"Place" and sexual and reproductive health in Australia

© 2020 Amie Lee BinghamSexual and reproductive health are significant public health concerns, and come with considerable costs to be individuals and the public, whether physical, emotional, mental or financial. There have been calls, particularly internationally, for responses to sexual and reproductive health issues to take an ecological perspective, addressing the multiple levels of influence on people’s health outcomes, such that interventions may potentially be more effective and enduring. ‘Place based’ approaches to health engage with ecological understandings of health, and a small body of literature has applied this framework to sexual and reproductive health. Few have done so within the Australian context, however. The aim of this thesis was to improve understanding of whether and how geographic location may be impacting on the sexual and sexual and reproductive health of Australians. In order to do so, three objectives were addressed: 1 - to explore associations between geographic location and sexual and reproductive health outcomes in Australia; 2 - to explore associations between geographic location and sexual and reproductive health risk behaviours in Australia; and 3 - explore the mechanisms by which geographic location may be affecting sexual and reproductive health behaviours and outcomes. Chapters 1 to 3 are introductory chapters, including a review of relevant literature pertaining to both sexual and reproductive health, and to conceptual frameworks which may inform place-based approaches to understanding health. Chapters 4, 5 and 6 present analyses of associations between ‘place’ and sexual and reproductive health outcomes and behaviours. Chapter 4 comprises a publication in analysing associations between country-level income inequality and notifications of Neisseria gonorrhoea in females. It finds that higher levels of income inequality were significantly associated with higher rates of notification for gonorrhoea. Chapters 5 and 6 report on analyses of a national dataset of prescribing data for the subdermal contraceptive implant and the levonorgestrel intra-uterine device, respectively, finding associations between living outside major cities and higher rates of prescription of long-acting contraceptives. The analyses also tested associations between proximity to specialist health services, such as Aboriginal Medical Services and Family Planning Clinics, but found little evidence of significant association. Chapter 7 presents the finding of a qualitative analysis of interviews with key informants in rural and regional areas of Australia, exploring mechanisms though which characteristics of their local communities may be affecting the sexual and reproductive health of young people. Participants were able to articulate a broad range of factors related to their location that were affecting these – and other – outcomes, including: the social context, broader social and political structures, local structural elements, and geographic location. Informed by findings from the qualitative analysis, Chapter 8 explores associations between alcohol availability and prevalent chlamydia at the level of postcode, multilevel analyses, finding no evidence of significant associations. Together, these analyses have contributed to a small body of Australian literature which takes a place-based approach to sexual and reproductive health outcomes. Showing associations at various levels, it emphasises the potential utility of taking an ecological approach to interventions designed to improve sexual and reproductive health – from the national level to the level of individuals