Introduction
International education is Australia’s fourth largest export, attracting more than 570,000 students by 1 September 2023, with 30% of these students studying in Victoria, Australia (Department of Education, 2023). Maintaining international students’ overall health and wellbeing during their study in Australia is listed as a key component of the Education Services for Overseas Students (ESOS) Framework, a legislation that sets national standards for education providers to deliver coursework to international students. Ensuring access and providing referral pathways to maintain international students’ health and wellbeing is listed under Standard 6. Education providers are to comply with this standard so they can maintain their registration as an education provider that can provide education services to international students (Department of Education, 2022a, 2022b).
Sexual and reproductive health (SRH) is integral to health and wellbeing (MacPhail & Stratten, 2023). Improving SRH literacy among international students is a key priority in the Australian Fourth Sexually Transmissible Infections (STIs) Strategy (Department of Health, 2018). Despite this goal, there are no Australia-wide SRH resources specific to this population. Consequently, each of Australia’s states and territories relied on its own funding to establish an SRH resource for international students, such as New South Wales Health’s International Student Health Hub (NSW Health, 2023). Similar resources are not readily available in other jurisdictions, including Victoria.
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The lack of nationwide SRH education programs specific to international students also means that each tertiary education provider is to rely on stakeholder goodwill and resources to develop SRH resources. Some examples include an SRH resource kit developed by the University of Wollongong in collaboration with international students and the Illawarra Shoalhaven Local Health District (MacPhail & Stratten, 2023) and Monash University’s Our Sexual Health online SRH training program for international students (Monash University, 2023). However, not all institutions offer such tailored SRH programs. Small tertiary education providers, such as English language colleges and private colleges, may lack the funds, human resources, and skills to deliver these initiatives (DeLacy et al., 2019). Inconsistencies in SRH education could result in students having to rely on their peers, resources from their countries of origin, and online sources to seek SRH information, even though the reliability of these resources is not guaranteed and may lead to further confusion (Chang et al., 2022; Lim et al., 2022; MacPhail & Stratten, 2023; Mundie et al., 2021; Women’s Health in the North [WHIN], 2020).
International students are not a homogenous group, and attitudes toward sex, sexuality, and SRH are influenced by the socio-cultural norms that exist in their countries of origin. Studies have shown that students from sex-negative backgrounds tend to have lower SRH literacy than students from sex-positive backgrounds and students from the host countries (Lim et al., 2022; WHIN, 2020), and that international students are more vulnerable to SRH-related issues than domestic students due to their general lack of knowledge on accessing SRH in host countries. Furthermore, international students face unique challenges to access SRH education and services. These include socio-cultural stigma around SRH in their country of origin and in Australia, lack of and inconsistent SRH education in countries of origin and in Australia, language barriers, unfamiliarity with the Australian healthcare system, and genuine concerns over the costs of accessing SRH prevention strategies such as long-acting reversible contraception and HIV biomedical prevention strategies such as PEP (post-exposure prophylaxis) and PrEP (pre-exposure prophylaxis) (Blackshaw et al., 2019; Burchard et al., 2011; Chang et al., 2022; Douglass et al., 2020; Engstrom et al., 2021; Lim et al., 2022; MacPhail & Stratten, 2023; Mundie et al., 2021; WHIN, 2020; Okeke, 2021; Parker et al., 2020; Phillips et al., 2022; Philpot et al., 2021; Sudarto et al., 2022).
Studies have found that many international students, especially those from sex-negative backgrounds, do not have the required knowledge and skills to maintain their SRH in Australia, possibly contributing to the low STI and HIV testing rates among this population (Douglass et al., 2020; Engstrom et al., 2021) as well as increased the risk of unplanned pregnancies (Multicultural Centre for Women’s Health [MCWH], n.d.). Stress related to SRH issues can negatively affect international students’ academic progress (Douglass et al., 2020; Lim et al., 2022; Liu et al., 2022; Okeke, 2021), and this can affect their student visa status, which requires students to meet the course requirements and maintain a satisfactory course progression (Study Australia, 2024). Failure to meet these requirements puts students at risk of visa cancellation, which could further complicate SRH-related emotional distress.
As part of their student visa conditions, international students in Australia are mandated to purchase an Overseas Student Health Cover (OSHC), which covers a portion of their medical expenses during their study in Australia (Study Australia, 2024). However, some expenses related to SRH are not covered under OSHC, or there is a waiting period before students can access these services, including pregnancy-related healthcare and termination of pregnancy (Bupa, n.d.; Poljski et al., 2014). Furthermore, some students are not aware whether SRH is covered under their OSHC due to limited information given by insurance providers and education institutions (WHIN, 2020). Consequently, many international students delay accessing SRH-related services, with SRH-related stigma making them embarrassed to seek advice from a general practitioner (GP) or they are unaware that they could talk to their GP about health issues related to SRH (Burchard et al., 2011; Mundie et al., 2021; Parker et al., 2020).
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While international students’ perspectives on SRH education have been well-researched (Baek et al., 2012; Burchard et al., 2011; DeLacy et al., 2019; MacPhail & Stratten, 2023; WHIN, 2020; Parker et al., 2020; Poljski et al., 2014), little is known about tertiary education providers’ perspectives on the topic. One report included staff perspectives on SRH education, but only from one institution, La Trobe University in Melbourne, Australia (WHIN, 2020). To address this gap, our research involved staff from various tertiary education providers to investigate their perspectives on barriers and opportunities for tertiary education institutions to deliver comprehensive SRH education tailored to international students. We also interviewed international students from diverse tertiary institutions in Victoria, Australia, to learn about their views on the topic to ensure that future strategies came from both staff and international students. Guided by the socio-ecological model, our research explores the interplay between socio-cultural factors (such as cultural stigma), individual factors (such as SRH literacy), and government policies among others that can influence health outcomes (Wold & Mittelmark, 2018).
Methods
We followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) Guidelines in our analysis and reporting (Tong et al., 2007). A copy of the COREQ Checklist can be found in Supplementary 4.
Research Team and Reflexivity
This study employed a community researcher (Hearn et al., 2022), BS, who is non-binary, has a Master of Arts degree, and is a former international student with professional experiences in qualitative research, health promotion, and international student services. The main research team consists of JJO, EPFC, and TRP, who are established sexual health researchers with extensive experience with sexual health, HIV and STI prevention strategies, and migrant communities. TRP has a background in qualitative research and was involved in cross-checking the themes. All authors contributed to the revision of the manuscript.
Theoretical Framework
This study used a theory-informed inductive study design (Varpio et al., 2020), whereby a socio-ecological model of health (Wold & Mittelmark, 2018) was used to inform the research. This model was deemed relevant to this study and was referred to throughout the data collection and analysis to explore various systemic and socio-cultural factors that influenced tertiary education providers’ views on SRH education specific to international students.
Participants and Recruitment
We used a purposive sampling method whereby participants who meet the selection criteria self-nominate to be involved in the study (Martinez-Mesa et al., 2016). There were two groups of participants from Victoria, Australia: staff working at tertiary education providers and international students. Staff were recruited from various tertiary education providers, including universities, English language colleges, and TAFE (Technical and Further Education) institutes. We included teaching, student support staff and managers, and health professionals working at university health services as they regularly engaged with international students and could offer insights specific to their professions. International students were included in the recruitment to complement staff perspectives and to ensure that future strategies came from both staff and international students. BS contacted potential participants via email to introduce themselves, provided an overview about the research project, confirmed participants’ eligibility, and arranged a time for an interview or a focus group. Recruitment was held between July 2022 and May 2023. This amount of time was required as we encountered difficulty in recruiting international student participants. This will be discussed further in the Limitations. Overall, 15 staff members and nine international students were interviewed. The selection criteria can be found in Table 1. Participants’ characteristics are summarised in Table 2. A summary of recruitment strategies is presented in Supplementary 1.
Table 1
Selection criteria
Tertiary education providers | International students |
|---|---|
Aged 18 years and above | Aged 18 years and above |
Currently working at a tertiary education provider (university, TAFE, English language college, private college) | Currently studying at a tertiary education provider (university, TAFE, English language college, private college) |
Hold a valid Medicare card | On a valid student visa |
All genders and sexualities | Hold a valid Overseas Student Health Cover (OSHC) |
All ethnicities and nationalities | All genders and sexualities |
All ethnicities and nationalities |
Table 2
Participants’ characteristics
Staff participants | Number (percentage, %) |
Gender | |
Cisgender woman | 12 (80) |
Cisgender man | 3 (20) |
Age group | |
20's | 1 (7) |
30's | 5 (33) |
40's | 7 (47) |
50s | 2 (13) |
Cultural backgrounds | |
Anglo Australian | 5 (33) |
Mediterranean Australian | 1(7) |
European Australian | 1 (7) |
East Asia | 4 (27) |
Southeast Asia | 2 (13) |
South America | 2 (13) |
Institution | |
English language college | 1 (7) |
TAFE | 3 (20) |
University | 11 (74) |
Roles | |
Administration staff (including student support and student adviser) | 8 (53) |
Teaching staff | 1 (7) |
Health staff (including nurses, GPs, and counsellors) | 6 (40) |
International student participants | Number (percentage, %) |
Gender | |
Cisgender woman | 2 (22) |
Cisgender man | 6 (67) |
Non-binary | 1 (11) |
Age group | |
Late teens | 1 (11) |
20's | 8 (89) |
Cultural backgrounds | |
East Asia | 5 (56) |
Southeast Asia | 2 (22) |
South Asia | 1 (11) |
Middle East | 1 (11) |
Institution | |
TAFE | 1 (11) |
University | 8 (89) |
Study level | |
Diploma | 1 (11) |
Undergraduate | 1 (11) |
Postgraduate | 7 (78) |
Data Collection
BS was the only person who conducted semi-structured in-depth individual interviews with each staff participant and focus groups with international students. We decided to include students’ perspectives to complement staff views. Focus groups were held with international students in conversational English; one focus group involved seven international students, and another focus group involved two international students. These groups were organised based on their availability. Interviews and focus groups were held between August 2022 and July 2023. There were no repeat interviews or focus groups. The interviews ranged from 45 to 60 min, and focus groups ranged from 90 to 100 min. A copy of the interview guides for staff participants can be found in Supplementary 2. A copy of the focus group guides for student participants can be found in Supplementary 3.
All interviews and focus groups were held via Zoom video conferencing software and were audio-recorded. Participants provided BS with a signed informed consent form prior to the interviews and focus groups. All recordings were kept confidential in a secure folder at the Melbourne Sexual Health Centre server, with access to these recordings restricted to BS and the lead researcher (JJO). Student participants received an e-voucher (A$50 or US$32) to compensate for their time and acknowledge their wisdom. Staff participants were not reimbursed due to their role as paid staff members.
All participants received a copy of the interview transcript to read, edit, and approve. Participants were sent a copy of this manuscript to add comments and additional thoughts and ensure the findings accurately reflect their opinions and experiences. This is part of the member-checking process to ensure that participants are active contributors to the research process (Birt et al., 2016).
Data Analysis
All interviews and focus groups were transcribed verbatim using a professional transcription company. Interview transcripts were collated using QSR International NVivo 14 and managed using Microsoft Word. Data integrity was maintained during the 1-year recruitment and data collection period by ensuring that only BS had access to the raw data and was responsible in analysing the data based on themes that emerged from the transcript. BS used a reflexive thematic analysis to interpret the data (Braun & Clarke, 2019). This method was chosen as it recognises researchers’ own knowledge, prior experiences, and biases that may influence the design and interpretation of the study, as well as to ensure transparency as researchers bring their own worldview into the research project. BS immersed themselves in the data, checked their own biases, identified initial codes, arranged them based on the general themes, and then further refined the themes into sub-themes. BS constantly searched for new and additional meanings and interpretations to challenge their own pre-existing knowledge. TRP cross-checked the analysis and the themes, and a consensus was reached after no additional themes could be identified from the data.
Ethical Consideration
The research was approved by the Alfred Hospital Ethics Committee (number 270/22).
Results
We identified five major themes from the data: barriers to accessing SRH education and services, the role of education providers to deliver SRH education to international students, barriers faced by education providers, opportunities and enablers for education providers to provide SRH education, and benefits of SRH education to international students. We further analysed the major themes and added several sub-themes. A summary of key themes, sub-themes, and sample quotes can be found in Table 3.
Table 3
Themes with sample quotes
Major themes: - sub-themes | Sample quotes |
|---|---|
Barriers faced by international students to access SRH education and services | |
- Systemic | |
Lack of SRH resources specific to international students | There is no sort of information brochure or activity or event for students to access information (Staff 12, 30's, cisgender woman, East Asian, university counsellor) |
Lack of SRH education in countries of origin and in Australia | [International students] may not have the same sex education that students might have had here in Australia. There might have been taboos or there might have been cultural things, so they’re coming to Australia without [SRH] knowledge (Staff 11, 40's, cisgender woman, European Australian, university administrator) |
- Individual | |
Socio-cultural stigma and taboo | A lot of it is stigma. You’re brought up in another culture where it isn’t the norm to talk about [SRH], so they’re probably not comfortable with it; they didn’t grow up talking about it. If that’s your cultural background, if that’s how you are brought up with your family, then you’re probably still going to carry that, feel stigma and embarrassment and not want to talk to people [about SRH] (Staff 1, 20's, cisgender woman, Mediterranean Australian, TAFE instructor) |
SRH only seen as relevant in a heterosexual marriage | We did get a lot of this idea that you wouldn’t need a sexual health check until you’re married. And even then, you wouldn’t need it because you’re just with one person (Staff 9, 30's, cisgender woman, South American, university administrator) |
English language competency | The challenge would be language. While students supposed to have a certain level of English, the level of English unfortunately is still basic (Staff 10, 40's, cisgender woman, Southeast Asian, TAFE administrator) |
Income level and financial constraints | I know anecdotally that cost is one of the key things that concerns students, especially around what is or is not covered by their health insurance (Staff 9, 30 s, cisgender woman, South American, university administrator) |
Lack of SRH literacy | [International students] have a very low knowledge [of SRH]. From what I observe, their understanding seems to be very low (Staff 8, 40's, cisgender woman, Anglo Australian, university health staff) |
Confusion over navigating the Australian healthcare system | Students don’t have the information [about the health system]. We tell them at orientation, ‘If you are feeling ill, you don’t go to the hospital, you go to a GP’, and you leave them with that information. But, students would [wonder], ‘Well, where would I find this GP? Who is this GP person?’ That would be very daunting (Staff 4, 40's, cisgender man, Anglo Australian, English language college administrator) |
- Interpersonal | |
Concerns over confidentiality | The main thing is confidentiality. [International students] don’t necessarily know [about] confidentiality. They would assume that your professors would have access to your medical files (Staff 5, 40's, cisgender man, East Asian, university health staff) |
Do not want to be judged by peers | They may not want to discuss [SRH] with other students, because students will spread things around without realising and then it becomes everyone’s business (Staff 1, 20's, cisgender woman, Mediterranean Australian, TAFE instructor) |
Role of education providers to provide SRH education to international students | |
Duty of care to maintain international students’ health and wellbeing | We have a duty to look after [international students], not just to provide them with education, but we are also responsible for their health and wellbeing if we want them to succeed at university (Staff 2, 40's, cisgender woman, Anglo Australian, university health service staff) Educational organisations like universities, schools, [have the] responsibility to teach the younger generation of the correct way of having intimacy and having a sexual relationship with someone, instead of someone having 10 kinds of STDs and transmitting it to a hundred or a thousand of people (Student 4, late teens, cisgender man, Middle Eastern, TAFE student) |
Barriers faced by education providers | |
- Systemic | |
Limited funding | [Providers] would need to exclusively rely on external funding, which is difficult to get. When we think of international students, we don’t necessarily include sexual health as one of them (Staff 9, 30's, cisgender woman, South American, university administrator) |
On-campus health clinics are over capacity or do not have the skills to provide culturally safe SRH information to international students | I don’t even know whether the medical centre [on campus] know how to deliver [SRH] messages properly, culturally appropriate for the students (Staff 15, 50's, cisgender woman, East Asian, TAFE administrator) |
- Individual | |
Socio-cultural taboo surrounding SRH | I’d say it was just a societal taboo, to talk about anything sexual. People feel a little uncomfortable talking about [SRH] (Staff 4, 40's, cisgender man, Anglo Australian, English language college administrator) |
Lack of SRH literacy | We don’t have the knowledge to talk about [SRH]. Let’s be honest, that’s probably been the main issue (Staff 11, 40's, cisgender woman, European Australian, university administrator) |
Concerns over students’ cultural and religious backgrounds | A lot of students [in my institution] are Muslim students [from South Asian countries]. I think in terms of religion, it’s probably somewhat of a barrier [to talk about] sexual health (Staff 10, 40's, cisgender woman, Southeast Asian, TAFE administrator) |
Opportunities and enablers for education providers | |
- Systemic | |
Government funding | [SRH education] should be government funded and government driven (Staff 12, 30's, cisgender woman, East Asian, university counsellor) |
Changes to the legislation | We need to look into providing the same, or a minimum, standard of care for all international students, because we know there are so many places where international students get badly treated [by their education providers] (Staff 9, 30's, cisgender woman, South American, university administrator) |
A national SRH program | It would be good if there’s a program set up by the government so that it’s consistent information across any place that they’re studying, (Staff 1, 20's, cisgender woman, Mediterranean Australian, TAFE instructor) |
- Individual | |
SRH knowledge hub | [A website] is really useful and it will be easier for us to have that link as our own reference guide. If we don’t know a certain topic, I can look at the website rather than [searching for] many resources; we don’t know which one is appropriate to use (Staff 7, 30's, cisgender woman, East Asian, university counsellor) |
SRH training | It would be great if we could have [a training], even if it was just understanding sexual health, how to be aware of certain things and [how to] approach [SRH related] conversations that is still within the boundary (Staff 8, 40's, cisgender woman, Anglo Australian, university health staff) |
- Interpersonal | |
SRH peer education program | [SRH education] not from your 60-year-old senior manager or not from your lecturer and not from your doctor. I think this is where the peer-to-peer space can excel (Staff 13, 30's, cisgender man, Southeast Asian, university administrator) |
SRH activities at student orientation | I personally think orientation day will be best way to promote sexual health. On the first day, they know there’s a link or a website [about SRH] available to them, so when they need it, they can find the information (Staff 7, 30's, cisgender woman, East Asian, university counsellor) |
SRH outreach team | It has to be outreach program, people specialising in sexual health or health in general. The institution can invite them during orientation week or throughout the semester (Staff 15, 50's, cisgender woman, East Asian, TAFE administrator) |
Benefits to international students | |
Increase SRH literacy and break down SRH-related stigma and taboo | Students would know what their [SRH] rights are and trusted services that they can access, that they are being listened to and respected in their decisions around their own sexual and reproductive health. If they don’t want to engage, that’s 100% fine. But if you do, and if you’re curious, you want to learn more, or if you have questions, just having trusted people that you can go to and the confidence that you will be looked after, that it will be confidential, that it won’t cost much, so they can look after you and you can go on with your life (Staff 9, 40's, cisgender woman, South American, university administrator) To reduce the stigma and overcome taboo. You’d be creating a safe space to let people to talk about [SRH]. People wouldn’t feel judged, raise awareness, and emphasise pleasure. Everyone has the right to seek pleasure but to also safely seek pleasure (Student 2, 20's, non-binary, East Asian, postgraduate student) |
“A lot of it is stigma”: Barriers to Accessing SRH Education and Resources
Both staff and student participants mentioned several barriers that influence international students’ access to SRH education and resources. These include systemic barriers (lack of resources on SRH specific to international students, lack of SRH education in countries of origin and in Australia), individual barriers (stigma and taboo around SRH, SRH only seen as relevant in a heterosexual marriage, English language competency, lack of SRH literacy, confusion over navigating the Australian healthcare system, income level and financial constraints), and interpersonal barriers (concerns over confidentiality, concerns over being judged by peers). In particular, we noted a view from a staff that some international students are concerned that their parents would know their SRH status if they accessed SRH services and clinics:
Confidentiality is a huge issue for international students, especially if their parents have paid for their [overseas student health] insurance. We’ve often got the question, ‘If I come and talk about this or mental health or sexual health, will my parents know?’ People are very grateful when we say, ‘No, it’s confidential. It’s just about you’. (Staff 8, 40's, cisgender woman, Anglo Australian, university health staff)
A staff member noted the influence of cultural norms around sexuality and sex that could result in on-going stigma and taboo around SRH:
They’re quite ashamed of talking about [SRH]. In certain cultures, it is forbidden. Sexual behaviour is forbidden, let alone talking about sexual health and how to stay healthy. And it’s a taboo topic regarding sexual health, and the general shame around holding [SRH] knowledge. (Staff 12, 30's, cisgender woman, East Asian, university counsellor)
“We do have a responsibility”: The Role of Education Providers to Deliver SRH Education to International Students
All staff and students said tertiary education providers should play an active role in providing SRH education to international students. Some staff participants noted the lack of SRH education in students’ countries of origin that contributed to international students having a low SRH literacy in comparison to domestic students, and this only further highlights the need for tertiary institutions to deliver SRH education to these students.
Indeed, many staff members reflected on providing SRH education as an institution’s duty of care to maintain international students’ overall health and wellbeing. A particular staff participant stated that education institutions are responsible in maintaining international students’ wellbeing as per the ESOS legislation:
[Providers] are to cover what’s in the ESOS, the National Code, Standard 6, because the National Code, Standard 6 says you must maintain students’ wellbeing (Staff 6, 50's, cisgender woman, Anglo Australian, university administrator)
Despite this, many staff participants mentioned several barriers to delivering SRH education to international students, and these will be discussed in the next session.
“It’s a societal taboo to talk about anything sexual”: Barriers Faced by Education Providers
Staff participants were asked about barriers that prevented them from developing and delivering SRH education to international students. We summarised their responses into two themes: systemic barriers and individual barriers.
Systemic Barriers to SRH Education
Many staff participants reflected on limited government funding as a primary systemic barrier to providing SRH education to international students. A few of them noted that SRH is often not prioritised in government funding, and available funding is often short-term and not designed for long-term, sustainable measures.
In addition to limited funding, a few staff participants stated that not all tertiary institutions have on-site health clinics where international students can access healthcare at low cost or for the cost to be absorbed by their OSHC providers. Indeed, health professionals working at a university health clinic mentioned limited resources in the healthcare setting that prevented them from engaging in conversation about SRH with international students:
We’re unfortunately very busy, so it’s not like if you had an accident on Saturday night that you could be guaranteed that on Monday morning you can come in and have a chat about post-exposure prophylaxis [PEP]. We have a triaging system for our nurses, but to be honest, we also have a very overworked nursing staff. (Staff 5, 40's, cisgender man, East Asian, university health staff)
Similarly, a staff participant stated that she lacks confidence in the ability of the medical centre in her institution “to deliver [SRH] messages that are culturally appropriate” (Staff 15, 50's, cisgender woman, East Asian, TAFE administrator).
Considering these barriers, a staff participant noted the lack of avenues within the higher education sector for international students to ask questions relating to SRH outside of a clinical setting:
If you’re an individual and you want support, and it’s not clinical, where do you go? They need guidance. The ecosystem, we have to build it. (Staff 13, 30's, cisgender man, Southeast Asian, university administrator)
Individual Barriers to SRH Education
In addition to the above systemic barriers, we found that some staff participants reflected on their own personal discomfort and lack of knowledge in SRH as reasons for their reluctance to talk about SRH with international students. A few staff participants mentioned that their own cultural upbringing has resulted in their hesitation to talk about SRH to international students, especially staff from sex-negative backgrounds. For one participant, the intersection of her cultural background, gender identity, and lack of knowledge on SRH made her feel uncomfortable to talk about SRH to international students, especially with male students:
For me, as a female, in front of [male] students, to talk about sexual health, it’s just not right. (Staff 15, 50's, cisgender woman, East Asian, TAFE administrator)
A few staff participants thought that SRH education would go against students’ socio-cultural norms, and they had concerns over upsetting and offending these students. A participant reflected on the lack of SRH training, resulting in staff not knowing how to respond to the students on SRH-related questions:
We don’t have training [on SRH]. What [do we do] if we’re approached by students? Staff need to be aware, using the right language, being professional, and refer them to the medical centre or somewhere else. (Staff 1, 20's, cisgender woman, Mediterranean Australian, TAFE instructor)
“We can normalise it as part of general health”: Opportunities and Enablers for Education Providers to Deliver SRH Education to International Students
Despite the above systemic and individual barriers, both staff and student participants were optimistic that tertiary education providers would be able to provide SRH education to international students. The themes were systemic (government funding and policy), individual (SRH knowledge hub and SRH training), and interpersonal (SRH peer-to-peer program, SRH-related activities at student orientation, and SRH outreach program). These are presented below:
Systemic Enablers: Sustainable Funding, Change in the ESOS Legislation, and a Government-Coordinated SRH Education Program
Many participants felt that both the state and federal government should provide on-going and sustainable funding to assist tertiary education providers in developing and delivering SRH education specific to international students. A few staff and student participants mentioned that OSHC providers could also contribute by providing funding to tertiary institutions. While most staff participants agreed that sustainable funding is needed, a particular staff participant believed that policy change is also needed to ensure that all tertiary institutions provide SRH education to international students:
I think having [SRH] in ESOS, where this is a topic that needs to be covered, an institution will go through that list to make sure they’re being compliant and make sure that they’re covering [SRH] issues. (Staff 6, 50's, cisgender woman, Anglo Australian, university administrator)
However, as stated earlier, not all institutions have the resources to develop a comprehensive SRH education program. A few staff from small education institutions stated that a systemic enabler would be for both the state and federal governments to develop and coordinate the delivery of a nationwide SRH education program. This would assist small education providers to provide SRH information to international students, and “at the very least, we can put [SRH] resources on the student portal” (Staff 15, 50's, cisgender woman, East Asian, TAFE administrator). This view was supported by a student participant, who believed that SRH education is the responsibility of the government “to provide [international students] with [SRH] knowledge because, at the end of the day, students interact with the general public” (Participant 3, 20's, cisgender woman, South Asian, postgraduate student).
A staff participant believed that a national SRH education program would ensure that all international students would receive SRH education by “providing the same [SRH] standard of service to all international students” (Staff 9, 30's, cisgender woman, South American, university administrator). A few staff participants noted that government would have more financial resources than individual institutions to create culturally relevant and multilingual SRH resources in collaboration with education institutions, community health organisations, international student associations, and SRH professionals:
An important component that we do is to co-design the information with international students, experts working with a group of international students, to get the information they need in a language they would understand. (Staff 6, 50's, cisgender woman, Anglo Australian, university administrator)
Individual Enablers: SRH Knowledge Hub and SRH Training Module
Many staff and international student participants believed that a comprehensive SRH knowledge hub would enable international students to gain SRH information and increase their SRH literacy. A staff participant believed that such a knowledge hub would enable students to access SRH information “anonymously rather than attending [an SRH] workshop because some students would be self-conscious to attend” (Staff 10, 40's, cisgender woman, Southeast Asian, TAFE administrator).
Additionally, staff and student participants mentioned the use of social media and online videos to increase engagement and destigmatise the topic. In this study, we found that an SRH knowledge hub would also benefit staff. A few staff participants said that a knowledge hub would also assist them in providing information to students, including referrals to SRH clinics, and act as “a resource for people like us who [give] advice to students (Staff 11, 40's, cisgender woman, European Australian, university administrator). In addition to contraception, HIV, and STI prevention strategies, staff and student participants agreed that the knowledge hub should also include information on understanding and navigating the Australian healthcare system, OSHC, and costs associated with SRH services and clinics, the human body and reproductive organs, pleasure, intimacy, consent, and respectful relationships. In this study, we also found that a few staff and student participants mentioned specific content to be created for sexually and gender-diverse international students to reflect their unique identities and experiences:
[There are] unique issues; sexual health for the gay community might talk about chem sex, chemical sex [sex involving the use of recreational or illicit drugs], or in the trans community, information about transitioning. Also, information about pronouns. It’s about sexuality education, but you [link it] with sexual health. (Student 2, 20's, non-binary, East Asian, postgraduate student)
Another enabler for staff is an SRH training module for both staff and international students. A few staff participants believed that SRH training would provide them with basic information about SRH issues commonly experienced by international students and ways to assist students in a professional and culturally appropriate manner:
It would be great if we could have [a training], even if it was just understanding sexual health, how to be aware of certain things and [how to] approach [SRH related] conversations that is still within the boundary. (Staff 8, 40's, cisgender woman, Anglo Australian, university health staff)
A staff participant mentioned that another benefit of a training module would be to increase staff confidence to talk about SRH to international students:
It might make people feel less uncomfortable, it might make people more open to having discussion with their students and it also might make the students feel more comfortable about [SRH]. (staff 4, 40's, cisgender man, Anglo Australian, English language college administrator)
Indeed, for a staff participant, SRH training should not be intended to make all staff an expert in SRH, but to equip them with enough knowledge so they can provide advice and referrals to students, especially for teaching staff who regularly interacts with international students:
Lecturers and tutors are responsible for students’ wellbeing. They don’t need to be the expert of providing SRH information, but they know the students, they see students regularly, so the role of tutors and lecturers is to be aware of services that are available to the students, so they can refer students to services. (Staff 2, 40's, cisgender woman, Anglo Australian, university health professional)
Interpersonal Enablers: Peer-to-Peer SRH Program, SRH Activities at Orientation, and SRH Outreach Program
In addition to systemic and individual enablers, many staff and student participants mentioned several SRH strategies based on social interactions, such as a peer-to-peer SRH education program. In this study, we found that a peer education model would enable staff to connect international students with trained peer educators so they could “get past that initial embarrassment phase, so they know that there’s information, there’s help, there are things available for them, and there are students to have [SRH] conversations with” (Staff 9, 30's, cisgender woman, South American, university administrator).
In addition to a peer education model, both staff and student participants suggested SRH activities at international student orientation programs to familiarise students with the topic. Despite this, a few staff and student participants were cautious that some students may be overwhelmed with the amount of information provided during their orientation program. A staff participant suggested that SRH information could be introduced at the orientation program and a link to an SRH knowledge hub to be made available in the student portal so that international students can access information in their own time.
We also noticed some concerns from a few staff and student participants that not all international students would feel comfortable to attend an SRH session or participate in SRH activities, and such activities must consider students’ gender and cultural norms. An opt-out option was suggested by a student participant, so that students “have the option that they can opt out if they’re extremely uncomfortable with thinking or encountering [SRH] topics (Student 8, 20's, cisgender woman, South Asian, postgraduate student).
However, as noted earlier, not all tertiary institutions have the resources to deliver SRH peer education programs and SRH-related activities during the international student orientation program. Some staff and student participants stated that a government-coordinated SRH outreach team consisting of SRH nurses and peer educators would enable tertiary institutions to provide SRH education to international students without relying on their limited resources. A few staff and student participants mentioned Study Melbourne Student Centre, a Victorian government initiative that provides support for international students, as a possible site for an SRH outreach team to interact with students and answer their questions “in a one stop shop, because students don’t have the mental capacity to run around and find different resources” (Student 3, 20's, cisgender woman, South Asian, postgraduate student). Another participant stated that a benefit of an SRH outreach team would be to break down cultural barriers around accessing healthcare services, especially for students who came from contexts where visiting a health clinic is reserved for serious medical conditions:
If you have a place for you to ask questions and [you’re] less stressed because, for some people, when they see [a] GP, they might think that things are getting very serious, so they might be feeling stressful. I think giving them a place that they can talk with less pressure, they can express their feeling more [easily] and the one who is listening can [provide] information and find ways to support them. (Student 9, 20's, cisgender man, East Asian, postgraduate student)
For a staff participant, an SRH outreach team should be embedded as part of a health and wellbeing outreach program to encourage conversation:
We can normalize it as part of the general health so students can understand that, ‘Yeah, I don’t know much about having a healthy sexual lifestyle, so I need to find out more about that’. Make it part of the [health] ecosystem, get rid of the taboos, show them that it’s okay, encourage conversations. (Staff 13, 30's, cisgender man, Southeast Asia, university administrator)
“Everybody benefits”: Benefits of SRH Education to International Students
All staff and student participants agreed that, when implemented, a comprehensive SRH education that incorporates the above strategies would have a positive impact on international students’ health and wellbeing during their study in Australia. For a student participant, SRH education would not only benefit international students, but also the wider Australian public:
International students are part of the entire community; they’re mingling with others, they’re having sex with others, so when they are sexually healthy, the entire community is also healthy. I think everyone benefits from increased sexual health, not just in international students. (Student 6, 20's, cisgender man, Southeast Asian, postgraduate student)
Additionally, many staff and student participants stated that an SRH education program could help destigmatise the topic among international students. A student participant added that obtaining SRH knowledge in Australia would enable international students to provide SRH information to their peers in their countries of origin:
For one, it can change their sexual lives here. The best thing would be that they go back to their country like India, Malaysia, whatever country they are from and have an impact in that community (Student 4, late teens, cisgender man, Middle Eastern, TAFE student).
A staff participant concluded:
[SRH] is part of their body, it’s part of their wellbeing; it’s about looking after all [aspects] of their health (Staff 8, 40's, cisgender woman, Anglo Australian, university health staff).
Discussion
This study investigated staff perspectives on whether tertiary education providers have a role to provide SRH education to international students, identify some barriers faced by education providers, and explore future opportunities to increase international students’ SRH literacy. We complemented their opinions with international students’ views to ensure that future strategies came from both staff and international students. In this study, we found that both staff and student participants agreed that tertiary institutions should provide SRH education to international students to maintain their overall health and wellbeing, especially since many international students have low SRH literacy due to the lack of or inconsistent SRH education in their countries of origin. Staff participants mentioned several systemic and individual barriers that prevented them from delivering comprehensive SRH education. Both staff and student participants mentioned several opportunities and enablers to overcome these barriers. Many staff and student participants believed that the implementation of these strategies would improve international students’ overall health and wellbeing which would positively contribute to their study outcomes.
This study adds to the existing literature by providing staff perspectives on SRH education specific to international students. Previous studies have noted barriers faced by international students to access SRH education and services (Burchard et al., 2011; DeLacy et al., 2019; Douglass et al., 2020; Engstrom et al., 2021; MCWH, n.d.; Lim et al., 2022; MacPhail & Stratten, 2023; Mundie et al., 2021; WHIN, 2020; Pang et al., 2021; Parker et al., 2020; Poljski et al., 2014). Past studies have also shown that international students wanted their education institutions to deliver SRH education programs consisting of peer education, online resources, and SRH-related activities at student orientation (Chang et al., 2022; Dunn & McKinnon, 2018; WHIN, 2020). Additionally, studies have shown that many female international students would like to have an option for SRH education to be delivered by female SRH staff and educators (Burchard et al., 2011; Poljski et al., 2014; WHIN, 2020). In this research project, we found that staff working at tertiary education institutions also shared similar views, suggesting that there is a consensus between staff and international students that tertiary education providers should be more proactive in providing comprehensive SRH education to international students. It aligns with the argument that tertiary education providers should act as health-promoting institutions, wherein students could gain academic knowledge and also learn about some strategies to maintain their overall health and wellbeing (DeLacy et al., 2019; Sanci et al., 2022; Suarez-Reyes & Van den Broucke, 2016).
Despite findings from previous and current studies, SRH education programs in tertiary education remain sparse, inconsistent, or absent (DeLacy et al., 2019). While SRH has been incorporated as part of the national Australian school curriculum (Ezer et al., 2020), no similar strategy or policy exists in tertiary education. As noted by Douglass et al. (2020), international students are more disadvantaged than domestic students on SRH knowledge due to the lack of or inconsistent SRH education in their home countries, coupled with socio-cultural stigma and language barriers, among other factors.
Lack of government policy and strategy has resulted in individual education providers developing their own SRH resources for international students based on their own goodwill, and with limited financial and human resources (DeLacy et al., 2019). We argue that both the federal and state governments are to make a firm commitment to develop comprehensive SRH education specific to international students and for such commitment to be reflected in relevant government policies such as the ESOS legislation and the National STI Strategy. A case study from Niger has shown that changes in government policy contributed to the development and implementation of a national youth engagement strategy in sexual and reproductive health (Benevides et al., 2019), while Cutherell et al. (2023) noted that changes in government policy should be seen as a long-term strategy that must be complemented with short-term initiatives such as outreach events and youth participation in sexual and reproductive health education. Indeed, strong political will, sustainable funding, and a collaborative approach are enablers to increase SRH knowledge among adolescents and young people (Plesons et al., 2019).
Furthermore, while this study interviewed staff and international students in Victoria, we noted a strong desire from staff and student participants for a nationwide SRH education program that would benefit all international students in Australia. We argue that federal and state governments need to fund the development and delivery of a nationwide SRH education program specific to international students that can be rolled out by all tertiary institutions in Australia. We suggest the topics that should be included in the program include navigating the Australian healthcare system, confidentiality, the human body and anatomy, pleasure, intimacy, and respectful relationships as SRH does not exist in a vacuum but is linked to respectful relationships and sexual rights (Okeke, 2022a; World Health Organization, 2023).
Developing a comprehensive SRH education requires a strong commitment from the government and collaboration from multiple agencies. We propose that governments work alongside tertiary education providers, OSCH providers, community health organisations, and international student bodies to ensure resources are culturally appropriate and relevant to students’ cultural norms, values, and experiences (DeLacy et al., 2019; Liu et al., 2022; Mundie et al., 2021; Okeke, 2021, 2022a, 2022b). Collaborations between government and non-government agencies have been shown to be effective in increasing SRH knowledge among adolescents in France (Nuttall et al., 2022) and Nigeria (Mbachu et al., 2020).
We also noted that health professionals working at university health clinics reported high workloads that prevented them from establishing SRH conversations with international students and raised concerns about whether health services can deliver a culturally competent service to international students. The Australian healthcare system is under immense pressure to deliver quality care under a tight budget (Biggs, n.d.). Additionally, Khatri and Assefa (2022) found that migrant communities are disproportionately affected by health inequity, as healthcare providers may not have the resources to deliver culturally appropriate care. This only highlights the importance of providing a comprehensive SRH education to international students as a public health strategy, as it has the potential to lessen the burden on the Australian healthcare system. Students would be able to gain information without requiring a doctor’s appointment and increase their SRH literacy that would contribute to their decision-making process to prevent the risk of unplanned pregnancies and HIV and STI transmissions while also building a consent-based respectful relationship and gaining pleasure from sexual activities. Given that international students are an integral part of the Australian social fabric, providing a comprehensive SRH education to them would benefit not only them but also the wider Australian public.
Limitations
One main limitation was the lack of engagement from tertiary education providers. We approached various universities, TAFEs, English language colleges, and private colleges and received minimal responses. This could indicate staff reluctance to talk about SRH, a barrier identified in this study. It further highlights the need to educate and train staff about SRH to overcome their own SRH-related stigma and to empower them to talk about SRH with international students. Furthermore, as indicated by some staff participants in this study, many tertiary education providers are under-resourced, which may have limited their ability to participate in this study and deliver SRH education to international students. This further highlights the importance of government-funded SRH education programs to assist providers with limited resources deliver a comprehensive SRH education to international students.
Another limitation was minimum participation from students who were enrolled in an undergraduate program, diploma, English language courses, and private colleges. Stigma, taboo, personal discomfort, and lack of interest in SRH are some factors that may prevent international students’ engagement with SRH (Liu et al., 2022; Mundie et al., 2021; WHIN, 2020). This further shows the need for SRH education as soon as international students arrive in Australia to challenge socio-cultural taboos and personal discomfort around SRH and to increase their SRH literacy. Time constraints could also be a barrier to participation as many international students balance academic and work commitments, thereby preventing them from participating in this study (Udah & Francis, 2022).
Furthermore, we could only speak to one teaching staff member, with most staff participants working in student administration, including student support and student advisers, as well as institution-based medical clinics and counselling services. As such, SRH may only be seen as an issue related to these professions, with teaching staff not perceiving themselves as having a role in SRH education. This may limit the opportunity to engage international students with SRH, as teachers and instructors interact regularly with international students. Providing SRH training to all staff could allow teaching staff to engage with the topic, where they can provide referrals to students instead of ignoring or dismissing the issue altogether.
Conclusion
This study found that a comprehensive SRH education program should be delivered by tertiary education institutions, and for such a program to incorporate multiple engagement strategies, including an SRH knowledge hub, peer educators, an SRH outreach team, and SRH training. This would create an ecosystem whereby international students would be able to gain SRH knowledge from various sources and not limited to the health setting. Such a program can only be successful with a strong policy and funding commitment from state and federal governments to support international students in Australia to make informed decisions relating to their SRH and to have access to affordable SRH services. A combination of a comprehensive SRH education program and increased access to affordable and culturally appropriate healthcare should be incorporated into the wider SRH promotion strategies that would benefit all members of the Australian society.
Policy Implications
We argue that the governments should review and update the current ESOS legislation, Standard 6, to specify SRH so all tertiary institutions could provide international students with SRH education and referrals to SRH services. This is to coincide with the development and delivery of a government-funded and coordinated nationwide comprehensive SRH education program specific to international students in collaboration with tertiary education providers, community health organisations, and international student bodies. We propose that such programs be included as an integral part of a national international student health and wellbeing program to destigmatise the topic. We extend our argument to include greater access to affordable healthcare for international students as part of a public health strategy.
Acknowledgements
We would like to acknowledge the staff and students who participated in this study and who shared their knowledge and wisdom to improve the overall health and wellbeing of international students in Australia.
Declarations
Ethics Approval
The research was approved by the Alfred Hospital Ethics Committee, number 270/22.
Competing Interests
The authors declare no competing interests.
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