Māori and Pacific young people’s perspectives on testing for sexually transmitted infections via an online service: a qualitative study

Participants and recruitment

Eligibility criteria included age 16–24 years, Māori or Pacific ethnicity, and any gender. Participants were recruited via community organisations that provide services, support and youth development opportunities to Māori and Pacific youth in Porirua and Lower Hutt (cities in the Wellington region of NZ with high Māori and Pacific populations). Participants in Groups 3 and 4 were not in employment, education or training (NEET) and completing strengths-based readiness to work programmes. Groups 1–3 met at the recruiting organisation premises (familiar to participants), and Group 4 met in a marae. Participants received a NZ$200 giftcard in recognition of their contribution to the research.

This study was approved by the University of Otago Human Ethics Committee (Health) on 31 January 2022 (REF H22/003).

Wānanga plan and data generation

We held four wānanga between November 2022 and May 2023, bringing groups of young people together to share knowledge and views about online STI testing in a non-judgmental space. We recognised participants as the experts and knowledge holders (consistent with a participatory approach).²¹ Fig. 1 describes key elements of the wānanga. Three members of our research team facilitated wānanga, all were female (Pākehā, Sāmoan/Palagi and Māori/Pākehā) with experience related to youth health, rainbow health, mental health, midwifery, Pacific and Māori health, qualitative and co-design research methodologies. Discussion focused on two topics: (1) online STI testing (presented here); and (2) making it easier for young people to access information and services for sexual health (reported in a separate paper). Discussions were audio-recorded with participants’ written consent and ideas generated in small break-out groups captured as written ‘groupwork’ notes. A facilitator took fieldnotes during the wānanga then undertook rapid notes analysis immediately afterwards to produce a succinct overview of discussions.

Fig. 1.

Plan used to guide wānanga with participants. ^AAfter the wānanga. Following analysis, a summary of the main findings was collated and emailed to participants (those who expressed an interest in receipt of a summary), community organisations and others who helped with aspects of this work. Feedback and questions were invited (but none received).

Analysis

The first two wānanga were transcribed verbatim by team members; the third and fourth (shorter meetings) used Sonix AI transcription software with manual correction of content errors in pertinent parts of the transcript. Fieldnotes were used to produce an initial framework for considering the data with analysis proceeding using inductive thematic analysis.²² Three team members familiarised themselves with written transcripts with coding undertaken sequentially by each member (TG then AD then SR). Codes and topic headings were generated and quotes that illustrated or supported topics were extracted from transcripts and stored in a table. The table was discussed among the team, which led to some revision and refining of the topics and agreement on three main themes. Selected quotes are used in results tables to support the key themes and ideas. Some quotes reflect unique views held by one or a few participants, and others reflect more commonly held views. Quotes have been edited for brevity (fillers and repetition removed) and annotated with the group number (G1-4), gender of the speaker (M, F) and ID (participant number) where distinguishable; gender and speaker ID were not always clear from audio-recordings. Some participants are over-represented in the quotes because they were the nominated spokesperson to share with the main group following group work.

Characteristics of participants

In total, 38 participants aged 15–24 years took part; 60% were female and 40% male. Half the participants were Māori and half Pacific ethnicities (14/19 were Samoan), 13% were sexuality diverse (gay, bisexual, pansexual) and two groups were NEET. Just under half (42%) self-reported having been tested for an STI in the past (14/23 females and 2/15 males). Table 1 describes the demographic characteristics of participants and groups.

General awareness of the topic (when and where to get an STI check)

The quiz activity opened the conversation about STI testing, prompting an opportunity to discuss key facts about testing for common STIs, when and where to get tested. Responses revealed that most participants knew STIs are common and can affect anyone (92%, 35/38). Over one-third thought STIs can be caught via a public toilet seat (39.5%, 15/38), suggesting some lack of awareness about skin-to-skin contact being the most likely mode of transmission. All knew STIs do not always have symptoms (100%, 38/38), and most understood that an STI needs to be treated because it would not go away by itself (92%, 35/38). Sixty percent thought getting an STI test would be painful (23/38), suggesting unfamiliarity with self-collected urine or swab sampling that is commonly used for asymptomatic chlamydia and gonorrhoea testing.

Collectively, groups had a reasonable understanding of when to get an STI check. Suggestions included: when sexually active, with a new partner, when you have more than one partner, when you want to, when someone has cheated, so you do not pass the STI on. Some suggested getting tested regularly; others thought every few months or every 6 weeks was appropriate. There were some omissions, with no mention of testing in pregnancy, when symptomatic, or when a partner tests positive. Some participants were less certain about where to get tested. The general practitioner (GP) or doctor were mentioned in three groups, and family planning and a youth health service were mentioned in two groups. One person asked if you could do the test yourself or get something from a pharmacy, another asked if you could go to the hospital, another said they would Google it. Most participants in Group 3 (NEET) did not know and no-one mentioned a sexual health clinic or student health service.

Further insight into participant knowledge of the topic was gained from final remarks when they were invited to share something they had learned or that stood out for them at the close of each wānanga. Comments included: ‘You can’t catch an STI from a toilet seat’, ‘It doesn’t hurt to get an STI test’, ‘STI tests are free for under 22-year olds’, ‘How a vaginal swab test works’, ‘What testing kits look like’, ‘You can get a test from your bum’, ‘It doesn’t hurt’, ‘Everything was pretty new’, ‘There are different types of test kits’, ‘You can self-test and at home’, ‘There is a website for online testing’, ‘Hearing about other’s opinions’, ‘Different resources that are available’, ‘Most young people don’t know about self-testing’, and ‘There was never an awkward moment’. These reflections highlight the overall positive nature of discussions and are suggestive of an increased awareness about STIs and testing.

Main themes relating to online STI testing

The three main themes identified from discussions are broadly described as: (1) ‘Potential to support autonomy’ (encompassing perceived benefits of online STI testing and positive features of the self-sample collection kits); (2) ‘Barriers and process-related concerns’ (reservations about online testing and self-sample collection); and (3) ‘Tailoring online STI testing to young people’s needs’ (supporting engagement with online STI testing).

Some participants drew on experience with coronavirus disease 2019 (COVID-19) rapid antigen tests (RATs) as they familiarised themselves with the self-sample kits. They commented that swabs looked like those used to test for COVID-19, but that they ‘just go in different places.’ Participants in Group 2 expressed a desire for STI testing to be as easy and accessible as COVID-19 tests, including the possibility of tests with immediate results (ie ‘point-of-care’ tests).

Theme 1: potential to support autonomy

This theme incorporates two sub-themes: (a) perceived benefits; and (b) positive features of home self-sample collection kits (Table 2). Participants were unanimous in their view that the cost of ordering a kit meant neither they nor their peers would be able to access this service. When asked to set cost aside, perceived benefits included convenience, accessibility, avoiding the embarrassment associated with a clinic visit, and the ability to use it in certain circumstances. Attributes of the kits favoured by some participants included: easy-to-use readymade kits and discreet packaging.

Theme 2: potential barriers and process-related concerns

Participants spent more time discussing barriers and aspects of the process they did not like or found confusing than positive aspects. Theme 2 is summarised in Table 3 and draws together two subthemes: (a) general barriers; and (b) specific process-related concerns. These reservations led some to question whether the test result would be accurate or reliable if they took their own sample, with related expressions of uncertainty about their own likelihood of using online testing.

Theme 3: tailoring online STI testing to young people’s needs

While considering the service and sample collection kits, participants shared practical ideas about how they would re-design some aspects to better meet the needs of their peers. Theme 3 ‘Tailoring online testing to young people’s needs’ summarises these suggestions, which included reducing cost, supporting knowledge about testing, improving accessibility to instructions, providing alternative ways to access tests and return samples, ensuring support for service users and making treatment easy to access (see Table 4). Supplementary Table S1 includes selected participant quotes that support the recommendations presented in Table 4.

Strengths and limitations

This study is the first to report on young people’s perspectives on online STI testing in NZ. Barriers, enablers and strategies that could be implemented to support engagement by Māori and Pacific young people were identified. Our recruitment method was a strength of the study. By working with community organisations that support youth development, meeting in convenient locations and offering gift cards, we achieved our recruitment goals. We had an equal split of Māori and Pacific participants, half of whom were NEET. The sample was inclusive of gender and sexuality diverse participants, with different levels of knowledge and STI testing experience to draw on. Many participants knew each other, had shared aspirations or were at similar stages in their lives. Humour and shared laughter were common throughout, particularly while reviewing kit contents in smaller, mostly gendered groups.

Limitations of the study include the use of mixed gender meetings, which we acknowledge might not align with some Pacific cultural protocols for discussions related to sexual health. We were led by the community organisations that arranged participant recruitment and all participants consented to take part knowing groups were mixed. Small group discussions were mostly gender-specific, but some participants might have felt less able to openly share views when reporting back to the mixed-gender group. We expected most participants in one of our groups to be sexuality or gender diverse based on communications with organisers, but most identified as cis-gender, heterosexual/straight, so some views unique to gender and sexually diverse Māori and Pacific young people will have been missed. Facilitators were unknown to participants, which could have been a positive or negative in terms of participants willingness to share. The inclusion of a male facilitator would have been beneficial for encouraging greater engagement by male participants. We explored Māori and Pacific perspectives as prospective users of online STI testing (similar to the approach taken in most of the published literature to date).¹³ Further research is needed to evaluate the experiences of actual service users in NZ to differentiate between real and perceived barriers. Feedback on the online testing website itself was not sought in this study. We acknowledge that some uncertainties around processes might have been clarified had participants directly engaged with the website, or been able to read the frequently asked questions (FAQs) section.

Implications

Increased access to innovative testing and treatment approaches has been identified as a priority area in the Aotearoa New Zealand Sexually Transmitted and Blood Borne Infection Strategy 2023–2030. Drawing directly on voices from priority groups, this study generated new knowledge about barriers, enablers and recommended changes that could inform future planning or policy related to online STI testing. A funded service would improve choice for young people, but if under consideration, it would be crucial to involve Māori and Pacific young people in the co-design of key elements in the testing pathway to maximise access and acceptability among these priority groups. To improve testing coverage (in any setting), investment is also needed in culturally appropriate health promotion^29,30 to support young people’s understanding of when, why and how to access a sexual health check.