Differences in STI knowledge accuracy and STI/HIV testing among a
random sample of college students: A secondary survey analysis.
Tyler G. James1,2,3 and Sadie J. Ryan1,2*
1. Department of Geography, University of Florida, Gainesville, FL, USA
2. Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
3. GatorWell Health Promotion Services, University of Florida, Gainesville, FL,
USA
*Corresponding author: [email protected]
Differences in STI knowledge accuracy and STI/HIV testing among a
random sample of college students: A secondary survey analysis.
Objective: This study aimed to describe STI knowledge accuracy and STI/HIV
testing service use in college students. Participants: A random sample of 991
university students aged 18-24, enrolled at a major public university, participated
in this study in February 2009. Methods: Students took a survey designed by
researchers in college health promotion and sexual health. Survey responses were
examined for differences in STI knowledge accuracy, and demographic and
behavioral predispositions to getting an STI or HIV test. Results: STI knowledge
and testing service use differed significantly by gender, race, sexual orientation,
STI/HIV testing history, and being sexually active in the past year. Conclusions:
These findings can inform health communication campaigns of specific
populations to target by providing identifiable sub-groups lacking STI knowledge
and not using testing services.
Keywords: sexual health; knowledge; HIV testing; STI testing; barriers
Introduction
Young adults and adolescents are the age group most affected by sexually
transmitted infections (STIs) in the United States, presenting a growing public health
concern. In 2008, an estimated 50% of new cases of STIs in the United States were in
people aged 15-24.1 The increased prevalence of STI and HIV infections in young
people has been attributed to increased sexual risk behaviors such as initiating sex at an
early age, having multiple sex partners, and failure to use condoms.2 A well-studied
sub-population of this age group are traditionally-aged, 18–24-year-old, college
students. College presents a unique opportunity for sexual freedom, and allows
increased social interaction where search costs for prospective sexual partners are
reduced, making it easier to find multiple casual sex partners.3 Studies have found that
50-75% of college students report having had casual sex, or having had a range of
physically intimate behavior including passionate kissing, oral sex, or intercourse, in the
past year.4,5 In addition to engaging in higher risk behaviors, young men and women
aged 15-24 also delay seeking treatment services when they believe that have an STI.6
A delay in seeking healthcare increases the likelihood of transmission and can
complicate treatment.7 This underscores the urgency of better understanding sexual
health behaviors in this age cohort to create more effective public health interventions,
and decrease the incidence of STIs in this age group, and thus, the general population.
Although sexual health knowledge is not proven to be directly associated with
safer sexual behaviors, knowledge is crucial for making well-informed sexual
decisions.8,9 In addition, STI knowledge influences behavioral determinants and
misconceptions associated with delayed treatment seeking and testing services.10 Sexual
health knowledge relating to STI transmission and treatment has been found to vary
widely across different demographic and behavioural groups.11–15 Females have
consistently shown higher knowledge accuracy pertaining to sexual health related topics
than males,13,16–19 possibly because females have more health information seeking
behaviors overall, than males.20 Students who are sexually experienced have higher
knowledge accuracy, when compared with their inexperienced counterparts,17,21 and
individuals in ethnic and racial minority groups are found to be equally or more
misinformed about STIs than their white counterparts.18,22
Low STI knowledge has also been identified as a barrier to STI and HIV testing.
In a qualitative study,23 some college students reported that although people knew
getting tested for HIV was important, some did not know the importance of getting
tested for other STIs. Focus groups conducted by the Centers for Disease Control and
Prevention24 identified limited knowledge regarding HPV as a barrier to identifying risk
reduction behaviors to prevent HPV infection and getting a preventative vaccine. In
addition to lack of knowledge, social stigma, testing costs, lower perceived risk, and
confidentiality concerns have been identified as barriers to STI testing.25,26 In single
female respondents aged 16 to 22.5 years, researchers identified eight “cons” to getting
tested for chlamydia and gonorrhea including barriers, fear and aversion, systemic,
treatment, confidentiality concerns, and partner trust.25 The most reported con to getting
tested were barriers, which included “finding the time” and financial strain when paying
for the test. Additional cons to getting tested were “not wanting to know the results,”
“the exam process,” “side effects of medicine,” “worrying about the clinic telling
people,” and “false accusations with partner.”25
Population specific information on knowledge, previous behaviors, and barriers,
are important for creating relevant public health interventions and health
communication interventions.27 Identifying and focusing on a target population can help
ensure that messages are designed in appropriate formats to increase awareness and
promote behaviour change in college students.12 To further our understanding of sexual
behaviors, STI knowledge, and STI and HIV testing history in this demographic group,
we analyzed the relationship with demographic and behavioral characteristics through a
secondary analysis of random sample, cross-sectional survey data collected at a large
public university in the southeast United States.
Methods
In 2009, GatorWell Health Promotion Services (gatorwell.ufsa.ufl.edu) administered the
Sexual Health Student Survey to better understand student sexual health behaviors,
knowledge, attitudes and information sources. Results were published as descriptive
statistics,28 and were not further analyzed. We requested access to the dataset to identify
demographic and behavioural differences in STI knowledge accuracy and getting an
STI or HIV test. The University’s Institutional Review Board classified the present
study as an exempt research study, as a secondary analysis of the Sexual Health Student
Survey of 2009 (IRB# 2015-U-0788).
Instrument Design
The Sexual Health Student Survey was designed in the fall of 2008 by researchers at
GatorWell Health Promotion Services specializing in assessments and sexual health.
The survey consists of nine sections: sexual health, contraception and pregnancy,
condom use, STI testing and HPV vaccination, pornography consumption, knowledge,
self-efficacy, sources of information, and campus sexual health resources. In total, the
instrument contained 125 items, 6 of which were demographic in nature. Items were
evaluated for face validity and inclusivity by content experts, prior to a pilot test of 107
students in Fall 2008. After modifications to the instrument, 21 students participated in
a field test prior to the survey’s administration in the Spring 2009.
Procedure
Upon receiving ethics approval from the University’s Institutional Review Board, the
University Registrar provided a random sample of 3,000 undergraduate and graduate
students. Students were notified via postcard about the survey the week prior to data
collection. The postcard outlined dates of data collection, basic information about the
survey, and the survey’s incentive. E-mails inviting participants to the online survey
were sent on February 9, 2009. Participation in the survey was completely voluntary
and anonymous. Prior to taking the survey, participants were required to read and agree
to an informed consent describing the survey’s contents and protection of information.
The first, middle, and last 10 participants taking the survey received an incentive
consisting of a 1-gigabyte flash drive. Inclusion criteria for the dataset required the
participant by a full-time student at the University and between the ages of 18 and 24.
Measures
We measured demographic data, STI knowledge, self-reported sexual behaviour,
STI/HIV testing history, and barriers to getting an STI or HIV test.
Demographics
Demographic items assessed age, gender, year in school, self-reported race and
ethnicity, and self-identified sexual orientation.
Knowledge
Content experts created 20-items to assess sexual health knowledge. This scale was
separated into three subscales: risk behaviour knowledge, STI prevention knowledge,
and pregnancy prevention knowledge. Each item was answered on a “true,” “false,” or
“don’t know” scale. As our analyses focus on STI knowledge, we removed the
pregnancy prevention subscale. The final STI knowledge accuracy scale for our
analyses consisted of 16 questions (Table 1). If a participant reported that they “don’t
know” the answer to an item, their response was coded as incorrect.
Sexual Behaviors
Sexual behavior items were benchmarked with the Healthy Gators Student Survey29 and
the American College Health Association’s National College Health Assessment.30 Four
primary questions were asked: sexual behaviors the participant had engaged in the past
year, the number of sexual partners in the past year, the gender of the sexual partners,
and participation in a monogamous sexual relationship.
Testing History
Testing history was identified using four items asking if the participant had (1) ever
been tested for HIV, (2) been tested for chlamydia in the past year, (3) been tested for
gonorrhea in the past year, and (4) been tested for any STI in the past year.
Statistical Analyses
Data were cleaned using the Statistical Package for the Social Sciences version 22.031
prior to being analyzed in R version 3.2.1.32 Dichotomous variables were created to
combine smaller demographic samples into groups that could be further analysed (i.e.,
sexual orientation was re-coded as “straight” or “not-straight,” race was coded as
“white” or “not-white”). STI testing history was coded “yes” or “no” by combining the
items asking about chlamydia, gonorrhea, and being tested for any STI in the past year.
STI knowledge accuracy was calculated by dividing the total number of correct answers
by the total number of questions.
We described the demographics of the entire sample by computing overall
frequencies and percentages. A Shapiro-Wilk normality test of STI knowledge accuracy
suggested that data were not normally distributed. Thus, we used non-parametric MannWhitney U tests to compare differences in STI knowledge accuracy by the demographic
and behavioral variables. To reduce the risk of Type I errors when running multiple
comparisons, we Bonferroni corrected our p value for STI knowledge (from p = 0.05 to
p = 0.007). A linear regression model was constructed to examine predictors of STI
knowledge accuracy. For this purpose, STI knowledge accuracy was treated as the
dependent variable and the set of predictor variables were: (1) self-reported race, (2)
self-reported gender, (3) sexual orientation, (4) age, (5) being sexually active in the past
year, (6) having an STI test in the past year, and (7) getting an HIV test ever. Data were
further analysed using chi-square tests and odds ratios to identify associations between
demographic variables and getting an STI or HIV test.
Results
Sample Characteristics
After inclusion criteria were met, the survey yielded a 33% response rate (n = 991). The
average age of respondents was 21.13 years (SD = 1.57 years). A majority of
respondents were female (61%), white (66%), and straight (95%). A large proportion
(76%) of the sample reported being sexually active in the 12 months prior to the survey.
Among these students, 68.9% reported being in a monogamous sexual relationship,
32.7% had ever had an HIV test, and 33.1% had been tested for any STI.
STI Knowledge Accuracy
Total score on the knowledge scale ranged from 12.5% to 100% (M = 79.87), with
higher scores indicating more accurate knowledge. Mann-Whitney U tests identified
significantly higher STI knowledge accuracy in females, whites, participants who were
sexually active in the past year, those who have gotten an STI test in the past year, and
those who had ever had an HIV test (Table 2). The regression model had low model fit
(adjusted R2 = 0.09, p < 0.0000; Table 3), but examination of the standardized beta
coefficients revealed that ever having an HIV test had the largest contribution to the
model (β = 0.1974, p = 0.0000). The unstandardized beta coefficient indicated a 5.5%
increase in STI knowledge accuracy with ever having had an HIV test.
STI/HIV Testing History and Barriers
Among the entire sample, 31% of students had ever received an HIV test and 31.5% had
got an STI test (including gonorrhea, chlamydia, and other STIs). Having got an HIV
test was associated with being non-white, not-straight, and being sexually active (Table
4). The odds of having had an HIV test in these groups were 1.52, 3.03, and 2.50 times
higher than their counterparts, respectively (Figure 1). Similarly, we found significant
differences in associations with getting an STI test in the past year between gender,
sexual orientation, and being sexually active (Table 5). The odds of having had an STI
test were higher in not-straight individuals, sexually active students, and females (2.58,
3.12, and 3.18 times higher, respectively; Figure 2). Several barriers to getting an STI
test were identified in students who were sexually active and had never been tested. The
most reported reasons for not getting an STI test was knowing their partner’s sexual
history (n = 335), followed by it being an awkward/scary experience (n = 69), and being
apprehensive of finding out the results (n = 39).
Comment
This research focused on exploring differences in STI knowledge accuracy and
STI/HIV testing history at a large public university in the southeastern United States.
Our results largely corroborate findings about students’ STI knowledge and testing
behaviors at other institutions. The raw item scores of STI knowledge accuracy suggest
that college students need additional information regarding HIV transmission, given that
less than 65% of students correctly answered questions relating to HIV transmission
from breast milk, saliva, and urine. In addition, only 52% of students knew that using
more than one condom at a time increases the likelihood of breakage. Students who do
not know this may be engaging in behavior they perceive to be safer, when in reality
their risk of condom breakage is increased. Our findings suggest that students who
identify as females, whites, sexually active, had received an STI test in the past year, or
an HIV test, had higher STI knowledge accuracy than their counterparts. When
controlling for other variables, having previously had an HIV test was the most
significant predictor of STI knowledge accuracy. This could be attributed to a health
education component and conversation focused on risk reductions in HIV testing
sessions.33
Barriers presented in this population are consistent with other studies of this age
group. The most reported reason for sexually active students not getting an STI test was
knowing their partner’s sexual history; however, this knowledge of their sexual history
may not always be accompanied with proof of a negative STI test result. Apprehension
about the test itself and fear of knowing the results were also identified as barriers to
getting tested. Health communication programs should further emphasize the benefits of
getting tested: that students can get peace-of-mind for knowing their status and being
connected to treatment if necessary.
Limitations and Recommendations for Future Research
Although this study adds to the insights from previous research in college
student sexual health knowledge, the following limitations should be noted. First, due to
the use of a random sample, these findings are generalizable to the sampled university’s
student population aged 18-24. However, this is only a sub-sample of the entire
population of 15-24 year olds who are adversely affected by STIs. It is strongly advised
that future studies concentrate on sampling from the general population to better
understand the knowledge and behaviors of the entire group. Secondly, our findings rely
on self-reported data regarding testing history. Participants may have not known the
specific STI test they received, and/or when they had received it, leading to possible
false-negative or false-positive responses when indicating a test in the past 12 months.
Furthermore, our linear model for STI knowledge captured a low proportion of the
variance. This suggests that there may be measurable factors that were absent from the
Sexual Health Student Survey. Future research using surveys similar to the Sexual
Health Student Survey should seek to identify additional predictors of STI knowledge
such as socioeconomic status and sexual education history. In addition, these data are
seven years old and, thus, nearly two full cohorts have entered and graduated from the
University. To compare changes in STI knowledge, sexual risk behavior, STI/HIV
testing history, and barriers to testing, an updated survey should be administered.
Conclusions
The current study’s findings contribute to the knowledge of this high risk
population by assessing STI knowledge accuracy and STI/HIV testing history in a
college population, confirming results of several other studies. Our findings indicate
that college students still lack knowledge about HIV transmission and basic STI risk
reduction strategies. These findings are in concordance with previous studies of similar
cohorts at other institutions, suggesting widespread similarities and useful large-scale
identification of targets for college populations in healthcare and STI education.
According to social marketing theory, successful behavior change interventions identify
specific populations and seek to understand the barriers, knowledge, and behavioral
determinants of that population.34 Our results can, therefore, inform college health
educators of specific populations to target for information-based and testing campaigns.
This can lead to improvements in sexual health literacy, increase the prevalence of
students getting tested for STIs and HIV, and, ultimately, decrease the incidence of STIs
in this age group.
Acknowledgements
We thank GatorWell Health Promotion Services and Ms. Samantha Evans, MS, CHES,
for access to the dataset. This study was supported by funding by the University
Scholars Program, Center for Undergraduate Research, University of Florida.
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Table 1. STI knowledge accuracy scale.
STI Knowledge Questions
“The majority of people who have sexually transmitted infections
(STIs) show no signs or symptoms.” (True)
“Anal intercourse without a condom is considered a low risk behavior
for contracting an STI.” (False)
“When used correctly, birth control pills prevent STI transmission.”
(False)
“Using condoms during sexual intercourse is the most effective way to
reduce the risk of STI transmission.” (True)
“Human Papilloma Virus (HPV) is considered to be a primary cause of
cervical cancer in women.” (True)
“A vaccine exists that helps prevent HPV in humans.” (True)
“Using a water-based lubricant with a condom decreases the likelihood
of breakage.” (True)
“Using more than one condom at a time increases the likelihood of
breakage.” (True)
“To use a condom effectively, it is important to check the expiration
date & to visually inspect the condom for any holes or tears.” (True)
“When putting on a condom, it is important to “pinch an inch” on the
top and then roll it down as far as possible on an erect penis.” (True)
“A person may contract HIV by coming into contact with:”
Blood (True)
Breast milk (True)
Saliva (False)
Semen (True)
Urine (False)
Vaginal secretions (True)
% Correct
84.0
86.6
96.3
82.5
85.5
84.7
69.6
52.1
97.4
84.9
98.4
57.3
61.6
94.6
52.4
89.5
Table 2. Mann-Whitney U tests for differences in STI knowledge.
N
M
SD
Median
Gender
Male
Female
HIV Test - Ever
No
Yes
Race
White
NotWhite
Sexually Active
No
Yes
Sexual
Orientation
Straight
NotStraight
STI Test – last
12m.
No
Yes
331
559
529
232
592
297
204
688
857
30
520
233
77.51
81.23
79.40
84.86
81.21
77.25
73.87
81.65
76.69
85.21
79.84
84.01
*p < 0.05 after Bonferroni correction
15.2
12.52
13.14
10.73
12.55
15.41
16.5
12.18
13.77
10.95
13.25
10.96
U
P-value
81636
0.003*
Effect
size
(r)
0.09
46492.5
0.000*
0.19
76060
0.001*
0.10
50375
0.000*
0.20
15907
0.025
N/A
49957
0.000*
0.14
81.25
81.25
81.25
87.5
81.25
81.25
75
81.25
81.25
87.5
81.25
87.5
Table 3. Multivariate model for STI knowledge accuracy.
Coeff.
94.59
β
SE
t
p
Having an HIV test – Ever
5.47
0.19
1.15
4.7
0.00*
Being sexually active – past 1
year
White
4.40
0.10
1.48
14.13
0.00*
3.89
0.14
0.96
4.02
0.00*
Straight
-3.13
-0.04
2.32
- 1.35
0.18
Female
2.81
0.10
0.96
2.93
0.00*
Age
- 0.97
-0.11
0.29
- 3.30
0.00*
Having an STI test – past 1
year
0.56
0.02
1.15
0.49
0.63
Constant
*p < 0.05 after Bonferroni correction
Table 4. Differences in HIV testing history.
n
Tested (%)
Female
173
34.1
Male
78
25.7
Gender
Race
White
Not-White
Sexual Orientation
153
98
Straight
Not-Straight
Sexually Active
Yes
No
232
18
238
14
*p < .05 after Bonferroni correction
Odds
1.49
CI95%
(1.09-2.04)
χ2
6.14
p
0.01
0.66
(0.48-0.9)
6.98
0.01*
0.33
(0.16-0.67)
10.1
0.00*
2.50
(1.38-4.53)
9.74
0.00*
28.0
37.1
29.8
56.3
32.7
16.3
Table 5. Differences in STI testing history.
n
Tested (%)
Female
200
39.9
Male
52
17.3
Gender
Race
White
Not-White
Sexual Orientation
159
93
Straight
Not-Straight
Sexually Active
Yes
No
235
17
241
12
Odds
3.18
CI95%
(2.25-4.51)
χ2
44.74
p
0.00*
1.12
(0.83-1.51)
3.00
0.08
0.39
(0.19-0.79)
7.29
0.01*
3.12
(1.66-5.85)
13.7
0.00*
29.4
35.5
30.5
53.1
33.6
14.0
*p < 0.05 after Bonferroni correction
Figure 1. Odds of HIV testing (±95% CI).
*p < 0.05 after Bonferroni correction
Figure 2. Odds of STI testing (±95% CI).
*p < 0.05 after Bonferroni correction