ORIGINAL RESEARCH

Sexually transmitted infection risk perception among female college students Mary T. Hickey, EdD, WHNP-BC (Clinical Associate Professor) & Chuck Cleland, PhD (Senior Biostatistician) College of Nursing, New York University, New York

Keywords Young adult women; sexually transmitted infections (STI); risk factors; women’s health. Correspondence Mary T. Hickey, EdD, WHNP-BC, College of Nursing, New York University, 726 Broadway, 10th Floor, New York, NY 10003. Tel: 212-998-5310; Fax: 212-995-3143; E-mail: [email protected] Received: August 2011; accepted: April 2012 doi: 10.1111/j.1745-7599.2012.00791.x

Abstract Purpose: To describe perceived risk for sexually transmitted infections (STIs) and sexual risk behavior among sexually active female college students. Data sources: An online, anonymous survey was used to collect data from 458 sexually active female students between the ages of 18–24 enrolled at a private, suburban university in the mid-Atlantic region. Conclusion: Most women in this study did not consider themselves at risk for contracting an STI, despite low levels of condom use. Perceiving no risk and never using condoms were both more common among women with just one sex partner. Further investigation of factors contributing to individual risk perception is warranted in order to develop effective prevention programs. Implications for practice: Nurses and advanced practice nurses who work with women, particularly at-risk women, should be aware of low levels of risk perception for STIs, despite engaging in risk-taking behaviors. Education regarding strategies to reduce and prevent contracting STIs should be incorporated into encounters with women seeking health care, and in health promotion settings.

Sexually transmitted infections (STIs) have reached epidemic proportions in the United States. There are approximately 19 million new infections reported each year, nearly half of which occur in people between 15 and 24 years of age (Centers for Disease Control [CDC], 2008). According to the CDC, in 2008, there were more than 1.5 million reported cases of Chlamydia and gonorrhea; these are the two most commonly reported STIs in the United States. There was a 5.1% increase in incidence of Chlamydia between 2009 and 2010; gonorrhea increased by 2.8% (CDC, 2011). Women are disproportionately affected for both diseases; Blacks have significantly higher rates than Whites (CDC, 2011). In order to address this growing epidemic, in 2001, the CDC recommended routine screening for asymptomatic, sexually active women, under the age of 26. Adherence to this recommendation, as well as newer, less invasive testing methods, such as urine testing, have likely contributed to the reported increased incidence; however, the CDC estimates actual incidence remains higher than reported. In an effort to reduce reinfection rates, the CDC also recommends routine treatment of partners.

Many STIs do not have recognizable symptoms, particularly in women, which may be associated with lack of surveillance, diagnosis, and treatment, as well as with decreased risk perception. Once detected, many infections are treatable with antibiotic therapy, although antimicrobial resistance is a growing problem with gonorrhea (CDC, 2011). In women, untreated STIs are associated with both short- and long-term health consequences, such as pelvic inflammatory disease, chronic pelvic pain, ectopic pregnancy, and infertility (CDC, 2008, 2011). Untreated Chlamydia and gonorrhea may also be associated with an increased risk of human immunodeficiency virus (HIV; CDC, 2008, 2011). STIs result in nearly $17 billion dollars in healthcare costs annually (CDC, 2011). Various physiologic and behavioral factors increase the risk for acquiring an STI, especially in women. Certain physiologic factors such as cervical ectopy increase the risk of contracting an STI; this condition is more common in women younger than 25 years of age and in women who use oral contraceptives (CDC, 2011; Hatcher et al., 2007). Specific lifestyle or behavioral factors are also associated with an increased risk: early age at first

C 2012 The Author(s) Journal of the American Association of Nurse Practitioners 25 (2013) 377–384 

 C 2012 American Association of Nurse Practitioners

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intercourse, number of lifetime partners, lack of condom use, and participation in other risk-taking behaviors, such as alcohol and drug use or sexual activity while under the influence of alcohol or drugs (CDC, 2011; Certain, Harahan, Saewyc, & Fleming, 2009; Denny-Smith, Bairan, & Page, 2006; Ford, Jaccard, Millstein, Bardsley, & Miller, 2004; Hatcher et al., 2007).

Risk reduction strategies Condom use has been shown to be effective in the prevention or reduction in risk of acquiring an STI (Alldred, Cox, & Mahoney, 2006); however, several studies have noted the inconsistent use of condoms, particularly in atrisk populations (Certain et al., 2009; Denny-Smith et al., 2006; Miksis, 2008; Winer et al., 2006). Reported condom use by sexually active adolescents and young adults (13–24 years of age) ranged from 16% to 50.6% in various studies (Certain et al., 2009; Ford et al., 2004; DennySmith et al., 2006; Ingledue, Cottrell, & Bernard, 2004). College-age women reported having more than one sexual partner in the past 12 months and using condoms 50% of the time or less often (American College Health Association [ACHA], 2009). Sipkin, Gillam, and Grady (2003) found similar results in a California based university study. A majority of students reported being sexually active; 47.7% had more than one partner in the past 12 months; however, only 31.8% reported consistent condom use. Chlamydial infection was detected in 3.4% (n = 4086) of the sample; 56.1% of infections were in women, particularly those between 20 and 24 years of age. Analysis of data from the National Longitudinal Study of Adolescent Health found that 86% of participants did not consider themselves at risk for contracting an STI, despite reporting low levels of condom use and positive gonorrhea and/or Chlamydia results (Ford et al., 2004).

Screening and educational services Given the increased risk in college populations, screening services for STIs have increased on campuses, particularly in light of new CDC recommendations. ACHA reports indicated that 93.8% of schools (N = 128) offer gynecologic services to women, including Papanicolaou (Pap) testing and routine STI and HIV screening (Smith & Roberts, 2009). Of those women who received testing (n = 82,427), 2.9% were positive for Chlamydia and 0.4% (n = 60,788) for gonorrhea. Koumans and colleagues (2005) examined the percentage of universities offering various types of health services to students. Sixty percent of the 736 colleges and/or universities surveyed have a student health center, offering STI testing, 378

M. T. Hickey & C. Cleland

OB/GYN services, including contraception, health education, and referrals. Condoms are available to students at 52% of the participating schools, in a variety of free or fee-based locations. Smith and Roberts (2006) analyzed data from 128 academic institutions with student health centers. Sixty-two percent of all visits were made by women; 23% of those visits were related to women’s health. Educational services on risk reduction and transmission prevention are less widely available. One study found that although a majority of colleges provide one form of STI education, fewer than one-third of colleges and/or universities (N = 736) include STI education or risk reduction information as part of mandatory student orientation programs (Koumans et al., 2005). Only 36.1% of students responding to the ACHA–NCHA survey reported receiving STI prevention information from their college or university; 22.6% reported receiving pregnancy prevention information (ACHA, 2009). Surprisingly, 51.3% and 47.4% received information on alcohol and drug use prevention, and sexual assault/relationship violence prevention (ACHA). Each of these areas is an important topic for discussion among sexually active females (Fantasia & Fontenot, 2011).

Purpose The purpose of this study was to examine sexual activity and condom use of female college students related to risk for acquiring STIs. Individual perceived risk and the importance of prevention were also explored. There were 17.8 million students enrolled in one of the 4300 degree granting colleges and universities in the United States during the fall of 2006; of those, 65% were women and 93% were between the ages of 18 and 29 (ACHA, 2009). Given these demographic findings coupled with the STI statistics, women enrolled in college, particularly those between the ages of 18 and 24, have higher rates of and are at higher risk for STIs.

Conceptual framework The Health Belief Model (HBM) was developed in the 1950s and has been used to guide the development of health promotion and disease prevention interventions (Rosenstock & Stecher, 1997). The model has been used extensively to explain and predict health behaviors, including sexual risk-taking research, HIV, HPV, and condom use (Downing-Matibag & Geisinger, 2009; Ford et al., 2004; Ingledue et al., 2004). According to this theoretical framework, four factors influence whether an individual uses preventive/protective health behaviors: (a) perception of susceptibility to negative health outcomes;

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M. T. Hickey & C. Cleland

(b) the perception of the severity of the negative outcome; (c) benefits of the preventive behavior in relation to the potential negative outcome; and (d) barriers and perceived barriers to implementing the protective behavior (Carpenter, 2010; Downing-Matibag & Geisinger, 2009) . Although the HBM is viewed by some as outdated, the original constructs and concepts are still applicable to gaining insight into decision making regarding sexual behaviors and risk taking. Low levels of “perceived threat,” “perceived susceptibility,” and “perceived seriousness” have been reported by at-risk populations, despite selfreports of risk-taking behaviors (low levels of condom use; multiple partners) (Denny-Smith et al., 2006; Ford et al., 2004; Ingledue et al., 2004). Given the aims of this study, the HBM provides a clear and useful framework to explore how women perceive individual risks and make decisions regarding use of strategies to prevent unintended consequences of sexual activity (pregnancy or STIs).

Materials and methods In this exploratory, descriptive pilot study, a convenience sample of female college students between the ages of 18 and 24 was recruited for participation from fall 2007 through spring 2008 at a private, suburban university in the mid-Atlantic region. After approval from the university Institutional Review Board, subjects were recruited through a campus-wide, e-mail announcement requesting sexually active females, with a male partner, aged 18–24, for participation in a self-administered, online survey. There was no incentive for participation. Limitations of age, and women who had been sexually active with a male partner were chosen based on STI statistics and increased risk for transmission in women who have sex with men. The link to a secure survey site was embedded in the e-mail. Students were redirected to the survey site, with no persistent link to their e-mail address. A letter of informed consent preceded the actual survey. At the end of the letter, there was an option to select “I consent;” once “clicked,” eligible participants were redirected to the survey. Those not consenting or selecting “male” were redirected out of the survey; those respondents who reported an age outside of the parameters (18–24) were not included in the data analysis. The survey was designed in an online, selfadministration format. It was divided into three parts: a demographic section; 23 questions relating to emergency contraception; and 21 items relating to sexual activity. Items on the survey were adapted for appropriate language, with permission from the Hunter College

Adolescent Health Study (HCAHS), which has been previously tested and used with participants between 15 and 21 years of age (Roye, Silverman, & Krauss, 2007). Minor revisions to language were made, as the original survey contained more explanations and definitions necessary for the younger potential participants. Revised items were distributed to experts in the field for clarification and content validity. Question types were forced answer, multiple-choice, and 5-point Likert scale; participants were able to skip questions. Four questions addressed sexual activity in the past 6–12 months, including the number of partners and the frequency of vaginal intercourse; six questions focused on methods to prevent pregnancy; five questions focused on risk-taking behaviors and risk reduction strategies; three questions were on communication with sexual partners, and three questions were on personal perceived risk and the distinction between pregnancy prevention and STI risk reduction. For perceived risk of STI, participants were asked to respond to the following statement: “I am not at risk for acquiring a sexually transmitted disease.” Responses ranged from “strongly agree” to “strongly disagree.” For purposes of summary and analysis, perceived risk was dichotomized into “none” (51.3%) versus “any” (48.7%). Specific questions from the survey are listed in Table 1. Data were not collected on STI history or previous STI testing. Data analysis included descriptions of condom use and other sexual risk and risk reduction behavior and perceived risk for STIs. Logistic regression was used to examine which variables were uniquely associated with (a) not perceiving risk for STIs, (b) never using condoms, and (c) having sex without a condom while using alcohol or drugs. Findings from the emergency contraception portion of the study have been previously published by this author (Hickey, 2008).

Results There were approximately 2800 women between the ages of 18 and 24 enrolled at the participating university between fall 2007 and spring 2008. This university population is primarily white (68.4%) and female (68.3%) (Adelphi University, University Data Book, 2008). Fifty percent of the student body reported a family income of $60–$100K; 23% reported income of $30–59K. Sixtythree percent of the student population “self-pay” the $23,000 annual tuition; of the 37% who receive some type of financial aid, 25% are university-driven scholarships (athletic, academic) (University Data Book). Five hundred sixty five women (20%) responded to the survey. Among the women who completed the survey, about 81% (n = 458) were sexually active and were 379

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Table 1 Selected items from the survey Survey question Please describe your sexual activity pattern during the last 6 months.

What percentage of the time did you use any of the following during vaginal sexual activity in the past 6 months?

Is there a difference between preventing pregnancy and reducing the risk of getting a sexually transmitted infection? How many times during the past 2 months have you had sex without your partner using a condom?

When you engage in sexual activity, how often are alcohol/drugs involved? If alcohol or drugs were involved in sexual activity did you use some sort of protection? If yes, what type of protection?

I feel comfortable discussing sexually transmitted disease risk with my partner. I can get my partner to use a safer sex method without any trouble. I am not at risk for acquiring a sexually transmitted disease. I am not at risk for getting pregnant.

Table 2 Description of risk: percent of survey participants Response categories One partner More than one partner More than three partners No partner Male condom (100%; 75%; 50%; 25%; 0%) Withdrawal (100%; 75%; 50%; 25%; 0%) Female condom (100%; 75%; 50%; 25%; 0%) Yes/No

Once 1–3 3–5 5–10 More than 10 100%; 75%; 50%; 25%; 0%

Yes/No

Condoms Withdrawal Diaphragm Other Strongly agree–strongly disagree

included in analysis for this article. The average age of participants was 21.0 years; other demographic characteristics of this sample were: 70.9% white, 11.9% black, 13.7% Hispanic, and 9.1% Asian/Pacific Islander, which is consistent with the university population. Twenty-five percent of the respondents resided in on-campus dormitories; 19% lived off-campus, not with family; and 56% lived with family. Participants in this study reported being comfortable discussing pregnancy prevention (95%) and STI risk reduction (86%) with their partners; 92% felt they could get their partners to use a safer sex method. Seventy-five percent reported having vaginal intercourse between one and four times per week. In order to prevent pregnancy, 63.4% were using oral contraceptives, 380

Total Living situation (n = 479)∗∗ Family Off-campus with friends Dorm Condom use (n = 464)∗,∗∗∗ Never Sometimes Always Sexual partners (n = 480)∗,∗∗ One partner only Multiple partners Perceived risk (n = 476)∗∗ No Yes Risk taking (n = 477)∗∗ No Yes

No perceived Condoms risk never

56.4 20.4 23.2

49.1 53.6 43.1

30.65 43.62 22.22

31.3 35.3 33.4

59.4 33.7 53.3

80.8 19.2

53.5 28.6

36.29 10.87

11.2 18.5

48.7 51.3

0.0 100.0

38.29 24.37

14.0 11.3

87.4 12.6

49.4 43.3

27.48 56.90

0.0 100.0

100.0 0.0 0.0

11.5 17.5 10.9 22.9 14.0 1.3

Notes. Associations tested for significance with Pearson’s chi-squared test. ∗ Significant (p < .05) association with perceived risk. ∗∗ Significant (p < .05) association with condoms never. ∗∗∗ Significant (p < .05) association with alcohol/drugs and no condom.

57.3% were using male condoms, and 23% were practicing withdrawal. Table 2 describes several key study variables both overall and by perceived risk for STIs, condom use, and sex without a condom while using alcohol or drugs. Perception of risk was associated with condom use; those who reported inconsistent condom use were more likely to perceive risk of STI. Number of sexual partners also was associated with perception of risk; those with one partner only were less likely to perceive risk. Those participants who reported multiple partners were more likely to use condoms consistently. Condom use also was associated with living situation and number of sexual partners. Students living in dorms were less likely to use condoms “never” than students living off-campus with friends. Students with multiple sex partners were less likely to use condoms “never” than students with one sex partner. The majority of participants in this study did not report sexual activity while under the influence of alcohol or drugs. For those who did, nearly two-thirds reported simultaneous condom use. Because having sex without a condom while using alcohol or drugs includes condom use as part of its definition, this risk-taking variable was associated with condom use in general, as expected. Students who used condoms “never” were more likely to have sex without a condom while using alcohol or drugs

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Table 3 Predictors of no perceived risk of sexually transmitted infections Odds ratio Living situation Dorm versus parents Off-campus with friends versus parents One sexual partner Condom use Sometimes versus never Always versus never ∗

p

Odds ratio 95% CI

condom χ

2

0.87 0.89 1.18

0.647 0.510

[0.56,1.44] [0.72,1.94]

2.34

0.001

[1.39,3.93]

0.41 0.90

Sexually transmitted infection risk perception among female college students.

To describe perceived risk for sexually transmitted infections (STIs) and sexual risk behavior among sexually active female college students...
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