Knowledge, attitudes and behaviours in relation to safe sex, sexually transmitted infections (STI) and HIV/AIDS among remote living north Queensland youth
Dr Patricia Fagan, Tropical Population Health Service, Cairns, Queensland 4870. Fax: (07) 4051 4322; e-mail Patricia_Fagan@health.qld.gov.au
Objective: To assess the knowledge, attitudes and behaviours of remote Aboriginal and Torres Strait Islander youth living in far north Queensland in relation to sexually transmitted infections, HIV/AIDS and safe sex.
Methods: Community consultation followed by local recruitment of a sample of young people who, in a facilitated same gender focus group setting, completed a questionnaire followed by open discussion of the issues in a range of remote locations during 2007.
Results: The remote living Indigenous youth demonstrated lower levels of knowledge in relation to STI and HIV and higher levels of partner change than was demonstrated in the 2002 national secondary school survey. Despite the high rates of bacterial STI in the region, there was an extremely low level of awareness of personal risk in relation to STI and HIV.
Conclusion: There is an urgent need to strengthen school-based sex education and to develop innovative approaches to sexual health promotion in addition to improving clinical sexual health service provision.
Persisting high rates of bacterial STI in remote Aboriginal and Torres Strait Islander populations across Australia1 are a cause for significant concern, not only because of the long-term impacts on the reproductive health of young women2,3 but importantly, because of the subsequent increased vulnerability to a generalised HIV epidemic.4 An understanding of the interaction between these infections and the human immunodeficiency virus (HIV) has galvanised the effort to reduce STI prevalence in endemic regions, a strategy now considered an integral part of HIV prevention.5–7
In far north Queensland (FNQ – the area covered in the Australian Bureau of Statistics’ Far North Statistical Division), youth sexual health vulnerability, evidenced by high rates of notifiable STI and their complications,8,9 was confirmed by the findings of a large community survey, the Well Persons’ Health Check (WPHC).10 In the late 1990s, the WPHC survey tested 1,420 Aboriginal and Torres Strait Islander people aged 15 to 34 from 26 north Queensland communities and found that 20% of the males and 21% of the females had an STI.11
Since that time, a number of health system initiatives directed at improved early detection and management of STI have been implemented. These initiatives had initially included activities directed at community engagement, education and prevention, but these faltered early on, and were not sustained. Today, in addition to persisting high STI rates, there is an increasing risk of HIV both from southern Queensland and from Australia's northern neighbour, Papua New Guinea, where an HIV epidemic is now well-established.12 Such an incursion would affect young men and women equally. The failure of health service-based initiatives on their own to achieve sustained reductions of STI in remote Australian settings has been the subject of some debate in recent times.13 In FNQ, it has led to a regional review of the existing strategy and the introduction of new approaches that emphasise community engagement and build sexual health promotion capacity as well as improved testing and case management systems.
In February 2006, a rapid sexual health promotion needs assessment was performed in the region to help identify a way forward.14 The rapid assessment suggested that most community members were unaware of a high risk for STI and had little knowledge of HIV/AIDS. In addition, school-based sexual health education in these remote settings was minimal and anecdotal reports of frequent high risk behaviour were a concern. Reliable local data that could shed light on these issues became a priority both for the development and monitoring of sexual health promotion activities. Consequently, this study exploring the knowledge, attitudes and practices of young people in relation to sexual health, was undertaken.
The target population and region
The target population for the study was Aboriginal and Torres Strait Islander young people (initially 18 to 22 year olds, changing to the 15 to 19 age group as the study proceeded) who were not in a steady ‘regular’ relationship and who live in remote FNQ. FNQ covers an area of around 273,000 sq km (about 16% of Queensland's total area) and is home to approximately 231,000 people of whom around 15–20% are Indigenous.15 The 15 to 19 year old population of the four remote communities from which the sample was drawn represents 53% of the Indigenous population of that age group in the region. Compared to the remainder of Queensland and Australia, the population in the remote communities in the study is younger, has lower levels of education and lives in more crowded homes (Table 1).
Table 1. Demographic overview of study area, Queensland and Australia.
|% under 25 years||53%||34%||33%|
|Median age||22 yrs||36 yrs||37 yrs|
|% population age 15+ completed Yr 12||33%||42%||41%|
|% households with 5+ people||39%||10%||10%|
|Average household size||4.0||2.6||2.6|
Community consultation and feedback
In each location support was sought from health service staff, managers (either government or community-controlled) and the District or Community Health Council, and preliminary meetings were organised to discuss the project. After explanation and some discussion, there was general agreement that the project would provide important data previously not available that would help in the battle against STI and HIV. A community partner was then nominated to work with the project team. Ethics approval was obtained from the regional Human Research Ethics Committee. The detailed findings and a community report have been provided to community representatives and health service managers in each location.
The data collection method involved the completion of a questionnaire in a same-gender focus group session followed by an open discussion that explored a pre-determined set of topics.
The questionnaire was adapted from the tool used in the third national survey of Australian secondary students.16 Questions were modified or added to reflect the environment and context of the study population. The questionnaire was initially tested on a small group of local Indigenous health workers and edited to assist English language comprehension. Many of the questions from the national study were retained so that comparisons (where appropriate) could be made.
One or two male and female members of the community (where possible of similar ages as the target group) were engaged to assist with recruitment. These recruiters, having been provided with a script and given guidance on recruitment techniques, were encouraged to target as broad a range of socio-economic contexts as available (e.g. church groups, street kids, sporting teams). The recruiters had no further role in the project. Between June and October 2007, 16 same-gender focus groups were conducted, led by two non-Indigenous and older same-sex facilitators. Two groups (one male and one female, each of approximately 10 participants) were held simultaneously, morning and afternoon on the same day in each of the four locations. Each focus group commenced with a general introduction and an explanation of the project, followed by self completion of the questionnaire. After a break, the facilitator led the discussion.
A pilot (two male and two female focus groups) was conducted to test the community processes, recruitment strategy and methodological design. On this occasion recruited participants were invited to bring a friend (single, of the same gender and similar age) to participate on the day (snowballing) and participants were each paid a cash incentive at the end of the session. Following the pilot some changes were made, the most significant being that the questionnaire content was clarified, the ‘snowballing’ recruitment approach was reconsidered (as youth were reluctant to invite others) and the participation payment was reduced as a result of community and stakeholder feedback that the original incentive was overly generous. A final alteration was made to the target age group. In the pilot site, actual participants ranged in age from 15 to 26, that is from adolescents who were not yet sexually active to young mothers. Life stage and experience varied widely across the group and inhibited discussion on sexual health matters. After consideration of the risk profile and consultation with community people in each subsequent location, the target age range was redefined to 15 to 19 years. Despite these modifications, the data from the pilot site was consistent with that from other locations and was included in the full study reported here.
An initial editing of the questionnaires was undertaken immediately following completion. The facilitator, with the participant's permission, scanned each questionnaire and, if gaps were identified, assisted completion. The data was then entered into a Microsoft Office Excel database, edited and cleaned.
The achieved sample was 152, of these 131 (57 males and 74 females) were aged 15–19 and the findings for this group are reported. One hundred and twenty eight (128) of these 131 respondents (98%) were Aboriginal and /or Torres Strait Islander, 20% reported they were in a regular relationship of six or more months, and all but two reported that they lived locally. The sample represented 15% of the male and 20% of the female population in the 15 to 19 year age group across the four locations.
Tables 2 and 3 summarise participant responses relating to knowledge and sexual behaviours and Table 4 reports on feelings about the last sex encounter. The findings are juxtaposed with those from the third national survey of Australian secondary students16 (referred to here as the “national survey/sample”). Sixty four per cent (64%) of the Indigenous sample reported that one could catch HIV from coughs and sneezes and 55% from hugging someone who has it. In addition, 68% thought a person could catch HIV from mosquitoes and 80% thought that the pill protected people from HIV. There was no significant difference in knowledge level across the Indigenous sample by gender (p>0.05) nor by location (p>0.05). Fifty one per cent (51%) of male and 67% of female participants recognised an accurate definition of safe sex and 81% indicated that wearing condoms during sex was the only way to be truly safe. However, 28% agreed with the statement that withdrawal was a good way to keep safe from STI and HIV, and 44% thought condom use only at ejaculation was sufficient protection.
Table 2. Proportion of knowledge questions on STI, hepatitis, HIV correctly answered.a
Table 3. Self reported behaviours: remote Indigenous sample (15–19 yrs) and national sample (grades 10 and 12).a
|Proportion of sample reporting SI||93%||74%||82%||36%||33%||35%|
|Proportion of sample reporting age <15 at first SI||66%||19%||40%||n/a||n/a||n/a|
|Proportion sample reporting age <16 at first SI||81%||47%||62%||n/a||n/a||n/a|
|Reported “always use a condom” in past yearb||66%||55%||60%||60%||46%||52%|
|Reported condom use at last SIb||81%||51%||66%||74%||58%||65%|
|Reported 3+ sex partners in last 12 monthsb||68%||31%||49%||23%||17%||20%|
|Reported “drunk or high” at last SIb||26%||18%||22%||28%||18%||23%|
Table 4. Feelings about last sex encounter (proportion reporting each feeling).a
|Not at all upset||60%||47%||82%||69%|
|Not at all used||43%||51%||80%||70%|
|Not at all guilty||38%||40%||71%||62%|
|Not at all worried||50%||31%||55%||48%|
The majority (82%) of the 15 to 19 year sample reported ever having sex and 62% (of the sample) reported an age at first sex of less than 16 years. Self-report of having had sex was associated with being male (chi sq 7.74, p<0.01), and for females, with older age group (chi sq for linear trend 5.45, p<0.05). Of the sexually active group, 34% of the males and 7% of the females reported an age at first sex of less than 14 years. Almost half (49%) the sexually active group reported three or more partners in the past 12 months. At the same time, 23% of the males and 33% of the females reported that their most recent sexual encounter was ‘not wanted’.
Sixty six per cent (66%) of the males and 55% of the females who reported having sex stated they always used a condom. However, when asked about condom use at last sex, 81% of the males reported using a condom but only 58% had earlier reported that a condom was available for use at that encounter. The most frequently reported reason for not using a condom was trust. Fifty-four per cent (males 30%, females 63%) said they did not use a condom at the last encounter because they trusted their partner and this was not correlated to relationship status (47% versus 53%). When asked how confident they feel to say no to unwanted sex, 42% of the males and 20% of the females reported that they felt “only a little or not at all confident”.
Almost 60% (males 58%; females 60%) reported that they were either not worried at all or “only a little worried and forgot it pretty quickly”, if they had unsafe sex. Catching HIV (38%), getting pregnant (31%) and catching an STI (21%) were the issues of greatest concern for the minority who did worry. Based on responses as to whether they were worried if they had unprotected sex, whether they thought they were at any risk for STI or HIV, and whether they were personally more at risk from STI if they lived in a large city (Brisbane) than if they lived in their remote home community, 88% of the total sample were assessed as having either a low or no sense of personal risk from STI/HIV.
While 60% reported that they had never sought advice for a sexual health problem or had a sexual health check from a health professional, 57% and 67% had sought information about STI and HIV respectively, from some source. Of those who had sought professional help or treatment, 41% of males and 68% of females rated the experience overall as “good” or “quite good”, but only 50% of the males and 71% of the females reported that they would go back if they needed. Sources for future advice on sexual health matters were nurses/health workers (74%), doctors (70%), family member (60%) followed by youth workers, friends and school.
The discussion that followed completion of the questionnaire lent support to the survey findings particularly in relation to information sources (the role played by health professionals, older family members and school) and the participants’ report that STIs were not regarded as a “big problem” where they lived, rather they were considered more common elsewhere, usually in larger towns. It also identified the role of videos and friends as sources of information on techniques for sex. Even so, the validity of self-report data depends on the degree of respondent honesty, and when asked (as the last question of the survey) how honestly they had responded, 81% of the females and 67% of the males reported they had been completely honest.
The importance of a representative sample was understood from the outset and young people from a broad cross section of the community in each location were encouraged to participate. The achieved sample, while not random, comprised a reasonable proportion (17%) of the target age group in each site and the findings are likely to reflect many of the characteristics of these populations. To the extent that there is bias in the findings it will tend, in our view, to underestimate the vulnerability of the source population as the participants were young people with the confidence and courage to come forward to participate – likely to be protective factors. The extent to which the findings can be generalised to the population of young people living in other locations across this remote region is open to question. The communities who participated are part of the broader region but relatively less remote and more accessible than are some of the other communities. Again, any bias is likely to underestimate vulnerability as the participants are more likely to enjoy better access to information and services by virtue of their less remote locations. The use of an English language questionnaire was perhaps not optimal, however it was appropriate as, while some participants may speak one of several local Indigenous languages, English is the single “common” language of communication and education in the participating communities.
The focus group method allowed participants time to complete the survey in a private space, provided a level of peer support and the opportunity for some learning in the discussion session that followed. This was furthered by the provision (in some locations) of a local sexual health worker who was available for questions at the conclusion of the session. The use of older same sex, non-Indigenous facilitators not previously known to the participants also appeared to work well and the support they provided facilitated completion of the questionnaire when literacy and/or comprehension may otherwise have presented an obstacle. The participants’ call for ‘more discussions like this’ during consideration of how to engage youth in sexual health awareness is an indication of their willingness to learn and talk about sexual health issues given the right environment. The sexual health worker and the facilitators also acted as possible referral points for participants if the need arose.
To our knowledge, this is the first time that sexual health knowledge, attitudes and practices in a sample of remote living Aboriginal and Torres Strait Islander youth have been reported using a tool that allows any comparison with mainstream Australian youth. That being said, given the concerns in relation to representativeness and generalisability, and in light of age disparities and the vast differences in geographic and life circumstances, benchmarking these findings with those from the 2002 national survey of Australian secondary students16 (that reported results by jurisdiction, but not by remoteness) demands extreme caution. The respondents in this study appear to have a similar level of knowledge as the national sample in relation to hepatitis, but a lower level of knowledge in relation to STI and, in particular, to HIV transmission characteristics (Table 2). Among the sexually active group, frequency of partner change seems to be greater in the Indigenous sample with 49%, versus 20% in the national sample, reporting more than three partners over the past 12 months.
Reported intoxication at last sex (22% versus 23% in the national survey) and condom use –“always” (60% versus 52% in the national survey) and “at last sexual encounter” (66% versus 65% in the national survey) – were similar (Table 3), though the inconsistency in the data reported for male condom use in this study makes interpretation of this measure difficult. The high proportion reporting that their most recent sexual encounter was “not wanted” (23% of the males and 33% of the females) stands in stark contrast to the 5% in the national sample who responded similarly to this question.16 We can only speculate on the circumstances that might give rise to this report. These could include consensual but ambivalent sex, transactional but consensual sex, and non-consensual coercion (rape). Associated with this, are the findings that the Indigenous young people expressed fewer positive and more frequent negative feelings in relation to their last encounter (Table 4), and that a significant minority reported a lack of confidence in saying no to “unwanted sex”.
In addition to the influence of socio-economic, geographic and other contextual factors on sexual debut, the proportion of a sample reporting that they have ever had sex is influenced by the age (and gender) distribution of the sample, a finding reflected here (Table 3) and in other studies. In the national sample, 46% of the females and 48% of the males in year 1216 reported ever having had sex. A recent study of urban Indigenous youth aged 12–18 in north Queensland17 found that 34% of the females and 60% of the males reported that they had ever had sex. The same study reported an age of sexual debut of less than 13 years for 10% of the females and 26% of the males who were sexually active – this compares with 2% for the females and 10% for the males among the sexually active group in this study. These differences are partly explained by differences in the age distribution of the samples.
The findings reported here combined with the hyper-endemicity of bacterial STI heighten the concern that young people in these settings are vulnerable to a generalised HIV epidemic. The question is what strategy or combination of strategies can best minimise this risk? The results of a recent Tanzanian trial demonstrate that improvement in knowledge and awareness of STI and HIV/AIDS is essential but insufficient protection for young people and that additional interventions designed to address sexual norms and risk behaviours are required.18 Some may argue that without actions that have a fundamental impact on the social determinants of health, significant and sustained reductions in STI prevalence will remain limited. That being said, from within the area of influence of the health system there is evidence from comparable populations in Australia that consistent and sustained clinical strategies supported by community can be effective.19–21 The experience of Nganampa Health Council19 underscores the importance of a sustained effort to achieve a lasting impact on STI prevalence.
We believe this issue requires such a sustained and committed health system response, one that combines a range of effective clinical strategies (periodically refined and adapted on the basis of local data) with community mobilisation, and sexual health promotion that embraces sexual health communications, social marketing and effective school-based programs.22 The latter must address the needs of younger as well as older teenagers. The evidence indicates that the former are even less certain (than older teenagers) of information about STI and pregnancy,23 yet a majority of this sample reported engagement in sexual activity at less than 16 years and regional data demonstrates that cases of STI are not uncommon from the age of 14 years.24
The critical comparisons for this study will be with the findings of repeat knowledge, attitudes and practices surveys planned for the same remote north Queensland population and age group in 2012, when sexual health promotion will have been established for some time. In the meantime, these findings help us to understand the target group and their needs better and thus to shape our response. They may also help to attract resources needed for further work in this area.
The survey and focus group project was funded as part of the evaluation component of funds received from the Office for Aboriginal and Torres Strait Islander Health in DoHA to enhance sexual health services in the Torres and Cape York region.