Recent technological changes are reshaping human interactions, including those related to sexual behavior e. Due to their prevalence and the potential consequences for sexual and mental health, these newer behaviors require to be tracked. Surveillance data on technology-related behaviors can inform health education interventions and curriculum by not only illuminating prevalence of behaviors but also documenting the impacts of engaging in such behaviors at all levels of the Social Ecological Model Education serves as the primary tool of instilling young people with knowledge to influence their sexual behaviors or practices in the ongoing campaign to reduce negative sexual health outcomes.
Formal channels, such as school-based sexuality and relationships education, have been shown, dependent on many factors such as dosage and delivery style, to have some impact on behaviors, practices and ultimately outcomes Tracking the formal and informal sources young people currently use, find useful and trust are vital for identifying where and through whom to communicate sexual health and well-being messaging. In Australia, the challenge of addressing adolescent sexual health is further complicated by a fast growing and increasingly diverse population, driven primarily through migration Between the and census the population grew by 1.
Immigration drove the bulk of this increase with the majority arriving from New Zealand, China and India The increasing social and cultural diversity of Australia justifies a need for ongoing surveillance of likely shifting knowledge, behavior and education in relation to adolescent sexual health and well-being. The dynamic nature of the Australian population, technological advances, and the resulting cultural shifts impact on young people's sexual health knowledge, behaviors and practices, and the education that informs them.
Research, as noted in the recent National Strategy, continues to be a vital part of informing public health and education efforts to ameliorate the increasing negative sexual health outcomes facing Australian youth and young adults. The purpose of the periodic surveys have been to inform progress on national strategic sexual health priorities, particularly relating to the level of knowledge about the transmission of HIV, STIs and rates of sexual behaviors. The survey was initiated amid concerns about the vulnerability of young people to HIV infection and the sense that both health and education authorities needed a more realistic picture of the knowledge and behaviors of young people if effective prevention was to be undertaken 17 , The data collected throughout the five iterations of the survey have given a robust picture of the sexual health knowledge, attitudes, beliefs, and practices of Australian young people.
The findings of these surveys have been widely used throughout Australia and have been relied upon, over the last 25 years, to guide the work of health professionals, teachers, youth workers, service planners, and policymakers. Survey results have been used to inform educational policy and sexual health programs, to improve the relevance of sexual health resources available to teachers, and by health departments to plan interventions for young people in Australia.
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Results have been published in reports 19 that have been made available to schools and education authorities, as well as in academic journals. The reports have been used as the basis for the development of classroom resources for sexuality education and health promotion materials for young people e. Previous research impacts from the first five surveys, as noted above, were made possible through inclusion of the following key topics:. Similar to previous iterations, it examined knowledge about HIV and other STIs, sexual behavior including sexting , and experiences of sexuality and relationships education, both formal and informal.
While the survey collected additional data via an online survey to boost numbers following difficulties recruiting using only the traditional school-based paper and pen survey methodology 19 , the survey used an exclusively online survey format for the first time.
This paper presents the study protocol and participant characteristics of the survey. To examine the knowledge, attitudes, beliefs and practices of Australian adolescents aged 14—18 years in relation to sexual health, including knowledge of HIV, sexually transmitted diseases, and blood-borne viruses. Where the same or very similar questions are asked, to compare the results of the survey with those of the , , , , and surveys to provide evidence of change in the sexual health knowledge, attitudes, beliefs, and practices of young Australians.
To disseminate survey findings via a published report, public presentations and other academic and public channels in order to enable government agencies and community-based organizations to develop appropriate interventions that enhance the sexual health and well-being of young people.
Extensive consultation with key stakeholders informed the development of the present survey instrument and protocol in line with principles of community-engaged research While parent groups were not specifically included in the end users group given results are predominately aimed at professionals in the field of adolescent sexual health, many of those consulted self-identified as parents. One-on-one conversations about the survey's content domains and recruitment options were held with leaders e.
A broader list of stakeholders e. The dominant themes that emerged and cut across all or most consultations indicated that: 1 the results from the past iterations of the study were widely used within policy and program planning across government, education, health, and community organizations, 2 all content domains from previous versions of the survey were considered important and should be kept if possible consultees understood the space limitations of surveys , 3 given the increasing burden on school teachers and administrators combined with the pervasiveness of internet access among young people in Australia, an online-only survey was the preferred and more feasible option, and 4 all partners indicated strong support and need for the survey and were willing to work alongside the research team to promote it.
But, you'll never get that survey into my school. However, we could work with you to let students know about it outside of the school. The survey, as well as its past iterations, was funded by the Commonwealth of Australia Department of Health. While the funders were consulted and kept informed about the progress and outcomes of the research, they did not have any influence over the methods or findings.
All items had a forced-choice format i. Given the ongoing periodic collection of data for the survey since , wherever possible, the same question wordings were used to facilitate continued opportunities for multi-wave comparisons. The full survey instrument including response options can be found in the Appendix Supplementary Material of this article.
Broadly, survey items covered four domains: socio-demographic information, knowledge, behaviors and education. Sociodemographics were measured using standard census-type items 21 including age, gender, year in school, school type government, catholic, other non-government , school make-up all boys, all girls, mixed, home schooled , place of residence approximated with a post-code , Indigenous status, and religion.
Due to ongoing high levels of immigration and the subsequent cultural and linguistic diversity in Australia, the survey also asked about country of birth including length of residency if not born in Australia , parental country of birth don't know options were included , and language s spoken at home. Additional demographics on sexual orientation and gender identity were ascertained with five standardized items developed internationally by the UCLA Williams Institute Similar to HIV, associations between knowledge and preventative behaviors has been documented in other research Within the Australian context, a prolonged national focus on reductions in hepatitis infections 27 , 28 and a focus on high HPV vaccination rates 29 supported the need to measure these STI knowledge sub-domains.
Sixteen questions focused on traditional STIs e. Four items covered vaccination and three items covered testing behaviors with follow-up questions on diagnosis for those indicating a positive test result. In line with the literature on the importance of peer norms and condom use 31 , two items assessed if participants thought condoms were commonly used among people their own age, and gender norms related to initiating condom use. Prior to asking a series of questions on behavior, participants were asked contextual questions about dating, through two items.
For each behavior, participants were asked to indicate at what age they first experienced it never, under 14, 14 up through For the purpose of the study, sex was defined as intercourse behaviors i. Participants who indicated they had not yet had sexual intercourse either anal or vaginal , were redirected to a series of questions on reasons they had not yet had intercourse. Items, adapted from the survey, were modified from existing scales 36 — Seventeen items asked participants to rate the importance of various reasons for not yet engaging in intercourse e.
Likelihood of engaging in intercourse anal or vaginal in the next year and before marriage, were also measured. Relationship status and opportunity were also assessed as potential precursors to sexual intercourse. The question mirrored a similar affect question for how sexually experienced participants felt about their last sexual encounter. Finally, four items assessed perceived social pressures from partners, friends, and parents to have sex or remain a virgin.
Participants indicating they had engaged in sexual intercourse anal or vaginal , were asked a series of questions on their sexual histories. Questions were adapted from previous versions of the survey. Condom use was assessed across up to eight items, four being follow-up questions based on initial answers.
In relation to the most recent sexual experience, condom use discussions with the partner, availability, and actual use were measured. If a condom was not used at the last sexual encounter, a list of possible reasons were provided to ascertain why. Finally, for those indicating vaginal sex experience, a check all that apply question asked which form s of contraception they used e. Other general recent sexual history questions asked about the gender of recent partners only males, only females, both and number of partners.
The remaining sexual behavior questions for sexually active adolescents focused on the last sexual experience to minimize recall bias Questions covered status e. Social media use over 2 months prior to the survey was assessed through a check all that apply question e. For each platform ticked, standardized follow-up questions were asked on how often respondents used them Occurrence of sexting behaviors in the past 2 months prior to the survey was measured using six standardized items [e.
For yes answers, a follow-up to each statement assessed how often the behavior occurred and whom did it involve e. Cyberbullying experience questions, similar to sexting behaviors, began with a check all that apply [e. Many interventions highlight empowerment of young people to engage in informal education through information seeking Such empowerment requires a young person to have the self-efficacy, or confidence, to seek information, trust in the source of information, and a willingness to regularly engage with the source e. Confidence to consult various sources of sexual health information avoiding HIV and other STIs, contraception decision-making, and sex in general was measured across 10 potential sources e.
Trustworthiness of 14 sources to provide accurate sexual health information was assessed. Participants were also asked to indicate if they had ever used the same 14 sources. For sources used, participants responded to follow-up questions on how often they had been used in the past year. A number of studies highlight the importance of relationships and sexuality education in ameliorating negative sexual health outcomes Participants were asked if they had ever had relationships and sexuality education at school.
Additional follow-up questions asked about the last time respondents had relationships and sexuality education; in particular, in which subject it was taught e. A final question to all participants offered a space to write, in their own words about their sexuality education at their school e. The 6th National Survey of Secondary Students and Adolescent Sexual Health is a cross-sectional survey of young people living in Australia, which is part of a series of repeated cross-sectional surveys of the adolescent population that began in Data for the 6th survey were collected between April and May via an anonymous online survey instrument containing between and items, dependent on skip logic and re-direction patterns, as described above.
Since , the surveys have obtained sample sizes of between 1, and 3, participants 19 , 44 — A goal of 3, participants was planned through minimum quota sampling 48 based on two sets of strata with medium effect sizes, both based on the most recent census ABS, The first strata encompassed year in school covering years 10 and 12 i. Initial year in school strata covered year 10 and 12 as these groups are consistent across all iterations of the survey. The second, independent strata included state and territory census data, with an oversample of twice the minimum quota for the smaller populations of Northern Territory, Australian Capital Territory, and Tasmania.
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Participants had to be between the ages of 14 and 18 years of age in order to participate in the survey given that the aim of the study was to report on sexual health knowledge and practices of high school adolescents, particularly those in years 10 and The age range allowed for capturing almost all possible year 10 and 12 students.
Participants needed to live in Australia. This research project used a mixed methods mostly quantitative with a few qualitative items anonymous online survey. The study cohort was recruited by using a two-phase recruitment strategy, described as follows:. Phase 1: Participants were informed of the study through Facebook advertising.
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This is higher than any other age group. Further, Australians, on average, spend 10 h a week on Facebook The Facebook ads did not provide for interactive communication with potential participants; they could initiate communication via an e-mail link on the survey website.
Adolescents interested in learning more about the survey were able to click on the advertisement itself, which then opened the survey homepage. Potential participants were able to click the link to start the survey or explore the website to learn more about the study. Upon clicking to begin the survey, participants were able to read a description of the study, the requirements for participation, the time commitment for completing the survey, and other relevant details about the research.
During Phase 1 of recruitment, the Facebook advertising strategy was refined so that advertisements were directed to potential participants based on established minimum quotas. That is, advertisements were directed toward sub-cohorts where quotas had not yet been met. For example, if fewer males than females were completing the survey, the Facebook advertisement was displayed more often to male adolescents until the quota for males was reached.
This back-up plan was necessary because of previous difficulties in recruiting adequate numbers of participants In fact, participant quotas were met through Phase 1 recruitment without needing to move to Phase 2. If required it had been planned to send out an email requesting assistance with participant recruitment to a wide range of contacts, such as Family Planning organizations, education groups, teachers, and other contacts within the education and sexual health sectors.
Potential participants who visited the survey website were greeted by the survey homepage, which contained links to start the survey. The first page of the survey was the Participant Information Sheet which described the study in detail and specified eligibility criteria. The Human Ethics Committee approved the information provided including supporting that it was written at a level appropriate for the age of the potential participants; additionally, no queries to explain the information sheet were received.
The survey then asked a series of screening questions to determine eligibility. Participants were unable to proceed to the next part of the survey unless they met the inclusion criteria of living in Australia and being aged between 14 and 18 years. If they met these inclusion criteria, they were asked to complete the survey, which was estimated to take 20 min. Answers to questions were captured as the participant moved through each page of the survey. Participants were able to resume the survey from the same device and browser for a period of 24 h in case of internet connection failure or if they needed to pause the survey.
After 24 h, participants were required to re-start the survey. A footer at the bottom of each page of the survey reminded the participant that they could choose to exit the survey at any time, and included a hyperlink to the Kids Helpline and Lifeline webpages and toll-free phone numbers for anyone who may have been feeling distressed. Upon completion of the survey, participants were directed to a final thank you and prize draw entry page which was separate from the survey in order to protect respondents' anonymity.
If an email address was provided, participants were asked if they would be willing to be contacted again via the email provided for future research. Participants were informed on the Participant Information Sheet and again on the draw entry page that all emails were kept in a separate password protected file with no identifiers that could be connected to the participants' survey responses.
Detailed cross-sectional findings will be reported for the survey, and, where possible, compared to those of , , , , and to identify trends and meaningful differences. Statistical analyses will be used as appropriate and may include non-parametric options, such as chisquare and parametric alternatives, such as correlation, ANOVA, logistic regression, and other multivariate analyses. Qualitative responses will be analyzed using standard thematic analysis procedures.
La Trobe University subscribes to and strictly adheres to the highest ethical standards in conducting research as laid out by the Australian government agency, the National Health and Medical Research Council Although the Participant Information Sheet recommended that people under 18 should discuss taking the survey with a parent or guardian prior to participating, it was not feasible to track such conversations.
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Further to logistical issues in obtaining parental consent for online survey participation, more recent scholarly work suggests adolescents are capable of providing consent to social science anonymous surveys 50 — The Ethics committee, for these reasons, approved a waiver of parental consent. There was a low risk of potential psychological or emotional stress for participants who were asked about their sexual experiences, particularly the unwanted ones. Reflection on the answers given may have caused minor distress. Given recent unwelcome media attention, there was an identified potential risk to investigators of the project including harassment leading to psychological, emotional, or social harm.
While predicted to be minimal, recent media coverage of other youth-oriented projects has shown this to be a possibility Every page of the survey included web and phone links to Kids HelpLine and Lifeline where participants could engage with services to address any distress experienced in taking the survey. Additionally, links and phone numbers for Kids Help Line and LifeLine were provided at the end of the survey as well as in the resources section of the survey website and on the PIS.
To protect the well-being of investigators, only the Chief Investigator was listed as the contact in the PIS. A university business email was used instead of the CI's email, and where appropriate, the CI screened incoming calls during data collection. The research team had pre-arranged support from the university media team to ensure appropriate responses to queries suspected of leading to press coverage. No phone calls were received during or after data collection and only two e-mails were received, one commenting on a lack of available options for persons identifying as asexual and one inquiring about the validity of the survey e.
Over the past 25 years, Australia has periodically conducted surveillance research on adolescent knowledge, behaviors, and more recently technology practices and educational experiences related to sexual health and well-being. Data from the 6th National Survey of Secondary Students and Adolescent Sexual Health adds to the robust history of knowledge of adolescent sexual health in Australia. Policymakers continue to utilize the information to inform national strategic priorities to address sexual health which in turn inform public health and health education responses to the latest trends in knowledge, behavior, and education.
The research team anticipates continued rates of high impact resulting from the publication of descriptive data in a comprehensive report and subsequent dissemination through peer-reviewed publications, academic and community presentations, and further analyses to support public health and health education sectors in addressing adolescent sexual health and well-being. Given the length of the survey, participants had to complete the knowledge and behavior sections of the survey, which contained the variables of primary interest to the funder, to remain in the final sample.
The survey was started by 25, participants with 8, completed through the behavior section of the survey. Of those, 6, fully completed the survey. Data cleaning required the removal of cases due to pranksters, usefulness of responses, and speeding e. Completion rate of the survey was The average completion time was The sociodemographic characteristics of participants are shown in Table 1.
The National Survey of Secondary Students and Adolescent Sexual Health provides updated surveillance data on the knowledge, behaviors and educational experiences of Australian youth. The 6th installment of the Secondary Student Survey builds on the impacts of previous versions of the survey by informing the work of health professionals, teachers, youth workers, service planners, and policymakers. Findings will indicate what knowledge is known and lacking , which behaviors young people are and are not engaging in and the types of sexual health education experiences they desire.
Beyond impacts in the field, the survey will, through academic channels e. The survey is one of very few world-wide to provide ongoing robust in-depth research into adolescent sex-related knowledge, behaviors and educational experiences. The United States has a long history of work in this space, though national data are limited to basic information into sexual behaviors [e. Similarly, research in the UK and Europe [e. No other national or international surveys examine adolescent knowledge on STIs and HIV or the informal and formal experiences of sexual health education.
The Australian survey provides a unique contribution to the field by covering, not only behavior or knowledge or educational experiences, but by covering all of them in one survey. Combined with the large, diverse sample obtained, the potential for examining, in-depth, a number of adolescent sexual health and well-being issues, will likely generate many new contributions to understanding the relationships between knowledge, education and behavior across a diverse sample of adolescents.
In particular, the constructs comprehensively measured knowledge, behavior, and educational experiences in the survey allow analyses that will contribute to the evaluation and development of theoretical perspectives in the field. The cross-sectional repeated nature of the survey provides a second equally important contribution to the field. Across six waves over 25 years, the survey has asked the same fundamental questions, often using identical wording.
This consistency provides the possibility of analyzing across cohorts' changes in knowledge, behavior and informal educational experiences. Mapping these experiences to policy, technological, medical, social and cultural shifts may provide a window into how adolescent sexual health and behavior has and has not changed since Understanding what has and has not changed, and under which contexts, may help to inform a broader understanding of the intricate interactions at a systems level that impact on adolescent sexual health and well-being 62 , Finally, the innovative methodology of the survey, namely changes in the recruitment and sampling procedures from previous iterations, may help to inform future national and international surveys with adolescent populations on sensitive topics.
The approach used documents obtaining national samples of young people recruited online to participate in sexual health research as not only feasible but achievable. The primary limitation of the survey is the potential for generalizability. First, despite using a very widely used platform for recruitment, not every young person in Australia is on Facebook, nor would all users have seen the advertisements.
Similar to many other sexual health studies, the Secondary Student Survey likely suffered a selection bias 68 , Other limitations include only being accessible to participants who could read and respond to an English language survey and had access to and knowledge of how to use an internet-enabled device. The reproductive and sexual health needs of adolescents differ from those of adults. Psychological, social, educational, environmental, and economic factors, among others, all play a role.
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United States teen pregnancy, birth, abortion, and sexually transmitted disease rates are higher than those in most other developed countries, and rising. Between 25 and 33 percent of adolescents forgo needed care 25 and many others lack access. The newly charged federal Office of Adolescent Health should take the lead in fostering cross-sector collaboration and supporting comprehensive health programs, providing all adolescents better access to high quality services that are responsive to their unique needs.
Specifically, both federal and state governments should:. World Health Organization website. National Institutes of Health website. Tolman, Deborah L. The Journal of Sex Research 40 1 : Handbook of Developmental Psychopathology. Cicchetti, ed. Beatty, A. National Research Council and Institute of Medicine. Singh, S. Family Planning Perspectives 32 1 — Santelli, John S. Annual Review of Public Health Ethier, Kathleen A.
Journal of Adolescent Health 38 3 : Martin, Joyce A. Centers for Disease Control and Prevention. Births: Final Data for National Vital Statistics Reports 57 7. Hoffman, Saul D. Centers for Disease Control and Prevention website. Silverman, Jay G. Journal of the American Medical Association 5 —9. Morbidity and Mortality Weekly Report 55 19 : Abma, Joyce C. National Center for Health Statistics. Vital and Health Statistics 23 Klein, Jonathan D. Preliminary Results: Great Expectations. Journal of the American Medical Association 10 ,
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