Methods

The study used a cross-sectional convenience-sample design with a single questionnaire delivered to participants covering basic demographics, travel details (for example, length of stay), sexual behaviour (number of partners and condom use in Australia, number of partners over 12 months prior to leaving UK) and substance use (alcohol, tobacco, illicit drugs) during and prior to the stay in Australia. The study tool was adapted from a previously validated questionnaire of risk behaviour in holidaymakers,3 9 with questions changed where necessary to account for differences in holiday length and location.

The questionnaire was implemented in Sydney (New South Wales: 28 April to 22 November 2005) and Cairns (Queensland: 1 to 6 August 2005). In both locations, the sample was recruited at backpacker hostels on a convenience basis. A full list of hostels in each study area was identified through local telephone directories. Hostels within the study areas were contacted by telephone and arrangements for study participation made on an opportunistic basis. Inclusion criteria for backpackers in the study were being a UK national, aged 18 to 35 years and having been in Australia for at least 2 weeks. Trained researchers approached all potential participants opportunistically, identified their match to inclusion criteria, and for those meeting the criteria asked if they had time to complete a short questionnaire. Those who assented were provided with an explanation of the study, assured of the survey’s anonymity and reimbursed AU$10 for their time; informed consent was recorded and compliance was 90.8% (n = 1012 out of 1114). Participants were provided with a self-completion questionnaire and pen and plain envelope in which to return the completed questionnaire to researchers. Envelopes were provided to ensure confidentiality and questionnaires were returned to researchers in sealed envelopes immediately after completion. Completed questionnaires were then returned to the UK and entered into SPSS for analysis. Three questionnaires were excluded as responses did not meet survey inclusion criteria for age or period of stay (despite respondents being asked about these prior to participation) and one questionnaire was spoilt (uncompleted and defaced). Analyses were conducted using χ² and Wilcoxon Signed Ranks Test, with logistic regression used to control for confounding relationships between variables when examining predictors of sexual behaviour.

Results

Two-thirds (66.2%) of the sample were male and median age was 23 years. A fifth (20.7%) of respondents had travelled to Australia with a long-term partner or spouse (partner). At the point of interview, participants had been in Australia for a median of 8 weeks, while median planned length of stay was 25 weeks. Table 1 presents basic demographic features of the sample, length of stay in Australia and frequency of substance use and nightlife participation in Australia by gender and partner status (arrived with or without a partner). Participants interviewed in Sydney were more likely to be male and single (arrived without a partner). Males and single participants were more likely to have used tobacco and illicit drugs in Australia and report visiting bars and nightclubs frequently.

Table 2 shows the number of sexual partners reported by participants in the 12 months prior to leaving the UK, and sexual behaviour in Australia, by gender and partner status. Of the total sample, 965 (95.7%) provided information on sexual activity. Almost three-quarters (73.2%) had had sex during their stay in Australia, including 68.9% of those who arrived single. Almost half (45.7%) of participants arriving single reported more than one sexual partner since arriving in Australia, as did 17.6% of those originally arriving with a partner. Among single participants who had sex, 40.9% reported not always using a condom and 24.0% had unprotected sex (that is, without a condom) with more than one partner. Males were more likely to report sex without a condom, multiple sexual partners and more partners in the UK prior to their trip. Almost three-quarters (70.9%) of those arriving single, and 25.0% of those with a partner, reported more than one sexual partner in the UK in the 12 months prior to their trip. Across all participants, mean number of sexual partners reported per 4-week period increased from 0.3 in the UK in the 12 months prior to the trip to 1.0 per 4-week period spent in Australia (z = 17.178; p<0.001).

Logistic regression was used to identify factors independently related to having had sex, sex without a condom and multiple sexual partners in Australia (table 3). Participants interviewed in Sydney were less likely to have had sex in Australia, while those arriving without a partner were less likely to have had both sex and unprotected sex. However, among those who had sex in Australia, odds of multiple sexual partners were over five times higher in those arriving single. Length of stay in Australia at time of interview was significantly associated with having had sex and having multiple sexual partners, while total planned stay was associated with unprotected sex and multiple sexual partners. Frequently visiting bars or nightclubs (5+ days a week) in Australia increased the odds of unprotected sex and multiple sexual partners, while odds of having sex in Australia were 3.5 times higher in those who frequently drank alcohol (5+ days a week; cf ⩽once per week). Illicit drug use in Australia was associated with both having sex and having more than one sexual partner. The number of sexual partners reported in the 12 months before leaving the UK to visit Australia was strongly associated with both having sex in Australia and having multiple sexual partners.

Discussion

British backpackers surveyed here showed elevated levels of sexual activity while in Australia, with greater numbers of sexual partners reported during the trip than during equivalent time periods in the UK. Four out of five had arrived in Australia without a partner, yet 68.9% of these had had sex by the time of survey and 45.7% had multiple sexual partners. Even among those arriving with a partner, almost one in five (17.6%) reported more than one sexual partner since arriving in Australia. A number of limitations need to be taken into account when interpreting findings from this study. Sampling took place on a convenience basis, with potential participants approached opportunistically in hostels that permitted researchers to use their premises for data collection. Combined with the lack of information available on the characteristics of backpackers visiting Australia in general, this means we cannot identify how representative participants were of all UK backpackers in Australia. Consequently, findings cannot be generalised beyond the sample used in this study. However, to minimise bias, all potential participants were approached by researchers and the refusal rate was only 9.2%. This high compliance rate may have been achieved through the provision of a small financial incentive to individuals living on a low budget. With sampling taking place part way through participants’ stays in Australia, findings will under-represent levels of sexual activity among backpackers during their total stay; higher numbers of partners were seen among those who had spent longer periods in Australia. Further, as with all surveys of risky behaviour, our study may also have been influenced by under-reporting or exaggeration of sexual behaviour. However, to minimise such effects, we used a methodology that ensured participants were fully informed of the survey’s purpose and were assured of confidentiality and anonymity in the data collection process.

Travelling and holidaying has long been associated with sexual risk-taking in young people.1 2 3 4 5 Research has found that those participating in independent, exploratory and active forms of travel, such as backpacking, show higher sensation seeking traits than those choosing organised, familiar, holiday styles.17 18 This suggests that backpacking appeals to people who are open to experimentation and risk-taking, which may extend to sexual risk-taking. In this study, 40.9% of “single” sexually active backpackers did not consistently use condoms in Australia and 24.0% had unprotected sex with multiple partners. Location of travel can be fundamental to perceptions of risk and travellers with high sensation seeking traits have been found to view Australia as a less risky location than other countries.17 This perception may also translate to backpackers’ judgement of the risks of sexual activity in Australia. Thus, while British travellers may hold reservations about having new sexual partners in, for example, Africa or Asia, they may perceive the travelling and local populations in Australia to be similar to those at home thereby reducing their risk perceptions of sexual activity here.

Consistent with other research,3 11 this study found that backpackers who are most sexually active at home are also more sexually active abroad (table 3). Other studies have found sexual expectations of a backpacking experience and a history of unsafe sex to also be influencing factors in sexual behaviour.11 Importantly, here both length of stay at time of survey and total planned stay were associated with risky sexual behaviour. Odds of sex without a condom were twice as high in those planning to stay in Australia over 12 weeks; odds of multiple sexual partners were five times higher in those who had already been in Australia over 12 weeks. The backpacking experience may itself engender a more experimental, less consequence-driven attitude towards sexual activity that develops with length of travel and increased socialisation with other backpackers. This indicates that backpackers, particularly those planning longer stays, are at elevated risk of STIs and other negative sexual health outcomes, even at the outset of their journey. Therefore, this is a key time to target backpackers with sexual health promotion messages via, for example, backpacker guide books, websites and medical services used in preparation for their journey.19 With perceived norms of peer sexual behaviour impacting on young people’s own behaviour,20 such information should stress that most backpackers having sex with new partners abroad routinely use condoms (here 59.0% of single backpackers having sex).

Sexual risk-taking is compounded by the social aspects of backpacking. Odds of having sex in Australia were 3.5 times higher in those who drank five or more times per week (cf ⩽once per week) (table 3). The influence of alcohol on sexual behaviour has been widely documented.21 22 Research elsewhere has found alcohol use to be one of the reasons most cited by backpackers for engaging in casual sex.11 In our study, illicit drug use in Australia was also independently related to having sex and multiple sexual partners in Australia (table 3). It is unknown if substance use and sexual activity occurred simultaneously among backpackers and survey findings cannot establish cause or effect. However, sensation-seekers have been found to be particularly susceptible to alcohol’s disinhibitory effects,23 while substances may be used specifically by individuals to excuse or enable behaviour they intend to adopt. Thus, both alcohol and drugs are used by young people to increase social confidence, facilitate sexual relationships and enhance sexual experiences,21 24 and these functions may be particularly pertinent to backpackers, who typically form short-lived yet intense relationships while travelling.25 Previously published work shows British backpackers increase their frequency of alcohol use in Australia (cf UK) and over half use illicit drugs.16 Much substance use occurs in nightlife and here regularly visiting bars/nightclubs in Australia was associated with multiple sexual partners and unprotected sex. Thus, such locations would appear appropriate for targeting sexual health interventions at backpackers, including distributing health promotion literature and free condoms and advertising sexual health services. Sexual health promotion campaigns have been directed at backpackers in parts of Australia.12 However, local campaigns alone may have minimal impact on sexual risk-taking behaviour or STI diagnoses in such transient populations. Outreach services may be important as they are frequently more effective with hard to reach groups.26 Further, the key role of hostels in backpackers’ social interaction and trip planning27 suggests these settings would be critical locations for sexual health interventions, and their staff important partners in sexual health promotion.

Overall, four in ten backpackers had had more than one sexual partner in Australia by the point of survey. These findings, and those from other studies,11 12 suggest that many backpackers have casual sexual relationships, predominantly with other backpackers,11 which are likely to be in close succession. High rates of partner change,28 along with unsafe sexual practices, create an ideal environment for STIs to rapidly spread. STIs are often asymptomatic and where backpackers do seek treatment, engaging their partners directly may prove difficult. However, those who seek testing and treatment for STIs may be a key population to adopt or pilot a patient expedited method of partner treatment (EPT). EPT is where a sexual partner of an infected person is treated without testing or medical consultation, usually through patient-delivered partner therapy (PDPT). Evidence suggests these strategies can lower re-infection rates29 30 and reduce the likelihood of patients re-establishing sexual relationships with an untreated partner.31 While not all sexual partners will be contactable, backpackers can spend prolonged periods in a single location and social group; especially when they are seeking employment to re-finance their travel. Further, backpackers’ prolific use of mobile phones, email and other online resources (for example,. online backpacker networks)32 means that although some liaisons may be brief, they have more opportunities than ever before of experiencing prolonged social relationships, maintaining communication or reconnecting with a previous sexual contact. There is currently little evidence on the effectiveness of PDPT in travelling populations yet, faced with such a challenging group, this (where possible) may be a pragmatic approach.

Addressing risky sexual behaviour in backpackers can only be achieved through a joint health promotion strategy between health services, local authorities, tourism organisations and other relevant organisations. Limited information exists on backpacker websites or in guidebooks to highlight the sexual risks facing backpackers on their travels. Without these public health messages, people preparing to travel may not consider the provisions they will need for safe sex, for seeking sexual health services (for example, emergency hormonal contraception, condoms, STI tests) while abroad or the sexual risks associated with alcohol and drug use on their journey. Regardless of the casual manner in which young people can plan and undertake backpacking tourism, it is nonetheless a profitable and growing industry. Like any industry it has a responsibility for the safety of those participating in it and this should include a commitment to protecting sexual health.