geographic coverage 4. Target groups 5. Aspects of sexual and reproductive health covered 6. Strategies used 7. Partnerships with other services 8. Tools/resources used to design this program 9. Has this program/service been evaluated? 10. Is the program/service ongoing? 11. What support might this program/service need? 12. Other relevant details/comments Mapping results From the circulation of this survey, the HealthWest Sexual and Reproductive Health Working Group received responses from 23 agencies, covering a total of 69 programs and services. It should be noted that while many of these programs and services do focus solely on sexual and reproductive health, some are also programs that have a wider wellbeing focus that involve components of sexual and reproductive health. For example, there may be a support group that meets monthly and introduces a different topic each week to its participants, where one week of this may involve discussion around sexual and reproductive health. Given the large number of responses received in the mapping, it has not been possible to give a detailed description of each program and service. This report, however aims to present

25 a snap-shot of activities in the catchment. In order to analyse basic information gained through the surveys, the information received has been presented according to target groups for interventions and aspects of sexual and reproductive health covered. These results are summarised below. For more detailed information on specific programs, refer to Appendices 1 and Initiatives according to target groups An important part of the mapping process undertaken by the working group was to find out population groups that specific initiatives are targeted towards. As discussed in the needs analysis section of this report, specific target groups have different sexual and reproductive health needs and each group needs its own approach to the issue. Table 4: Summary of SRH initiatives according to target groups. Target group Brimbank Hobsons Maribyrnong Melton Wyndham Catchment Statewide Total Bay -wide Young people CALD Women Health professionals ATSI People who use drugs or alcohol SSA Sex workers Teachers Parents Men PLWHA 1 1 People with a disability Families and couples 1 1 Some initiatives in the above table are represented more than once, as their target population groups fit into more than one category. For example, there are programs that are run with newly arrived young people, and so will be placed under both headings of CALD and young people. There are also cases where programs are represented more than once when they are run over two or more LGAs. The results, in this case, highlight that there are a great deal of sexual and reproductive health initiatives in the catchment that are aimed at young people, an important target group in sexual and reproductive health promotion. However, there are some other important populations groups that have less attention given to their specific needs, such as Aboriginal and Torres Strait Islanders, same-sex attracted people and people living with a disability. It is also important to note that there are no current sexual and reproductive health projects

26 targeted at people in prison in the catchment. The consequences of these results on the sexual and reproductive health of the population in the HealthWest catchment will be discussed further in the conclusion to this report. For a more detailed representation of data on sexual and reproductive health initiatives and their target groups, refer to Appendix 1: SRH initiatives according to target groups. 2. Initiatives and the aspects of sexual and reproductive health that they cover For information on the specific aspects of sexual and reproductive health that programs cover, please refer to Appendix 2. It is hoped that the table in this appendix will assist interested stakeholders to find out more about initiatives in the catchment and link in with other services. The table gives an overview of topics or components of programs or services, but is limited in that it cannot demonstrate the complexities of each. It is important to note from the table in Appendix 2 that there are some aspects of sexual and reproductive health that gain less of a focus than others. Aspects most commonly covered by initiatives include STIs/HIV and safe sex, sexual decision making and contraception information, and healthy relationships. Menopause, on the other hand, is only addressed by eight programs listed in the table. Given that three of these eight programs are based at the Royal Women s Hospital and are state-wide, there is little that is targeted specifically to women in the western region. This means that women in the west seeking information or support in dealing with menopause may be limited in their options. 3. Secondary school nurses Because of the large number of programs run by secondary school nurses, their activities under sexual and reproductive health have not been included in the above mapping. It is recognised, however, that secondary school nurses play a large role in sexual health education in the HealthWest catchment. In the catchment, there are 14 secondary school nurses, employed by the Department of Education and Early Childhood Development (DEECD), who cover a total of 24 schools in the western metropolitan region. School nurse activities that are based around sexual and reproductive health include education sessions, health days, sex education curriculum development with teachers, and use of People Living with HIV/AIDS Victoria s HIV Speakers Bureau. The format of sexual health education sessions varies, with some schools choosing to carry them out in the classrooms and others via whole year level workshops during health days. Sexual health education in some schools is delivered through health and physical education programs, while others deliver it through their pastoral care program. Depending on the school, some secondary school nurses are also involved in the delivery of Core of Life (interactive session on pregnancy and childbirth), Sex Factor (performance with comedians dealing with sexual and reproductive health issues) and Girls Talk, Guys Talk (a

27 whole-of-school approach to sexual and reproductive health, run with year 9 students in one school per year). School nurses are also involved in the West CASA Sexual Assault Prevention Program for Secondary Schools. In terms of sexual and reproductive health education in schools, it is useful to know that not all schools in the catchment have a nurse, and this may impact the levels of student support and education delivery around sexual and reproductive health in schools without a nurse

28 The HealthWest Partnership Sexual and Reproductive Health Forum On 16 th March 2010, the HealthWest Sexual and Reproductive Health Working Group held a forum that aimed to: Present and build on the sexual and reproductive health needs analysis and mapping already carried out by the HealthWest Sexual and Reproductive Health Working Group; Highlight the on-the-ground issues for working in this area; and Identify the opportunities for action The forum had 31 participants, who were representative of 15 different agencies. Participants were given an opportunity to give their feedback on this report in its draft form, and were also involved in group activities that aimed to identify barriers and enablers for sexual and reproductive health in the West, as well as key actions for various stakeholders. Where possible, feedback from forum participants has been incorporated into this report, with much forming part of the recommendations for future action (presented in the conclusion to this report). The work that participants contributed to on identifying barriers, enablers and areas for action will feed into HealthWest s planning for sexual and reproductive health in the period. For more details, please contact HealthWest for a copy of the forum s report

29 Limitations While the information presented in this report has given us an initial idea of what is happening around sexual and reproductive health in the HealthWest catchment, there are some limitations to its accuracy and use. Needs analysis Readily available data on sexual and reproductive health in the western region is very limited. While most data and research results presented in the needs analysis section of this report is taken from studies at a national and state level and compared with the make-up of the catchment, planning for HealthWest s work in sexual and reproductive health would greatly benefit from more comprehensive research into the sexual and reproductive health status of its population. Mapping The organisations, programs and services presented in the mapping results do not provide a comprehensive view of all sexual and reproductive health initiatives in the region. It is possible that initiatives have not been mapped, as their organisations were not originally identified as key stakeholders, and with competing work demands, some organisations with sexual and reproductive health initiatives may not have had capacity to answer the survey. Definitions of sexual and reproductive health also differ. The working group has tried to work from a very broad definition of sexual and reproductive health in order to capture a broad range of initiatives. However, not every agency works from such a broad definition, so what may seem to be a program with sexual and reproductive health components to one agency may not be to another, and this may have led to a lack of comprehensive information being collected in the survey. Another limitation of the mapping and the way in which it is presented here is that it does not distinguish between those programs focussed solely on sexual and reproductive health and others that focus on a wide range of issues relating to health and wellbeing, but include components on sexual and reproductive health. Given the large number of initiatives that were listed as covering sexual and reproductive health, there has not been scope within this report to demonstrate the complexities of each. Programs listed are extremely diverse in their design and this is not reflected in the mapping

30 Conclusion Findings The majority of this report has dealt with an analysis of sexual and reproductive health needs in the HealthWest catchment and the initiatives that are already taking place in relation to the priority area. From the results of these two tasks, there are four main findings that can be drawn. 1. There is very limited research that has been done to analyse sexual and reproductive health in the catchment: While the lack of data on the sexual and reproductive health status of the population is partly due to the lack of nationally-agreed data collection (e.g. for abortion), there is still significant scope to increase our knowledge of the sexual and reproductive health status of the population in the HealthWest catchment. Specific gaps include the experiences of certain population groups (e.g. the ATSI population, SSA people) and their experience of sexual and reproductive health locally (i.e. what issues and barriers members of these groups experience in relation to sexual and reproductive health, services or programs seen as available to these groups and the and how appropriate they are to their specific needs). 2. There is already strong commitment to sexual and reproductive health in the catchment by various stakeholders: The mapping exercise found that there are at least 68 programs or services relating to sexual and reproductive health, run by 23 different agencies that are either based in the catchment or accessible to those living in the catchment. The process of mapping and contacting stakeholders also found that even in cases where agencies contacted did not have any specific programs that relate to sexual and reproductive health in the catchment, there was significant interest in being more involved in the priority area. 3. Current sexual and reproductive health initiatives are not equitably spread across target groups: The needs analysis section of this report highlighted the diversity of the HealthWest catchment, and the sexual and reproductive health inequalities that are apparent in these groups. Mapping has found that initiatives are heavily weighted to young people (under 25). While this is an important target group for sexual and reproductive health initiatives and the number of programs for this group should not be reduced, there are some key target groups that are receiving less attention, such as Aboriginal and Torres Strait Islanders, same-sex attracted

31 people, sex workers and people living with a disability, young people not engaged in school, people in prison. 4. The majority of existing programs and services are not currently poised to respond to the broader social determinants of sexual and reproductive health: A literature review revealed a significant need for programs to be aimed at the social determinants of health, such as gender, sexuality and ability. Upon initial analysis of the mapping results, it appears that many programs sit in a similar place on a health promotion spectrum. In other words, many programs and services aim to give information and build skills of community members in relation to their sexual and reproductive health as individuals, however there are few that work with a broader population focus, such as strengthening community action or creating supportive settings. Further analysis is required to develop a comprehensive understanding of how effective programs are in dealing with the social determinants of health. It is also recognised that addressing these determinants is often beyond the scope of organisations. Recommendations Based on the findings from the needs analysis and mapping presented in this report, the HealthWest Sexual and Reproductive Health Working Group has developed a number of recommendations for consideration by HealthWest member agencies and other relevant communities of interest. It is hoped that these recommendations will form the basis of HealthWest s sexual and reproductive health action plan for the period. For HealthWest s Integrated Health Promotion Plan for sexual and reproductive health, it is recommended that resourcing be sought for the following activities: 1. Given the lack of accurate data on sexual and reproductive health in the catchment and the commitment of many agencies to the priority area, there is an opportunity for joint research and data collection to be carried out locally, and for HealthWest to undertake a feasibility project for this. Further research on sexual and reproductive health in the West should include consultations with members of specific target groups, and should focus on their local experience of sexual and reproductive health. As several participants in the HealthWest Sexual and Reproductive Health Forum indicated, it would be beneficial for further research to include a more gendered analysis of sexual and reproductive health across all population groups, as well as sufficient consultation with various CALD communities. Issues that need to be explored more extensively in the catchment include young parents, unwanted sexual behaviour and its effects throughout life, HIV rates, unplanned pregnancy, and the impact the internet, including cyber sex and cyber bullying

32 2. Further analysis of current programs should be carried out to find out where they sit on a health promotion continuum. HealthWest s Healthy Communities, Healthy Lives Model of Care is a vital tool in gaining this understanding. As has been described earlier in this report, sexual and reproductive health is largely determined by broader social determinants of health, and based on further analysis using the Healthy Communities, Healthy Lives model, programs that are responding to the social determinants of health can be further examined to determine their most effective components and opportunities for possible expansion. For a summary diagram of the Healthy Communities, Healthy Lives Model of Care, please refer to Appendix 3. Analysis should also include information on the evidence base used in the design of programs. In a further analysis of current programs, consultation can be broadened to include the programs and views of more organisations, and as indicated by forum participants, more attention in this area should be given to the mental health, alcohol and other drugs and homeless sectors, as well as Maternal and Child Health and young parents programs. 3. New programs can be designed to fill the gaps already mentioned, especially target groups that have little coverage in the region, whose sexual and reproductive health needs are expressed in the needs analysis section of this paper. These groups include Aboriginal and Torres Strait Islanders, same-sex attracted people and people living with a disability. Opportunities for joint work or program expansion to support these groups can be explored. 4. More support can be offered to workers involved in sexual and reproductive health, such as information sharing opportunities and training. Finally, it is recommended that any initiative coming from this report be aimed not only at specific issues such as STIs or abortion, but include components where the broader determinants of sexual and reproductive health are addressed. Attention must be given to the provision of access to culturally appropriate information, resources and services, as well as an analysis of how aspects such as gender roles and stigma play a part in the sexual and reproductive health of population groups. Initiatives must be coordinated with a range of stakeholders so that links are made with other priority areas such as mental health, alcohol and other drugs, and violence against women. There has been increasing recognition internationally as well as in Australia that this is the most effective approach to sexual and reproductive health (O Rourke 2008). HealthWest now has the opportunity to follow the lead of national and state-wide agencies in this area in generating local examples of best practice in sexual and reproductive health to gain wider support for this holistic approach

33 Appendix 1: SRH initiatives according to target groups Brimbank Program Name Organisation Specific Target Group Young people Headspace Western Melbourne Headspace Western Melbourne Young people ROCKET Western Region Health Centre Young People CALD Women s Health Clinic ISIS Primary Care Women, CALD women African Settlement Group Women African Settlement Group Migrant Resource Centre North West African Women Migrant Resource Centre North African Women West Healthy Mothers Healthy Babies ISIS Primary Care Pregnant women from disadvantaged backgrounds Women s Health Clinic ISIS Primary Care Women, CALD women Parents Healthy Mothers Healthy Babies ISIS Primary Care Pregnant women from disadvantaged backgrounds Step Out Good Shepherd Isolated young parents Hobsons Bay Program Name Organisation Specific Target Group Young people Action Centre at Hoppers Crossing Family Planning Victoria Young people Headspace Western Melbourne Headspace Western Melbourne Young people Community Health Program Rehab ISIS Primary Care Males Nursing Hobsons Bay Father Son Nights Laverton College ISIS Primary Care Year six boys and their fathers Keeping Safe Program ISIS Primary Care Year nine students ISIS Primary Care Bayside College ISIS Primary Care Secondary students Altona North Sexual Diversity Workshops Hobsons Bay Youth Service Secondary students year 9 and above Proud Group Hobsons Bay Youth Service SSA Young people AGED Challenges of Life Hobsons Bay Youth Service year olds Assert Hobsons Bay Youth Service Young women years old Risky Business Hobsons Bay Youth Service Young men years old Miss Independent Hobsons Bay Youth Service Young women years old CALD ISIS Primary Care Women s Health Clinic ISIS Primary Care Women, CALD women Pap test Information Sessions Papscreen Victoria Burmese communities (Chin, Karen) Women ISIS Primary Care Women s Health Clinic ISIS Primary Care Women, CALD women We are Women Too Papscreen Victoria Women with disabilities People who use drugs or alcohol Needle and Syringe Program ISIS Primary Care People who use drugs SSA Proud Group Hobsons Bay Youth Services SSA young people age years

34 Men Community Health Program Rehab ISIS Primary Care Males Nursing Hobsons Bay Father Son Nights Laverton College ISIS Primary Care Year Six Boys and their fathers Parents Father Son Nights Laverton College ISIS Primary Care Year Six Boys and their fathers People with a disability We are Women Too Papscreen Victoria Women with disabilities Maribyrnong Program Name Organisation Specific Target Group Young people Headspace Western Melbourne Headspace Western Melbourne Young people Youth and Women s Health Nurse Western Region Health Centre Women and Youth Role Leadership Program Footscray City Maribyrnong City Council Youth Year 9 students College Services Youth Counselling Maribyrnong City Council Youth Services year olds Health Professionals FARREP Western Region Health Centre Medical and allied health staff at WRHC Women Youth and Women s Health Nurse Role Western Region Health Centre Women and Youth Maribyrnong Maternal and Child Health Nurse Maribyrnong Maternal and Child Health Teachers Teacher Training Western Region Health Centre Grade 5 and 6 teachers People who use drugs or alcohol Needle and Syringe Program Western Region Health Centre People who inject drugs Families with children from birth to school age Melton Program Name Organisation Specific Target Group Young people Sex Education in Primary School Djerriwarrh Health Service Primary school students Secondary Schools Djerriwarrh Health Service Secondary school students Samesex Attracted and Transgender Program Djerriwarrh Health Service Same sex attracted and transgendered young people Parent and Student Puberty and Djerriwarrh Health Service Parents and students Hygiene Sessions Backdoor Youth Health Service Djerriwarrh Health Service Young People aged years Girlworx Girls Group Djerriwarrh Health Service Girls aged PSST Partnerships in Safer Sex Testing Melton Shire Council Youth Services Young people Disengaged and at risk of homelessness Melton Shire Council Youth Melton Shire Council Youth year olds Services Services CALD Well Women s Clinics Djerriwarrh Health Service Women, CALD women Refugee Reproductive Health Djerriwarrh Health Service Refugee men and women Women Healthy Mothers Healthy Babies Djerriwarrh Health Service Women Well Women s Clinics Djerriwarrh Health Service Women Local Government Initiative: Djerriwarrh Health Service and Melton City Council Pap Screen Victoria Women using community health and local government services

35 SSA Samesex Attracted and Transgender Program Teachers Teacher Training of Human Development Sessions in Primary Schools Parents Young Pregnant and Parenting Program Djerriwarrh Health Service Djerriwarrh Health Service Djerriwarrh Health Service Same sex attracted and transgendered young people Teachers Young parents Healthy Mothers Healthy Babies Djerriwarrh Health Service Women Parent and Student Puberty and Djerriwarrh Health Service Parents and students Hygiene Sessions Wyndham Program Name Organisation Specific Target Group Young people Action Centre at Hoppers Crossing Family Planning Victoria Young people Headspace Western Melbourne Headspace Western Melbourne Young people Sexuality Education Program ISIS Primary Care Primary and Secondary School Students Wyndham City Council Youth Wyndham City Council Youth year olds Services Services Women Healthy Mothers Healthy Babies ISIS Primary Care Pregnant women from disadvantaged backgrounds Wyndham Maternal and Child Wyndham Maternal and Child Mothers Health Health Teachers Sexuality Education Project ISIS Primary Care Teachers Parents Healthy Mothers Healthy Babies ISIS Primary Care Pregnant Women from disadvantaged backgrounds Catchment-wide Program Name Organisation Specific Target Group Young people WELS Human Relations Program Women s Health West, Western Region Health Centre, Maribyrnong City Council Youth Services Newly arrived young people Girls Talk Guys Talk Women s Health West Year 9 students, their teachers and parents Unnamed Gathering Place Indigenous teenagers Victoria University Sexual and Women s Health West CALD young women Reproductive Health Program DAS West, Western Health DAS West, Western Health Clients of DAS West (youth 12-22, adults 22 and over) CALD WELS Human Relations Program Women s Health West, Western Region Health Centre, Maribyrnong City Council Youth Services Women s Health West Newly arrived young people Victoria University Sexual and CALD young women Reproductive Health Program Health professionals Maternal and Child Health Nurse Women s Health West Maternal and Child Health Project (FARREP) Nurses Mama and Nunu Women s Health West Health professionals

36 Women Victoria University Sexual and Reproductive Health Program Women s Health West CALD young women Project Undertaken by VU students Health Works Female service users who inject drugs Women s Health Week Health Works Female service users who inject drugs Marie Stopes International Marie Stopes International Women of reproductive age ATSI Unnamed Gathering Place Indigenous teenagers People who use drugs or alcohol Project Undertaken by VU students Health Works Female service users Men s Health Campaign Health Works Service user who inject drugs Women s Health Week Health Works Female service users who inject drugs Mobile Drug Safety Worker Role Health Works People who use alcohol and drugs DAS West, Western Health DAS West, Western Health Clients of DAS West (youth 12-22, adults 22 and over) Sex workers Increasing access to Health Works those who engage in sex work Health Works Street based sex workers Teachers Girls Talk Guys Talk Women s Health West Secondary teachers Parents Girls Talk Guys Talk Women s Health West Parents of Year 9 students Men Men s Behaviour Change Sessions Relationships Australia Sunshine Men Men s Health Campaign Health Works Service user who inject drugs Marie Stopes International Marie Stopes International Men who have completed their family or are sure they don t want (any more) children (in the future) Families/couples Relationships counselling Relationships Australia (Sunshine) Families and couples seeking counselling for relationship issues State-wide Program Name Organisation Specific Target Group Young people Young People s Health Service Royal Children s Hospital Young people experiencing homelessness The Action Centre Family Planning Victoria Young people under 25 Melbourne Sexual Health Centre Melbourne Sexual Health Centre Young people Positive Speakers Bureau CALD The Women s Health Information Centre (WHIC) The Women s Health Information Centre (WHIC) Menopause Education Program Put a Little People Living with HIV/AIDS Victoria The Royal Women s Hospital The Royal Women s Hospital Spring in Your Step Health professionals Nurse credential program Papscreen Victoria Nurses Women from newly arrived emerging communities Women of any age experiencing menopause but especially women from CALD backgrounds

37 Women The Women s Health Information Centre (WHIC) The Women s Health Information Centre (WHIC) Menopause Education Program Put a Little Spring in Your Step The Royal Women s Hospital The Royal Women s Hospital Well Women s Clinic The Royal Women s Hospital Women Outpatient clinic The Royal Women s Hospital Women ATSI The Women s Health Information Centre (WHIC) The Royal Women s Hospital All women (focus on women from newly arrived emerging communities, women who experience violence, mental health issues, ATSI, or women with complex needs) Women of any age experiencing menopause but especially women from CALD backgrounds ATSI women Melbourne Sexual Health Centre Melbourne Sexual Health Centre Indigenous People who use drugs or alcohol Melbourne Sexual Health Centre Melbourne Sexual Health Centre IDUs SSA Melbourne Sexual Health Centre Melbourne Sexual Health Centre MSM Sex workers Melbourne Sexual Health Centre Melbourne Sexual Health Centre Sex Workers Teachers School and Community Sexuality Education Parents School and Community Sexuality Education PLWHA Connect Line HIV and Sexual Health People living with a disability Individual Specialist Education Service Family Planning Victoria Family Planning Victoria People Living With HIV AIDS Victoria Family Planning Victoria Teachers (as well as school nurses, youth workers, etc.) Parents (on request) People Living With HIV AIDS People with a disability

38 Appendix 2: Programs and the aspects of sexual and reproductive health that they cover Program Name Organisation Coverage Pregnancy & child Birth, Maternal Health, Postnatal Health & Pregnancy Choices Sexual Decision making & Contraception information STIs/HIV & Safe Sex Sexual Issues for Couples & Sexuality & Relationship Concerns Contraception Provision Sexual Violence & Domestic Violence Self Esteem & Emotions Cervical Screening Puberty Body Image Healthy Relationships Racism Access to Services & Referral Parenting Sexuality/Same Sex Attraction FGM Testing (STI/Pregnancy) Risk Minimisation Mental Health Alcohol & Drugs Breast Awareness Menopause Counselling Immunisation Gynaecological issues African Settlement Group Step Out WELS Human Relations Program Victoria University Sexual and Reproductive Health Program Maternal and Child Health Nurse Project (FARREP) Mama and Nunu (FARREP) Migrant Resource Centre North West Good Shepherd Women s Health West, Western Region Health Centre, Maribyrnong City Council Youth Services Women s Health West Women s Health West Women s Health West Brimbank X X X Brimbank X X Catchment X X X X X X X X X X Catchment-wide X X X X X Catchment-wide X X X X X X X X X Catchment-wide X X X X X X X

39 Program Name Organisation Coverage Pregnancy & child Birth, Maternal Health, Postnatal Health & Pregnancy Choices Sexual Decision making & Contraception information STIs/HIV & Safe Sex Sexual Issues for Couples & Sexuality & Relationship Concerns Contraception Provision Sexual Violence & Domestic Violence Self Esteem & Emotions Cervical Screening Puberty Body Image Healthy Relationships Racism Access to Services & Referral Parenting Sexuality/Same Sex Attraction FGM Testing (STI/Pregnancy) Risk Minimisation Mental Health Alcohol & Drugs Breast Awareness Menopause Counselling Immunisation Gynaecological issues Girls Talk Guys Talk Unnamed Action Centre at Hoppers Crossing Headspace Western Melbourne Pap test Information Sessions We are Women Too Nurse Credential Program Local Government Initiative: Djerriwarrh Health Service and Melton City Council Men s Behaviour Change Sessions Women s Health West The Gathering Place Family Planning Victoria Headspace Western Melbourne Pap Screen Victoria Pap Screen Victoria Pap Screen Victoria Pap Screen Victoria Relationships Australia Sunshine Catchment-wide X X X X X X X X X X X Catchment-wide X X X X X Wyndham, Hobsons Bay X X X X X X X X X X X X X X X X Wyndham, Hobsons Bay, Brimbank, Maribyrnong X X X X X X X X X X X X X X X X X X X Hobsons Bay X Hobsons Bay X State Wide X Melton X Catchment-wide (Mainly NorthWest) X X X

40 Program Name Organisation Coverage Pregnancy & child Birth, Maternal Health, Postnatal Health & Pregnancy Choices Sexual Decision making & Contraception information STIs/HIV & Safe Sex Sexual Issues for Couples & Sexuality & Relationship Concerns Contraception Provision Sexual Violence & Domestic Violence Self Esteem & Emotions Cervical Screening Puberty Body Image Healthy Relationships Racism Access to Services & Referral Parenting Sexuality/Same Sex Attraction FGM Testing (STI/Pregnancy) Risk Minimisation Mental Health Alcohol & Drugs Breast Awareness Menopause Counselling Immunisation Gynaecological issues FARREP Youth and Women s Health Nurse Role ROCKET Needle and Syringe Program Teacher Training Project Undertaken by VU students Men s Health Campaign Increasing access to Health Works those who engage in sex work Women s Health Week Mobile Drug Safety Worker Role Western Region Health Centre Maribyrnong X X X X X X X X X Western Region Health Centre Maribyrnong X X X X X X X X X X X X X X X X X X X X X X X Western Region Health Centre Western Region Health Centre Western Region Health Centre Brimbank X X X Maribyrnong X X X X X X Maribyrnong X X X X X X X X X X X X Health Works Catchment-wide X X X Health Works Catchment-wide X X X X X Health Works Catchment-wide X X X X X Health Works Catchment-wide X X X X X X X X X X X X X Health Works Catchment-wide X X X

41 Program Name Organisation Coverage Pregnancy & child Birth, Maternal Health, Postnatal Health & Pregnancy Choices Sexual Decision making & Contraception information STIs/HIV & Safe Sex Sexual Issues for Couples & Sexuality & Relationship Concerns Contraception Provision Sexual Violence & Domestic Violence Self Esteem & Emotions Cervical Screening Puberty Body Image Healthy Relationships Racism Access to Services & Referral Parenting Sexuality/Same Sex Attraction FGM Testing (STI/Pregnancy) Risk Minimisation Mental Health Alcohol & Drugs Breast Awareness Menopause Counselling Immunisation Gynaecological issues Community Health Program Rehab Nursing Hobsons Bay Needle and Syringe Program ISIS Primary Care Women s Health Clinic ISIS Primary Care Women s Health Clinic Sexuality Education Project Sexuality Education Program Father Son Nights Laverton College Keeping Safe Program ISIS Primary Care Bayside College Altona North Healthy Mothers Healthy Babies ISIS Primary Care ISIS Primary Care ISIS Primary Care ISIS Primary Care ISIS Primary Care ISIS Primary Care ISIS Primary Care ISIS Primary Care ISIS Primary Care ISIS Primary Care Hobsons Bay X Hobsons Bay X X Hobsons Bay X X X X X X X X Brimbank X X X X X X X X X X X X X Wyndham X X X X X X X X X X X X X X Wyndham X X X X X X X X X X X X X X X X X X Hobsons Bay X X X X X X X X X Hobsons Bay X X X X X X X X X Hobsons Bay X X Wyndham and Brimbank X X X X X X X X

42 Program Name Organisation Coverage Pregnancy & child Birth, Maternal Health, Postnatal Health & Pregnancy Choices Sexual Decision making & Contraception information STIs/HIV & Safe Sex Sexual Issues for Couples & Sexuality & Relationship Concerns Contraception Provision Sexual Violence & Domestic Violence Self Esteem & Emotions Cervical Screening Puberty Body Image Healthy Relationships Racism Access to Services & Referral Parenting Sexuality/Same Sex Attraction FGM Testing (STI/Pregnancy) Risk Minimisation Mental Health Alcohol & Drugs Breast Awareness Menopause Counselling Immunisation Gynaecological issues Sex Education in Primary School Young Pregnant and Parenting Program Refugee Reproductive Health Secondary Schools Same Sex Attracted and Transgender Program Healthy Mothers Healthy Babies Teacher Training of Human Development Sessions in Primary Schools Well Women s Clinics Parent and Student Puberty and Hygiene Sessions Djerriwarrh Health Service Djerriwarrh Health Service Djerriwarrh Health Service Djerriwarrh Health Service Djerriwarrh Health Service Djerriwarrh Health Service Djerriwarrh Health Service Djerriwarrh Health Service Djerriwarrh Health Service Melton X X X X X X X X X X Melton X X X X X X X X X X X X X X X X X Melton X X X X X X X X X X X X X X X X Melton X X X X X X X X X X X X X X Melton X X X X X X X X X X Melton X Melton X X X X X X X X X X X X Melton X X X X X X X X X X X X X Melton X X X X X X X X X X X X X

43 Program Name Organisation Coverage Pregnancy & child Birth, Maternal Health, Postnatal Health & Pregnancy Choices Sexual Decision making & Contraception information STIs/HIV & Safe Sex Sexual Issues for Couples & Sexuality & Relationship Concerns Contraception Provision Sexual Violence & Domestic Violence Self Esteem & Emotions Cervical Screening Puberty Body Image Healthy Relationships Racism Access to Services & Referral Parenting Sexuality/Same Sex Attraction FGM Testing (STI/Pregnancy) Risk Minimisation Mental Health Alcohol & Drugs Breast Awareness Menopause Counselling Immunisation Gynaecological issues Backdoor Youth Health Service Girlworx Girls Group Leadership Program Footscray City College Youth Counselling Sexual Diversity Workshops Proud Group Challenges of Life Assert Risky Business Miss Independent Wyndham City Council Youth Services Djerriwarrh Health Service Djerriwarrh Health Service Maribyrnong City Council - Youth Services Maribyrnong City Council - Youth Services Hobsons Bay Youth Service Hobsons Bay Youth Service Hobsons Bay Youth Service Hobsons Bay Youth Service Hobsons Bay Youth Service Hobsons Bay Youth Service Wyndham City Council Youth Services Melton X X X X X X X X X X X X X X X X X Melton X X X X X Maribyrnong X X X X X X X X X X X Maribyrnong X X X X X X X X X X X X X X X X Hobsons Bay X X Hobsons Bay X X X Hobsons Bay X X X X X Hobsons Bay X X X Hobsons Bay X X X X X Hobsons Bay X X X X X X Wyndham X X X X X X X X X X X X X X X X X

44 Program Name Organisation Coverage Pregnancy & child Birth, Maternal Health, Postnatal Health & Pregnancy Choices Sexual Decision making & Contraception information STIs/HIV & Safe Sex Sexual Issues for Couples & Sexuality & Relationship Concerns Contraception Provision Sexual Violence & Domestic Violence Self Esteem & Emotions Cervical Screening Puberty Body Image Healthy Relationships Racism Access to Services & Referral Parenting Sexuality/Same Sex Attraction FGM Testing (STI/Pregnancy) Risk Minimisation Mental Health Alcohol & Drugs Breast Awareness Menopause Counselling Immunisation Gynaecological issues PSST Partnerships in Safer Sex Testing Maribyrnong Maternal and Child Health (Note: SRH is not main focus) Wyndham Maternal and Child Health Marie Stopes International The Women s Health Information Centre (WHIC) The Women s Health Information Centre (WHIC) Menopause Education Program Put a Little Spring in Your Step Well Women s Clinic Outpatient clinic Melton Shire Council Youth Services Maribyrnong Maternal and Child Health Wyndham Maternal and Child Health Marie Stopes International The Royal Women s Hospital The Royal Women s Hospital The Royal Women s Hospital The Royal Women s Hospital Melton X X X X X X X X X X Maribyrnong X X X X X X X X X X X X X Wyndham X X X X X X X X X X X X Catchment-wide X X X X X X Statewide X X X X X X X X X X X X X X X X X Statewide X X X X X X X X Statewide X X Statewide X X X X X X X X X

45 Program Name Organisation Coverage Pregnancy & child Birth, Maternal Health, Postnatal Health & Pregnancy Choices Sexual Decision making & Contraception information STIs/HIV & Safe Sex Sexual Issues for Couples & Sexuality & Relationship Concerns Contraception Provision Sexual Violence & Domestic Violence Self Esteem & Emotions Cervical Screening Puberty Body Image Healthy Relationships Racism Access to Services & Referral Parenting Sexuality/Same Sex Attraction FGM Testing (STI/Pregnancy) Risk Minimisation Mental Health Alcohol & Drugs Breast Awareness Menopause Counselling Immunisation Gynaecological issues Positive Speakers Bureau Connect Line HIV and Sexual Health Young People s Health Service Individual Specialist Education Service The Action Centre (City) School and Community Sexuality Education Melbourne Sexual Health Centre People Living With HIV AIDS Victoria People Living With HIV AIDS Victoria Royal Children s Hospital Family Planning Victoria Family Planning Victoria Family Planning Victoria Melbourne Sexual Health Centre Statewide X X X Statewide X X X Statewide X X X X X X X X X X X X X X X X X X X X X X X Statewide X X X X X X X X Statewide X X X X X X X X X X X X X X X X Statewide X X X X X X X X X X X Statewide X X X X X X X X TOTAL

46 Appendix 3: Healthy Communities, Healthy Lives Model of Care