The feasibility of recruiting young men in rural areas from community football clubs for STI screening
Correspondence to: Ms Judy Gold, Centre for Epidemiology and Population Health Research, Burnet Institute, GPO Box 2284, Melbourne, Victoria 3001. Fax: (03) 9282 2138; e-mail: email@example.com
Objective: To investigate the feasibility of recruiting young men from rural football clubs for screening for sexually transmitted infections (STIs).
Methods: Young men aged 16 to 29 were recruited from four football clubs outside of metropolitan areas in Victoria, Australia, and completed a questionnaire about sexual activity, knowledge and history of STIs, and alcohol and drug use, and provided a urine sample for STI testing.
Results: One hundred and eight participants completed the questionnaire and 92 (85.2%) also provided a urine sample. More than 90% of eligible players present at the clubs on the night of the study participated. Eighty-seven participants (80.6%) had ever had penetrative sex, with 33 (39.3%) reporting a new sexual partner in the past three months. Among those who had ever had sex, the prevalence of chlamydia was 3.9% (95% CI 0.8-11.0). While the majority of participants visited their doctor in the past year (78.7%) and were comfortable with the idea of an annual STI screen, few had ever discussed sex or STIs with their doctor or had a previous STI test.
Conclusion: Young men from rural areas may be at considerable risk of STIs and many have not been previously tested. However, most are willing to participate in screening programs and the high participation rate achieved in this pilot project demonstrates the potential for screening to be successfully extended into non-medical settings such as sporting clubs.
Implications: Young people at risk of STIs can be successfully recruited for STI screening from community settings.
There is increasing recognition of the importance of men as a ‘reservoir’ of chlamydia infection and continued debate about the inclusion of men in chlamydia screening programs, yet men have been largely overlooked in sexually transmitted infections (STIs) prevalence studies.1-3 Studies of STIs in non-Indigenous, non-homosexual Australian men are limited to medical and education settings.4 Young men are of particular interest as they account for the majority of bacterial STI notifications among men in Australia.5
Young people can be a challenging group to access for educational and research purposes; the need for ‘innovative’ screening strategies is often mentioned.6,7 These strategies have often involved screening in non-standard venues such as streets and other public spaces, detention facilities, schools and youth organisations, with varying success.8-10 Previous studies conducted in Australian high schools involving chlamydia screening have reported overall response rates of below 50%.11-13 Home-based chlamydia screening using specimen postage has been trialled; however, response rates among young men trail those of young women and remain consistently below 40%.14-17
Sporting clubs, such as football clubs, provide an opportunity to reach a large number of young men for STI research and education; approximately 650,000 Australian men aged 15-24 years participate in organised sporting activities.18 We present the results of a study that aimed to assess the feasibility of recruiting young adult men from sporting clubs in rural areas in the State of Victoria, Australia, for the purposes of conducting STI research and education.
The study was conducted from June to August 2005. A sample of Australian Rules football clubs located in rural/regional areas of Victoria were initially contacted via telephone. Clubs agreeing to participate were visited two weeks prior to recruitment to explain the project to the players, provide them with additional information and give them the opportunity to ask any questions about the study. Recruitment was conducted in the club rooms following a mid-week training session. All players attending training that night were approached by study researchers as they entered the club rooms and asked if they would like to participate.
Players were eligible to participate if they were aged between 16 and 29 years. After providing written informed consent, players completed a questionnaire that asked about sexual activity, knowledge and history of STIs and alcohol and drug use, and provided a urine sample for STI testing. All participants received health information and condoms and participating clubs received two signed match day footballs and were provided with refreshments or reimbursed to provide refreshments for all club members after training.
Urine samples were stored at four degrees overnight before being transported to the Department of Microbiology at the Royal Women's Hospital, Melbourne, for testing. After extraction (Roche Molecular Biochemical, Mannheim, Germany), each DNA sample was amplified by PCR for four targets: Chlamydia trachomatis, Neisseria gonorrhoeae by COBAS Amplicor (Roche Diagnostics, Branchburg, NJ, USA) and Mycoplasma genitalium and Beta globin as described previously.19,20 Players who tested positive for any of the infections were contacted via telephone by a sexual health physician, with treatment provided free of charge. Those who tested negative for the infections were contacted via their nominated preferred method (phone/post/email) within three weeks of sample collection.
All data were entered into Microsoft Access 2002 databases and analysed using STATA version 7.0.21 Statistical analyses included descriptive statistics, crude and age-adjusted odds ratios to investigate associations between variables and exact methods for binomial proportions to calculate prevalence rates with 95% confidence intervals. Ethics approval for this project was granted by the Victorian Department of Human Services Human Research Ethics Committee and the Monash University Standing Committee on Ethics in Research Involving Humans
Of the seven football clubs initially contacted, six were interested in participating. However, because of time constraints with the approaching end of the football season, four clubs participated in the project. One hundred and eight participants completed the questionnaire and 92 (85.2%) also provided a urine sample. Although information regarding the number of eligible players present was not collected, it was observed by researchers that very few players declined to participate. It is estimated that more than 90% of eligible players present at the clubs on the night of the study participated.
The mean age of the sample was 20.6 years with 37 (34.3%) aged under 18 years (see Table 1). All participants were non-Indigenous, Australian-born, and reported English as the main language spoken at home. Eighty-seven participants (80.6%) had experienced penetrative sex (penile-vaginal or anal sex), with a median age at sexual debut of 16 years. The median lifetime number of sexual partners among those who had ever had sex was six (range 1-80), with a median of one sexual partner in the past year (range 0-10). Thirty-three (37.9%) of those who had ever had sex reported a new sexual partner in the past three months with a median of two new partners (range 1-5). Two participants reported having engaged in deep kissing with a male (1.9%) but no further same-sex contact was reported.
Table 1. Characteristics of participants.
|Age|| || |
|Region of residence|| || |
|Country of birth|| || |
|Aboriginal or Torres Islander origin|| || |
|Education level|| || |
|Did not complete high school||21||19.4|
|Still at high school||35||32.4|
|Completed high school||27||25.0|
|Still in tertiary education||4||3.7|
|Lifetime number of sexual partners|| || |
|Number of new sexual partners in past three monthsb|| || |
Ninety-two urine samples were collected; of these, 77 (83.7%) were from participants who had ever had sex. Three cases of chlamydia were diagnosed, corresponding to a prevalence of 3.9% (95% CI 0.8-11.0) among those who had ever had sex. Chlamydia infection was associated with having more than one partner in the past 12 months (9.1%, 95% CI 1.9-24.3) and having a new sexual partner in the past three months (6.9%, 95% CI 0.8-22.8). The prevalence of both gonorrhoea and Mycoplasma genitalium infection was 0% (95% CI 0.0-4.7).
Fewer than one-fifth of participants had ever discussed sex or STIs with their doctor (18.5%) or had previously been tested for an STI if they were sexually active (19.5%). However, more than three-quarters of participants (78.7%) had visited their doctor for their own health in the past year and 74.1% stated a yearly STI check-up with their doctor would be acceptable.
There are few published papers in the literature that have assessed the feasibility of recruiting young adult men from sporting clubs for conducting STI research and education. With a participation rate of more than 90%, we demonstrated that football clubs in rural Victoria can be successfully utilised as novel and effective recruitment sites for engaging young men in STI research and education. There is no reason why our recruitment methodology could not be replicated in sporting clubs in other parts of Australia and the world – indeed, a study has recently been completed in football clubs in urban areas with a similarly high participation rate.22 This recruitment methodology provides a unique opportunity to reach a large cross-section of young people in the community and is cost effective as many specimens can be collected at the same time by a limited number of staff.
Compared with the corresponding age groups in the nationally representative Australian Study of Health and Relationships (ASHR), a similar proportion of participants in this study reported having experienced vaginal sex, and mean numbers of lifetime and recent sexual partners were comparable.23
We found a prevalence of chlamydia infection in those who had ever had sex of 3.9%, and higher among those with more than one sexual partner in the past year. This prevalence estimate is similar to estimates in overseas, population-based, weighted studies in young men,24-27 but higher than that reported in community settings earlier in Australia.11,13,28 A recent Australian review calculated a community-based chlamydia prevalence of 1.5% (95% CI 1.1-1.9) among non-Indigenous men, and 1.2% (0.8-1.7%) among adolescents and young adults (including males).4 Thus it appears that chlamydia infection rates among this group of sexually active non-metropolitan young men are similar, if not higher, than populations of a similar age in predominantly urban settings. No gonorrhoea or mycoplasma infections were detected in this sample, most likely reflecting the lower prevalence of these infections among the general (asymptomatic heterosexual) male population29,30 and the small study size.
Encouragingly, the majority of participants were comfortable with the proposed strategy of an annual STI screen,31 despite only a minority reporting having ever discussed sex and STIs with their doctor or having previously had an STI test. Given that a majority of participants had visited their doctor in the past year, this approach would be a feasible option for capturing a large proportion of this age group
As with all studies, there are a number of limitations that must be considered when interpreting results. While it was observed by the study team that the vast majority of players took participation seriously, players often completed the questionnaire in close proximity to each other, which may have resulted in altered reporting of behaviour. This effect was probably most evident in reports of sexual experience with the same sex, with no participants reporting homosexual experience other than kissing, compared with 2% of 16-19 year-olds and 7% of 20-29 year-old men in the ASHR.32 Given the stigmatisation of homosexual activity in rural areas,33 it is not implausible that this behaviour was under-reported in this group.
We conservatively estimated a participation rate of 90% or greater as it was observed that only a small number of eligible players present chose not to participate. However, it was not possible to be completely accurate in measuring participation because of the logistics of the recruitment process. Those who chose to participate may be more sexually active than non-participants,34 but as only a small number of players declined to participate this is unlikely to have a significant effect on the study results. Finally, all participants were recruited from football clubs and thus may not be representative of all young men living in regional and rural areas.
Our study was very successful in recruiting an under-studied, non-metropolitan, young male population. This population is highly sexually active and the detected prevalence of chlamydia infection was reasonably high. The high participation rate was very encouraging and suggests that STI screening is acceptable to this age group. Our results indicate that there is considerable potential to successfully expand STI educational and testing campaigns further into community settings.
Jane Hocking receives support from an NHMRC Public Health Postdoctoral Fellowship and Margaret Hellard from an NHMRC Career Development Fellowship and VicHealth Public Health Senior Researcher Fellowship.