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Sexually transmitted infection risk exposure among black and minority ethnic youth in northwest London: findings from a study translating a sexually transmitted infection risk-reduction intervention to the UK setting
  1. M Gerressu1,
  2. G Elam1,
  3. R Shain2,
  4. C Bonell3,
  5. G Brook4,
  6. J Dimmitt Champion2,
  7. R French1,
  8. J Elford5,
  9. G Hart1,
  10. J Stephenson1,
  11. J Imrie6,7
  1. 1
    Centre for Sexual Health and HIV Research, University College London, London, UK
  2. 2
    University of Texas Health Science Center, San Antonio, Texas, USA
  3. 3
    London School of Hygiene and Tropical Medicine, London, UK
  4. 4
    Patrick Clements GUM Clinic, Central Middlesex Hospital, London, UK
  5. 5
    Department of Public Health, City University London, London, UK
  6. 6
    National Centre in HIV Research, University of New South Wales, Sydney, Australia
  7. 7
    Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Mtubatuba, South Africa
  1. Ms M Gerressu, Centre for Sexual Health and HIV Research, University College London, Mortimer Market Centre, Off Capper Street, London WC1E 6JB, UK; mgerressu{at}gum.ucl.ac.uk

Abstract

Objectives: Young black women are disproportionately affected by sexually transmitted infections (STI) in the UK, but effective interventions to address this are lacking. The Young Brent Project explored the nature and context of sexual risk-taking in young people to inform the translation of an effective clinic-based STI reduction intervention (Project SAFE) from the USA to the UK.

Methods: One-to-one in-depth interviews (n  =  37) and group discussions (n  =  10) were conducted among men and women aged 15–27 years from different ethnic backgrounds recruited from youth and genitourinary medicine clinic settings in Brent, London. The interviews explored the context within which STI-related risks were assessed, experienced and avoided, the skills needed to recognise risk and the barriers to behaviour change.

Results: Concurrent sexual partnerships, mismatched perceptions and expectations, and barriers to condom use contributed to STI risk exposure and difficulties in implementing risk-reduction strategies. Women attempted to achieve monogamy, but experienced complex and fluid sexual relationships. Low risk awareness, flawed partner risk assessments, negative perceptions of condoms and lack of control hindered condom use. Whereas men made conscious decisions, women experienced persuasion, deceit and difficulty in requesting condom use, particularly with older partners.

Conclusions: Knowledge of STI and condom use skills is not enough to equip young people with the means to reduce STI risk. Interventions with young women need to place greater emphasis on: entering and maintaining healthy relationships; awareness of risks attached to different forms of concurrency and how concurrency arises; skills to redress power imbalances and building self-esteem.

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Young women under 25 years of age and those from black ethnic backgrounds are disproportionally affected by sexually transmitted infections (STI) in the UK.1 In 2006, young women accounted for 74% of chlamydia and 64% of genital warts diagnoses in women. A UK study of three genitourinary medicine (GUM) clinics identified younger age (in women) and Caribbean ethnicity among the key determinants of STI re-infection within one year of a previous diagnosis.2 Effective interventions are needed in the UK to address these high STI rates.3 However, there are few effective interventions, evaluated using randomised controlled trials, available in community or sexual health settings.46

The Young Brent Project is a UK Medical Research Council-funded study exploring the feasibility of adapting Project SAFE (Sexual Awareness For Everyone) across cultural and service contexts from the USA to young people in the UK. Project SAFE is a highly effective behavioural cognitive intervention developed to reduce STI re-infection in low-income African-American and Mexican-American women in San Antonio, Texas, USA.7 It comprises three sessions lasting 3–4 h held once a week with small groups of women (n  =  5–6) from a single ethnic background with a recent non-viral STI. The sessions are delivered through interactive facilitation techniques and correspond to the AIDS Risk Reduction Model: (1) recognition of one’s risk; (2) committing to reducing risk and (3) enacting practical effective solutions.7 8 Efficacy was demonstrated in two randomised controlled trials over 1 and 2 years’ follow-up with STI infection rates cumulatively 39.8% higher in the control group compared with the intervention group.7 9

This paper presents data on barriers to the uptake of risk-reduction strategies revealed during the qualitative phase of our translation research, the Young Brent Project. The perceptions and context of risk behaviours were explored to determine the necessary changes to Project SAFE to ensure relevance to the UK target group. Details of the translation process are presented elsewhere.10

METHODS

Between October 2006 and February 2007 two female researchers conducted one-to-one in-depth interviews (n  =  37) and group discussions (n  =  10; two to 10 participants per group) in northwest London (Brent) with men and women aged 15–27 years from different ethnic backgrounds. Brent was selected as an ethnically diverse borough with a high black Caribbean population and high deprivation and teenage pregnancy rates.11 12

Participants were purposively selected by age, sex and type of recruitment site to include diverse sexual behaviours and experiences. Recruitment sites included a GUM clinic, an employment programme, a specialist education service for those not attending mainstream school, youth clubs and addiction and teenage pregnancy services. Group discussions were conducted with pre-existing youth groups from a subset of these sites and were of mixed age, sex and ethnicity. Interviews and group discussions were conducted concurrently, enabling us to explore data gathered in one session further in the next and engage with group dynamics, group norms and individual perspectives while triangulating findings.

Participants of different ethnic backgrounds were recruited after community consultations identified a need for our translated intervention to be inclusive rather than targeting only young black Caribbean women. Although Project SAFE was aimed at women, men were included in the formative research to provide further insight into the factors contributing to STI re-infection in women. Table 1 summarises the sample characteristics.

Table 1 Sample characteristics

All participants received an information sheet about the project and a sexual health website/helpline sheet. Signed consent was obtained from all participants. In-depth interviews were conducted at the recruitment site or another location preferred by participants, using a topic guide covering life circumstances, awareness and perceived risk of STI, sexual experiences, pregnancy, alcohol and drug use. Visual aids and role-play techniques were used in the group discussions to help participants articulate their views on desirable/undesirable partner characteristics, cultural and gender differences, STI risk situations and the ease/difficulty of discussing sexual history, sex, condoms and STI with partners. Interviews were audio-recorded, transcribed verbatim and analysed using the principles of Framework.13 14 Interview content was organised into themes derived from the topic guide and interview narratives. Using Excel as a data-management tool, similarities and differences between individuals and groups were identified. Two researchers crosschecked transcripts, derived themes and charts.

The study was approved by the Brent Medical Ethics Committee.

RESULTS

Avoidance of STI was a concern for young people. In some instances, low perceived vulnerability to STI arose due to limited STI/HIV knowledge and overreliance on obvious symptoms. However, STI risk exposure also occurred among those with good knowledge who had intentions to minimise risk or believed they were adopting appropriate risk-reducing strategies. Even STI experiences did not always lead to a re-evaluation of strategies or consistent condom use.

Risk-reducing strategies described by young people included getting to know partners before sex, STI testing before stopping condom use, entering only mutually monogamous relationships, using condoms outside relationships or with new partners, and in a few instances consistent condom use. Here we focus on the three dominant factors that contributed to STI risk exposure and difficulties in implementing risk-reduction strategies: (1) concurrent sexual partnerships; (2) mismatch of perceptions and expectations and (3) barriers to condom use.

Concurrent relationships

Although young people aspired to monogamous relationships, concurrent sexual partnerships were common and occurred as casual encounters within relationships, between relationships and as co-terminous relationships. STI risk exposure could be active with the participant having multiple sexual partners, or passive when a participant’s partner had multiple partners. Table 2 summarises the types of concurrent relationships identified and box 1 provides explanatory quotes.

Table 2 Concurrent sexual partnerships: circumstances, type and risk

Active concurrent partnerships while single

Young people described casual partners as “links”. Some younger men felt it was important to have several “links” available, particularly for sex when single. Men described little emotion or respect and no expectation of monogamy from “links”. This increased the likelihood of multiple partners and STI risk. In contrast, women reported being in a vulnerable emotional state when having casual partners and concurrent partners, describing heartbreak, times of confusion and loneliness.

Active concurrent partnerships within relationships

Both men and women reported sex outside their relationships or with someone who already had a partner. Women attributed this to being bored with a partner, unable to end a relationship, being in an emotionally vulnerable state such as seeking revenge for a partner’s infidelity and re-visiting previous partners because of lingering feelings or familiarity. Men explained needing sex when regular partners were unavailable, wanting more varied sex or to prevent boredom and difficulty resisting temptation. Some saw their ability to persuade other women to have sex as a way to boost self-esteem.

Experiences of sex outside their relationships were viewed by some young people as: (1) intentional when there was an intent to cheat, whether for revenge, pleasure or personal satisfaction; or (2) unintentional as a result of excess alcohol or an opportunity occurring during unhappy or transitional relationships.

Passive concurrent partnerships within relationships

Women reported exposure to STI risk having agreed not to use condoms within what they believed were mutually monogamous relationships, unaware of their partner’s other sexual partner(s) or having misjudged their relationship status as permanent rather than casual. While expressing that sharing a partner was unacceptable, some women stayed in relationships when suspecting or after discovering infidelity. Condom use was not necessarily consistently enforced but some women used regular STI testing as a strategy to ascertain fidelity and be safe. In contrast, men generally believed that their girlfriends did not have sex with other men and that it would be otherwise unacceptable.

Box 1 Concurrent relationships, perceptions and expectations

Concurrent partnerships while single

“This was after I split up with the love of my life… he’d left me for another girl.… I turned really, really horrible in the space of about a year.” Woman, age 23 years, interview

Active concurrent partnerships within a relationship

“[After bad break up] There was one situation where actually I met this guy at college… he said I’ve got a girlfriend. I said I don’t care, I didn’t ask you about your girlfriend.” Woman, age 23 years, interview

Intentional

“It’s for myself not just to stop me from getting bored [of my girl]. ’Cause girls are different. They can look in the mirror and think ‘oh I look good!’… Same way I need something to big myself up. Girls can do their nails, do their hair, makeup, put nice tight dresses.… All we can do is get a hair cut, maybe a massage.” Man, age 24 years, focus group

 Unintentional

“I was going out with this guy that I’d been seeing for a year and… [I] just had sex with this [other] guy on a drunken night and it was nothing… there was no need for it, I’m not having problems with my relationship.” Woman, age 19 years, interview

“When I get into a relationship I don’t want to be sleeping with other girls. Things happen because the relationship is not healthy or you could be drunk one night… it just happens by mistake, it could be an accident.” Man, age 22 years, focus group

Passive concurrent partnerships within a relationship

“He was with another girl but he told me that they broke up and then when I found out I was pregnant she was pregnant so… our kids are one day apart.” Woman, age 19 years, interview

“My friends were like… you’ve got chlamydia and he’s obviously cheating on you. And I was so blind to it I was like no, no, no, he’s all right. I don’t know I might have got it somewhere or another but I didn’t listen to them.… I just went to clinic got myself checked out… [just] carried on.” Woman, age 24 years, interview

“Obviously we’re together but I still don’t trust him a hundred per cent.… I don’t know.… If something’s put on a plate, whatever, even though we’re in a relationship you don’t know what they’ll do [men].” Woman, age 18 years, interview

Expectations

“Just ’cause of the way that I felt about him and how he [said] that he was sorry and it was a mistake and… ’cause… (pause) I believe it was a mistake, that he was sorry. So I just decided to have a go at it [the relationship] again.” Woman, age 18 years, interview

“It was OK for him to do it [cheat] because he was a man. It wasn’t OK for me to do it because I was his woman. But to me I don’t understand that, men, a lot of men, think like that. If you’re going to cheat on your man he’ll never ever accept you back.” Woman, age 24 years, interview

[Girlfriends cannot sleep with another man] “they’re not meant to be misbehaving, meant to be… a one man girl only.” Man, age 22 years, interview

“I think every single person [6 men] I’ve slept with has had sex with someone else whilst they’ve been sleeping with me.… Yeah two I didn’t think [were] sleeping with other people I found out later.” Woman, age 23 years, interview

Confused relationship status perceptions

“The only person I have been with [recently] is my daughter’s dad…. I think I do it because if I do feel like I need to sleep with someone he’s the easiest person to go to.… We spend a lot of time together and we go out, we do everything that people in a relationship would do… on the one hand I’m saying to you we’re not together but you can’t sleep with anyone else, it’s sort of sending mixed messages.… Just don’t want [relationship].… So much has happened throughout the years and I think I hold grudges! And until I can sort of say all right then I’m going to get past that, there’s nothing would ever come of it.” Woman, age 23 years, interview

Perceptions and expectations

A mismatch between men and women in their perceptions and expectations of regular and casual partners had an important impact on risk-reduction strategies (box 1). Men mainly described distinct partner categories, whereas women’s perceptions were more fluid and underpinned by greater expectations or hope of casual encounters developing into more committed relationships. Women also reported establishing sex-only relationships to avoid emotional entanglements, but these distinctions could be difficult for them to maintain.

Although some women expressed feeling lonely without a boyfriend, none claimed they needed one. Nonetheless, the ability to end undesirable relationships was problematical for some women, particularly when confidence was associated with male attention. This vulnerability was labelled as low self-esteem by some, whereas others described lacking confidence, low expectations of partners and difficulty communicating with partners without labelling them as low self-esteem. Furthermore, strong feelings for a partner and insecurity in finding and rebuilding the same closeness made leaving a cheating partner difficult.

Barriers to condom use

Condom use was recognised as the main way of preventing STI transmission, but consistent use was rarely achieved (box 2).

Defined by relationship

Condom use was deemed necessary for sex outside a relationship with “links” or unfamiliar partners. It did not occur or was inconsistent within relationships, with partners trusted to be STI free and/or with partners after GUM check-ups.

Overestimating relationship status was a problem among women, whereas some men but no women described deciding not to use condoms, despite suspecting some STI risk.

Defined by partner risk perceptions

Young people generally accepted that anyone could have an STI and that you cannot tell by looking; however, women spoke of taking into account closeness, knowledge of past partners and “vibes” in assessing partners’ STI risk. Men in turn categorised girls, which determined STI risk and the nature of their relationship. They spoke about “good” and “bad” girls based on reputation, behaviour, appearance, previous partners and the ease with which they were willing to have sex.

Box 2 Condom use barriers: active decision versus lack of autonomy

Active decision

“Sometimes I just take my chances… living dangerously man (laughs)… depending on the person as well.… Looks, looks.… That’s about it really. If I find her highly attractive ’cause normally those are the ones that are passing it on as well (laughs)!… I don’t know, it’s just silly behaviour.” Man, age 22 years, interview

Pressure

“Once you sort of caved in and said OK.… It was a lot more difficult.… I was sort of just really weak, I just didn’t really stand up for myself… wanted to please him which sounds really stupid.… So I just gave in.” Woman, age 20 years, interview

Age differences leading to power imbalances

“I think when I was younger it was sort of down to the guy.… I think that’s how I got pregnant the first time.… Didn’t know when to ask!… Because he was a lot older than me… you sort of put age to experience.” Woman, age 23 years, interview

Embarrassment

“I didn’t feel like I could put my hand round to check, to feel, to make sure [condom was on]… didn’t even… want to look at it [penis].” Woman, age 22 years, interview

Perceptions of condoms

Associating condoms with reduced pleasure, interrupting sex and lack of trust hindered their use, as did limited knowledge about STI and condoms.

Lack of autonomy

Lack of control arising from being drunk or having sex impulsively featured frequently across accounts of unprotected sex among men and women. However, recurring overarching themes for women were lack of control due to power imbalances within relationships and inability to express sexual needs and desires. Lack of agency undermined sex-related planning and negotiation or led to yielding control.

Experiences of having older male sexual partners were common among younger women, who felt they were more sophisticated, mature and provided opportunities such as cars and money. However, age differences particularly in early relationships led to misplaced confidence in older men’s condom skills, knowledge and claims of being STI free, as well as women yielding control to them.

Other barriers for women included: embarrassment about genitals; condoms being taken off during sex; giving in to pressure and not knowing when and how to ask for condom use. Gender stereotypes also hindered some women’s ability to carry and suggest condom use and resulted in beliefs that sex was about a man’s enjoyment and that condoms were a man’s responsibility.

DISCUSSION

Findings from interviews, which focused on detailed past and present personal experiences, and group discussions, which provided insight into peer interactions and norms within various combinations of peer groups, enabled us to understand the circumstances within which young women experience and conceptualise their STI risk.

Young women’s risk-reduction strategies were undermined by: exposure to concurrency through partners incorrectly believed to be monogamous; underestimations of personal risks and flawed partner risk assessments. Poor communication, lack of planning, excess alcohol and condoms’ association with lack of trust and pleasure further restricted their use when risk was perceived. Power imbalances particularly with older men and in early relationships led women to cede control of condom use, or not have any control. Low self-esteem, low expectations of relationships and weak communication skills also created barriers to risk-reduction as high-risk relationships were maintained. The breadth and depth of skills needed by these young women to address barriers to STI risk-reduction suggest that sexual health interventions should be delivered by skilled facilitators over time rather than in the form of written information or one-off events.

Key messages

  • Interventions for young women need to address gender power imbalances, emotional vulnerability, low self-esteem and provide skills to enter into and maintain healthy relationships.

  • Concurrency played an important role in sexually tranmitted infection-related risk among our target population and took different forms, in particular a mismatch between gendered expectations.

  • Different forms of concurrency affect women’s risk perceptions and risk-reduction strategies and require consideration in developing interventions that resonate with their sexual landscape.

  • Sexual health interventions need to be delivered by skilled facilitators over time rather than in the form of written information or one-off events.

Limited sexual health knowledge among young people and associated STI risks have been described in similar contexts,15 16 but we were able to understand in greater detail why those with knowledge fail to implement risk-reduction strategies. In addition, although young people report greater numbers of sexual partners and concurrent partnerships compared with older people,17 little previous work has focused on the context of concurrency. We found that concurrency played an important role in STI-related risk and took different forms. Differences in cause and outcome for young men and women, and different levels of agency, have implications for women’s risk perceptions and risk-reduction strategies that need to be considered in developing interventions that resonate with their sexual landscape.

Condom use based on subjective assessments of partners’ STI risk, and communication barriers due to social expectations and gender stereotypes, have been reported in studies worldwide.18 Power imbalances and age differences are also risk factors in dating violence among young women.19 These barriers to STI risk reduction were replicated in our findings, with the benefit of contextual understanding to inform interventions. Conclusions about the association between self-esteem and sexual behaviour vary. The review by Goodson et al20 questions the linear association of self-esteem and adolescent sexual behaviour favouring the inclusion of self-efficacy, self-control and youth development in interventions.20 As a broad concept self-esteem requires further exploration; however, the emphasis identified here and deemed necessary for the target population relates to the importance of helping young women feel empowered to consider their own emotional and sexual needs and be able to enter and maintain healthy relationships.

The purposively selected recruitment sites provided access to groups at higher risk of STI, which were the main target for the intervention; however, these tended to be located mostly in deprived areas of Brent or accessed by disadvantaged young people. Compared with England as a whole, black Caribbean and black African populations make up a two and a half times greater proportion of the population in the most deprived areas and unemployment rates are twice the average UK rate.21 22

The number of non-black and Asian young people interviewed was lower than planned due to limited numbers attending the selected sites, the ethnic make-up of the areas and the epidemiology of STI in London. We did not find differences in accounts by recruitment site but the study was not designed to explore how accounts varied by site distinct from age and gender.

Although we may have sufficient ethnic diversity in our sample to tailor Project SAFE to the needs of young women at risk of STI in northwest London, further work may be required to adapt this intervention in localities with different ethnic compositions to account for different relationship and sexual behaviour norms.

We did not have sufficient numbers to make conclusive comparisons by ethnicity but found distinct variations in STI risk perceptions and behaviour based on gender rather than ethnicity or age. We also found behavioural cues derived from youth, generational and local affiliations. The strong influence of gender and common youth culture on sexual behaviour and risk-taking across ethnic groups supports research in south and east London on ethnic and cultural differences in sexual behaviour and relationships.23 24

Exposure to STI risk due to blind faith in partners, particularly older partners and greater naiveté about sex, were particularly problematical during early relationships. These were mainly reported as current circumstances by less experienced respondents and as past ones by more experienced respondents, suggesting they relate more to early relationships than age. However, problems with concurrency, relinquishing control and forming/remaining in unhealthy relationships were not age or experience related but were more general female experiences.

Social disadvantages including poverty and limited opportunities are likely to influence the identified risk behaviours;2527 however, investigating these in depth and tackling the key factors leading to social exclusion was beyond the scope of this study. More work needs to be done to address underlying social circumstances in the process of encouraging STI risk reduction. Further research resulting from our findings is in progress to examine the mechanisms and wider socioeconomic influences leading to risk taking.

Project SAFE reduced STI re-infection rates by taking a multifocused approach to encouraging the recognition and reduction of personal STI risk, including understanding transmission, symptoms and consequences; providing a variety of risk-reduction strategies; improving communication; making condoms pleasurable; building self-esteem and exploring relationship choices.28 Our work indicates that these are all relevant to the UK target group and highlights the importance of addressing barriers to achieving risk-reduction strategies beyond STI knowledge, skills in condom use and condom negotiation. It identifies areas to be addressed in STI reduction interventions/counselling, and integrated with teenage pregnancy prevention targeting young women in the UK to bridge the gap between knowledge, intentions and behaviour.

Gender-based variations in the experience of risk, power and communication reported here emphasise the relevance of single-sex sessions to address these problems. However, lack of information, self-esteem and difficulties within relationships also affected young men. These areas require further exploration with young male participants. As we found many of the elements of Project SAFE to be relevant to STI reduction among men, the feasibility of a UK version for young men should be explored.

Acknowledgments

The authors are indebted to the young people of Brent who participated in each stage of the study and the providers of youth and sexual health services in Brent who gave their insights throughout the project and assisted in the recruitment. The authors are extremely grateful to all of the co-investigators and collaborators for the hard work and expert guidance provided throughout the project: Andréa Longoria, Sheralyn Mitchell, Reyes Ramos and the Project SAFE team at the Department of Obstetrics and Gynecology, University of Texas Health Sciences Center at San Antonio; Dr John McSorley and the team at Patrick Clements Clinic, Central Middlesex Hospital; Marble Magezi and Alex Blair from The African Child; Anna Erenbourg from the University College London Centre for Sexual Health and HIV Research; Dr Connie Smith from Westside Contraceptive Services; Dr Robert Power from the Macfarlane Burnett Institute, Melbourne, Australia; Winnie Ssanyu-Sseruma from the African HIV Policy Network and the Health Protection Agency for supporting the secondment of GE.

REFERENCES

Footnotes

  • Funding: The Young Brent Project is funded by the Medical Research Council (G0500117). The views expressed are those of the authors and not necessarily those of the MRC or the health departments.

  • Competing interests: None.

  • Ethics approval: The study was approved by the Brent Medical Ethics Committee.

  • Contributors: JI had the original idea for the study and initiated collaboration with RS. JI developed the study design and applied for funding in collaboration with RS, GB, JE, GE, JS and JDC. CB and RF contributed to the study design as members of the steering group. RS made all Project SAFE data available for the study. GH and GE took over as joint chief investigators during the first year of the project. GE supervised all aspects of the study and was responsible for the management of the grant. GE and MG carried out the fieldwork, analysis and data interpretation. MG wrote the first draft of the paper, which was revised by GE. All authors contributed to subsequent drafts. MG and GE are joint guarantors.