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Access to sexual health services for young BME men

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VOL: 103, ISSUE: 43, PAGE NO: 32-33

Author Martin Samangaya, MSc, BSc, RN

Health promotion adviser, Stockport Primary Care Trust

A study that explores whether men aged 16-25 from BME communities are aware of the sexual health services available and whether they can access them easily.

Abstract Samangaya, M. (2007) Access to sexual health services for young BME men.

BACKGROUND: Data from a male, nurse-led drop-in service revealed that attendance by men aged 16-25 years from BME communities was lower than that of white men in the same age range.

AIM: To explore whether men aged 16-25 from BME communities are aware of the sexual health services available and whether they can access them easily.

METHOD: A questionnaire was distributed to various youth groups and at community health day events. The sample comprised 55 young people from BME communities aged 16-25.

RESULTS: The response rate was 85%, 62% of whom had heard of the services. However, only 31% had accessed them. Embarrassment was the major factor hindering use of services.

CONCLUSION:More advertising of sexual health services is needed in places frequented by young people from BME groups and more services should be offered in non-traditional locations.

BackgroundUptake of health and sexual advice services by young men is poor (Health Development Agency, 2005; 2003). In an age of soaring rates of sexually transmitted infections (STIs), including HIV/AIDS, it is crucial to encourage young men to seek help and advice. The Men’s Health Forum (2003) has suggested that sex education is too biological and biased towards female reproduction and rarely addresses young men’s needs. A culture of macho behaviour, suspicion of formal settings and fear of showing vulnerability are seen as potential barriers to reaching young men (HDA, 2005). The Race Relations (Amended) Act emphasises the requirement to promote racial equality in access to services (HMSO, 2003). Bradford’s Health of Men team was established in 2001 to promote health in an environment that is non-threatening and easily accessible outside traditional health settings. Before the establishment of a new PCT in April 2006, Bradford City Teaching PCT served most inner-city areas in Bradford, covering a population of 150,000. Over 60% is from minority ethnic groups (particularly south Asian) of which 12-15% are males aged 16-25 (Brierley, 2003). The locality includes some of the most deprived areas in Bradford, where young people are more likely to be teenage parents. Accessing services is a particular issue for these young people (Brierley, 2003). One of the men’s health team projects is The Lads’ Room, a drop-in service open to men aged 16-25. It is based at the district council’s city-centre information shop for young people, which is open Monday-Saturday to offer help and advice on issues such as housing, college courses, national awards and job applications. The Lads’ Room is run by qualified male nurses who offer confidential advice on sexual health or other health issues. It offers free condoms, chlamydia screening and can refer or signpost young people to other services. Information collected on the number of young men attending drop-in sessions includes age, sex and ethnicity and if it is a first attendance. The majority (85%) are from a white background, with only 15% from black and minority ethnic (BME) communities. These figures precipitated this study to determine why attendance by young men from BME communities is low. It was also important to establish if the same was true of the PCT’s other sexual health services and what can be done to improve access.

Literature reviewThe government has outlined strategies to address the rising incidence of STIs in the UK (Department of Health, 2001; House of Commons Health Committee, 2003). In 2002, the ‘sex lottery’ campaign was launched, to raise awareness of STIs among 18-30-year-olds, highlighting the importance of safer sex and the prevention of infections (Johnson, 2003). Getting patients to talk about sexual health is one of the biggest challenges in primary care (The Teenage Pregnancy Unit, 2001). The subject is still taboo in many communities, and finding the right words to teach or explain anything related to sex can be difficult. Talking about sexual health with people from BME groups may pose further challenges, especially regarding language and terminology (Low et al, 2001). The government has encouraged healthcare providers to address health inequalities among BME groups (DH, 2003). In order to achieve equality and better access to services such as sexual health, culturally appropriate models of service provision and health promotion are needed (Naz Project London, 2006) and should be based on understanding the barriers that hinder certain communities from accessing these services fully. Previous literature on BME communities has concentrated on sexual behaviour and the incidence of STIs (Fenton et al, 2005; Moss et al, 2004; Connell et al, 2004). A recent survey by the Naz Project London (2006) of around 3,000 young people from BME communities aged 15-18 years looked at their sexual health knowledge, attitudes and behaviour, while Beck et al (2005) tried to identify the barriers to accessing sexual health services among the Bangladeshi community in East London and discovered that the services were seen as culturally insensitive.

AimThe aim of this research was to determine the accessibility of sexual health services for men aged 16-25 years from BME communities in a particular area of the PCT in Bradford. Further aims were to determine factors influencing attendance and what can be done to improve accessibility.

MethodEthics and informed consentEthical approval was granted by the Bradford research ethics committee and the Bradford South and West PCT research and development unit. The research was explained to each young man and a letter accompanied the questionnaire. Verbal consent was obtained from each. Sample and questionnaire distributionA questionnaire (Fig 1) was distributed to men aged 16-25 who were from BME communities and attending youth groups. The team had not worked at any of the groups, thus avoiding potential bias and ensuring that participants’ knowledge of sexual services came from other sources. Two community development workers involved with the Pakistani and Bangladeshi communities assisted with distribution of questionnaires and with any language issues. Some of the questionnaires were also distributed at the ethnic minority communities health days, the majority of which (although geared for one particular ethnic group) attracted young people from black African, black Caribbean and south Asian backgrounds. An envelope was given with the questionnaire so it could be sealed after completion to ensure anonymity. The questionnaire itself was anonymous and the only personal details recorded were age, ethnic background and sex. It comprised 11 structured, semi-structured and open questions and took 5-10 minutes to complete. The young men were offered assistance if they did not understand the questions.

ResultsBetween March and June 2006, 65 questionnaires were distributed and 55 (85%) were filled in and returned. The majority of respondents were aged 16-18, although older men up to 25 years of age were also represented; 42% were Pakistani, 18% Bangladeshi, 13% Indian, 11% black Caribbean, 9% black African and 7% mixed race. A total of 34 (62%) participants were aware of sexual health services in their area; these were then asked to state where they had heard about them. A footnote explained that sexual health services are ‘places where people are offered advice on contraception and sexually transmitted infections’.The majority (62%) had heard of the services available in Bradford through the information shop. Only 17 of the 55 participants (31%) had accessed sexual health services in Bradford. When they were analysed according to age, it was found that a significantly higher proportion in the 19-25 age group had accessed the services compared with the 16-18 age group (p=0.02, chi-square test). The proportion of respondents from each ethnic group who were accessing services was also determined (26% of Pakistani respondents, 30% of Bangladeshi, 43% of Indian, 17% of black Caribbean, 60% of black African and 25% of mixed race respondents) but these differences were not significant. Fig 2 shows the various services accessed by the 17 participants,demonstrating that the information shop was well known, with 14 accessing services from here. Only three had accessed more than one service. The participants were asked where they would go if they had a sexual health problem (Fig 3). The most popular was the GP surgery (39 participants; 71%), while 21 (38%) said they would go to the information shop and seven (13%) did not know where to go. Further analysis highlighted that five of these were in the 16-18 age group, one in the 19-21 group and one in the 22-24 group. All 25-year-old participants knew where to attend. Participants were asked about factors that might stop them accessing sexual health services. Thirty-six out of 55 (66%) identified embarrassment as a major factor (Fig 4). The second most common (40%) was not being able to attend at appropriate times, and 26% did not know where to go. Seven (13%) cited religious beliefs as preventing them from accessing services. Of these, six were aged 16-18 and one was 25; three were Pakistani, two Bangladeshi, one black Caribbean and one mixed race. Only four (7%) participants gave being sexually inactive as the reason they would not access services. All were in the 16-18 age group, two were Pakistani and two Bangladeshi. They also cited religious reasons for not attending sexual health services. Participants were asked where they thought would be an appropriate place to advertise the available sexual health services in Bradford (Table 1) and what could help improve accessibility of services (Table 2). Advertising was the most popular response, cited by 25%. Table 1. Places suggested by participants to advertise sexual health services (n=55)

Suggested places for advertisingNumber (% of total participants)
Youth clubs/centres12 (22%)
Schools7 (13%)
College/university7 (13%)
Bars/pubs7 (13%)
TV/radio6 (11%)
Newspapers/magazines6 (11%)
GP surgeries5 (9%)
Public places5 (9%)
Shops4 (7%)
Public transport3 (6%)
Public toilets2 (4%)
Internet2 (4%)
Billboards2 (4%)
Sports centre1 (2%)
Sure Start centres1 (2%)
Leaflets1 (2%)
Pharmacies1 (2%)
Don’t know5 (9%)

Table 2. Participants’ suggestions on ways to improve accessibility to sexual health services (n=55)

Ways to improve accessibilityNumber (% of total participants)
Advertise more10 (18%)
Opening times/more appointments available6 (11%)
Discrete location5 (9%)
More services/more places3 (6%)
Location2 (4%)
Educate in schools2 (4%)
Sexual health issues discussed more1 (2%)
GPs providing SHS1 (2%)
Work with Sure Start1 (2%)
Parent education1 (2%)
Awareness of services1 (2%)
Don’t know10 (18%)

DiscussionThere was a good response rate to the questionnaire from an age group that can be difficult to engage with. Since many questionnaires were distributed at youth groups/clubs, it was not surprising that 53% of participants were16-18-year-olds. This was a plus point, because boys in this age group are going through puberty and are more likely to have unprotected sex or cause unwanted pregnancies (HDA, 2003). Knowing about sexual health services at an earlier age would be beneficial. The participants’ ethnic background was probably a fair representation of the composition of the communities in this part of Bradford. There was no statistically significant difference between ethnic groups in terms of the proportion who had heard of or accessed sexual health services. Older men, however, were more likely to have accessed them. Participants at the upper end of the age scale will probably have been in more relationships and had more need of contraception. While those aged 16-18 may not be in stable relationships, if they are sexually active they may still need to access services. Chlamydia infections have recently increased in the UK (Men’s Health Forum, 2006; Health Protection Agency, 2005a). In the Bradford area STIs have continued to increase among young people, with under-20s accounting for 34% of all people diagnosed with chlamydia, 27% with genital warts and 37% with gonorrhoea (Bradford District Development Partnership, 2006). Nationally, BME groups are disproportionately affected by certain STIs. In 2004-2005 they accounted for 55% and 46% of gonorrhoea diagnoses in heterosexual men and women respectively. Incidences were higher among those aged 16-25, highlighting the need to make services more accessible to these communities (HPA, 2005a). The information shop was the service most often accessed by participants. Most of those aged 16-18 who had used sexual health services had accessed this particular service. When asked to evaluate it, many said it was more relaxed because it is staffed by male nurses, and was easy to access in the city centre (White and Cash, 2003). Although not all participants may have needed to access sexual health services it is important that they know where to go for help and advice. Participants were asked which of the four main services they had heard of or accessed - GP surgeries, GUM clinic, information shop/Lads’ Room and Connexions (a young people’s service that offers help and advice on various issues including health). The questionnaire included space to mention other services and a box to tick if they did not know where to go. Most participants (71%) said they would go to a GP surgery with a sexual health problem. This is unsurprising since the majority of young people have been brought up believing that GPs are the first port of call for health matters. Men are known to be less likely than women to visit their GP (White, 2005) so it is interesting that the majority of our participants would go to see their doctor with a sexual health worry. Perhaps many do not understand that sexual health problems can be dealt with elsewhere, suggesting a need for PCTs and health authorities to educate them about sexual health services. Several reports have highlighted problems with getting appointments at GP surgeries and difficulties with receptionists, who often deter young people from attending services (BBC News, 2005). This is a pity because chlamydia screening has recently been introduced at some GP surgeries as part of a national screening programme. The information shop was well known by participants, with 38% saying they would access it if they had a sexual health problem. Many will probably have heard about other sexual health services through the information shop, where there are leaflets, posters and an electronic display board advertising them. The GUM clinic was cited by 27% as a place where they would access services. However, the footnote on the questionnaire giving the definition of a GUM clinic (Fig 1) may have artificially boosted this figure. Two participants mentioned hearing about sexual health services at local massage parlours. Health promotion workers have provided sexual health information, free hepatitis B vaccinations, sexual health advice, free condoms and lubricant in these locations. The majority of local colleges provide ‘personal, social and health education’ sessions through the school nursing team and other healthcare professionals, who discuss sexual health and signpost students to other services. In view of this it might be expected that the number of participants who knew about sexual health services would have been higher, but 13% did not know where to go with a sexual health problem. Older participants were more likely to know where to go than younger men. It is important to know why young people are not accessing sexual health services. In our survey embarrassment was cited as a major contributing factor (66%), which has also been shown in previous studies (Sherman-Jones, 2003; Jacobson et al, 2001; Jewell et al, 2000). In some cultures and communities, sex is still a taboo subject, so for many young men, accessing services and talking about intimate details may require courage. Some 40% of participants said finding an appropriate time to access services was an issue. As mentioned earlier, men have traditionally been slow to seek health advice and services. Part of the reason is that many work 9am-5pm and may be reluctant to take time off to attend services that are only available during these hours (Fathers Direct, 2006). Seven (13%) participants cited religious beliefs as stopping them from accessing sexual health services. Of these, six were in the 16-18 category and one was 25-years-old; three were Pakistani, two Bangladeshi, one black Caribbean and one mixed race. It is also evident from the response to this question that the 16-18-year-olds may have stronger religious beliefs than those in the older groups (another factor may be that people in the younger age group are more likely to be living with their parents).Religion has often been given as a reason why young people from BME communities do not access sexual health services, especially those with south Asian backgrounds who may be Muslim (Upfront, 2006). Four participants (7%) had not accessed sexual health services because they were not sexually active and all were in the 16-18 age group. These participants also stated they would not attend sexual health services for religious reasons. The main reason for including the answer about ‘not being sexually active’ in the questionnaire was to ascertain how many young people considered themselves sexually inactive as this would explain their reasons for not accessing services. Several places were suggested to advertise sexual health services. The most popular suggestion (22%) was youth clubs and centres, which are a focal point for many young people, while 14 participants suggested schools, colleges and universities as ideal places. In the past, healthcare professionals in Bradford have given talks in these educational institutions about sexual health services, though a few religious schools have refused permission. Bars and pubs were also suggested as possible places to advertise. The Pitstop Pilot Project, run by Knowsley PCT, was successful in advertising health checks for men over 50 using eye-catching, colourful posters and leaflets in bars and pub toilets to advertise services. The uptake was a major success because information was available at places that the majority of men visited (Kirkcaldy and Robinson, 2005). One suggestion to improve sexual health services in Bradford was to advertise more. Large-scale advertising can have a huge impact, such as the 1980s adverts on HIV/AIDS which helped to reduce the incidence of STIs in England (HDA, 2004). Another suggestion was to have a more discrete location for services. One participant stated: The GUM in Bradford is located outside the students’ healthcare building and a large amount of people see the people going in.’ The Teenage Pregnancy Unit (2001) suggested that the location of young people’s services is crucial to their success and such services should be placed where they are easily accessible while offering discretion and confidentiality. Other possible locations include school-based sexual health drop-in sessions, which may be controversial but might help to increase awareness of sexual health matters among young people earlier in their teens. Limitations of this studyA limitation of this study is the sample size. However, there are challenges in conducting a study on the sensitive subject of sexual health, especially in this age group. The data analysis seems to show consistency and validity in answers given by participants. ConclusionThe rise in STIs remains a major public health threat, with the past decade seeing a substantial increase in high-risk sexual behaviour in the British population (Public Health Laboratory Services, 2002). In addition, the teenage pregnancy rate in the UK remains one of the highest in Europe (Lawlor and Shaw, 2004). Service providers need to target young people, who are more at risk of exposure to STIs and risky sexual behaviour (HPA, 2005b). Adverts in places frequented by young people from BME groups would be beneficial. It is also important to convey the sexual health message to teenagers, so that when they become sexually active they know where to access services. In addition, agencies should work with young people to offer services in non-traditional locations. The majority of participants said they would go to their GP if they had a sexual health problem. 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