A Swiss behavioral surveillance survey among Sub-Saharan Africa migrants living in Switzerland, with and for the African community.
ANSWER – African Net Survey – We Respond!
Von Luciano Ruggia, Raphaël Bize and Françoise Dubois-Arber / Bundesamt für Gesundheit BAG
Between the end of August and December 2013, an internet based survey named ANSWER will collect data about sexual health, sexual behavior and risk taking among Sub-Saharan African migrants (SSAm) living in Switzerland. This research is carried out by the Institut de médecine sociale et préventive (IUMSP, Lausanne) on a mandate from the Federal Office of Public Health (FOPH), in cooperation with the Swiss Aids Federation (AHS) and other institutions addressing the prevention and information needs of the African population living in Switzerland.
The main aims of the ANSWER Survey are the following:
- To establish a first baseline for the HIV/STI related behavioral surveillance among the SSAm population.
- To test the methodology of an internet based approach among SSAm and of the corresponding recruitment and communication strategy.
- To collect data on HIV/STI knowledge and perception, on sexual behavior, prevention, testing and access to care and treatment among this population.
- To provide the evidence needed to adapt, increase and improve prevention work for and with this community.
In Switzerland, SSAm are identified as being a population with a high HIV prevalence, according to the relevant epidemiological data, second only to MSM (men having sex with other men). (1) It is also recognized that there is a general lack of behavioral surveillance data for SSAm. In particular surveillance data about sexual behavior is lacking. (2)
The SSAm population living in Switzerland mostly come from countries with a generalized HIV epidemic (> 1% HIV prevalence) and it is estimated that the HIV prevalence in SSA population living in Switzerland is high although no reliable prevalence studies are available. For other STI, very little data is available among SSAm.
In 2009, according to the Federal Office of Statistics (FOS), between 70'000 and 100'000 SSAm (approximately 3% of the foreign resident population) were living in Switzerland. Also according to FOS, the main nationalities represented in 2009 were the following: Eritrea 7’368; Somalia 6’394, Congo (Kinshasa) 5’844; Angola 4’362; Cameroun 4’333; Nigeria 2’862; Ethiopia 2’803; etc. (3)
They also constitute a very young population, 80% are younger than 40 years old (therefore highly sexually active), and living mainly in large cities (Zurich, Genève, Lausanne, Berne, Fribourg, Bienne). (3) It can also be considered that this population is growing and that the estimation of the FOS is missing the amount of undocumented SSA living in Switzerland.
The socioeconomic differences among SSAm are extremely large, especially if we consider the illegal migrants and the refugees. Country of origin, language and culture only add to the complex situation of this population, which should never be approached as a unique and coherent group. Stigma and discrimination towards HIV positive people still run strong among SSAm and are therefore additional factors of complexity to any analytical or intervention effort.
The HIV epidemiological data for SSAm suggest a worrying public health impact of HIV on this group. In 2002, 191 new HIV diagnosis were registered among SSAm living in Switzerland (43.6% of the heterosexual transmissions); in 2012, 73 new diagnosis were registered among them (27% of the heterosexual transmissions). Late detection is also a major problem in this population, more than in any other group.
The questionnaire has been prepared by the IUMSP in a similar way as other behavioral surveillance surveys in Switzerland, such as the GaySurvey which targeted MSM (conducted on a regular base since 1987). When possible, existing indicators or questions, already used before or compatible with other surveys have been used. Contact with similar initiatives in other countries has also been established and, when possible, questions have been shared. All those elements will help with data analysis and results interpretation.
Attention has been given to create a narrative experience in the questionnaire, helping people not to abandon it at mid-way. Community sensitive terminology has also been used whenever possible. Cognitive testing was used to check for discrepancies between what was conceived by researchers and what is actually understood by the target audience. Finally, the duration has also been measured and filling in the questionnaire should not take more than 30 minutes.
Beside socio-demographic data, questions target knowledge of HIV and STI, general health status as perceived by the respondent, intimate life and relationships, circumcision, contraception, use of condoms, residence status and integration in Switzerland, perception on HIV discrimination, drug use, etc.
An internet based research
It is generally recognized that the SSAm community is difficult to reach and that conducting a survey in this population raises difficult methodological questions. Any approach will have advantages and limitations that need to be clearly recognized and discussed.
For our survey we decided to use an internet based questionnaire, which is increasingly used in behavioural surveillance in hard to reach populations.
The choice of using an internet based approach was taken after discussing with SSAm about their own use of internet and their opinion about this approach. SSAm make an intensive use of internet, although sometime in different ways to those an educated Swiss person would. Clearly computer and internet are used as a communication instrument, to keep in contact with the family in the country of origin or in order to communicate with other community members. SSAm do not necessarily “read” much text on internet, but they watch a lot of videos with all kinds of contents. Social networks are also extremely important and widely used for the auto-organization inside the community.
In order to overcome some of the mentioned obstacles and to reach a maximum number of respondents, we have designed a communication campaign fitting the research design.
Firstly, we will focus on internet by producing a series of videos of well-known African personalities in the SSAm community in Switzerland, carrying the message of the importance of taking part in this survey. We strongly believe that, because of the importance of oral communication among Africans, those videos will better carry the message than any lengthy written text. A specific facebook (FB) group dedicated to the survey will be set up. This FB page will be used to distribute the videos, to link other existing groups as well as to provide information about all events related to the survey, either at national or at local level. The FB page will be animated and moderated during all the data collection period.
Secondly, in order to reach people using internet in a less intensive or different way, an information campaign will be set up focusing on sport, culture, religious and other events aimed at the African community or in settings (health consultations, hairdressers, internet cafés, etc.) frequented by them. This will be mainly organized locally by AHS branches and by the Afrimedia mediators (cultural mediators of the AHS). An information leaflet will be produced to support those actions.
A central point of the project is a strong involvement of the community in all phases of the project. Getting SSAm involved in this survey won’t be an easy task, because of the fragmented composition of this population (languages, cultures, countries of origin, socio-economic status, etc.).
In order to achieve a strong involvement, we set up first a Steering Group, charged of discussing and validating all the strategic elements of the project. The Steering Group is composed of a well balanced mix of professionals and of community representatives. This group started to meet regularly at the initial development phase of the project and will continue to do so until the very end, including supporting the dissemination of the project’s results.
Other forms of involvement are the implication of SSAm in the different testing phases of the questionnaire (cognitive testing, field test) as well as for the translations and for the communication work. The promotion phase of the survey will also rely on a strong field activity conducted by the mediators of the Afrimedia program during events aimed at the SSAm community or in specific settings.
The end of the data collection is planned for December 31st, 2013. This will be followed by an analytical phase and the full report will be published by the IUMSP during 2014. Dissemination of results is also planned, including dissemination among the SSAm community itself.
* Luciano Ruggia, Federal Office of Public Health (FOPH), Bern
Françoise Dubois-Arber and Raphaël Bize, Institute of social and preventive medicine (IUMSP), Lausanne University Hospital, 1004 Lausanne, Switzerland.
In order to maximize the participation rate, we ask every member of the SSAm community or any person working with them to help disseminate the information and the link about our survey.
Questions and enquiries: luciano.ruggia@bag,admin.ch
Federal Office of Public Health (FOPH). National Programme for HIV and Other Sexually Transmitted Infections 2011–2017, Bern, 2010 (http://www.bag.admin.ch/hiv_aids/05464/05465/12491/index.html?lang=en)
Manzanares, L.; Ruggia, L., Le VIH/sida et autres infections sexuellement transmissibles auprès des populations migrantes: Un état des lieux. Bern, 2011 (http://www.bag.admin.ch/hiv_aids/05464/05484/05487/index.html?lang=en)
Federal Office of Statistics. Statistique de la population résidante de nationalité étrangère (PETRA), 1991-2009. Neuchâtel, 2009 (http://www.bfs.admin.ch/bfs/portal/fr/index/infothek/erhebungen__quellen/blank/blank/petra/01.html)