Peer educators and professionals identified a lack of training as a major challenge in effectively providing sexual health promotion through peer educators. This was no doubt linked to the small proportion of their role that was dedicated to sexual health. While many had a role focused on general health and wellbeing (of which sexual health was one part) or sexuality (which is one component of sexual health), none of the surveyed peer educators had a role based entirely on sexual health. From such a starting point it is unsurprising that peer educators identified gaps in their own understanding of the topic. Of the surveyed peer educators, 17% received no training at all and only a third believed they had received adequate training for the sexual health aspects of this role. Despite this, a larger proportion felt that they were well or very well prepared for the role. While this may seem inconsistent with the level of training provided, it likely reflects the valuable previous experience and background knowledge that individuals driven to participate as peer educators may possess. However not all peer educators share this confidence, with half of respondents feeling less than well prepared.
This lack of training may be a driving factor behind the lack of events tailored to the needs of priority populations within sexual health, such as students from LGBTI and international communities. Tailoring for the LGBTI community showed considerable disparities between its different components. Looking solely at sexuality, 72% of peer educators reported having aspects aimed at lesbian, gay and bisexual students. In comparison, the number tailoring content towards transgender and intersex students was much lower, at 44%. However both these groups were considerably more likely to be targeted in promotions than international students. This is surprising given that international students make up a significant portion of the overall university cohort. Indeed in the Student Survey international students outnumbered LGBTI responses and national figures show that international students represent over a quarter of the total higher education population (Australian Government Department of Education and Training, 2016c). In addition, culturally and linguistically diverse people (representing the majority of international students) are listed alongside men who have sex with men (from the LGBTI community) and youth as priority populations under Australia’s most recent Sexually Transmissible Infections Strategy (Australian Government Department of Health, 2014).
From this and the qualitative data from peer educators and professionals in this study, it is clear that international students need to be a focus within sexual health, yet current promotions do not seem tailored to address this demographic. When asked why peer educators had not considered a given demographic, the most common response across all categories was simply that it did not occur to them. Referring specifically to the lack of promotions targeting international students the second most likely answer was that they didn’t know enough about the relevant issues. These answers are unsurprising in the context of the very low proportion of student leader roles occupied by international students. Despite making up 25.8% of Australian university student enrolments in 2015 (Australian Government Department of Education and Training, 2016c), less than 6% of student leaders from the Promotion Survey were international students.
The under-representation of international students may stem from structural features of the types of student leader roles these peer educators are undertaking. When looking specifically at international students, the short duration of the role and the need to have been previously involved in the organisation may inhibit those on short term exchange from taking on a role. However it is also likely that racism, whether conscious or unconscious, could be influencing the likelihood of international students gaining the type of leadership positions that would be associated with being a peer educator. In a previous Australian study it was found that resumes submitted under names of non-Anglo-Saxon origin received fewer interview offers, with this effect particularly evident in roles with high levels of customer interaction (Booth et al., 2012). Given the high level of interaction with other students involved in a peer educator role it is possible that international students are missing out on opportunities due to these biases.
In terms of the lack of training, peer educator roles are frequently of short duration, typically lasting a year or less, and as such the potential for, and desirability of, extensive training is greatly reduced compared to professional educators. This is congruent with reviews of peer educator programs focusing on sexual health, where training was generally of short duration (Kim and Free, 2008; Tolli, 2012). In addition, this research has shown that in the university sphere, a lack of understanding of the requirements of peer educator roles on behalf of the parent organisation (as distinct from sexual health focused organisations) may leave students with a lack of direction and appropriate training.
This in turn can have negative impacts on providing timely events and information for the student body. While many event-holding respondents reported having their sexual health promotion in orientation week to set community standards as a new cohort arrived, many other respondents were not able to achieve this. Despite realising the benefits of early events, some peer educators expressed disappointment in how late their events took place, due to a lack of preparation linked to the starting dates of the short term roles. This is especially important as orientation week and the first weeks of university often entail a significant number of social events, elevated levels of alcohol consumption and higher instances of unwanted sex (Kimble et al., 2008). Combined with the higher likelihood of attracting students during less assessment intensive periods, it is likely that earlier events would be more beneficial than those only occurring later in the year.
Another key challenge in providing appropriate sexual health promotion to university students is the heterogeneity of needs. Despite sharing the student identity and a place of learning, university students can have a range of different needs and preferences. One key example of this was seen in discussions on whether mixed gender or single gender sessions were a better approach for university students. Peer educators and professionals identified advantages and drawbacks to either strategy, often related to the nature of the group being targeted. While transgender and intersex students may be excluded from a single sex event, this approach may be the only feasible one if working with international students from cultures where discussing sex is a greater taboo. From this and other examples we can see that there is not going to be one single method or event that can fulfil the needs of every student. As with all health promotions, it is vital to assess the needs of the community of interest and adapt the approach accordingly. Similar to the dialogue method in science communication (Burns et al., 2003), it is only by engaging with these communities and sharing their knowledge and perspectives that we can hope to effect change.
Of course taking the time to engage with a group comes with its own set of challenges and costs. For the peer educators themselves investigating the needs of their organisation may happen on an anecdotal level, but it is unlikely that many students would have the training, time or resources to undergo large scale research on the topic. As such, this PhD has aimed to determine trends across specific groups of interest within universities in order to
facilitate action where it is most needed. These issues are addressed in research question two, with findings discussed in section 7.2 in this chapter.
Similar to the lack of resources and training necessary to evaluate the needs of their organisation, peer educators may also find it difficult to evaluate the success of completed events. Peer educators identified four key elements of success for a sexual health promotion: 1) the number of people reached, 2) transfer of knowledge, 3) attitudes changed and 4) behaviours changed. The transfer of knowledge measure has clear parallels with the deficit model thinking that has historically dominated science communication (Simis et al., 2016). However the inclusion of factors such as attitudinal change indicate that at least some peer educators agree with previous research suggesting that while important, knowledge is not the only determinant of attitudinal change (Sturgis and Allum, 2004). Only one of the measures of success; attendance, could be easily measured by peer educators. This may help to explain the prominence of low attendance as an area of concern for student leaders. In the Promotion Survey, engaging the community or getting people to attend events was the most commonly selected challenge of those listed, chosen by more than half of the respondents. While overcoming the awkwardness and stigma related to sexual health was less commonly reported in the survey, it was clear from interview responses that shame and stigma had a key role to play in determining attendance and success for a sexual health event. The shame related to sex and sexual health prevents that first, easily measureable step of simply turning up, and by doing so greatly restricts the number of people who could have their attitudes or behaviours changed. This has clear links to previous research where interviews with young people showed that even the act of undertaking a chlamydia test (as distinct from testing positive) could risk damaging one’s reputation and cause feelings of shame and stigma (Balfe et al., 2010). From the respondents’ data, and the available literature, it is likely that amongst the small number of people who do attend sexual health promotion events at universities a high proportion already have positive attitudes and high levels of knowledge about the topic. In this scenario, it is unlikely that events will help to change attitudes or behaviours among those most at risk unless modifications are made to render them more appealing to the target audience.