*2.5. Sample Demographics*

The sample consisted of 111 participants from across the Greater Western Sydney (see Table 1). The majority of participants were female (51.4%), with a nearly equal number of males (47.7%) and one participant identifying as transgender. Participants' ages at the time of participation ranged between 16 and 60, with a mean age of 22.90 (*SD* = 5.25). Most participants were single (*n* = 82.9%) and had no children (94.6%). Seventy-six participants arrived in Australia between 2000 and 2009 (68.4%) with their close kin (mother 83.8%, father 71.2%, sibling 46.8%). The majority migrated from Sub-Saharan Africa (25%), closely followed by South-East Asia (24%), with the others migrated from East Asia (13%), the Middle East (11%), Eastern Europe (9%), the Pacific (6%), the Americas (6%), Western Europe (4%), and North Africa (2). The mean age at the time of migration was 11 years old (Mean (M) = 11.90, Standard Deviation (SD) = 4.67). The majority spoke English as a primary language (66.7%). Twenty-four languages were noted by those whose primary language was not English. The majority indicated a religious affiliation (87.4%), with 55% of those being Christian/Catholic. Ninety-five participants were heterosexual (85.5%), eight were bisexual (7.2%), five were homosexual (4.5%), one identified as lesbian (0.9%) and one identified as other (0.9%), and prefer not to say (0.9%), respectively.


**Table 1.** Demographic information for the study sample.

#### **3. Results**

The present study sought to examine the role an individual's culture has in the construction of their sexual and reproductive health. Table 2 presents the degree to which a participant's cultural identity was determined by their cultural connectedness to their Country of Origin, Australian Culture, Community, or Family.

**Table 2.** Cultural identity in relation to participants' perceived cultural connectedness (%).


The results indicate that stronger identification with one's family positively correlates with seeking help from an intimate partner, a doctor, community leaders, and seeking no help. Table 3 depicts correlations between the measures of cultural connectedness and sources of help. Table 4 depicts correlations between the sources of help. The results indicate significant positive correlations between a strong identification with one's country of origin and seeking help from an intimate partner, parents, a sexual health clinic, the Internet, and a doctor.

**Table 3.** Bivariate correlations between measures of cultural connectedness and sources of sexual and reproductive health (SRH) help-seeking.


*Note*. Correlations marked with an asterisk (\*) and double asterisk (\*\*) were significant at *p* < 0.05 and *p* < 0.01, respectively.



*Note*. Correlations marked with an asterisk (\*) and double asterisk (\*\*) were significant at *p* < 0.05 and *p* < 0.01, respectively.

Analyses indicated significant correlations between the identification with one's country of origin, Australian culture, one's community, and one's family and various sources of help, whereby stronger connections related to stronger inclinations toward seeking help from specific sources. Interestingly, seeking help from an intimate partner or doctor/general practitioner (GP) was significant across all measures of cultural connectedness. Additionally, seeking help from various sources often related to seeking help from other

sources. However, stronger inclinations to seek help from a relative or sexual health clinic were significantly related to lower inclinations to seek no help.

To identify group differences between participant's religious identifications (No Religion, Catholic/Christian, Greek Orthodox, Islamic, Buddhist, Other) among the various sources of help (Intimate Partner, Friend, Parent, Relative, Sexual Health Clinic, Internet, Doctor/GP, Community Leaders, No Help), Kruskall-Wallis nonparametric tests were conducted to accommodate the uneven group sizes. A statistically significant difference was identified for receiving help from parents (*X* 2 [5, *N* = 111] = 11.30, *p* < 0.05, *η* <sup>2</sup> = 1.16).

These results suggest significant differences between religious groups in regard to seeking help from parents. No significant differences, however, were found between the six religious categories—most likely due to small group sample sizes. However, the results show a significant difference only between religious affiliation and seeking help from a parent. Table 5 depicts the degree to which individuals of various religious identities seek help from their parent(s).


**Table 5.** Participants' perceived likelihood of SRH help-seeking from parent among religious identities.

The present study also sought to determine which sources individuals felt most comfortable seeking help from. Table 6 indicates participants' perceived likelihood (in percentage) to seek help from various sources. Doctors/GP (92.7%), sexual health clinics (88.1%), the Internet (84.1%), and intimate partners (81.1%) were among the most likely sources of help, while community leaders (72.5%), relative(s) (60%), and no help (56.8%) were among the most unlikely sources of help.

**Table 6.** Perceived likelihood (%) of SRH help-seeking depending on source.


The present study also sought to ascertain the most dominant barriers and facilitators to individual's help-seeking attitudes. Among the barriers hindering individuals' helpseeking, a lack of knowledge was identified as the most dominant barrier (45.9%). This was followed by concerns regarding concealment from one's family and community (36.0%). These results are complimented by the facilitator of help-seeking, whereby an increase in knowledge was identified as the most dominant facilitator of help-seeking (63.1%). Similarly, assurance of concealment was identified as the second most dominant facilitator of help-seeking (45.9%). Tables 7 and 8 depict the barriers and facilitators of help-seeking.


**Table 7.** Participants perceptions of potential barriers to SRH help-seeking.

**Table 8.** Participants perceptions of potential facilitators of SRH help-seeking.


To contextualise the key findings, participants' sexual and reproductive health histories were recorded. It was identified that 60.40% (*n* = 67) of the participants were currently sexually active. Of the 111 participants, 49.50% (*n* = 55) used contraceptives, 11.70% (*n* = 13) did not use contraceptives, and 38.70% (*n* = 43) preferred not to answer. Table 9 depicts the types of contraceptives participants have previously used.


**Table 9.** Types of contraceptives used by 1.5 generation migrants in Australia.

With regard to prior sexual health concerns, 2.7% (*n* = 3) of participants had previously been diagnosed with an STI. Among those, 66.7% (*n* = 2) were diagnosed with gonorrhoea, while 33.30% (*n* = 1) were diagnosed with herpes. Additionally, 66.7% (*n* = 2) took antibacterial medications, while 33.3% (*n* = 1) sought help from a doctor. When queried about the duration leading to their help-seeking behaviours, it was revealed that 66.70% (*n* = 2) sought help within 1—3 days of having sex while 33.3% (*n* = 1) sought help within 4—7 days. Participants justified this by saying that they were not aware that they were infected with an STI (*n* = 2, 66.7%) and that they were hoping that the STI would go away without intervention (*n* = 1, 33.3%).

In terms of pregnancy, 9.0% (*n* = 10) had previously experienced an unplanned pregnancy. Among these participants, 40% (*n* = 4) kept the child, 40% (*n* = 4) terminated the pregnancy, 10% (*n* = 1) organised an adoption, and 10% (*n* = 1) preferred not to answer on the outcome of the pregnancy.

#### **4. Discussion**

This study was designed to investigate the role of culture and religion on sexual and reproductive health indicators and help-seeking attitudes amongst 1.5 generation migrants

using a quantitative survey. Overall, the results suggest that 1.5 generation migrants were most likely to seek help from doctors/general practitioners (92.7%), sexual health clinics (88.1%), the Internet (84.1%), and intimate partners (81.1%) regarding clinical SRH issues. For support on non-clinical SRH matters, the results suggest that 1.5 generation migrants feel the least comfortable seeking SRH support from community leaders (72.5%) and relative(s) (60%). These findings can be further contexualised when culture and religiosity are considered.

With regards to the role of cultural connectedness on 1.5 generation migrants SRH helpseeking, the results indicate significant positive correlations between a strong identification with one's country of origin and seeking help from an intimate partner, parents, a sexual health clinic, the Internet, and a doctor. Stronger identification with one's family positively correlates with seeking help from an intimate partner, a doctor, community leaders, and seeking no help. This is in line with research indicating that some youths of minority and migrant backgrounds often struggle to engage with their parents when they experience an SRH concern for fear of the consequences of transgressing ethnocultural or religious protocols held in high esteem by their parents [12,13]. However, this was not the case for all of the 1.5 generation migrants in this study. This may be because these migrants feel more connected to their parents in line with their collectivist ethnocultural values [14]. For those who sought help from parents, it could also be that both the youth and their parents have acculturated more than popular discourses give them credit for [14].

In this study, strong identification with Australian (secular, individualist, capitalist and Eurocentric) culture positively correlates with seeking help from an intimate partner, relatives, a sexual health clinic, a doctor, and community leaders, while stronger identification with one's community positively correlates with seeking help from an intimate partner, relatives, a doctor, community leaders, and seeking no help. Other studies highlighted that culture as a significant factor in SRH help-seeking [6]; however, the findings of this study suggest that 1.5 generation migrants are not influenced by culture to the same extent as their older counterparts [14]. These findings suggest that the colloquially perceived ethnocultural values between more recent migrants and those with a longer history in Australia are not so incongruent [14]. These findings can inform contemporary discourses about young migrants and their SRH help-seeking needs.

The study inquired about whether religious affiliation influenced 1.5 generation migrants' SRH help-seeking. The analyses identified a significant difference only between religious affiliation and seeking help from a parent. This may be because increased religiosity has been linked to difficulties in seeking help for SRH issues from close family members due to fear of social sanctioning, as contemporary Australians youths' sexual behaviour is often at odds with religious doctrine [2]. Notably, those with no religious affiliation were slightly more likely to seek help from parents, yet there were no statistically significant differences between the six religious affiliations. The findings therefore suggest that more inquiry is needed into the role of religiosity and SRH help-seeking amongst young migrants and culturally and linguistically diverse youth.

To support access to SRH supports, the reduction in barriers and increase in facilitators is required. In this study, the top three barriers as perceived by 1.5 generation migrants were; not knowing where to access SRH services (45.90%), ensuring that their family and community did not find out (36.00%), and not having enough money to pay for SRH services (28.80%). Likewise, being made aware of where the services are (63.10%), being confident that no one would find out (45.90%), and access to services which are free/low cost (36.90%) were identified as the most dominant facilitators of help-seeking. These findings are aligned with Australian and international research with minority youth, aged 16 to 24, indicating that increased awareness of services that provide inconspicuous access to free SRH services improve youth SRH outcomes [15–18]. For instance, SRH support provided at university campuses can offer confidentiality from family and the community and often include billing options for local and international students that require minimal to no payment upfront [17,19,20]. However, such services are only accessible to those whose social determinants allow them the privilege of attending university. Considering that religion was an important influence in help-seeking, religious organisations may be well placed liaisons between youths, their families and communities, and SRH services.

#### **5. Limitations**

The study findings reiterate the role of cultural connectedness and religiosity in SRH help-seeking for migrant youths. The study has also highlighted key areas which require further consideration and investigation. The purposeful nature of the sampling strategy helped to achieve a varied sample with the aim of capturing perspectives from various ethnic, religious, and migration backgrounds. However, the country of origin of the sample was not proportional, as most participants were from sub-Saharan Africa. In addition, the majority of participants were Catholic or Christian, which may not reflect many 1.5 generation migrants who do not prescribe to Christianity. This cultural similarity may mean the full breadth of cross-cultural SRH help-seeking perspectives and behaviours have yet to be explored. Additionally, although participants' mean age of migration was 11 years old, those who arrived much younger may not experience as much pressure or culture clash, as they may have been too young to remember or for their families to feel that they had to adhere to the rules of their ethnic origins. The age of participants is also relevant in relation to when they migrated to Australia. For instance, as the participants aged, they may be less likely to recall or recount their experiences as children. Further, their perspectives of SRH help-seeking were asked in relation to the present versus helpseeking in the past, which would have included fewer SRH services and engagement from community services and networks. Irrespective of age at participation, it seemed that for the migrants in this study, religion appeared to hold more weight in determining their SRH help-seeking attitudes. More exploration is needed to determine the interaction between age of migration and SRH help-seeking and outcomes. Finally, the analysis was restricted, as one-way ANOVAs could not be conducted on the studies due to the small and uneven sample sizes; as such, Kruskall-Wallis tests were used instead. Ultimately, generalisations cannot be made about the different perspectives among such groups, and further study is recommended to assess the effect of diverse religious backgrounds on SRH help-seeking amongst migrants in Australia.

Although participants of this study were recruited from a number of Western Sydney suburbs, this was done in relation to seven Western Sydney University campuses and surrounding off-campus venues (e.g., major shopping malls). As a result, the participants are likely to have been university students or staff and therefore well-educated. In such a case, the participants would potentially have a heightened capacity to both understand and critically analyse the statements before sorting them. As such, the sample may not be representative of the many 1.5 generation migrants who may not have high levels of education. With lower levels of education come lower levels of health literacy [21]. Consequently, participants' perspectives on health care services and the engagement of these migrants with those services may be influenced by their increased ability to scrutinise, navigate, and mediate their experiences within the Australian health care system compared to other groups of migrants. Expansion of this study to include a broader variety of 1.5 generation migrants is therefore required.

#### **6. Conclusions**

The influence of a cross-cultural upbringing is often noted in the extant literature as a potentially challenging factor in migrant youths' sexual and reproductive health helpseeking. Amongst the 1.5 generation migrants in this study, there were no significant differences between ethnocultural groups or levels of cultural connectedness in relation to sexual and reproductive health help-seeking. While cultural norms of migrants' country of origin can remain strong, it is religion that seems to have more of an impact on how 1.5 generation migrants construct, experience, understand, and engage with various aspects of SRH. The present study's results suggest differences between religious groups in regard

to seeking help specifically from youths' parents. Notably, participants who reported having 'no religion' were more likely to seek help with sexual and reproductive health matters from their parents. Given that religion can play such an important role in youths' sexual and reproductive health religious organisations may be well-placed to encourage youth help-seeking. This may be a means of addressing the barriers that youths perceive to accessing support in ways that ensure equitable and easy access to confidential and low to no cost sexual and reproductive health services.

**Supplementary Materials:** The following are available online at https://www.mdpi.com/1660-4601/ 18/3/1341/s1, Text S1: Participant Information Sheet, Demographic Questions and Quantitative Survey.

**Author Contributions:** Conceptualization, T.D.; Data curation, T.D. and D.A.; Formal analysis, T.D., J.T. and Z.M.; Funding acquisition, T.D.; Investigation, T.D.; Methodology, T.D.; Project administration, T.D. and D.A.; Software, T.D.; Supervision, T.D.; Validation, J.T.; Writing—original draft, T.D. and J.T.; Writing—review and editing, T.D., D.A., J.T., Z.M. and V.M. All authors have read and agreed to the published version of the manuscript.

**Funding:** Western Sydney University as well as the Translational Health Research Institute and the School of Health Sciences (both organisations within Western Sydney University) provided funding for this research through Early Career Research Grants in 2015. However, these units did not have a role in the design, collection, analysis and interpretation of data.

**Institutional Review Board Statement:** This study is part of a larger research project examining the SRH of 1.5 generation migrants in Australia and ethical approval was received from the Human Research Ethics Committee of Western Sydney University. In addition, informed consent to participate in this study was obtained from all participants (approval date and code: 19 June 2015, H11168).

**Informed Consent Statement:** Informed consent was obtained from all subjects involved in the study.

**Data Availability Statement:** The data presented in this study are available on request from the corresponding author. The data are not publicly available due to ethical restrictions on public access.

**Acknowledgments:** We would like to thank Janette Perz whose mentorship and sponsorship of this research made it possible. We would also like to thank the participants who provided their time and voices to this project, which would not have been possible without their candour during data collection and trust in the aims and goals of the research.

**Conflicts of Interest:** The authors declare no conflict of interest.
