Original research article

Social and psychosocial factors associated with high-risk sexual behaviour among university students in the United Kingdom: a web-survey

International Journal of STD & AIDS 2015, Vol. 26(6) 369–378 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0956462414538950 std.sagepub.com

E Chanakira1, EC Goyder1, JV Freeman1, A O’Cathain1, G Kinghorn2,3 and M Jakubovic4

Abstract In the UK there are limited data about university students’ risky sexual behaviour. A cross-sectional web-survey was conducted to investigate factors associated with high-risk sex among students at two UK universities. High-risk sex was reported by 25% of 1108. High personal sexually transmitted infection (STI) risk perception and permissive attitudes towards casual sex were associated with high-risk sex for both men (odds ratio [OR]: 12.12; 95% confidence interval [CI]: 4.10–35.81; OR: 2.49; 95%CI: 1.11–5.56, respectively) and women (OR: 22.31; 95% CI: 9.34–53.26; OR: 3.02; 95% CI: 1.82–5.01, respectively). For men, drinking alcohol (OR: 17.67; 95% CI: 1.90–164.23) and for women age and frequent drinking (OR: 2.02; 95% CI: 1.05–3.89; OR: 1.89; 95% CI: 1.08–3.31, respectively) were associated with high-risk sex. However, perceiving an average student as more likely to contract STIs (men, OR: 0.34; 95% CI: 0.16–0.75) or HIV (men, OR: 0.44; 95% CI: 0.20–0.96; women, OR: 0.42; 95% CI: 0.28–0.63) and finding it difficult to discuss sexual matters (women, OR: 0.60; 95% CI: 0.39–0.91) were negatively associated with high-risk sex. Most of the factors found were similar to other populations, but some psychosocial factors showed complex patterns of association that require further investigation.

Keywords Sexual behaviour, high-risk behaviour, public health, students, web-survey, sexually transmitted infection, HIV, AIDS, sexual health, United Kingdom Date received: 28 November 2013; accepted: 12 May 2014

Introduction Sexually transmitted infections (STIs) have remained a priority health area in the United Kingdom (UK).1 At population level contracting STIs results in considerable morbidity or mortality2–4 and for healthcare providers, treatment and prevention efforts often leads to huge healthcare costs.5–7 Worldwide8 and UK9,10 estimates consistently show that young people under 25 years old have the highest incidence and prevalence of most commonly diagnosed STIs, primarily attributed to high-risk sexual lifestyles.10–12 Most UK university students fall into this age group but there are limited data about their sexual behaviour. The dearth of literature in this important public health population in the UK has been noted earlier.13 However, among the general British population repeat cross-sectional probability sample surveys exist (National Survey of Sexual Attitudes and Lifestyles [Natsal]) for men and women

aged 16–59 years (Natsal-1), 16–44 years (Natsal-2) and 16–74 years (Natsal-3).14 It is argued that university students are among the most sexually-active population groups15 with several studies in the USA16–18 and the UK19 showing a high proportion of at least 70% reporting being sexually 1 University of Sheffield, School of Health and Related Research, Sheffield, UK 2 University of Sheffield, South Yorkshire Comprehensive Local Research Network, Sheffield, UK 3 Sheffield Teaching Hospitals NHS Foundation Trust, Department of Genitourinary Medicine, Sheffield, UK 4 University of Sheffield, University Health Service, Sheffield, UK

Corresponding author: Elton Chanakira, University of Sheffield, School of Health and Related Research, 30 Regent Court, Sheffield, S1 4DA, UK. Email: [email protected]

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active. Most importantly, a significant proportion of sexually active students engage in risky sex such as inconsistent condom use during penetrative vaginal or anal sex and having multiple sexual partners.17,19–22 Engaging in these behaviours theoretically increases the risk of acquiring STIs. Currently there is great emphasis on social determinants of health.23,24 For sexual health, age, gender, religion, ethnicity, socio-economic status, area of residence and psychoactive substance use/misuse have been identified as some of the important factors that influence risky sex across populations.1,4,25–30 The general pattern in countries such as the UK and USA tends to show that younger people, men, less-religious individuals, some Black and minority ethnic groups, those of lower socio-economic status and/or urban residence and those who use/misuse alcohol and other drugs tend to report risky sexual behaviours. Interventions aimed at reducing risky sex in populations also tend to recommend the use of programmes with strong theoretical underpinnings.31 Most theories of health behaviour have identified risk perception, self-efficacy, attitudes and behavioural intentions as key concepts that determine protective behaviours among populations.32–34 Our study is important because it is currently unclear if some of the factors listed above are associated with high-risk sex among UK university students. An understanding of the sexual behaviour of students is also important because it remains the key determinant of STI transmission.35 Our study aimed to investigate the social and psychosocial factors associated with high-risk sexual behaviour among a sample of UK university students.

Methods Participants and procedure In November 2007, all registered students at two universities in a city in the north of England were invited to participate. A web-survey was considered ideal because it increases self-disclosure and uninhibited responses,36 thus increasing the likelihood of collecting accurate sensitive sexual behaviour data. Two weeks before survey activation, pre-notification posters were placed around the two university campuses. All students at one of the two universities were invited to participate via an email message (email group). Permission to send an email invitation to the other institution was declined by the local Research Ethics Committee due to concerns about the volume of email requests sent to students for research purposes. Consequently students from this institution were invited via an intranet announcement message (intranet group).

A study information sheet was included on the website and to activate the survey participants had to consent by clicking a radio button on the homepage. When the first survey page was activated participants were automatically assigned an anonymous identifier number. The survey was active for six weeks. Two weeks after activation one reminder email was sent to the email group but web administrators for the intranet group failed to broadcast a reminder. Fifteen cash prize draws of 100 were offered to all participants.

The questionnaire and measures The questionnaire was adapted from Natsal-2.12 The tool was modified into a self-completion web-survey and a pilot study was conducted with 20 university students. In general web-surveys should be short to complete,37 therefore several survey items from the original Natsal-2 tool were dropped. Included items were those identified in the literature and in consultation with experts (clinicians, public health and sex survey practitioners) as key STI risk markers or important confounders. Household classification items from Natsal-2 were dropped, because these are less accurate proxy measures of social class for university students38 and there is evidence suggesting that education attainment is more strongly associated with sexual behaviours than socioeconomic status.14 The main outcome of interest for our study was a sexual behaviour risk score coded as 1 (high-risk) or 0 (low-risk) behaviour. To be classified as having high-risk a participant had to report both having had two or more sexual partners and, inconsistently used condoms in the past year. Those reporting either; ‘‘no multiple partners’’ (1 or no sexual partner) or consistent condom use in the past year were classified as low-risk. This definition is similar to that of unsafe sex used by NATSAL 2000.12

Statistical analyses Data were analysed using SPSS (version 19) and statistical significance was considered as p  0.05. Initially, the relationship between high-risk sex and each potential explanatory variable were explored using Chi square or Fisher’s exact tests. Following this initial stage, stepwise logistic regression analysis was used to investigate the relative strength of these relationships. Gender was treated as an effect modifier because of the known sexual behaviour differences between men and women.12 All statistically significant variables in the bivariate analyses were included in the stepwise regression models, age (for men) was also included because of its theoretical significance.39 Initially both forward and backward stepwise procedures were used to find the model that best predicted high-risk sex.

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Ethical approval

Table 1. Participant characteristics.

The study was approved by the University of Sheffield Research Ethics Committee.

Results Of the approximately 49,891 students registered at the two universities at the time of the survey 3511 responded, thus providing a 7% conservative estimate of the response rate. The estimated response rate by mode of survey invitation is 13% (3101/23,194) for the email group and 1% (289/26,697) for the intranet group. A web-survey programming error resulted in the first 2007 (57%) participants’ data being saved out of sequence and without number identifiers in the database. This meant that responses from different survey pages from an individual participant could not be linked thus rendering these data unusable for this study. However, there were no major differences for participants with linkable and non-linkable data (Table 1). All subsequent analyses in this paper are based on those participants with linkable data (n ¼ 1504). The majority were single (96%), drank alcohol (86%), aged under-25 years (83%), White ethnicity (82%), UK born (78%), women (60%) and did not belong to a religion (60%) (Table 1).

High-risk sexual behaviour The valid data for the classification of risk behaviour were based upon respondents who did not have a missing value for either number of partners or consistency of condom use in the past year (n ¼ 1108). Thus 25% (n ¼ 281) of the eligible responding students were classified as having high-risk sexual behaviour. Twentyseven percent of the total eligible women (n ¼ 680) and 24% of eligible men (n ¼ 422) were classified as having high-risk sexual behaviour. During bivariate analyses the following were statistically associated with high-risk sex for both men and women: ethnicity, alcohol consumption, frequency of drinking, importance of religion, risk perception (personal and comparative risk perception), attitudes (premarital sex, ‘‘one-night stands’’ – referred to as casual sex) and ideal sexual lifestyle (Table 2). For men: attitudes towards concurrent partnerships for cohabiting couples and for women: age, marital status, country of birth, belonging to a religion and ability to discuss sexual matters with a partner were also associated with high-risk sex.

Variable Gender Men Women Missinga Age group (years) 16–19 20–24 25þ Missing Ethnicity White Black Asian Chinese Other Missing Level of study Undergraduate Post-graduate Missing Year of study First year Second year Third yearþ Missing Marital status Married Separated/widowed/divorced Single Missing Country of birth UK Europe International Missing Belong to a religion Yes No Ever drink alcohol nowadays Yes No Missing

Linkable, n ¼ 1504 (%)

Non-linkable, n ¼ 2007 (%)

572 (39.8) 865 (60.2) 19 (1.3)

810 (42.5) 1097 (57.5) n/a

520 695 239 1

(35.8) (47.8) (16.4) (0.1)

672 (34.5) 929 (47.7) 346 (17.8) n/a

1183 30 84 82 62 14

(82.1) (2.1) (5.8) (5.7) (4.3) (0.9)

1619 38 115 69 76 n/a

1135 (78.3) 315 (21.7) 5 (0.3)

(84.5) (2.0) (6.0) (3.6) (4.0)

1456 (75.1) 484 (24.9) n/a

639 366 440 10

(44.2) (25.3) (30.4) (0.7)

818 (42.1) 500 (25.8) 623 (32.1) n/a

41 6 1028 3

(3.8) (0.6) (95.6) (0.2)

67 (4.3) 17 (1.1) 1473 (94.6) n/a

834 71 162 11

(78.2) (6.7) (15.2) (0.7)

1253 (79.5) 100 (6.3) 223 (14.2) n/a

426 (39.7) 647 (60.3)

511 (33.1) 1031 (66.9)

1148 (86.1) 185 (13.9) 4 (0.3)

1622 (86.6) 250 (13.4) n/a

a All missing values relate to item non-response and exclude those who viewed the survey webpage but did not answer any question.

Logistic regression These data were further analysed using multiple logistic regression to examine which factors were jointly

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Table 2. Distribution of independent variables across risk groups. Men Independent variable Age group 24 yrs 25 yrs Ethnicity White Black Asian Chinese Other Level of study Post-graduate Undergraduate Year of study First year Second year Third year þ Marital status Married Unmarried Country of birth UK Europe (excluding UK) International (excluding Europe) Ever drink alcohol nowadays? No Yes How often (on average) have you had an alcoholic drink of any kind during the past 12 months? 1 day a week Once or twice a month Presently do you regard yourself as belonging to a religion? Yes No How important are religion and religious beliefs to you, now? Important Not important Based on your sexual activities in the past year, how would you rate your risk/chance of catching an STI? Not very much/Not at all (low risk) Great/Quite a lot (high risk)

Women

Low-risk sex (%)

High-risk sex (%)

270 (83.9) 91 (91.0) 52 (16.1) 9 (9.0) 242 8 33 21 14

Chi-value (df) p value

3.15 (1) 0.076

(76.1) 84 (84.8) 10.85 (4) 0.024a (2.5) 4 (4.0) (10.4) 2 (2.0) (6.6) 3 (3.0) (4.4) 6 (6.1)

Low-risk sex (%)

High-risk sex (%)

407 (81.4) 164 (91.1) 93 (18.6) 16 (8.9) 419 10 23 27 19

(84.1) 162 (91.5) (2.0) 3 (1.7) (4.6) 3 (1.7) (5.4) 1 (0.6) (3.8) 8 (4.5)

Chi-value (d.f.) p-value

9.27 (1) 0.002

12.90 (4) 0.010a

76 (23.6) 17 (17.0) 246 (76.4) 83 (83.0)

1.94 (1) 0.164

108 (21.6) 29 (16.2) 392 (78.4) 150 (83.8)

2.39 (1) 0.122

148 (46.3) 41 (41.0) 79 (24.7) 27 (27.0) 93 (29.1) 32 (32.0)

0.85 (2) 0.654

219 (43.9) 129 (25.9) 151 (30.3)

0.09 (2) 0.956

79 (44.4) 44 (24.7) 55 (30.9)

7 (2.3) 3 (3.2) 0.217 (1) 0.707a 297 (97.7) 92 (96.8)

28 (5.8) 0 (0.0) 457 (94.2) 173 (100.0)

10.43 (1)

Social and psychosocial factors associated with high-risk sexual behaviour among university students in the United Kingdom: a web-survey.

In the UK there are limited data about university students' risky sexual behaviour. A cross-sectional web-survey was conducted to investigate factors ...
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