Identifying future research needs for the promotion of young people's sexual health in New Zealand.

• Author: Jackson, Sue

Abstract

An increasing focus on the sexual health status of New Zealand youth has followed in the wake of somewhat alarming statistics on abortion rates, sexually transmitted infections and teenage pregnancy. The call for further New Zealand research to guide policy and practices to improve the sexual health status of young people, as stipulated in the Sexual and Reproductive Health Strategy (Ministry of Health 2001a), is both timely and necessary. This paper addresses the question of what research is needed to inform the improvement of young people's health status. Two approaches are employed: firstly, the paper reviews current New Zealand literature to identify the research knowledge currently available to inform development of the strategy, and, secondly, the paper draws on the findings of a scoping study that aimed to identify research needs from the perspective of those working as educators, service providers and researchers in the field of adolescent sexual health. Taken together, the literature review and study findings suggest the need for more qualitative research to illuminate the evident gap between young people's knowledge and practice, and the considerable need for more evaluation of both services and sexuality education programmes.

INTRODUCTION

Currently there is national concern about the reproductive health status of New Zealand youth. Available data suggests there is a chlamydia epidemic that peaks in the 15-19 years age group, with the rates of gonorrhoea also high and increasing (Ministry of Health 2001b). In addition to concerns about sexually transmitted infections (STIs), New Zealand currently has the third-highest teenage pregnancy rate in the OECD, with rates among young Maori and Pacific women comprising a significant component of this statistic (Statistics New Zealand 2001). The increasing rate of adolescent abortions among young women suggests that a significant number of these pregnancies are unwanted (Singh and Darroch 2000). Coupled with, and related to, these facets of young people's reproductive health are data that reveal patterns among teenagers of decreasing age of first sexual intercourse and an increasing number of sexual partners (Dickson et al. 1993, Marsault et al. 1997). Indeed, recent New Zealand research suggests that, conservatively, around one-third of teenagers are sexually experienced before the age of 16 (Fenwicke and Purdie 2000). Early sexual behaviour is associated with greater likelihood of teenage pregnancy (Woodward, Horwood et al. 2001) and poor sexual health (Andersson-Ellstromet et al. 1995, Durbin et al. 1993, Seidman et al. 1994, Thompson et al.1993).

There are substantial costs associated with these reproductive health problems among youth. On one level there are the economic costs of providing services for sexual health problems and supporting young women who choose to parent their children alone. At another level there are health costs such as those arising from the association of STIs with pelvic inflammatory disease and ectopic pregnancy (associated with infertility) for young women and non-specific urethritis for young men (Youngkin 1995). Other potential health costs include physical or psychological problems associated with pregnancy, and the need for long-term health care where risky, early and frequent sexual intercourse leads to HIV Aids. The social costs may have wide-ranging effects, from loss of education and loss of employment or employment opportunities in the future, to loss of family and friends. Clearly, we are a society that needs to be addressing the reproductive health status of our youth.

The Sexual and Reproductive Health Strategy (Ministry of Health 2001a) presented the need for ongoing research to identify effective ways of working with youth to improve their sexual and reproductive health. Indeed, the document specifies "information" as the fourth arm of the strategy, incorporating the very general goal to "undertake relevant research, including evaluation of this strategy". To date, however, it seems that government strategies and policies on young people's reproductive and sexual health have drawn primarily on overseas research and a handful of New Zealand studies, a good number of which are limited by "mainstream" samples (that is, predominantly Pakeha, urban and heterosexual).

While it is evident that more New Zealand research is needed, it is important to establish the focus of that research. One way of doing so is to examine the current literature and identify the gaps; this approach informs the first goal of this article. Another way is to seek the views of those working and researching in the area of young people's sexual health who, on the basis of their first-hand knowledge and experience, can provide valuable input on the needs and directions for both policy and research on young people's sexual health issues; this approach informs the second goal of this article. The article then integrates these two sources of information to suggest implications for a research agenda aimed at informing practices to enhance the sexual wellbeing of New Zealand youth.

NEW ZEALAND SEXUALITY RESEARCH

A literature search of New Zealand research on young people's sexuality and sexual health produced a database of 56 published articles, books or reports between 1975 and 2002. Most of the literature is relatively recent, all but seven dating from 1990 onwards. The majority of these publications were on the topics of sexual health (17.8%), sexual behaviour (17.8%), teenage pregnancy (14.3%), sexuality education (12.5%), sexual coercion and abuse (8.9%), and sexual knowledge and attitudes (7.1%). The remaining articles spanned, in order of prevalence, sexuality, homosexuality, social policy and risk factors or risk taking. Most publications were articles in New Zealand or Australasian journals (46.4%), international journals (28.6%) or reports (15.1%), the remainder constituting books, book chapters, conference papers, dissertations and professional publications. The following review is mainly of peer-reviewed publications, and focuses on practice rather than theory.

Overall the literature is dominated by quantitative research, most typically the use of surveys or structured interviews that are subsequently statistically analysed for frequency of reported events, correlations between reproductive health status and psychosocial factors, or group differences (such as gender, age and ethnicity). For example, a myriad of individual, social and family factors have been identified as risk factors related to early sexual experience, unsafe sex practices, unwanted pregnancies and STIs. The risk factors include conduct disorder, poor educational performance, early maturation, child sexual abuse, ethnicity, and socio-economic disadvantage (e.g., Lynskey and Fergusson 1993, Dickson et al. 1993, Paul et al. 2000, Woodward, Fergusson et al. 2001, Fergusson et al. 1997). The literature on risk factors or predictor models is useful because it identifies the broad social and psychological factors associated with risky sexual behaviours. However, a statistical approach is unable to identify the nuanced ways those factors operate at the level of individual understanding. Taking socio-economic status or class, for example, educational aspirations encourage contraception use among middle-class girls, but for workingclass girls risky sexual behaviours may allow them to escape school (Nash 2001a).

Understanding how social and cultural factors operate to influence young people's sexual behaviour is paramount to the development of effectively targeted sexual and reproductive health programmes. Using predictor models, as most risk factor studies do, does not explain the meanings of socio-cultural factors, nor does it access the more complex factors influencing sexual behaviours such as those pertaining to the relationship. For example, qualitative research suggests that trusting a partner (Flood 2001), romance (Gavey and McPhillips 1997, Jackson 2001), stage of the relationship (Flood 2001, Wight 1994), gender role expectations, gender power dynamics and the subjective meanings of condoms (Wight 1994) all influence safe sex practices or decisions about having sex. Prevention strategies that fail to account for social, cultural and relationship milieu are...