Predictors of exposure to sexual health education among teens who are newcomers to Canada.
Article Type: Report
Subject: Health promotion (Evaluation)
Health promotion (Demographic aspects)
Sex education (Evaluation)
Sex education (Demographic aspects)
Teenagers (Sexual behavior)
Teenagers (Surveys)
Authors: Salehi, Roxana
Flicker, Sarah
Pub Date: 12/22/2010
Publication: Name: The Canadian Journal of Human Sexuality Publisher: SIECCAN, The Sex Information and Education Council of Canada Audience: Academic Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2010 SIECCAN, The Sex Information and Education Council of Canada ISSN: 1188-4517
Issue: Date: Winter, 2010 Source Volume: 19 Source Issue: 4
Topic: Canadian Subject Form: Teenage sexual behaviour
Geographic: Geographic Scope: Ontario Geographic Code: 1CONT Ontario
Accession Number: 253926190
Full Text: Abstract: The aim of this component of the Toronto Teen Survey was to explore predictors of access to sexual health education among urban youth with a focus on newcomers to Canada. A total of 1216 teens were surveyed through community-based agencies. The sample was diverse in terms of age, gender, race, language, religion, length of residency in Canada, and sexual behaviour. Most participants (65%) were born in Canada with 33% born elsewhere. The one third of those born elsewhere (11% of the total sample) who reported living in Canada for three years or less were identified as "newcomers" for the purposes of this analysis. Overall, 92% of the total sample indicated that they had received some sexual health education through classes or workshops and 8% said they had received no such education. Controlling for gender, age, religion, socioeconomic status, and sexual experience, all youth not born in Canada were significantly less likely to report having received sexual health education than those born in Canada. Within this group, 81.2% of those identified as newcomer youth had received some sexual health education compared to 91.8% for youth who had been in Canada longer and 93.7% for Canadian born youth.

Acknowledgements: The authors would like to thank the entire Toronto Teen Survey Team, including Dr. Robb Travers, Dr. June Larkin, Dr. Jason Pole, Susan Flynn, Crystal Layne, Adrian Guta, our youth advisors and all the students who helped us collect this valuable information. We are also grateful to all our youth participants and the community agencies that welcomed us. This study was funded by the Ontario HIV Treatment Network and the Canadian Institutes of Health Research, which also provided scholarship and salary support for the authors. We are also very appreciative of Drs. Michaela Hynie and Michael Friendly for their critical feedback on this manuscript.

Introduction

Systematic reviews demonstrate that exposure to broadly-based sexual health education programs can have a positive effect on adolescent sexual health behaviour (Alford, 2003; Kirby, Laris, & Rolleri, 2007; Kirby, Laris, Rolleri, & Associates, 2006). However, some sub-populations of youth, including racialized youth and teens who are new to Canada, encounter barriers to timely and appropriate access to such information (McKeown et al., 2008). In order to better understand and address those barriers, the present study investigated predictors of access to sexual health education among urban youth in Toronto with a particular focus on newcomer youth, namely immigrant, refugee, or "undocumented" youth who have lived in Canada for three years or less.

Background

Toronto is often referred to as the world's most ethnically-diverse city. It is home to more than 80 ethnic groups speaking over 100 languages. Half of the city's population (1,237,720 people) is foreign-born (Statistics Canada, 2008), four out of ten people are members of a racialized group, and one in four children aged 6-15 are new immigrants (City of Toronto, Social Development and Finance & Administration Division, 2006). About 7% of the people of Toronto were born in a country where HIV is endemic (Public Health Agency of Canada, 2007).

Although immigrants to Canada are more highly educated than ever before, they are also more likely to be economically disadvantaged. In 2001, one of every three children in families of recent immigrants was poor (compared to 16% for those with Canadian-born parents) although variations exist among and within newcomer sub-populations based on ethnicity, gender and legal status (City of Toronto, Social Development Finance & Administration Division, 2006). The dual burden of poverty and social exclusion creates

Some immigrant youth are knowledgeable about sexual health because the cultural context of their home country allows for a more open dialogue regarding sexuality. For others who come from conservative or religious backgrounds, the cultural context of sexu

Although there are many similarities among immigrant families from more traditional or conservative backgrounds with regards to their attitude towards sexuality, there is also great heterogeneity among and between cultures in terms of the ways in which se acculturating children and the way they view sexual health education in schools. Youth, themselves, also go through a transformation when trying to reconcile "old" and "new" values regarding sexuality. Some youth may feel hesitant, fearful, or ashamed to

In addition to the cultural/religious barriers discussed above, newcomer youth also face systematic barriers in accessing sexual health education. Local, as well as global research, indicates that HIV and other STIs follow patterns of inequity, with margi

In a review of 39 randomized and quasi-randomized controlled trials of abstinence-plus education HIV prevention programs in the United States, Canada and the Bahamas, Underhiil, Operario and Montgomery (2007) found that schools and community facilities we parents struggle with finding employment (Suarez-Orozco, 2009). This situation simply leaves little time for youth to participate in community programs.

The present study

Previous qualitative research with immigrant youth and families has documented the challenges they may encounter in accessing sexual health information (AIDS Committee of Toronto, 2006). To our knowledge, the present study is the first large-scale quantit

Methods

This article is based on data from the Toronto Teen Survey (TTS), a community-based participatory research study that asked youth about their sexual experiences, as well as barriers and facilitators to accessing sexual health clinics and education. TTS is

Study variables

Exposure to sexual health education was a binary variable (youth either had or had not received some sexual health education). Responses were developed from the following stem question: "Please check all the places you have had sexual health classes or wo

Gender was a 4-level variable. Respondents were given four categories of gender to choose from: male; female; transgender; and two-spirited. Only 10 respondents chose either transgender or two-spirited. Given these small numbers, only those selecting male

Immigration status was a 3-level variable: "Born in Canada"; "Born elsewhere and lived in Canada four years or more"; and "Born elsewhere and lived in Canada three years or less"). The following two survey questions were used to construct the immigration

Language spoken most often in the home was a binary variable. Those who spoke languages other than English in their homes were classified as such.

Religion was a 5-level variable (None, Catholic, Protestant, Muslim, Other) developed based on respondents selection of up to seven choices from 17 choices. "None" included: Agnostic, No religion, and Atheist; "Protestant" included: Anglican, Baptist, Lutheran, United, and Protestant Christian. Those who identified as Catholics and Muslims were classified as such. Everyone else was classified as Other.

Race was a 5-level variable (South Asian, East/ South East Asian, Black, White, and Other). Those identifying as Black African, Black Canadian, and Black Caribbean youth were classified as Black. European and Canadian white groups were classified as White. In order to improve the power of the test, in the logistic analysis, we combined the South and East/ South Asian groups and analyzed them as Asians. Due to small numbers, all others were classified as Other.

Parent education was a 3-level variable (University or College, High school or Less, and Don't know) and was used here as a proxy for socio-economic status. The number of people who said they didn't know about their parents education was simply too many to ignore (n=180, 15% of our sample) and hence, this group was included in our analysis.

Sexual activity was a bivariate variable based on the question "We understand that "having sex" means different things to different people. In your opinion, have you had sex?" Those who said they think they have had sex were classified as "experienced". Those who said they have not had sex or were not sure if they had, were classified as "inexperienced or unsure".

Age was a 2-level variable (younger and older). Adolescents aged 13-15 were categorized as younger and those aged 16-18+ were categorized as older. Respondents were given 6 categories to choose from: 13 years old, 14, 15, 16, 17, 18 years old or older. In order to increase cell numbers, the 13-, 14-, and 15-year-olds were re-coded into "younger adolescents," and the 16-, 17-, and 18+-year-olds were re-coded into "older adolescents". Our community partner, Planned Parenthood, felt that older and young adolescents face different sets of sexual health issues. Younger adolescents are more likely to be sexually inexperienced, to live at home, and to be dependent on their parents. Older adolescents are more likely to be involved in romantic relationships, to have jobs (and consequently a little bit more autonomy), and to live independently. It is also known that sexual activity is positively correlated with age meaning that older adolescents are more likely to be sexually active.

Statistical tests

Descriptive statistics were calculated for the demographic variables stratified by the outcome variable (having received some sex education). Chi Square tests (two tailed, p<0.05) were performed to determine statistically significant differences between groups. A binary logistic regression model was developed in order to estimate the odds of receiving some sex education with the following covariates: age, gender, race, religion, parental education (as proxy for SES), immigration, and sexual behavior. The language variable was not included in the multivariate analysis because as a general rule, languages most spoken at home has been used as a proxy to measure the level of acculturation in families and hence, it strongly correlates with the length of time since migration (Barusch & Spaulding, 1989; Chien, George, & Armstrong, 2002; Guilamo-Ramos, Jaccard, Pena, & Goldberg, 2005; Stevens, Seid, Mistry, & Halfon, 2006; Zanchetta & Poureslami, 2006). Therefore, including language would have reduced the power of analysis. Analysis was performed using an ENTER method in which the covariates were entered in three blocks. Block One contained demographic variables (age, gender, religion, race, parental education). Block Two contained acculturation variable (length of time spent in Canada). Block Three contained the behavioral variable (sexual activity). Only youth who provided responses for all relevant variables were included in the logistic analysis. Data were incomplete for 134 youth, hence a total of 1061 participants (89% of sample) were included in this analysis.

Results

Respondent characteristics

The sample was diverse in terms of age, gender, race, language, religion, length of residency in Canada, and sexual experience (Table 1). Religious diversity was reflected in the 9.4% identifying as Muslim, 27.4% Catholic, 27% Protestant and 18% reporting no religion. Parental education was high with 59% reporting that their parents had university or college education. Thirty four percent of youth reported being sexually experienced based on their personal assessment of what they understood "having sex" to mean.

Most participants were born in Canada (65%), 33% were born elsewhere and had lived in Canada for four years or more, and 11% were born elsewhere and reported living in Canada for three years or less. It is this latter group, designated here as "newcomers", that was of particular interest in the present study.

Sources of sexual health education

Respondents were invited to check all applicable options on a list of places where they "have had sexual health education classes and workshops." Table 2 compares those responses for youth born in Canada and those born elsewhere who had been in Canada for either three years or less (newcomers) or for a longer period of time. A summing of all responses for the possible sources of sexual health education shows that schools (elementary and secondary) had 1472 responses, youth groups had 454, religious groups 78, and other 33. The excess of responses over respondents is consistent with the finding that 6 1% of respondents reported receiving sexual health education from more than one source although 15% cited elementary school as their only source and 13% cited secondary school as their only source (data not shown). Youth groups, cited by 37% of the total sample, and religious groups, cited by 7% were proportionately much less likely to be identified as an only source. Newcomer youth (in Canada for 3 years or less) were about one half as likely to report elementary school (32.1%) than were students born elsewhere who had been in Canada longer (62.5%) (Table 2).This pattern, although less pronounced, was also found for high school and youth groups. Overall, about 92% of the total sample had some sexual health education classes or workshops, and 8% did not.

Factors associated with some versus no exposure to sexual health education

The bivariate analysis (Table 3) showed that in terms of exposure to sexual health education, there were statistically significant differences between newcomers, Canadian-born youth, and longer-term immigrant youth ([chi-square] = 25.116, df = 2, P < 0.01 ); while 6.3% of Canadian-born youth had never received sexual health education, 18.8% of newcomer youth (defined as youth born elsewhere who have lived in

Canada for three years or less) reported never having received any sexual health education. As for longer term immigrant youth (those born elsewhere and living in Canada for 4+ years), 8.2% reported never having received any sex education. While a sizeable majority of sexually experienced and not experienced or unsure youth reported exposure to some sexual health education (95.5% and 89.3% respectively), this difference was statistically significant ([chi-square] = 13.392, df = 1, p < 0.01). Similar differences were found for ethno-cultural group and exposure to sexual health education ([chi-square] = 8.675, df = 3, P < 0.01 ); East and South East Asian youth had notably less exposure (83.5%) than did Black, South Asian and White youth (91.8%-97.0%).

Modelling predictors of exposure to sexual health education

In our multivariate analysis (Table 4), a test of the full model with all predictors against a constant-only model was statistically reliable ([chi-square] = 32.415, df = 16, P = 0.009) indicating that the predictors, as a set, reliably distinguished between those who had received some sexual health education classes or workshops and those who had not. Controlling for all other variables, newcomers (those who had lived in Canada for three years or less) were 5 times less likely to have received sexual health education compared to Canadian born youth (OR = 0.191). Those who said they were sexually inexperienced or unsure were two times less likely to have received sexual health education compared to those who said they were sexually experienced (OR = 0.53).

Discussion

This study explored predictors of exposure to sexual health education in a highly ethno-culturally and racially diverse sample of Toronto youth aged 13-18. Since the sample was based on pre-existing youth/ community groups, youth who did not access those programs were excluded. This non-random sampling yielded a unique population of participants among whom about 85% were from racial and ethno-cultural groups other than white Caucasian, 33% were not born in Canada (i.e., immigrants), and 11% of the total sample were considered to be newcomers to Canada on the basis of their having been in Canada for three years or less at the time of the study). Although this 11% represented 138 individuals, we believe it to be one of the largest samples of newcomer youth to Toronto to have been studied in this way.

Exposure to sexual health education

Among all participants, schools (elementary and secondary) were most often cited as a source of sexual health education. For newcomer youth especially, who may have limited knowledge of or access to other community programs, school is a particularly crucial point of contact. As noted in the Canadian Guidelines for Sexual Health Education (2008):

It is noteworthy that a sizeable percentage of participants also cited other non-school settings as sources of sexual health education with community youth groups being predominant among these other sources. The fact that youth groups were often cited may be partly a function of our sampling method but it probably also reflects a different kind of experience in such settings which may suggest needs and issues not always addressed in schools. Further exploration into the similarities and differences in these settings may be merited. Despite our finding that the vast majority of youth reported some exposure to sexual health classes or workshops, we did not assess here the extent or content of that exposure. Although we consider below the reasons why newcomer youth may not have experienced sexual health education, it is a concern that 8% of our total sample indicated that they had never received any such education in a province where sexual health education (as a component of the health curriculum ) is a currently mandated part of the grade seven and nine school curriculum.

Newcomer youth

Although 81.8% of newcomer youth had experienced some sexual health education, the 18.8% who had not represent a notable and important unmet need. We have previously cited a number of possible reasons for this lack of exposure to such education, whether in schools or community groups. While our research can document this inequity in exposure to sexual health education, an inequity that also pertains in relation to access to sexual health services (Salehi et al., 2009), this evidence is primarily a motivator rather than a guide to action. While our findings indicate that most immigrant youth eventually receive sexual health information through school or community services, this should not deter action to address the inequity for youth who have more recently arrived including those who arrived in their later teens and thus missed the offerings in elementary and early high school.

Although an international consensus on sexual rights remains a work in progress (World Association for Sexual Health, 2008), the acknowledgement of sexual rights as an aspect of human rights that includes sexuality education (World Health Organization, 2008) is widely cited, including in the Canadian Guidelines for Sexual Health Education (2008; p. 6). In the present context, a rights perspective indicates the need to address inequities in access to sexual health education for all youth including newcomer youth. For newcomer youth, action is needed on previously identified limiting factors including lack of awareness, language barriers, parental hesitancy (particularly about non-mandatory educational activities), and also family circumstances that require youth to care for younger siblings (Suarez-Orozco, 2009). Schools and other agencies are in a position to address these and other such factors through curricular revision, incorporating sexual health education into English as a Second Language (ESL) classes, giving particular attention to youth from HIV endemic countries, and institutional support for educators currently seeking to address the needs of newcomer youth.

Limitations and Analytical Challenges

The survey was administered in English only. Several measures were taken to ensure that the survey was accessible to those youth for whom English was not a mother tongue. During the survey, participants were encouraged to raise their hand and ask questions if they were not sure what a particular word meant. As time went by, we learned which questions and/or words were particularly difficult for youth in general, and for newcomer youth who were not fluent in English. Time was devoted at the beginning of each session to explain more challenging areas. Moreover, a professional interpreter was used for one session where a youth worker identified the need. Despite these efforts, language and understanding were complicating limitations.

Racial categorizations, e.g. "Black", were somewhat over-inclusive and may not have adequately reflected the richness and complexity within each group. Our use of parental education as a proxy for SES may be problematic .Although SES is typically positively correlated with parental education, this may not have been the case among immigrants. Given that Canadian immigration is granted on a points-based system, applications from more highly educated immigrants are favored. Additionally, previous research has shown that many highly educated immigrants have problems finding adequate employment and thus earn salaries well below what they should be earning based on their education level (McKeown et al., 2008; Ornstein, 2006). Given the high proportion of immigrant youth in the current sample, it is probable that our SES variable has been confounded, perhaps explaining its lack of association with exposure to sexual health education.

Although length of time in the host country is an important proxy for acculturation, it most certainly cannot fully measure acculturation on its own. Acculturation is an extremely complex concept and to paint a more realistic picture of how acculturation influences the health of immigrant youth, one needs to appreciate the heterogeneity of immigration experiences of youth and the many interacting variables at play (loss of old friendships, intergenerational conflicts, legal status, etc.)(Abraido-Lanza, Armbrister, Florez, & Aguirre, 2006).

It should also be noted that our definition of newcomers (lived in Canada three years or less) is not commensurate with other studies that have used census definitions of newcomer (i.e., less than five years). Because we were working with adolescents at the time that we developed with survey, we felt this shorter time period would more accurately reflect the concept of "newcomerness." In retrospect, asking respondents to tell us how many years they had lived in Canada (as opposed to having them choose categorical responses) may have been a wiser approach.

Another limitation of this analysis is our crude measure of "some sex education." Our analysis looked at whether youth had received any sexual health classes or workshops at all from a number of possible sources (with presumably different philosophical and curricular orientations to the subject matter). Finally, this analysis did not address the quantity or quality of the sexual health education that youth received from the sources they identified. It was our expectation that, at a minimum, sexual health education should include conversations about how to pursue pleasure, develop healthy relationships, determine the consequences of unprotected sex, and protect against violence and coercion (Fine & McClelland, 2006; Tolman, 2002).

Concluding observation

A recent study of high school graduates in Ontario found that students were generally satisfied with the sexual health education they received, although many wished they could have received the same information at a younger age (Meaney, Rye, Wood, & Solovieva, 2009). Our study suggests that age, access and diversity are important considerations in shaping sexual health education to meet the needs of an increasingly heterogeneous population and to close the gaps for those with unmet needs, and particularly for newcomer youth.

References

Abraido-Lanza, A.F., Armbrister, A.N., Florez, K.R., & Aguirre, A.N. (2006). Toward a theory-driven model of acculturation in public health research. (Author abstract), 96, 1342-1345.

AIDS Committee of Toronto. (2006). Youth Migration Project. AIDS Committee of Toronto.

Alford, S. (2003). Science and success: Sex education and other programs that work to prevent teen pregnancy. HIV & sexually transmitted infections. Washington, DC: Advocates for Youth.

Anisef, P. (2005). Issues confronting newcomer youth in Canada: Alternative models for a national youth host program. CERIS--The Ontario Metropolis Centre, York University, Toronto, ON.

Barusch, A.S., & Spaulding, M.L. (1989). The impact of Americanization on intergenerational relations: An exploratory study on the U.S. Territory of Guam. Journal of Sociology and Social Welfare, 16, 61-79.

Chien, L.Y., George, M.A., & Armstrong, R.W. (2002). Country of Birth and Language Spoken at Home in Relation to Illicit Substance Use. Canadian Journal of Public Health, 93, 188-192.

City of Toronto, Social Development Finance Administration Division. (2006). Youth and new immigrants in Toronto. Toronto, ON: City of Toronto.

Dowsett, G., Aggleton, E, Abega, S., Jenkins, C., Marshall, T., Runganga, S. et al. (1998). Changing gender relations among young people: The global challenge for HIV/AIDS prevention. Critical Public Health, 8, 291-309.

Espin, O.M. (1999). Women crossing boundaries: A psychology of immigration and the transformations of sexuality. New York, NY: Routledge.

Farmer, P., Connors, M., & Simmons, J. (Eds.). (1996). Women, poverty, and AIDS: Sex, drugs, and structural violence. Monroe, ME: Common Courage Press.

Fine, M., & McClelland, S. (2006). Sexuality education and desire: Still missing after all these years. Harvard Educational Review, 76, 297-338.

Flicker, S., & Guta, A. (2008). Ethical approaches to adolescent participation in sexual health research. Journal of Adolescent Health, 42, 3-10.

Flicker, S., Guta, A., Larkin, J., Fridkin, A., Travers, R., Pole, J. et al. (2010). Survey design from the ground up: Collaboratively creating the Toronto Teen Survey. Health Promotion Practice, 11, 112-122.

Glazier, R.H., Creatore, M.I., Cortinois, A.A., Agha, M.M., & Moineddin, R. (2004). Neighbourhood recent immigration and hospitalization in Toronto, Canada. Canadian Journal of Public Health, 95, 130-34.

Guilamo-Ramos, V., Jaccard, J., Pena, J., & Goldberg, V. (2005). Acculturation-related variables, sexual initiation, and subsequent sexual behavior among Puerto Rican, Mexican, and Cuban youth. Health psychology: Official Journal of the Division of Health Psychology, American Psychological Association, 24, 88-95.

Kirby, D.B., Laris, B.A., & Rolleri, L.A. (2007). Sex and HIV education programs: Their impact on sexual behaviors of young people throughout the world. Journal of Adolescent Health, 40, 206-217.

Kirby, D.B., Laris, B.A., Rolleri, L.A., & Associates, E.T.R. (2006). Sex and H1V education programs for youth: Their impact and important characteristics. Scotts Valley, CA: ETR Associates.

Maticka-Tyndale, E., Shirpak, K., & Chinichian, M. (2007). Providing for the sexual health needs of Canadian immigrants. Canadian Journal of Public Health, 98, 183-187.

McKay, A., & The Sex Information Education Council of Canada. (2004). Adolescent sexual and reproductive health in Canada: A report card in 2004. The Canadian Journal of Human Sexuality, 13, 67-81.

McKeown, D. (2007). Sexual health in Toronto 2007. Toronto, ON: Toronto Public Health.

McKeown, D., MacCon, K., Day, N., Fleiszer, P., Scott, F., & Wolfe, S. (2008). The unequalcity: Income and health inequalities in Toronto, 2008. Toronto, ON: Toronto Public Health.

Meaney, G.J., Rye, B.J., Wood, E., & Solovieva, E. (2009). Satisfaction with school-based sexual health education in a sample of university students recently graduated from Ontario high schools. The Canadian Journal of Human Sexuality, 18, 107-125.

Minkler, M., & Wallerstein, N. (2003). Community-based participatory research for health. San Francisco, CA: Jossey-Bass.

Morrison, L., Guruge, S., & Snarr, K. (1999). Sri Lankan Tamil immigrants in Toronto: Gender, marriage patterns, and sexuality. In G. Kelson & B. Delaureat (Eds.), Gender, Immigration, and Policy (Vol. 36, pp. 144-160). New York, NY: New York University Press.

O'Brien Teengs, D., & Travers, D. (2006). "River of life, rapids of change": Understanding HIV vulnerability among two-spirit youth who migrate to Toronto. Canadian Journal of Aboriginal Community-Based HIV/AIDS Research. 1, 17-28.

Ornstein, M. (2006). Ethno-racial groups in Toronto, 1971-2001. A demographic and socio-economic profile. Institute for Health Research, York University, Toronto, ON. ISBN: 1-55014-450-2.

Public Health Agency of Canada. (2007). HIV/AIDS in Canada among persons from countries where HIV is endemic. H1V/AIDS Epi Update, Catalogue No: HP37-7/2007E (pdf); ISBN 978-0-662-47368-8.

Public Health Agency of Canada. (2008). Canadian guidelines for sexual health education. Ottawa, ON: Public Health Agency of Canada.

Salehi, R. (2010). Intersection of health, immigration, and youth: A systematic literature review. Journal of Immigrant and Minority Health (First published online in 2009). 12, 788-797.

Salehi, R., Flicker, S., Layne, C., Flynn, S., Larkin, J., Travers, R. et al. (2009). Intersection of access to sexual health services, migration status, and youth: What happens when you ignore intersectionality? Paper presented at the Canadian Public Health Conference.

Shirpak, K., Chinichian, M., & Sepali, G. (2009). Sexual Health of Immigrants. Workshop offered through Alberta Society for Promotion of Sexual Health. Alberta, Canada.

Statistics Canada. (2008). Census snapshot--Immigration in Canada: A portrait of the foreign-born population. 2006 Census.

Stevens, G.D., Seid, M., Mistry, R., & Halfon, N. (2006). Disparities in primary care for vulnerable children: The influence of multiple risk factors. Health Services Research. 41,507-531.

Suarez-Orozco, C. (2009). The social mirror: Cultural psychology and academic trajectories of immigrant children in schools. Community Health Systems Resource Group Symposium Series, Multiple Diversities: Child/Youth Identity and Life Outcomes, Toronto, ON.

Tolman, D.L. (2002). Dilemmas of desire. Cambridge, MA: Harvard University Press.

Travers, R., & Carolo, H. (2004). Challenges, complexities and solutions: A unique HIV research partnership in Toronto. Canada. Paper presented at the 3rd International Conference on Urban Health, Boston. MA.

Travers, R., Leaver, C., & McClelland, A. (2002). Assessing HIV vulnerability among lesbian, gay, bisexual, transgender, transsexual (LGBT) and 2-spirited youth who migrate to Toronto. The Canadian Journal of Infectious Diseases. 13(Suppl. A), 71A.

Underhill, K., Operario, D., & Montgomery, P. (2007). Systematic review of abstinence-plus HIV prevention programmes in high income countries. PLoS Medicine. 4, 1471-1485.

World Association for Sexual Health. (2008). Sexual health for the millenium: A declaration and technical document. Minneapolis, MN: World Association for Sexual Health.

World Health Organization (WHO). Sexual health working definitions (these definitions do not represent an official WHO position). Retrieved on November 19, 2010, http://who.int/reproductive health/gender/ sexualhealth.html

Zanchetta, M.S., & Poureslami, I.M. (2006). Health literacy within the reality of immigrants' culture and language (Report). Canadian Journal of Public Health, 97, S26-30.

Roxana Salehi (1), Sarah Flicker (1), and the Toronto Teen Survey Team

(1) Faculty of Environmental Studies, York University, Toronto, ON

Correspondence concerning this article should be addressed to Dr. Sarah Flicker, Faculty of Environmental Studies, HNES 109, York University, 4700 Keele Street, Toronto, ON, M3J 1P3. E-mail: flicker@yorku.ca
Since schools are the only formal educational
   institution to have meaningful (and
   mandatory) contact with nearly every
   young person, they are in a unique position
   to provide children, adolescents and young
   adults with the knowledge, understanding,
   skills and attitudes they need to make and
   act upon decisions that promote sexual
   health throughout their lives (p. 19).


Table 1 Sample demographics *

Total                                1216    %

Age (years)
13-15                                 628   52
16-18+                                546   45

Gender
Female                                652   54
Male                                  543   45
Two-spirited or Transgender            10    0.1

Race
South Asian                           116   10
East and South East Asian             176   14
Black                                 463   38
White                                 235   19
Other                                 188   15

Religion
No religion                           218   18
Catholic                              333   27
Muslim                                114    9
Protestant                            328   27
Other                                 163   13

Parents education
High school or less                   313   26
University or collage                 715   59
Don't know                            182   15

Immigration
Born Can., here 10+ yrs               794   65
Not born Can.; here 4+ yrs            267   22
Not born Can., here 3 yrs or less     138   11

Languages most often
  spoken at home
English is one of them                998   82
English is not one of them            218   18

Sexual experience
Inexperienced or unsure               741   61
Experienced                           418   34

* Missing responses constituted 0-1.7% of the total for
all variables except race (3%), religion (5%), and sexual
experience (5%).

Table 2: Sources of sexual health education by length of time in
Canada *

                    Canadian-born, lived in    Born elsewhere, lived
                    Canada 10+ years (n=780)    in Canada 4+ years
                                                      (n=263)

Source                     N       %                  N       %

Elementary school         532     68.2               165     62.5
High school               478     61.3               178     67.4
Youth groups (a)          320     41.0                98     37.0
Religious groups           48      6.2                21      8.0
Other                      23      2.9                 7      2.7
Never                      36      4.6                17      6.4

                    Born elsewhere, lived in Canada
                        3 years or less (n=137)

Source                         N       %

Elementary school              44     32.1
High school                    75     54.7
Youth groups (a)               36     26.3
Religious groups                9      6.6
Other                           3      2.2
Never                          25     18.2

* Note: Sources are not mutually exclusive in that respondents were
asked to check all of the places they had sexual health classes or
workshops.

(a) Youth groups may have consisted of homework clubs, YMCA,
after-school programs, parks and recreation groups, and other
unspecified.

Table 3 Bivariate analysis comparing those who have had some sexual
health education with those who have had none

                                          Total   No sexual health
                                                       ed (b)

                                            N        N       %

Demographic variables (a)

Total                                      1216     100     8.2
Age (years)
  13-15                                     551      44     8.0
  16-18+                                    637      53     8.3
Gender
  Female                                    652      50     7.7
  Male                                      543      48     8.8
  Two-spirited or transgender                10       1    10.0
Race *
  South Asian                               116       5     4.3
  East and South East Asian                 176      29    16.5
  Black                                     463      38     8.2
  White                                     235       7     3.0
  Other                                     188      20    10.6
Religion
  No religion                               218      21     9.6
  Catholic                                  333      26     7.8
  Muslim                                    114      11     9.6
  Protestant                                328      19     5.8
  Other                                     163      16     9.8
Parents education (proxy for SES)
  High school or less                       313      23     7.3
  University or collage                     715      60     8.4
  Don't know                                182      17     9.3
Acculturation variable
Length of time spent in Canada *
  Born in Canada, lived 10+ years           794      50     6.3
  Born elsewhere, lived 4+ years            267      22     8.2
  Born elsewhere, lived 3 years or less     138      26    18.8
Behavioural variable
Sexual experience *
  Not experienced or unsure                 741      79    10.7
  Experienced                               418      19     4.5

                                          Some sexual health

                                               N      %

Demographic variables (a)

Total                                         1116   91.8
Age (years)
  13-15                                        507   92.0
  16-18+                                       584   91.7
Gender
  Female                                       602   92.3
  Male                                         495   91.2
  Two-spirited or transgender                    9   90.0
Race *
  South Asian                                  111   95.7
  East and South East Asian                    147   83.5
  Black                                        425   91.8
  White                                        228   97.0
  Other                                        168   89.4
Religion
  No religion                                  197   90.4
  Catholic                                     307   92.2
  Muslim                                       103   90.4
  Protestant                                   309   94.2
  Other                                        147   90.2
Parents education (proxy for SES)
  High school or less                          290   92.7
  University or collage                        655   91.6
  Don't know                                   165   90.7
Acculturation variable
Length of time spent in Canada *
  Born in Canada, lived 10+ years              744   93.7
  Born elsewhere, lived 4+ years               245   91.8
  Born elsewhere, lived 3 years or less        112   81.2
Behavioural variable
Sexual experience *
  Not experienced or unsure                    662   89.3
  Experienced                                  399   95.5

(a) Missing responses represented 0-1.7% the total for all variables
except for race (3%), religion (5%) and sexual activity (5%).

(b) Responses indicate places where youth said they had received
sexual health classes or workshops. Options were elementary and
secondary school, youth groups, religious groups, "other", and "never
had such classes". * P < 0.05

Table 4 Binary logistic model

                                                      B      S.E.

Gender                                                .131   .233
Age                                                  -.344   .378
Race
  Asian                                              -.315   .335
  Black                                              -.214   .355
  Other                                               .229   .490
Religion
  Catholic                                            .134   .336
  Muslim                                              .235   .423
  Protestant                                          .534   .373
  Other                                               .019   .394
Parents education
  College or university                               .296   .360
  Don't know                                          .353   .318
Immigration
  Born elsewhere lived in Canada 4+years             -.466   .452
  Born elsewhere living in Canada 3 years or less   -1.654   .450
Sexual experience                                    -.647   .310
Immigration by age interaction
  Immigration 1 by age                                .433   .595
  Immigration 2 by age                               1.428   .663
Constant                                             2.906   .549

                                                    NVald    df   Sig.

Gender                                                .315    1   .575
Age                                                   .831    1   .362
Race                                                 1.992    3   .574
  Asian                                               .882    1   .348
  Black                                               .363    1   .547
  Other                                               .218    1   .640
Religion                                             2.484    4   .648
  Catholic                                            .160    1   .689
  Muslim                                              .309    1   .579
  Protestant                                         2.052    1   .152
  Other                                               .002    1   .962
Parents education                                    1.243    2   .537
  College or university                               .678    1   .410
  Don't know                                         1.233    1   .267
Immigration                                         14.656    2   .001
  Born elsewhere lived in Canada 4+years             1.063    1   .302
  Born elsewhere living in Canada 3 years or less   13.516    1   .000
Sexual experience                                    4.352    1   .037
Immigration by age interaction                       4.637    2   .098
  Immigration 1 by age                                .531    1   .466
  Immigration 2 by age                               4.636    1   .031
Constant                                            27.989    1   .000

                                                    Odds Ratio

Gender                                                   1.140
Age                                                       .709
Race
  Asian                                                   .730
  Black                                                   .807
  Other                                                  1.257
Religion
  Catholic                                               1.144
  Muslim                                                 1.265
  Protestant                                             1.706
  Other                                                  1.019
Parents education
  College or university                                  1.345
  Don't know                                             1.423
Immigration
  Born elsewhere lived in Canada 4+years                  .627
  Born elsewhere living in Canada 3 years or less         .191
Sexual experience                                         .523
Immigration by age interaction
  Immigration 1 by age                                   1.542
  Immigration 2 by age                                   4.169
Constant                                                18.287

Variable entered on step 1: Gender, race, religion, age. Variables
entered on step 2: Immigration. Variables entered on step 3: sexual
experience. Variables entered on step 4: Interaction terms (age by
immigration). Reference categories: Gender (males); Age (16-18), Race
(White), Religion (No religion), Parents Education (high school or
less), Immigration (Canadian-born), Sexual experience (experienced).
Gale Copyright: Copyright 2010 Gale, Cengage Learning. All rights reserved.