Sexually Transmitted Diseases:
Trends in Sexual Behavior, Testing, and Knowledge in Young People; 2006–2011
Lim, Megan S. C. PhD*†; Bowring, Anna L. MPH*; Gold, Judy PhD*; Aitken, Campbell K. PhD*†; Hellard, Margaret E. PhD*†
From the *Centre for Population Health, Burnet Institute, Melbourne, VIC, Australia; and †Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
Maelenn Gouillou, Tim Spelman, and Jane Hocking provided statistical advice. Recruitment was conducted by volunteers from the Burnet Institute. Recruitment materials were donated by the Big Day Out, Emma and Tom’s Life Juice, Cadbury Schweppes, Marie Stopes International, Durex condoms, Family Planning Victoria, the Australian Government Department of Health and Ageing, the Victorian Department of Justice, headspace National Youth Mental Health Foundation, Youth Projects, Free Condom Project, and Hepatitis Victoria.
Conflict of Interest and Source of Funding: M.S.C.L. receives funding from an NH&MRC early career fellowship and M.E.H. receives funding from the NH&MRC as a senior research fellow. Funding for individual years of the study was provided by the Burnet Institute (2007, 2009, and 2010), NH&MRC (2006), the Windermere Foundation and Pierce Armstrong Foundation (2008) and the Victorian Department of Health (2011). The authors gratefully acknowledge the contribution to this work of the Victorian Operational Infrastructure Support Program received by the Burnet Institute. The authors have no conflicts of interest to declare.
Correspondence: Megan Lim, PhD, Centre for Population Health, Burnet Institute, 85 Commercial Rd, Melbourne, 3004 VIC, Australia. E-mail: email@example.com.
Received for publication February 20, 2012, and accepted June 19, 2012.
Abstract: Cross-sectional surveys were conducted annually from 2006 to 2011 at a music festival. Eight thousand one hundred sixty-five young people completed surveys. STI testing rates increased over time, but there was an increase in the prevalence of some sexual risk behaviors and little improvement in STI knowledge between 2006 and 2011.
Annual notifications of chlamydia in Australia increased by 57% from 47,434 in 2006 to 74,305 in 2010.1 Although some of this increase can be attributed to increased chlamydia testing, there is also evidence of increasing chlamydia incidence.2,3 Risk factors for chlamydia acquisition in young people include unprotected sexual intercourse, multiple sexual partners, and new sexual partners.4,5
Monitoring trends in sexual behavior is a vital public health measure, assisting interpretation of trends in sexually transmitted infections (STI) notifications,6 and evaluation of sexual health promotion programs.7 In Australia, most sexual behavior surveillance targets those at high risk of STI, such as men who have sex with men8 and sexual health clinic attendees.9 Surveillance studies of young people are generally based in settings such as households10 and schools,11 which may be biased by missing high-risk young people who do not live with their parents, do not have a landline telephone, or who do not attend school. Most young people fall somewhere between high- and low-risk groups, and it is important to identify and reach them to collect data on behavioral trends.
Conducting behavioral surveillance at a music festival provides a unique opportunity to access a large number of at-risk young people outside residential, educational, or clinical settings. We previously reported on a decrease in overall sexual risk behaviors trends from 2005 to 2008 among young people attending a music festival in Melbourne.12 Since 2008, STI notifications in Australia have continued to increase, so it is important to monitor behavior trends during this period. Here, we provide updated trends in sexual behavior, sexual health knowledge, and testing in this population, from 2006 until 2011.
Cross-sectional surveys were conducted annually from 2005 to 2011 at the Big Day Out music festival in Melbourne, Australia (available at: www.bigdayout.com). Methods have been reported previously.12,13 Each year, we procured a market stall and invited people aged between 16 and 29 years to complete a brief paper questionnaire about “Sex, drugs, and rock’n’roll.”
Questionnaires took 10 to 15 minutes to complete. Topics covered by questionnaires varied slightly each year, but key questions remained the same (with the exception of the 2005 pilot questionnaire; this year is excluded from analyses). In 2008, a shorter questionnaire was used to enable recruitment of a greater number of participants.
In 2006 and 2008, the festival was also used to recruit participants for subsequent health promotion intervention studies.14,15 In 2009, survey participants were offered chlamydia testing by providing a mailed urine sample at home.16 This may have biased responses to the knowledge statement Chlamydia can be diagnosed with a urine test, thus 2009 data were excluded from trend analysis on this statement.
Partner types were defined on the questionnaire as regular (boyfriend/girlfriend/partner) or casual (all other partners). A new partner was defined as someone with whom sex had occurred for the first time in the previous 3 months. An STI test included tests for any infection but excluded pap smears. STI knowledge was assessed with a series of statements, which could be deemed by participants as “true,” “false,” or “don’t know”; “don’t know” was considered incorrect. Condom use was consistent (always used a condom) or inconsistent (usually, sometimes, or never used a condom).
Analysis was conducted in STATA 11. Temporal trends in reported behaviors were assessed by including “year of survey” as a continuous variable in logistic regression and adjusted for age and gender, where odds ratios represent the average change per year in reported behaviors. Individuals were not tracked over time. Participants who reported never having had sex were excluded from trend analysis on all behavioral questions but were included in STI knowledge outcomes. Differences in STI testing between groups were determined using a t test.
Ethics approval was granted by the Victorian Department of Human Services (2005–2007) and the Alfred Hospital (2008–2011).
A total of 8165 young people completed questionnaires; 60% were female and the median age was 20.8 years (Table 1). Demographic characteristics varied slightly across the years, most notably in 2008 when more participants in older age-groups were recruited.
Overall, 83% reported ever having had sex, with no change over time (Table 2). Adjusting for age and gender, there was a significant decrease in the percentage reporting regular partners and a significant increase in the percentage reporting casual partners. Consistent condom use with casual partners decreased significantly.
The percentage reporting an STI test in the past 2 years increased significantly between 2006 and 2011, within all subgroups analyzed (Table 3). Testing was more frequently reported by females than males (P < 0.01), those aged 20 to 29 than those aged 16 to 19 (P < 0.01), and those residing in metropolitan Melbourne than rural Victoria (P < 0.01).
The proportion knowing that chlamydia can cause infertility and that STIs may be asymptomatic increased over time (Table 4). The 3 questions related to diagnosis and treatment of STI were the most poorly answered (between 35% and 53% correct), with no change over time.
The results of this study suggest increased prevalences of some sexual risk behaviors among young people from 2006 to 2011; reporting regular partners decreased, reporting casual sexual partners increased, and the percentage consistently using condoms with casual partners decreased over time. In addition, consistent condom use with multiple, regular, and new partners remained at low levels. These behaviors may result in negative outcomes, such as STI acquisition or unplanned pregnancy.
STI testing is an important public health measure in STI control, and has been the focus of recent health promotion campaigns and public policies.17,18 Some progress is evident; reported STI testing increased between 2006 and 2011. Testing was less common in males and in those aged <20 years; this parallels Australian laboratory surveillance findings.19 Worryingly, these groups are also more likely to return a positive test.19
Testing among participants residing in rural Victoria was less common than those in Melbourne. Past research shows that rural general practitioners are less likely to offer chlamydia testing than their metropolitan counterparts.20 Young people report various difficulties in accessing appropriate health services in rural areas, including confidentiality concerns and lack of transport to access services.21,22 This study provides some evidence that rural youth are catching up to their city peers as the percentage tested increased by an average of 9% each year (compared with 5% per year in Melbourne).
Between 2006 and 2011, reporting of regular partners decreased, whereas reporting of casual partners increased. This possibly represents a change in how young people define their behavior as opposed to a change in behavior. However, even if young people perceive otherwise, regular partners are not necessarily less risky than casual partners.5,23 Many surveillance systems, research projects, and evaluations differentiate between casual and regular sexual partnerships,4,5,23–25 but few researchers have explored how young people interpret these terms. Further investigation is needed to better understand these findings and to design appropriate health promotion messages.
Correct responses to 2 knowledge statements increased over time: People infected with STIs often do not have any symptoms, and Chlamydia can make women infertile. Both of these facts were publicized in an Australian government campaign, implemented in mid-2009.18 The most poorly answered statements (with no change over time) were those related to STI diagnosis and treatment options (urine testing, Pap smear testing, and antibiotic treatment). This is concerning as lack of knowledge about testing, and treatment options may be a barrier to STI screening.26–28 Health promotion campaigns should encourage testing by providing practical information about the options available.
This study has limitations. In this repeat cross-sectional study, differences observed in sexual behavior each year may be because of differences in the sample selected. The age and gender profile of the sample varied each year, which was accounted for in multivariate analysis, but there may have been other characteristics, which were not measured or controlled for. The degree to which these convenience samples are representative of all festival attendees or the Australian population is not entirely known. Compared with the Australian population, our sample is more highly educated and reported more frequent drug use, binge drinking, and sexual risk behaviors.13,29 Even if our study participants are not representative of young Australians in general, they clearly remain an important group to study as they reported high levels of sexual risk behaviors and should be targeted—and reached—by sexual health promotion campaigns. To gain a clear understanding of young people’s sexual risk behaviors, it would be useful to combine findings with information from surveillance conducted in schools, clinics, households, and other venues to improve geographical and population coverage.
Although reported STI testing increased, the prevalence of some sexual risk behaviors increased, and we observed little improvement in STI knowledge between 2006 and 2011. Novel and effective health promotion strategies to increase knowledge and testing and reduce risk behaviors (such as evidence-based sexual education at schools,30,31 health promotion using social network websites32 and mobile phones,14 increasing rates of health care provider initiated testing,33 and community-based chlamydia screening34), are urgently needed among this population group.
1. The Kirby Institute; Sydney MA, ed. 2011 HIV, Viral Hepatitis and Sexually Transmissible Infections in Australia Annual Surveillance Report. The Kirby Institute, University of New South Wales, Sydney, 2011.
2. Vodstrcil L, Fairley C, Fehler G, et al.. Trends in chlamydia and gonorrhea positivity among heterosexual men and men who have sex with men attending a large urban sexual health service in Australia, 2002–2009. BMC Infect Dis 2011; 11: 158.
3. O’Rourke K, Fairley C, Samaranayake A, et al.. Trends in chlamydia positivity over time among women in Melbourne Australia, 2003 to 2007. Sex Transm Dis 2009; 36: 763–767.
4. Navarro C, Jolly A, Nair R, et al.. Risk factors for genital chlamydia infection. J Sex Reprod Med 2003; 3: 23–34.
5. Lim MS, Goller J, Guy RJ, et al.. Correlates of Chlamydia trachomatis
infection in a primary care sentinel surveillance network. Sex Health 2012; 9: 247–253.
6. Low N. Caution: Chlamydia surveillance data ahead. Sex Transm Infect 2008; 84: 80–81.
7. Gold J, Goller J, Hellard M, et al.. Impact evaluation of a youth sexually transmissible infection awareness campaign using routinely collected data sources. Sex Health 2011; 8: 234–241.
8. Zablotska IB, Kippax S, Grulich A, et al.. Behavioural surveillance among gay men in Australia: Methods, findings and policy implications for the prevention of HIV and other sexually transmissible infections. Sex Health 2011; 8: 272–279.
9. Goller JL, Guy RJ, Gold J, et al.. Establishing a linked sentinel surveillance system for blood-borne viruses and sexually transmissible infections: Methods, system attributes and early findings. Sex Health 2010; 7: 425–433.
10. Smith AM, Rissel CE, Richters J, et al.. Sex in Australia: The rationale and methods of the Australian Study of Health and Relationships. Aust N Z J Public Health 2003; 27: 106–117.
11. Smith A, Agius P, Mitchell A, et al.. Secondary Students and Sexual Health: Results of the 4th National Survey of Australian Secondary Students, HIV/AIDS and Sexual Health. Melbourne, Australia: Australian Research Centre in Sex, Health and Society, La Trobe University, 2009.
12. Lim MS, Hellard ME, Aitken CK, et al.. Surveillance of STI risk behaviour among young people attending a music festival in Australia, 2005–08. Aust N Z J Public Health 2009; 33: 482–484.
13. Lim MS, Hellard ME, Hocking JS, et al.. Surveillance of drug use among young people attending a music festival in Australia, 2005–2008. Drug Alcohol Rev 2010; 29: 150–156.
14. Lim MS, Hocking JS, Aitken CK, et al.. Impact of text and email messaging on the sexual health of young people: A randomised controlled trial. J Epidemiol Community Health 2012; 66: 69–74.
15. Gold J, Lim MS, Hocking JS, et al.. Determining the impact of text messaging for sexual health promotion to young people. Sex Transm Dis 2011; 38: 247–252.
16. Sacks-Davis R, Gold J, Aitken CK, et al.. Home-based chlamydia testing of young people attending a music festival–who will pee and post? BMC Public Health 2010; 10: 376.
17. Commonwealth of Australia. Second National Sexually Transmissible Infections Strategy 2010–2013. Canberra, Australia: Australian Government Department of Health and Ageing, 2010.
18. Osborne D, Rogers K. Sexual Health Campaign Tracking for the National Sexually Transmissible Infections Prevention Program. Sydney: Prepared by Woolcott Research, for the Department of Health and Ageing, 2010.
19. Dimech W, van Gemert C, Stoove M, et al.. A laboratory network for sentinel surveillance of chlamydia: Results after 2 years of the ACCESS laboratory network (2008–2009). In: Australasian Sexual Health Conference: Canberra; September 2011.
20. Sawleshwarkar S, Harrison C, Britt H, et al.. Chlamydia testing in general practice in Australia. Sex Health 2010; 7: 484–490.
21. Quine S, Bernard D, Booth M. Health and access issues among Australian adolescents: A rural-urban comparison. Rural Remote Health 2003; 3: 245.
22. Warr D, Hillier L. ‘That’s the problem with living in a small town’: Privacy and sexual health issues for young rural people. Aust J Rural Health 1997; 5: 132–139.
23. Lescano CM, Vazquez EA, Brown LK, et al.. Condom use with “casual” and “main” partners: What’s in a name? J Adolesc Health 2006; 39: 443.e1–e7.
24. Rowe S, Higgins N. Surveillance of Notifiable Infectious Diseases in Victoria, 2008. Melbourne, Australia: Communicable Disease Prevention and Control Unit, Wellbeing, Integrated Care and Ageing, Department of Health, Victoria, 2010.
25. Grulich AE, De Visser RO, Smith AM, et al.. Sex in Australia: Injecting and sexual risk behavior in a representative sample of adults. Aust N Z J Public Health 2003; 27: 242–250.
26. Pavlin NL, Gunn JM, Parker R, et al.. Implementing chlamydia screening: What do women think? A systematic review of the literature. BMC Public Health 2006; 6: 221.
27. Meyer-Weitz A, Reddy P, Van den Borne HW, et al.. Health care seeking behaviour of patients with sexually transmitted diseases: Determinants of delay behaviour. Patient Educ Couns 2000; 41: 263–274.
28. Blake DR, Kearney MH, Oakes JM, et al.. Improving participation in Chlamydia screening programs: perspectives of high-risk youth. Arch Pediatr Adolesc Med 2003; 157: 523–529.
29. Lim MS, Hellard ME, Aitken CK, et al.. Sexual-risk behaviour, self-perceived risk and knowledge of sexually transmissible infections among young Australians attending a music festival. Sex Health 2007; 4: 51–56.
30. Kirby DB, Laris BA, Rolleri L. Sex and HIV education programs: Their impact on sexual behaviors of young people throughout the world. J Adolesc Health 2007; 40: 206–217.
31. Grunseit A, Kippax S, Aggleton P, et al.. Sexuality education and young people’s sexual behavior: A review of studies. J Adolesc Res 1997; 12: 421–453.
32. Gold J, Pedrana A, Sacks-Davis R, et al.. A systematic examination of the use of online social networking sites for sexual health promotion. BMC Public Health 2011; 11: 583.
33. Guy RJ, Ali H, Liu B, et al.. Efficacy of interventions to increase the uptake of chlamydia screening in primary care: A systematic review. BMC Infect Dis 2011; 11: 211.
34. Kong F, Hocking J, Link CK, et al.. Sex and sport: Chlamydia screening in rural sporting clubs. BMC Infect Dis 2009; 9: 73.
© Copyright 2012 American Sexually Transmitted Diseases Association