Community attitudes to the sexual behaviour of young people in an urban area with high rates of sexual ill-health

Context Adults in any community are a potentially important source of sexual health information for young people. Open discussion of sexual health issues is associated with low rates of sexual ill-health. Adults who disapprove of teenage sexual behaviour are poor sources of advice. The study of adult attitudes to the sexual behaviour of young people is relevant to work on improving access to sexual health services. Setting Adults' attitudes to the sexual behaviour of young people in an urban area with high indices of sexual ill-health were documented. Design Data were collected via questionnaires administered in popular shopping areas by local people after training. Results A total of 283 interviews were completed. Eighty-eight percent of respondents thought that the likely age of first sex among young people was under the age of consent but only 8% thought that the acceptable age of first intercourse was under 16 years. Knowledge of local services was suboptimal. Twenty percent of respondents did not know where young people could get contraception or advice on sexual health issues. Less than half (42%) suggested a general practitioner with a similar proportion suggesting a family planning clinic (FPC) or Brook clinic. When asked what services FPCs provide, only 40% mentioned contraception and 32% did not know. Despite their lack of knowledge, the majority (84%) of respondents would tell a young person where they could obtain contraception or sexual health advice. Seventy-six percent thought parents and 56% thought schools are the key sources of sexual health information for young people. Conclusions Adults resident in this area have negative attitudes to the sexual behaviour of local young people and suboptimal knowledge of local contraceptive services. They do, however, identify themselves as potentially important sources of sexual health advice and may therefore benefit from more information and an opportunity to discuss their attitudes.


Introduction
Young people in the UK experience exceptionally high rates of sexual ill-health. More than 41 000 women aged under 18 years became pregnant in England and Wales in 2002 1 and 1% of the 16-19-year-old female population seen in genitourinary medicine (GUM) clinics in England, Wales and Northern Ireland in 2001 was diagnosed with chlamydia infection. 2 Lack of sexual health information contributes to sexually transmitted infection (STI) and unwanted pregnancy among this age group. [3][4][5] Adults (particularly parents) are potentially important sources of sexual health information but may withhold this information if they feel that sexual activity among young people is inappropriate or if they do not have the relevant information themselves. Positive attitudes to teenage sexual activity and open discussion of sexual health issues between parents and teenagers are associated with low rates of teenage pregnancy. [6][7][8][9][10] Negative attitudes may increase the difficulty of service access if the service must be hidden to avoid disapproval. Some successful approaches to the reduction of sexual ill-health among young people have involved 'community-wide' initiatives to facilitate the open discussion of sexuality and sexual health issues. [11][12][13] This implies that community attitudes to the sexual behaviour of young people have important effects on the sexual health of this age group.
Many young people in England and Wales feel that the adults (particularly parents, teachers and health professionals) in their community disapprove of early sexual activity. 3 This perception limits access to sexual health information and services since young people are afraid to ask about sex and relationships and hide their use of sexual health services. [3][4][5]14 Fifty-two percent of young people find it easy to talk to their mother about sex and relationships and 26% find it easy to talk to their father. 15 There is some evidence to support the presence of negative attitudes among health professionals 16,17 and teachers 18 but there is less information on parental attitudes and those of other significant adults within the extended family or professionals such as youth workers. The much-publicised political debate on the subject reinforces the idea that adults are negative about sexual behaviour among young people but may not provide accurate signals as it has been dominated by a conservative minority. 19 Defining 'community attitudes' is difficult since most communities include individuals with diverse and often conflicting opinions. Even very local data will include diverse views and this is particularly true in urban areas with transient and ethnically diverse populations. 20 Adults who disapprove of sexual activity among young people are likely to be poor sources of information on sex and relationships. Data on community attitudes to the sexual activity of young people are therefore relevant to those working to promote sexual health among young people. In this paper we present the results of a community survey of attitudes to sexual activity among young people in an urban area with exceptionally high rates of sexual ill-health.

Study parameters Aims
The study aimed to document the views among the adult residents of the Bermondsey area of the London Borough of Southwark on the following questions: q At what age are young people living in the area most likely to first have sex (defined for the purposes of this study as heterosexual intercourse)? q At what age is it acceptable for young people to start having sex? q How much importance do young people place on safety (in terms of the prevention of pregnancy and sexually transmitted infection) when they first have sex? q Where can young people get information on contraception and sexual health issues locally? q What services do family planning clinics provide and for whom? q Would you tell a young person where they could go for information and advice on contraception and sexual health issues? q Who do you think are the key people responsible for giving information and talking to young people about sex, relationships and contraception?

Setting
The data were collected in an inner-city area with very high levels of socioeconomic deprivation, an ethnically diverse population and exceptionally high rates of sexual ill-health. The London Boroughs of Lambeth, Southwark and Lewisham have the highest rates of conceptions in under-16-year-olds 21 and the highest rates of abortion for all ages in the UK (8428 abortions performed in 2001). In addition, a quarter of the total cases of genital chlamydia infection diagnosed in London GUM clinics were diagnosed in these Boroughs. 22 Southwark is the eighteenth most deprived local authority in England. 23 Sixty-three percent of the population defines itself as White British, 26% as Black or Black British, of which 16% define themselves as African and 8% as Caribbean. 24

Methodology
Sexual ill-health is known to be associated with socioeconomic deprivation 10 therefore a methodology was chosen to facilitate the participation of those who might find a formal interview intimidating and/or those with low levels of literacy. It was felt to be important to collect data in a community setting away from sexual health services to reach those who do not use local services. Anyone over the age of 16 years was eligible for inclusion in the study. In each session passers-by were approached and invited to participate in the research by local people who had received training in research techniques (subsequently referred to as researchers). If they agreed the questionnaire was then administered and the responses recorded by the researcher. A total of 283 interviews were completed in four sessions in July 2002. Two sessions were at Bermondsey market (both in the morning), one session was at Surrey Quays shopping centre (in the evening) and one session was in a local park (at lunchtime). The number of individuals approached who refused to be interviewed was not formally recorded and this is recognised as a possible limitation of this study.
Following consultation with local youth and community workers, the researchers were mainly recruited from the parents' social group of a local primary school. The survey team comprised five interviewers and a research co-ordinator. All interviewers were female, aged 28-37 years and three were from ethnic minority communities, two were unemployed and two were single parents. Two of the interviewers were completely new to research.
All interviewers received two half days of training and piloted the schedule among themselves and with friends and family. Their feedback on the acceptability of some questions was used to develop the questionnaire. The team was given ongoing support during the project with regular sessions to discuss problems and share successful ways of working.
The questionnaire included 13 questions, five of which collected demographic information about the respondents. The remaining seven questions corresponded to the aims of the study listed above.

Analysis
The numerical data were analysed using SPSS for Windows (SPPS Inc., Chicago, IL, USA), and t-tests were used to compare the mean responses by different groups of respondents to the first questions concerning likely and acceptable age of first intercourse. Two further questions invited respondents to explain their answers: (1) At what age do you think it is acceptable for young people to first have sex? (2) How much importance do you think young people place on safety when they first become sexually active? Themes in these data were identified and each comment coded according to these themes. Examples of comments that illustrate the themes mentioned most frequently were identified and are quoted to illustrate the numerical findings.

Demographics
Eighty-seven percent of interviewees lived locally. Sixtyseven percent of respondents were women, 31% men and less than 2% were interviewed as a couple. The age range of the sample is given in Table 1. Twenty percent of the respondents classified themselves as being from an ethnic minority compared to 37% of the population of Southwark. Chi-square testing showed that the ethnic breakdown of the sample was different to that of Southwark at the 5% significance level. Sixty-three percent of respondents were parents.

Perceived age of sexual activity
A majority of respondents (88%) thought that the likely age of first sex among young people in Bermondsey was under the age of consent but only 8% thought that the acceptable age of first intercourse was under 16 years (Table 2). The median age of acceptable first intercourse was thought to be 16 years (Table 3). The majority of respondents (52%) thought that it was important to wait until the age of 16 years because it was only then that young people were sufficiently emotionally mature. Eighty-six respondents mentioned the need to be responsible or mature when explaining their answers to this question.
"hopefully their minds and bodies will be mature enough to handle the pressure." "I think this age is more acceptable as the person is more mentally and physically aware of the dangers and health reasons why you should not have sex at an early age." "At 12 there is too much responsibility, at 16 they will know more about the risks and themselves." There was no significant difference between men and women as regards the ages at which they believe young people are having sex. However, when asked what was an acceptable age of first sexual intercourse, women gave a significantly higher age than did men (17.2 vs 16.8 years, p = 0.045). Parents' estimation of the likely age of first sex was significantly lower than non-parents (13.5 vs 14.1 years, p = 0.001) and parents' estimation of the acceptable age of first sex was significantly higher than non-parents (17.2 vs 16.8 years, p = 0.006).
The respondents felt that young people placed very little importance on safety (in terms of the prevention of pregnancy or STIs), with 72% stating that safety was of little or no importance to young people at the time of first heterosexual intercourse ( Table 4). The commonest reasons for this were thought to be irresponsibility (35%) and lack of information (25%). Knowledge of local services Knowledge of local services was suboptimal. Despite there being a large GUM medicine service, a FPC that is open every weekday and a Brook London clinic in the area, 20% of respondents did not know where young people could get contraception or information/advice on sexual health issues in the area. Less than half (42%) suggested a general practitioner (GP), with a similar proportion (41%) suggesting a FPC or Brook clinic. A further 18% gave the name of a local health centre that offered both GP and family planning services and a further 17% gave nonspecific responses such as 'health centre' or 'clinic'. None of the respondents mentioned the local GUM clinic.
When asked what services FPCs provided only 40% of the respondents mentioned contraception and 33% did not know.
Despite their lack of knowledge the vast majority (84%) of respondents would tell a young person where they could obtain contraception or sexual health advice (if they knew). Seventy-six percent thought parents and 56% thought schools are the key sources of information for young people on sex, relationships and contraception.

Discussion
Individuals from a wide range of ages and ethnicities were recruited but men and those from ethnic minorities were under-represented. The study would have benefited from a more formal sampling system to generate information from a group more representative of the local population.
Our respondents may have an inaccurate impression of the age at which young people in the area first have sex. Whereas 88% of those interviewed in Bermondsey thought that young people first have sex under the age of 16 years, the National Survey of Sexual Attitudes and Lifestyles (NATSAL II) shows that 30% of young men and 26% of young women report first heterosexual intercourse under the age of 16 years. 25 At a national level, young people also have an inaccurate perception of the age of first intercourse with 46% of young people stating that the majority of adolescents have sex before the age of 16 years. 15 However, high rates of sexual ill-health among young people in Bermondsey compared with national indicators suggest that sexual behaviour in the area is not representative of that in the rest of England and Wales and no local-level data on age of first intercourse are available to facilitate a more accurate analysis of our findings.
Although our respondents felt that most young people have sex under the age of 16 years, the majority felt that this was unacceptable. More respondents gave 16 years as the acceptable age of first intercourse than any other age. Sixteen is the median age of first intercourse reported by the NATSAL II study; 25 the views of our respondents on what is acceptable are therefore consistent with what is happening at a national level.
We documented a view that young people are not concerned about the prevention of STI and unintended pregnancy at the time of first intercourse with the reasons for this given as 'irresponsibility' and lack of information. The description of young people as irresponsible suggests a negative view of their approach to sexual health. The identification of lack of information as a contributory factor is significant since the respondents identified themselves (most respondents were parents) as the key individuals responsible for informing young people about sexual health issues. This finding differs from those of other studies that report parents as reluctant to discuss sexual health issues with their children because of embarrassment and a perception that young people 'know it all already'. 4 The 'tracking survey' commissioned as part of the evaluation of the Teenage Pregnancy Strategy found  that only one-fifth of a national sample of parents said that they personally had given their child a lot of information about sex and relationships. 15 The view that parents are key sources of sexual health information is important since discussion of sexual health between parents and their children rather than the referral of this responsibility to schools is associated with better sexual health indicators among young people. 26 The suboptimal knowledge of local sexual health services among our respondents is a barrier to their potential role as educators of young people. There is some evidence to show that extending outreach programmes to the parents of teenagers is effective at preventing adolescent pregnancy 11 and sexual health service information targeted at local adults might be an important part of the teenage pregnancy prevention strategy in the area.

Conclusions
Adults resident in this urban area with high indices of sexual ill-health have inaccurate perceptions of the sexual behaviour of young people and suboptimal knowledge of local contraceptive services. If given information about the actual sexual behaviour of young people and about local service provision they identify themselves as potentially important sources of sexual health advice.