The higher-risk group

While the higher-risk group made up only approximately 23% of the student population in this study, they represented nearly 70% of the total number of sexual intercourse partners in the previous year. As people who have multiple sexual partners in a year are more likely to report having had an STI, it is likely that this subgroup would be overrepresented in terms of negative sexual health outcomes (Grulich et al., 2014b) and as such should be a focus for sexual health promotion. Thus far, however, the sexual health promotion needs of this population have not been fully explored in Australia. This thesis represents one of very few such attempts to address this lack of understanding.

Higher-risk respondents who had attended university sexual health promotion events were likely to consider them relevant or very relevant, however the proportion of this group attending sexual health events was low. As many university sexual health promotion events are optional rather than mandatory, this would allow for the possibility of a self-selecting sample already interested in sexual health, similar to the volunteer bias found in sexuality research (Wiederman, 1999). This suggests that the small proportion of higher-risk students currently reached by sexual health promotion events may be mostly those who are already engaged with sexual health issues. To more effectively promote sexual health issues, it is clear that different strategies need to be used in order to reach an audience beyond this highly engaged group.

Lack of advertising was the most commonly selected response as to why higher-risk respondents had not attended a university sexual health promotion. However as the respondents were not asked to rank the options they selected this does not imply that it was the most compelling reason, simply the most common. The next most likely response ‘I already know enough about sexual health’ suggests the possibility of a feedback loop. If high self-perception of sexual health knowledge makes a student less likely to attend an event, they have little chance of encountering new information to challenge this attitude. This suggests that simply offering the information is not enough. In order to attract those most at risk other elements appealing to the higher-risk group must be provided. While the

use of incentives has already been shown to be effective at increasing participation in sexual health testing (Currie et al., 2010), it is not simply the higher numbers that are important, but the fact that the additional people gained were probably less likely to seek out information and testing on their own.

Higher-risk students were more than twice as likely to have had a sexual health test in the past 12 months when compared with the lower-risk, sexually active students, however over half of the higher-risk group had not been tested within the past year. While this shows considerable room for improvement, it remains comparable with Australian averages with 38.0% of men and 50.0% of women who had multiple partners in the previous year reporting testing in that period (Grulich et al., 2014b). When higher risk respondents who had never been tested were asked what factors influenced their decision, the two most commonly selected responses from the higher-risk group were ‘I haven’t had many sexual partners’ and ‘my behaviours aren’t risky’, despite the group being defined on the risk factor of having more sexual partners. This disconnect between behaviour and risk perception that has also been identified in a number of other studies on sexual health in universities (Downing-Matibag and Geisinger, 2009; Hickey and Cleland, 2013). A risk analysis perspective suggests this perception will be hard to overcome, as in general people base risk judgments on what they feel, not just what they think (Slovic et al., 2004). Activities marked by a positive emotion or affect are more likely to be deemed less risky and more beneficial, with factors such as sexual desire producing exceptionally powerful emotions (Slovic et al., 2004). This indicates that trying to encourage testing by talking about the negative outcomes for higher-risk groups will likely be hampered by a low self-perception of risk. Instead, destigmatising testing and framing it as a proactive and responsible choice for all sexually active young people may be a more effective approach to increase participation.

For both higher-risk and lower-risk groups a social event with a sexual health message was the most preferred event, matching current sexual health promotion activities as reported by the Promotion Survey respondents. However despite sexual health testing placing a close second in terms of higher-risk group ranking it was the least likely type of event to be currently taking place in universities. Given the reported willingness of Australian university students to increase testing (MacPhail et al., 2017) and success of previous

university trials of programs that combined sexual health screening with a modest incentive (Currie et al., 2010), this suggests the possibility of effective expansion in this area.

Of all the suggested incentives, free alcohol was the least likely option to be present at university sexual health events, despite alcohol being the most selected tangible incentive for higher-risk students. While university groups may hesitate to use alcohol due to concurrent aims to reduce binge drinking or the relatively higher cost, the provision of refreshments has already been used as an incentive for participation in successful on-site STI testing programs in settings such as football clubs (Gold et al., 2007). While more attractive incentives such as alcohol or money may be more expensive to provide, the increased uptake of testing can make it the more economical option once labour costs are included (Currie et al., 2010).

Social factors were another key motivator for encouraging higher-risk respondents to attend promotions, as shown by the high rankings of ‘knowing a friend who was going’ and ‘combined with social activity’. This is congruent with previous research which found that a student’s social support can play a defining role in determining important choices such as whether to drop out of university (Wilcox et al., 2005). This further suggests that focusing on campus groups with pre-existing social ties will be an effective means of maximising attendance at sexual health promotion events.

Pleasure, emergency contraception and abortion were topics where interest from the higher-risk group was significantly greater than coverage by existing events. The high ranking of pleasure on this list may reflect a widespread lack of discussion in existing sex education, with fewer than 7% of young Australian women having learnt about it at school (The Equality Rights Alliance’s Young Women’s Advisory Group (YWAG), 2015). As pleasure was the most frequently selected topic that young Australians reported preferring to learn outside of school (Giordano and Ross, 2012), socially oriented sexual health events at university may provide a good platform for this information. Aside from encouraging “the possibility of having pleasurable and safe sexual experiences” (World Health Organisation, 2006) as per the World Health Organisation’s definition of sexual health, such an addition may help to attract audiences who would not otherwise attend.