In Canada, sexually transmitted infections (STIs) and their social impacts are distributed unequally across the population with young people bearing a disproportionate burden of disease compared with older populations. In 2007, British Columbia’s (BC’s) highest rate of chlamydia was among women ages 20–24 years (1624 cases per 100 000 compared with the provincial average of 228 per 100 000),1 and the highest gonorrhoea rates were among men ages 20–24 and 25–29 years (94 and 105 cases per 100 000, respectively, compared with the BC average of 29 cases per 100 000).2 These rates are increasing: between 1997 and 2007, chlamydia rates for females aged 20–24 years have increased 192%1 3 while gonorrhoea rates for men aged 20–24 years have increased 221%.2 3 STIs also disproportionately affect BC’s North, where rates are higher than in southern health regions4 (for example, 408 cases of chlamydia per 100 000 in the Northern Interior Service Delivery Area1).

STI testing can facilitate timely treatment and provides a mechanism through which to address the public health and social burden of STIs.5 While there has been significant research on structural and socio-cultural influences affecting access to HIV testing,6 7 there is a paucity of research that directly examines how features of youth’s social context can affect their experiences with STI testing (for example, HIV testing requires a blood sample (whereas many common STIs require only a urine sample) and most research related to barriers to HIV testing has focused on men who have sex with men, intravenous drug users and other high-risk populations). Instead, STI prevention research has focused on individual risk factors,8 9 which provide an insufficient basis for population-level improvements in sexual health.10^–12 Socio-cultural influences (for example, gender, culture and place) as well as structural features (for example, clinic hours and locations) should be considered determinants of youth sexual health9 14^–17 because these features can present significant barriers to youths engaging in STI testing.12 14 18 19 Thus, the current study was undertaken to investigate the experiences of youths accessing STI services and adult service providers in a variety of service settings; we also analyse how those perspectives and experiences are shaped by socio-cultural and structural forces in four communities in BC, Canada.

METHODS

Study settings

(1) Vancouver (total population 2 116 581)20 in Canada’s Pacific Southwest. STI testing is offered at numerous sexual health clinics, medical clinics, public health units and hospitals, which are accessible by car or public transport throughout the week, including evenings and weekends at some locations. Eight observation visits were conducted at three youth and sexual health clinics.

(2) Richmond (population 174 461)21 is a suburb adjacent to Vancouver and accessible by public transport to/from Vancouver. Sexual health services in Richmond include youth clinics, walk-in clinics, public health units and a hospital, some of which are available during evenings and weekends. Eleven observation visits were conducted at three youth and sexual health clinics.

(3) Prince George (population 70 981)22 is a northern city that serves as a hub for northern health services. Testing is available at the public health unit, a university student health centre, a women’s health centre, medical clinics and a hospital. Testing is available on weekdays with very limited evening and weekend hours. Eight observation visits were conducted at three youth and sexual health clinics.

(4) Quesnel (population 9326)23 is a northern rural (we define rural as municipalities with populations of less than 10 000 that are outside the larger urban centres’ commuting zones24) community (located 115 km south of Prince George. Testing is available at the public health unit, hospital and medical clinics, and services are available during the daytime (except lunchtime) on weekdays. Two observation visits were conducted at a youth and a sexual health clinic.

Data collection and analysis

Data were collected using in-depth interviews and naturalistic observations at clinics in each community (observations were conducted with expressed permission from each clinical setting).25 Posters and pamphlets were used to recruit youths aged 15–24 years (currently and/or previously sexually active) from clinical sites (for example, youth sexual health clinics, STI clinics) and non-clinical sites (for example, coffee shops, university campuses). Participants who wanted to enrol in our study rang our study office and were asked five questions to determine if they were eligible (for example, age 15–25 years; English speaking; live in one of the study communities; are HIV negative; and had had a STI test or considered having one). We used a purposive strategy to select a sample of male and female youths who reported a variety of STI testing experiences, ranging from youths who had tested more than once to those who had never been tested. Participants could choose to be interviewed by a male or female and provided written informed consent.

We also conducted key informant interviews with service providers (for example, clinicians) about their experiences providing STI testing services and the policies and practice guidelines that inform their work with youths. Service providers were recruited through our visits to each community and during our observations at participating clinics. Most service providers gave us tours of their facilities to gather additional observational data.

Interviews were semi-structured, used open-ended questions and provided participants with opportunities to discuss their experiences with STI testing and their perceptions about the factors that affected those experiences. Our interviews were informed by an interview guide that helped us ensure that we covered the interview topic areas (for example, deciding to get tested). The guide also included examples of prompting/probing questions that interviewers could use, where appropriate. Participants also completed a socio-demographic questionnaire. Interviews were conducted in private settings with each interview lasting about 1 hour. During observational visits to clinic waiting areas, we made detailed field notes about the design of clinic spaces; observations of youths entering the clinic and privacy levels for clients in the waiting area. Eleven clinics were observed two to five times.

Interviews were recorded, and transcripts and observational notes were analysed using Nvivo. Coding schemes to identify themes were developed at author meetings and revised as new concepts emerged during data collection and analysis. Analysis was conducted by reading transcripts and field notes during which themes were iteratively developed. The analysis presented in the current manuscript focuses on youths’ experiences and also draws on interviews with service providers to contextualise the youth’s stories. Follow-up interviews were conducted with a convenience sample of 10 young men and 8 young women to gather feedback on preliminary findings and used to revise/test the emerging themes. The follow-up interviews provided an opportunity to further explore themes related to the notion of “feminised” clinic spaces, as well as to gather more information about youths’ perspectives on geographical and cultural contexts that were perceived to be less lesbian, gay, bisexual and transgender (LGBT) friendly. The analytical process also included discussions among the co-authors regarding their reflections on how personal standpoints (for example, gender; socioeconomic status) informed their interpretations.

RESULTS

Sample characteristics

We interviewed 70 youths (37 females; 33 males, ages 15–24 years) with diverse socio-demographics and backgrounds. The mean age was 20.6 years. We also interviewed 22 health care and social service providers. See tables 1 and 2 for details. All participants are identified with self-selected pseudonyms.

Socio-cultural and structural features of STI testing

Participants identified three factors that affect their experiences related to STI testing: (1) social and physical features of their community, (2) characteristics of the clinics and (3) knowledge gaps related to testing.

Social and physical features of community

Participants presented concerns about privacy and confidentiality in their communities. To alleviate these concerns, some youths from the larger southern communities (Richmond and Vancouver) told us they travelled (often by public transport) to different neighbourhoods in Vancouver to access testing without being seen by someone they might know. As an 18-year-old man from Vancouver explained:

“I didn’t want to go (for testing) in my area because I didn’t want people to know me, because I’m scared of people who are going to be like, ‘Oh what are you doing?’”

In the northern communities (Prince George and Quesnel), concerns of confidentiality and anonymity were more pronounced. As a 24-year-old man living in Prince George explained:

“But you worry, like, ‘Oh I wonder if it’s someone’s mom,’ or ‘I’m going to run into this person some other way,’ and be like, ‘Oh no!’ Especially if there was a bad thing that came out of it or whatever. So, you kind of worry at a smaller place about the confidentiality. Like this could be your friend’s mom or your co-worker.”

Another important concern in all the communities is related to social norms regarding homophobia and heterosexism. In particular, service providers in Quesnel and Prince George told us that, to their knowledge, very few LGBT youths access testing in their communities. A female nurse from Quesnel explained that being “out” in some communities, such as Quesnel, may not be safe:

“You wouldn’t want to be gay in this town, and be ‘out’ and young. That’d be very dangerous.”

Service providers, especially in the northern communities, recognised that heterosexism and homophobia contributed to missing opportunities for LGBT-specific sexual health counselling. For example, when we asked young people to tell us whether they were invited to identify their sexual orientation during clinical encounters, most reported that they perceived that they were presumed to be heterosexual, including several participants who identified in our study as being LGBT.

Youths living in the northern communities reported that they had far fewer opportunities to leave their communities to seek testing elsewhere since they had poor access to public transportation and often depended on their parents for transport. A female nurse from a remote First Nation’s health centre gave an example of how living in rural places can influence a young person’s access to testing:

“So if you’re say 14, and you’re in Grade 8 at [a remote reserve], and you’re peeing and it’s burning and you have some discharge, you got to ask your mom or a family member to take you to town [] There’s a huge risk of confidentiality breach for that young fellow.”

Characteristics of the clinics

Youths worried that their family doctor might breach confidentiality by discussing their STI-related visit with parents or other relatives who also are patients in the same practice. As a 20-year-old woman from Vancouver explained, she suspected that her mother’s relationship with their family doctor presented a risk for a confidentiality breach:

“Like she [my family doctor] talks issues with my mother, and my mother finds out through her. [] So that would be a little ‘iffy’.”

This prevented the woman from seeking STI testing through her family doctor; fortunately, she was able to access testing in a walk-in clinic. Limited service hours were also frequently cited as a problem, although limited hours of operation were particularly pronounced in Prince George and Quesnel. A female nurse from Quesnel explained how students there experience difficulties accessing the public health unit, which only provides testing services during 4 hours per week and how these hours of operation coincide with school hours:

“It’s a problem that we’re not open in the evenings [] we’re not open on Saturdays when kids might be downtown on their own.”

Many youths also described being stressed in the clinic waiting/reception areas. As a 21-year-old woman from Prince George explained:

“The clinic was probably the most nerve-wracking part—I knew people in the waiting room. It’s like, some people’s voices carry. And the receptionist could talk a little quieter about why I’m there.”

Some participants described clinics as ‘feminised’ spaces because of décor (for example, pink colour schemes; proliferation of posters about women’s health) and because the waiting rooms were primarily populated by women. For example, a 22-year-old woman from Richmond explained how the social spaces at a youth clinic she had previously accessed made her testing experience more comfortable:

“It’s very relaxed, very casual; you know they have signs up saying, ‘It’s a cell phone-positive zone.’ [] And they have magazines and lots of information pamphlets and the receptionist is young and so she looks very approachable when you come in. And I’ve never felt judged.”

Other young women and men told us that clinic spaces should be more gender-neutral in their décor and more “youth-friendly”.

Knowledge gaps related to testing

Many of the young women were unaware that having a Papanicolaou (Pap) test is not the same procedure as being tested for STIs, and service providers confirmed that most female patients did not differentiate between Pap and STI testing. A nurse from Vancouver explained:

“People are shocked to find out when they’ve gone for what they think was ‘everything’. [] They think by asking for a Pap, they’ll get it all.”

Most of the young men were unaware that a urine-based test for gonorrhoea is now available in many locations (although during our study period it was not widely used in Quesnel); thus, reducing the need for urethral swabs, which nearly every young man described as an impediment to their seeking testing.

DISCUSSION

These findings point to opportunities to improve STI testing services for youths. For example, in order to promote young people’s uptake of testing services, clinics would best be located in youth-accessible places and clinic hours should accommodate the schedules of young people. In some instances, perhaps most obviously in rural and/or more remote communities, school-based clinics (that offer general health services as well as sexual health services) could promote accessibility to testing and other sexual health services.26 27

“LGBT-friendly” services also need to be more widely available, especially in geographical and cultural contexts that are homophobic.28 Assuming that every young woman or man who presents for STI testing is engaged solely in heterosexual sex may mean that clinicians (and youths) miss opportunities to engage in important and potentially emancipatory discussions about sexual identities, diversity and the promotion of sexual health. Moreover, clinicians and public health service providers could model positive attitudes regarding diversity of all forms, including multiple sexual identities.

The décor of clinic waiting areas could be modified to be more youth-friendly and offer more gender-neutral décor options (for example, neutral colours; men’s magazines in waiting areas). Within some jurisdictions, the introduction of “men-only” clinic hours has been successful (while this approach has not yet been introduced at the clinics involved in our study, several are considering offering men-only hours and one Vancouver clinic will pilot-test this in 2009).29 30 While addressing concerns about privacy and confidentiality in rural/remote communities is complex, small actions may have some positive effects. For example, some of the clinics we visited attempted to provide privacy (albeit limited) by using frosted glass between the patient waiting area and the street front. As well, some clinics offer patients the opportunity to complete a pencil-and-paper intake form in the reception area in order to avoid having to state aloud their reasons for visiting the clinic.

Finally, in light of our findings related to youths’ low levels of awareness regarding Pap testing and urine-based testing (we noted this in every study site), it behoves the public health community as well as clinicians to systematically inform young people on both of these important issues (for example, public campaigns, patient counselling). That the Pap test remains confused with STI testing almost 50 years after its advent in Canada reflects negatively on health promotion and education efforts. That many young men continue to report that they avoid testing because they do not know that they could access urine-based testing,, rather than a urethral swab, also indicates a men’s health promotion problem and a potential lost treatment opportunity in this high-risk group. Although the design of the current study does not permit broad generalisations or statements regarding causality, it elicits insights that could be used to generate youth sexual health interventions.