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Increasing Knowledge of Sexually Transmitted Infection Risk Increasing Knowledge of Sexually Transmitted Infection Risk Versie Johnson-Mallard, PhD(c), MSN, ARNP Cecile A. Lengacher, RN, PhD Jeffrey D. Kromrey, PhD Doris W. Campbell, PhD, ARNP, FAAN Cecilia M. Jevitt, CNM, PhD Ellen Daley, PhD Karla Schmitt, PhD exually transmitted infec- tions (STIs) are a major S threat to public health. Without intervention,experts predict dramatic increases in cases.1 Research on both knowledge and perceived risk of STIs among women of childbear- ing age is very limited. Because of the rising number of human immunod- eficiency virus (HIV) infections and other STIs among this patient popu- lation, health directives should in- clude behavioral interventions with the aim of empowering women with increased knowledge as well as an in- creased perception of risk of STIs. Positive behavior changes are plausible with STI prevention mes- sages and services for at-risk women by means of nurse-directed interven- tions with the intention of enhancing perceived risk as well nosed with two-thirds of the estimated 12 million new cases as increasing knowledge of STIs in women.2-4 The purpose of of STIs annually in the United States. After only a single this study was to test the effects of an educational/behavioral exposure, women are twice as likely as men to acquire infec- intervention on knowledge and perceived risk of STIs in tions from pathogens causing gonorrhea, chlamydia in- women of childbearing age. fection, hepatitis B, and chancroid.3,7 Chlamydia is a leading cause of reproductive morbidity in women.3 Moreover, ac- I Background and Significance quired immune deficiency syndrome (AIDS) surveillance The rates of incidence of STIs such as syphilis, herpes sim- data indicate that young people between the ages of 13 and plex virus (HSV), gonorrhea, and chlamydia have increased 24 account for a larger proportion of HIV cases than AIDS dramatically in heterosexual women.5,6 Women are diag- cases, and the number of female youth becoming HIV in- 26 The Nurse Practitioner • Vol. 32, No. 2 www.tnpj.com Sexually Transmitted Disease fected exceeds that of males.5 of STIs in the educational intervention group compared with Sexually transmitted infections are of particular distress the control group. among women because of the potential for acute and life- (H2): There will be significant increases in perceived risk threatening complications during pregnancy.8-10 Other than of STIs in the educational intervention group compared with HIV, exposure to STIs such as Chlamydia trachomatis, Neis- the control group. seria gonorrhoeae, syphilis, HSV,and bacterial vaginosis dur- Analysis of variance (ANOVA) was used to test the hy- ing pregnancy has been associated with undesirable potheses and compare changes in knowledge and perceived pregnancy outcomes.6 Each year, an estimated 20,000 infants risk between the two groups. Sexually transmitted infec- are born to women who test positive for the hepatitis B sur- tion knowledge and perceived risk group comparisons were face antigen (HbsAg). Fetal death secondary to premature made between the intervention and control groups before delivery, pneumonia, and sepsis can occur as a result of HbsAg infection. Untreated syphilis during pregnancy Women are diagnosed with two-thirds of the can lead to stillbirths, neonatal deaths, estimated 12 million new cases of STIs and infant disorders such as deafness, neurologic impairment, and bone de- annually in the United States. formities.10 Many cultures and religions have an expectation of marriage and mutual monogamy during the educational/behavior intervention and after the educa- pregnancy. An expectation of monogamy sometimes con- tional/behavior intervention to address whether the edu- tradicts teaching STI prevention and condom use. There- cational/behavior intervention had an effect on knowledge fore, STI prevention during pregnancy has focused on and perceived risk. screening for particular STIs. However, STI incidence and prevalence are particularly high among young adults and Sample pregnant females.11,12 Adolescents who are pregnant may be The sample included 104 women attending two universities. at especially high risk because of their sexual history, likely Sample size was selected using power analysis based on a reduction in condom use, which may be viewed as unneces- medium effect size requiring a minimum sample of 88. The sary because of pregnancy, and the fact that pregnancy re- overall mean age of the sample was 21 years. Of the 104 par- sults in additional physiologic vulnerability to STIs.11 ticipants, 44.2% (n = 46) identified themselves as African- Manlove et al12 reported that 33% of births to women of all American, 45.2% (n = 47) as Caucasian, 4.8% (n = 5) as ages in the United States occur outside of marriage and 79% Hispanic, and 5.8% (n = 6) defined their race as “other”. of births to teens are outside of marriage. Women need to know their STI risk and to learn prevention techniques, es- Instrumentation pecially those without assurances of mutual monogamy. Sexually Transmitted Infection Knowledge Survey (STIKS)—a 29-item multiple choice survey. The questions I Study Design addressed prevention, transmission, treatment, and symp- An experimental study was designed to determine whether toms of STIs. The questions were grouped according to gen- participating in an educational program has a positive ef- eral knowledge relating to STI prevention, possible fect on knowledge and perceived risk of STIs. A two-group transmission from mother to child, cognitive awareness re- randomized control pretest/posttest research design was used lating to prevention of STIs during pregnancy and ability to to analyze whether a significant increase in knowledge and identify general understanding of treatment planning for perceived risk of STI would be seen in the educational in- STIs. Content validity was computed to be .93. Each item on tervention group when compared with the control group. the survey was scored “1” for correct responses and “0” for In addition, the reliability of two instruments was measured: incorrect responses. The estimate of reliability (Cronbach’s the Sexually Transmitted Infection Knowledge Survey alpha) for STIKS was 0.76. Potential scores on this instru- (STIKS) and the Perceived Risk of Sexually Transmitted In- ment could range from 0 to 29 with higher scores indicative fection Survey, which were developed in 1998 to measure of greater STI knowledge. knowledge and perceived risk of women in their childbear- Perceived Risk of Sexually Transmitted Infection Sur- ing years. vey—a five-item instrument, using a five-point Likert scale. Data analysis was based on two hypotheses: The estimate of reliability (Cronbach’s alpha) for the Per- (H1): There will be significant increases in knowledge ceived Risk of Sexually Transmitted Infection Survey was www.tnpj.com The Nurse Practitioner • February 2007 27 Sexually Transmitted Disease .71. A higher range on the scale indicated a higher perceived cussion. Specifically, the directives of the intervention were risk for contracting an STI. to increase STI knowledge, encourage adoption of preven- tive behaviors (limiting number of sex partners), and to in- Procedures crease women’s perceptions of their risk of STIs and their Permission to conduct the study was obtained from the In- need for incorporation of healthy sexual behaviors. stitutional Review Board for Human Subjects of the univer- A structured discussion and answer session was con- sities. The schools’ deans and the professors of each class also ducted in an open forum about STIs. To increase knowledge granted permission to use their students as study subjects. regarding STIs, explanations were provided about the po- Each participant was given a written description of the study tential sequelae of undiagnosed and untreated STIs. The and assured that participation was voluntary. Procedures for study conductors emphasized the importance of condom the protection and privacy of human subjects were followed use (female or male), choosing an appropriate sex partner, throughout the study. The principal investigator so- licited potential sample study partici- Women need to know their STI risk and pants: women 18 to 48 years of age, techniques for prevention, especially those able to speak, read, and write English at the seventh grade level, and who without assurances of mutual monogamy. were willing to participate in the in- tervention and the follow-up posttest. Study participants were recruited from a sample of students monogamy, dental dam or saran wrap use to shield the vulva in a baccalaureate level nursing program. These students area during oral sex, and potential adverse effects of anal/rec- had not yet been exposed to any formal nursing class lec- tal sex. The potential effects of STIs on pregnant women and tures about STIs. The surveys were completed in a comfort- their fetus, as well as the importance of safer sex practices able setting with the principal investigator monitoring, during pregnancy were also addressed. Structured lecture providing assistance, and helping to ensure confidentiality and discussion were supplemented with slides depicting con- of responses. doms, dental dams, and spermicidal agents used to decrease Participants were randomized (using a table of random potential risk of STI transmission from partner to partner numbers) to either the intervention group or the control and from mother to fetus. group during the preintervention phase. Both sets of partic- ipant groups were asked to complete the Demographic Data Results Form, STIKS, and the Perceived Risk of Sexually Transmit- The mean age of the sample was 21 years (range from 19 to ted Infection Survey two times—at baseline and 1 week af- 39 years). Demographic factors (such as age, ethnicity, and ter the intervention. Measurements from the control group children) were approximately equivalent in the two groups were used to compare outcomes of the educational/behav- (see Table: “Demographic Characteristics”). The mean age ioral intervention as well as to test the reliability of STIKS for initiating sexual intercourse was 15 years old.
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