Discussion
Young people with a history of ≥1 STI who do not belong to a priority population may be avoiding their GPs for sexual healthcare. This group of young people is at risk of STIs, and research is needed to determine how to best provide adequate sexual healthcare for this population.
Young people experience higher rates of sexually transmissible infections (STIs) and lower screening rates than the general population in Australia, particularly in Greater Western Sydney (GWS).1–3 In recent years, the prevalence of STIs in young Australians has been increasing when compared with other age groups.4–6 In 2013–14, chlamydia rates increased in both males and females in GWS.7 This rate was greatest in the 20–29 year age group.8
Patients with sexual health concerns are largely managed by general practitioners (GPs).9 However, asymptomatic screening rates remain low in young Australians, and it is known that many STIs are often asymptomatic.1,10 As chronic STI infections correspond with increased morbidity, it is necessary to determine if young Australians avoid accessing sexual healthcare from their GP; this is important to address the sexual health needs of this demographic.1,11–14
Current STI guidelines define priority populations as those significantly at risk of STIs.1 These groups include Aboriginal and Torres Strait Islander peoples, men who have sex with men (MSM), sex workers, people in custodial settings and those who inject drugs.1 These people can access publically funded sexual health services (PFSHS) for sexual healthcare.1,13 However, PFSHS cannot provide these services to all young people as they are only funded for the aforementioned groups.1
A specific subpopulation of young people who are not defined as a priority population may also be at risk of sexual ill-health. This includes those with a history of ≥1 STI.15–17 Currently, PFSHS triage these young people to their GPs for sexual healthcare.
Unfortunately, it is understood that young people feel uncomfortable discussing sexual health concerns with their GPs.9 Incidentally, young Australians attending PFSHS prefer to seek sexual healthcare from PFSHS rather than a GP.18 However, the reasons why young Australians may avoid seeking sexual healthcare from their GPs have not been explored in a general practice setting. When surveyed in a sexual health service, it is currently understood that the factors deemed important when accessing sexual healthcare are the same for young Australians that belong to a priority population as those who do not.18 As the majority of sexual healthcare occurs in general practice, it is necessary to assess these factors among young people accessing general practice services.
The aims of this study were to:
- determine whether young Australians avoid seeking sexual healthcare from a GP
- identify whether the factors deemed important to young Australians belonging to a priority population were the same as those who did not belong to a priority population when accessing sexual healthcare in a general practice setting.
Methods
A cross-sectional survey of young adults aged 18–30 years was conducted in September 2015 (Appendix 1, online only). Participants were recruited from 10 general practices across eight GWS suburbs. Those who were aged 18–30 years and comprehended English were eligible to participate in the study.
An adapted survey tool collected data regarding participants’ demographics and their experiences with GPs for sexual healthcare.19 Participants were divided into priority populations (as previously defined) and the rest of the population (non-priority population).1 These two populations were compared using independent chi-squared proportional analysis. Within the non-priority population, those who had a history of ≥1 STI were compared with the remainder of the non-priority population using independent proportional analyses. These comparisons were used to determine whether the different groups were less likely to seek sexual healthcare from their GPs.
The factors deemed important when attending a GP for sexual healthcare were compared between participants from priority and non-priority populations using self-reported Likert scales. Non-parametric Mann-Whitney U-test analysis was used as a result of our positively skewed data. This determined whether a significant difference existed between the responses of these two groups.
Ethics approval was obtained from the Human Research Ethics Committee at Western Sydney University, reference number H93067.
Results
Surveys were completed by 256 participants, with a >80% response rate. Of the 256 respondents, 98.8% (253/256) resided in GWS. In total, 6.6% (n = 17) belonged to a priority population. The remaining 93.4% (239/256) did not belong to a priority population group. The demographics of our population are reported in Table 1.
| Table 1. Demographics of the surveyed population |
| Characteristic |
n (%) |
| Sex |
|
Male
Female
Other |
102 (39.8)
153 (59.8)
1 (0.6) |
| Sexuality |
|
| Heterosexual |
233 (91.0) |
| Homosexual |
16 (6.3) |
| Bisexual |
7 (2.7) |
| Indigenous status |
|
Aboriginal
Torres Strait Islander |
6 (2.3)
0 (0.0) |
| Non-Indigenous |
250 (97.7) |
| First language |
|
| English |
183 (71.5) |
| Other |
73 (28.5) |
Self-reported history of STIs among participants
Of the 256 participants, 13.3% (34/256) had a self-reported history of at least one diagnosed STI (Table 2).
| Table 2. Sexually transmissible infection prevalence among participants* |
| Sexually transmissible infection |
n (%) |
| Chlamydia |
17 (6.6) |
| Gonorrhoea |
6 (2.3) |
| Herpes simplex virus |
5 (2.0) |
| Genital warts |
2 (0.8) |
| Syphilis |
1 (0.4) |
| Hepatitis A |
1 (0.4) |
| Hepatitis B |
1 (0.4) |
| Human immunodeficiency virus |
1 (0.4) |
| *Hepatitis C not included as no history recorded by any participant |
Priority population
In total, 17 participants belonged to a priority population, and these participants were less likely to seek help from their GPs for sexual healthcare than the participants who belonged to the non-priority population. This was associated with fear or a perceived history of judgement from their GP (X12 15.03, P <0.00001).
Non-priority population with a history of ≥1 STI
Participants who did not belong to a priority population but had a history of ≥1 STI were less likely to seek help from their GPs for sexual healthcare when compared with the rest of the non-priority population. This was associated with fear or a perceived history of judgement from their GPs (X12 19.7, P <0.00001).
Most important factors in choosing a service for STI screening
There was no significant difference between the expressed important factors for choosing a service between the priority population and the non-priority population. For both populations, the top three factors were: confidentiality, staff knowledge and staff attitudes. This comparison is summarised in Table 3.
| Table 3. Comparison of the most important factors for choosing a general practitioner for sexual healthcare between those in a priority population and those who are not (Likert scale was 1–5 based on importance: 5 = very important, 4 = important, 3 = neutral, 2 = not very important, 1 = not important) |
| |
Those identifying as a priority population |
Those not identifying as a priority population |
|
| Factor |
Number |
Median |
IQR |
Number |
Median |
IQR |
P value |
| Confidentiality |
17 |
5 |
0 |
236 |
5 |
1 |
0.516 |
| Staff knowledge |
17 |
5 |
1 |
232 |
5 |
1 |
0.705 |
| Staff attitudes |
17 |
5 |
0.5 |
232 |
5 |
1 |
0.741 |
| Discuss sexual health with ease |
17 |
5 |
1 |
232 |
5 |
1 |
0.837 |
| Location of service |
17 |
4 |
1 |
234 |
4 |
2 |
0.150 |
| Past experience |
17 |
4 |
1 |
235 |
4 |
2 |
0.911 |
| Sample collection |
17 |
4 |
2 |
234 |
4 |
2 |
0.685 |
| Range of staff services |
17 |
4 |
1.5 |
232 |
4 |
1 |
0.216 |
| Pharmacy nearby |
17 |
3 |
2.50 |
234 |
4 |
1 |
0.207 |
| Disconnection |
17 |
3 |
2.5 |
233 |
3 |
1 |
0.686 |
| Privacy of location |
17 |
3 |
2 |
235 |
3 |
2 |
0.497 |
| Anonymous testing |
17 |
3 |
4 |
235 |
3 |
2 |
0.588 |
| No Medicare Benefits Schedule |
17 |
3 |
3.5 |
235 |
3 |
2 |
0.313 |
| Offered testing |
17 |
3 |
2 |
232 |
3 |
2 |
0.719 |
| IQR, interquartile range |
Discussion
This study facilitated the identification of two groups of young Australians that may be avoiding sexual healthcare from their GPs because of a perceived fear of judgement from their GPs. This included those belonging to previously defined priority populations and those not belonging to a priority population who have a history of ≥1 STI.
Those belonging to a priority population were more likely to avoid sexual healthcare from their GPs because of a fear or history of judgement. Current literature indicates that GPs are unlikely to discuss sexual healthcare with MSM patients and that MSM patients are unlikely to express their sexual health concerns to their GPs.19,20 Although priority populations have access to PFSHS and community groups such as the AIDS Council of NSW, this does not necessarily mean that all people belonging to a priority population access these services. Our finding highlights that those belonging to a priority population continue to see their GPs; however, it is unknown if they also accessed a PFSHS. Future research should assess how many young Australians in priority populations depend solely on their GPs for sexual healthcare to determine the significance of our finding.
In this study, those not defined as a priority population but with a history of ≥1 STI were more likely to avoid sexual healthcare from their GPs. This is a crucial finding as it represents a group of young Australians who require sexual healthcare but are choosing not to seek it. This is also of interest as it contradicts current literature that reports that young people not belonging to a priority population regard GPs as an appropriate point of care for sexual health.18 As young Australians are disproportionately affected by new STI infections, our study suggests that this sub-population of young people may not be receiving optimal and necessary sexual healthcare from their GPs.
Prior to this study, the factors young Australians deemed important when accessing sexual healthcare in a general practice setting had not been explored. This study explored the general practice setting exclusively and similarly found no statistically significant difference among these factors when comparing young Australians belonging to a priority population with those that do not belong to a priority population. This indicates that the factors deemed important are the same across both populations of young Australians. This may provide possible focuses for ongoing GP education to promote optimal sexual healthcare for all young Australians.
This study was limited by not accessing young Australians who did not speak English. The survey also did not specify whether patients were sex workers, injecting drug users or from a custodial background. At-risk young people only included MSM and Aboriginal and Torres Strait Islander peoples. Therefore, further research should be conducted on other groups of at-risk young Australians not captured in the current study.
Conclusion
Young Australians who do not belong to a priority population but have a history of ≥1 STI remain at significant risk of acquiring additional STIs. Unfortunately, this group is also less likely to attend a GP for sexual healthcare. Positive factors that were considered important for young people when seeking sexual healthcare included: confidentiality, staff knowledge and staff attitudes. Overall, we have facilitated the identification of a group of young Australians not previously defined as a priority population who may be avoiding their GPs for sexual healthcare despite being at an increased risk of sexual ill-health.
Appendix 1 – Survey