‘Every strategy needs to be contributing to erasing the stigma’: Māori and Pacific young people talk about overcoming barriers to testing for sexually transmitted infections

Participants and recruitment

To support participant recruitment, we undertook stakeholder engagement to seek practical advice and contacts of people or groups that might be willing to assist with recruitment in the Wellington region. Over 6 months, we met with 10 Māori and Pacific adults working in the community as educators, health promoters, youth workers, and school nurses. This resulted in successful links with four (non-health related) organisations that provide services, support, wellbeing and resilience programs to Māori and Pacific rangatahi. These organisations approached potential participants, explained the study and obtained signed informed consent on our behalf. Eligibility criteria are: age 16–24 years; Māori and/or Pacific ethnicities; and willing to share views about sexual health in a group setting.

The University of Otago Human Ethics Committee (Health) approved this study on 31 January 2022 (REF H22/003).

Wānanga overview and data generation

We ran four wānanga (workshops) for four different groups of rangatahi between November 2022 and May 2023. Wānanga were facilitated by three members of our research team: (1) TG, Pākehā; (2) AD, Sāmoan/Palagi (European); and (3) MC, Māori/Pākehā. All were cis-female aged in their 30s and 40s with a mix of experience related to youth health, mental health, midwifery, Pacific and Māori health and co-design research.

Three meetings were held at the community organisation venues and one in a local marae (Māori meeting house). In Groups 1, 2, and 4, a team member of the organisation was present for parts of the wānanga, while in Group 3, the organisation team member stayed nearby but not in the same room. Wānanga ran for 1.5–3.5 h, dependant on group availability. Participants in Groups 3 and 4 were not in education, employment or training (NEET) and involved in readiness to work/train/study programs. They took part in our wānanga immediately after one of their scheduled meetings so these wānanga were shorter in duration. Participants received a $NZD200 gift card in recognition of their contribution to the research.

Fig. 1 shows an overview of the plan used to guide wānanga. Discussion was split into two parts: (1) views towards online STI testing (reported separately);²³ and (2) understanding and overcoming barriers in access to STI testing (presented here). Participants were asked to imagine they worked in the community and had been tasked with coming up with practical ways to overcome some of the barriers they had identified as limiting access to STI testing. Wānanga concluded by inviting participants to share something they had learnt or that stood out, how they felt at the end of the session and plans for the rest of the day. A local, evidence-based website about sexual health was shared, and pamphlets on STI testing offered in English and Māori. Facilitators had contact details for support organisations in case any participant expressed a need for information or support (no-one did).

Fig. 1.

Plan used to guide wānanga (workshops).

Wānanga were audio-recorded, and ideas generated in group discussion were captured by participants as written group work notes. The first two meetings were transcribed verbatim by two members of the research team, the third and fourth (shorter meetings) were transcribed using Sonix AI software with a member of the team manually correcting any content errors in pertinent parts of the transcript by re-listening to the audio. Team member AD took fieldnotes throughout each wānanga and undertook rapid analysis immediately afterwards to generate bullet-point summaries.

Data analysis

We used an inductive thematic analytical approach, starting with data familiarisation (reading transcripts and summaries) followed by an iterative coding process, development and refinement of themes.²⁴ Lead facilitator TG undertook initial coding, with subsequent review and additions by AD and SR. A table was produced with broad topic headings and subheadings incorporating codes, short notes and selected quotes from transcripts. This was then split into two tables: one related to barriers to STI testing; and the other with content related to overcoming barriers. Theoretical coding was then undertaken by AD (Sāmoan) for data related to barriers to STI testing. Data were grouped thematically drawing on two holistic models of health and wellbeing: (1) the Pacific Fonofale model;²⁵ and (2) the Te Whare Tapa Whā Māori model.²⁶ The Fonofale model provides a way of conceptualising Pacific wellbeing using the fale (traditional Sāmoan house) to represent the different constructs of health.²⁵ Developed by Karl Pulotu-Endemann in 1984, this model recognises the importance of interconnected Pacific values (family, culture and beliefs, spiritual, physical, mental and other aspects of wellbeing) together with surrounding influences such as time, environmental and context.²⁵ Similarly, the Te Whare Tapa Whā is a model developed by Mason Durie in 1994 that depicts a wharenui (traditional Māori meeting house) to symbolise the strong foundation upon which the four equal walls or dimensions considered important for Māori health and wellbeing sit. These dimensions are: (1) physical; (2) mental and emotional; (3) social (whānau/family, friendships); and (4) spiritual values and beliefs are inter-related and each supports the others.²⁶ Both models recognise that all dimensions are considered as equally important components of a whole, so in the context of sexual health, consideration should be given to the individual and to family, communities, friends and the surrounding environment or context. When discussing strategies to overcome barriers, participants referenced both the Fonofale and Te Whare Tapa Whā models as being important frameworks for the development of health promotion strategies.

Our main findings are presented in tables, with inclusion of a figure that provides a visual overview of results. Quotes were selected to illustrate key themes and ideas and include both unique and more common, shared views. Quotes have been annotated with group number (G1-4), gender (M, F) and speaker ID (number) where possible; however, gender and speaker ID could not be distinguished for all participants. Some quotes were edited for brevity (e.g. removal of fillers, repetition). Several participants are over-represented in the quotes because they were the nominated spokesperson when reporting back following small group discussions.

Participant characteristics

Table 1 describes the demographic characteristics of the 38 participants (15–24 years old) in the four groups. Groups included a mix of ages, genders (60% female), ethnicities (50% Māori, 50% Pacific of whom 14/19 were Sāmoan) and participants who were NEET.

Awareness of STI testing

Overall, 42% of participants reported having had an STI check in the past with variability between groups (ranging from 21% in G3 to 75% in G2). When asked to call out the name of an STI as part an ice-breaker activity to open the conversation about STIs, chlamydia and gonorrhoea were mentioned in all groups and syphilis was mentioned in only one group. There was a general understanding of when to get an STI check, with suggestions including: when sexually active, with a new partner, having multiple partners, suspicions of cheating, or to prevent transmission. However, gaps existed, such as not considering testing during pregnancy, when symptomatic, or when a partner tests positive. There was less certainty about where to get tested. General practitioners or doctors were cited in three groups, while Family Planning and a Youth Health Service were noted in two groups, some asked if self-testing or testing at a pharmacy or hospital were possible and someone said they would Google it. In Group 3, most participants lacked knowledge about where to go, and sexual health clinics or student health services were not brought up in any group.

When invited to share what stood out to them at the end of the session, we saw evidence of increased understanding about STI testing.²³ Some participants noted the positive experience of engaging in conversations and sharing opinions about STI testing in their groups. They highlighted an absence of awkwardness during discussions and noted the benefits of hearing others’ perspectives. Several comments suggested that participation in this work had helped dispel fears or misconceptions related to STI testing. For example, people noted that they had learnt how STIs are passed on and that it does not hurt to get an STI check.

Barriers to STI testing and suggested strategies to overcome these

Fig. 2 summarises the overall findings from this work with the five themes identified as barriers to STI testing shown in the centre of the figure, and two main themes related to participants’ ideas about how to overcome some of these barriers depicted around the outside (Fig. 2). Table 2 summarises the barriers to STI testing that centred around five overlapping themes: differences in cultural values and expression, family and friends, educational gaps, psychological factors and structural obstacles. Cultural and family values are intertwined and in turn linked to educational gaps and psychological barriers.

Fig. 2.

Overview of study findings: participant-identified barriers to accessing STI testing and suggested strategies to overcome them.

When discussing potential ways to address some of the barriers, there were two main themes: (1) with content related to suggested strategies about ‘what’ could be done (described in Table 3); and (2) ideas about ‘how’ these strategies might be effectively delivered (described in Table 4). Conversations about ‘what’ touched on the need for free and flexible sexual health services, but with a primary focus on the importance of better education and health promotion for young people and their parents. A range of activities were suggested to reach youth ‘where they are’ (including use of social media platforms such as TikTok, as well as in church, marae and other community settings). Participants identified the need for strategies to be underpinned by culturally appropriate approaches relevant to their own (Māori and Pacific) worldviews. They felt that parental and community involvement were key and that reframing the narrative about STI testing was necessary to facilitate easier conversations. They suggested opening the way to improved knowledge and awareness about sexual health was an important way to reduce stigma. Feedback following group work in Group 1 included:

We think every strategy needs to be contributing to erasing the stigma, the bad stigma associated with this topic. (G1)

Several participants drew on experience with community-led coronavirus disease 2019 (COVID-19) public health initiatives. For example, one participant raised the example of a successful social media campaign run by and for their community to promote vaccination. The implication was that this approach could also work to foster a culture where STI testing is considered important not just for the individual, but for their wider whānau (family):

We had young people who did these clips, and then people that you see at the food plaza or you know at the market, and they’re telling their stories, their reasons why they wanted to get the vaccine. And a lot of it, it wasn’t for selfish reasons, you know it wasn’t for their own personal self but for their whakapapa. (G2, F1)

Strengths and limitations

This is the first qualitative exploration of barriers facing Māori and Pacific young peoples’ access to STI testing and highlights ways in which some of these barriers could be addressed. Our recruitment method was a strength of the study. By gaining support from community-based youth organisations that had strong existing links to groups of young people, we reached a diverse mix of participants inclusive of Māori and Pacific, a mix of genders and sexual orientations, as well as participants who were NEET. The four meetings proceeded as planned with all participants who had signed up attending, which is testament to the valuable work our supporting organisations undertake for rangatahi in their communities. Participants were given giftcards in the spirit of reciprocity to acknowledge their time and the knowledge they shared, which likely added to their motivation to participate. Care was taken to ensure participants would feel willing and able to share views on the topic, by meeting in venues that were convenient and familiar, many participants already knew or knew of each other, or were from the same geographical communities. Participants were involved in setting the group kawa (culture) and shared ideas upfront about what was or was not acceptable. Food was shared, and karakia used to open and close the meetings. We observed that humour and shared laughter were common among participants throughout the wānanga, perhaps serving as a tool to overcome embarrassment or awkwardness and to foster a relaxed environment.³³ Overall, participants were engaged and expressed curiosity about the topic as evidenced by a steady flow of conversation and ideas. Knowledge-sharing went both ways; facilitators shared information about STI testing during the wānanga and a summary of research findings was disseminated to organisations and participants once data had been collated.

Limitations of the study include our inability to link the speaker identities to specific quotes. This meant we could not undertake detailed analysis of any differences or similarities in ideas in relation to gender or ethnicity. The absence of a male facilitator is likely to have limited the way male participants contributed to discussions (they were also in the minority in two groups). While participants agreed to participate in a mixed-gender group (organised by supporting community organisations), this may not align with some cultural preferences when it comes to talking about sexual health; this will potentially have impacted on some participant’s level of comfort and ability to openly share views. Our facilitators had no prior relationship with participants which might have made the topic easier to talk about for some participants, but more difficult for others. The views and experiences shared by this group of urban-dwelling Māori and (mostly Sāmoan) Pacific young people in one region of Aotearoa will not necessarily be reflective of those held by others. Participants in Groups 1 and 2 (the main contributors to the ‘ideas’ generation part of the wānanga) were mostly Pacific ethnicities, so the breadth of ideas incorporating Māori perspectives is likely to have been limited.

Conclusion

In this study, Māori and Pacific young people described factors that impede their ability to access STI testing, with complexities related to their cultural identities adding additional barriers over and above those experienced by their Pākehā peers. They identified a need for free, flexible services for STI testing, together with community-based education and health promotion that considers their values and worldviews. Participants suggested reframing messages about STIs to place emphasis on protection of general health, whānau and community wellbeing would help to normalise conversations, and over time could help reduce the long-held stigma that continues to surround sexual health. Addressing the barriers identified in this work is critical to eliminate the inequitable burden of STIs experienced by Māori and Pacific young people. Prioritising, resourcing and building a culturally capable workforce to design and deliver health promotion will help equip Māori and Pacific young people and their families with knowledge and skills to maintain good sexual health and wellbeing.