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-

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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

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.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. The lead- and the Perceived Risk of Sexually Transmitted Infection ing method of family planning was oral contraceptives Survey. (48.9%; n = 51). Condom use was reported by 45.2% (n = 47) of the women. However, it was not statistically clear I Description of the Intervention whether condom use was being identified in conjunction The educational intervention was designed from empirical with or as a birth control method. standards and guidelines from the Centers for Disease Con- In response to a question on sexual partner behavior, trol and Prevention.13 The principal investigator performed 42.4% (n = 44) of participants reported one sex partner, the intervention using an educational presentation includ- 15.3% (n = 16) reported two sex partners, and 5.7% (n = ing discussion and PowerPoint slides. The PowerPoint pre- 6) reported three sex partners (see Table: “Self-Reported Sex- sentation depicted condoms, dental dams, and instructions ual Behaviors”). Women were asked to report past incidence on their proper use. The intervention was supplemented of diagnosed STI. Eighty-three percent (n = 87) reported with an informational brochure that experimental subjects previous episodes of STIs. Women were specifically asked were encouraged to review at least three times each week. whether they had difficulty asking their sex partner to use a The supplemented information was intended to relate condom. Ninety-one percent (n = 95) of the women re- changes in STI knowledge and safer sex behavior by rein- ported difficulty asking their sex partners to use a condom. forcing information introduced in the presentation and dis- The experimental group received the educational/be-

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havior intervention 1 week after pretest. Demographic Characteristics Both groups received the posttest 2 weeks after pretest. In testing the first Intervention Group Control Group hypothesis (H ), a group mean differ- n = 51 n = 53 1 Age ence was noted in the intervention 19-25 46 (90.2%) 47 (88.7%) group after being exposed to the educa- 26-39 5 (9.8%) 6 (11.3%) tional/behavior intervention. Overall, the group mean (M = 26.1 SD ± 2.6) for Ethnicity the intervention group was higher, in- African-American 26 (50.9%) 20 (37.7%) dicating greater knowledge about STIs Caucasian 21 (41.2%) 26 (49.0%) at posttest compared with the control Hispanic 2 (3.9%) 3 (5.7%) group mean at posttest (M = 21.0 SD ± Native-American — 1 (1.9%) 2.3). Defined as “other” 2 (3.9%) 3 (5.7%) The educational/behavioral inter- Number of Children vention resulted in statistical signifi- 0 45 (88.2%) 47 (86.8%) cance between group differences at 1 5 (9.8%) 5 (9.4%) posttest regarding STI knowledge and 2 — 2 (3.8%) perceived risk for women receiving 3 1 (1.9%) — the educational/behavioral interven- Note. Dashes indicate no data reported. tion F (1,102) = 109, p < .0001, indicat- ing the brief (30-minute) educational/ behavioral intervention had an effect on the experimental group. Self-Reported Sexual Behaviors In testing the second hypothesis

(H2), the results revealed a significant Intervention Group Control Group main effect in group mean (M = 4.0 SD n = 51 n = 53 Age at first sexual encounter ± 1.0) at posttest for perceived risk of 12-14 12 (23.5%) 8 (15.1%) STIs in women exposed to the interven- 15-17 26 (50.9%) 24 (45.3%) tion compared to the control group mean at posttest (M = 7.9 SD ± 2.3). 18-20 8 (15.8%) 13 (24.6%) The interaction effect suggests differen- 21 and above 1 (1.9%) 1 (1.8%) tial changes between the two groups. Number of sex partners within last year The interaction effect of the perceived 0 9 (17.6%) 15 (28.3%) risk mean revealed that the treatment 1 24 (47.1%) 20 (37.7%) group changed rather substantially be- 2 8 (15.8%) 8 (15.1%) tween pretest and posttest, but only a 3 3 (5.8%) 3 (5.7%) modest change for the control group 4 or more 7 (13.7%) 7 (13.2%) was noted (see Table: “Mean and Stan- Difficulty asking sex partner to use a condom 44 (86.2%) 51 (96.2%) dard Deviations for Perceived Risk at Had a sexually transmitted infection 41 (80.4%) 46 (86.7%) Pretest and Posttest”). Analysis of variance was used to fur- ther examine the pretest and posttest Mean and Standard Deviations for Perceived Risk at Pretest and scores and the STI education interven- Posttest tion (see Table:“Posttest of Intervention Effect on Knowledge and Perceived Pretest Posttest Risk”).The interaction between the time STI perceived risk N Mean SD Mean SD of assessment (pretest vs posttest) and Intervention group 51 7.6 2.1 4.0 1.0 the group was statistically significant for Control group 53 8.0 2.2 7.9 2.3 knowledge, F (1,102) = 97.74, p < .0001; F (1,102) = 53.41, and p < .0001 for per- Note. 1 week between pretest and posttest for both groups. ceived risk.

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practice nurses are in a variety of healthcare settings and Posttest of Intervention Effect on Knowledge should ensure that their patients have a good understand- and Perceived Risk ing of treatment options and relevant health education in- formation related to STIs. This study tested a nursing Source df F MS p intervention and may influence women’s health by elimi- STIKS nating knowledge gaps and adding to evidence-based prac- Between subjects tice. Creative nurse-directed interventions could give power Intervention group 1 37.79* 294.02 .0001 to women who gain the knowledge to perceive STI risks and Error 102 (7.78) to take personal action at circumventing high-risk behav- Within subjects iors. The results confirmed that brief educational interven- Time of assessment 1 50.49* 213.23 .0001 tions related to STIs and targeted at increasing knowledge Time by group 1 97.74* 412.73 .0001 could be effective. This study corroborates previous investi- Error (time) 102 (4.22) gations that found that brief educational interventions can influence knowledge of STIs.3,14 Perceived Risk Between subjects REFERENCES Intervention group 1 46.94* 235.19 .0001 1. Flannigan J. Chlamydia: the nurse’s role in diagnosis, treatment and health Error 102 (5.01) promotion. Nurs Stand. 2006. 20(41). 59-64. Within subjects 2. Linderberg CS, Solorzano RM, Bear D, Strickland O, Galvis C, Pittman K. Reducing substance use and risky sexual behavior among young, low-in- Time of assessment 1 59.30* 178.11 .0001 come, Mexican-American women: comparison of two interventions. Appl Nurs Res. 2002;15(3):137-148. Time by group 1 53.41* 160.42 .0001 3. Van Devanter N, Gonzales V, Merzel C, Parikh NS, Celantano D, Greenberg, Error (time) 102 (3.00) J. Effect of an STD/HIV behavioral intervention on women’s use of the fe- male condom. Am J Public Health. 2002;92(1):109-115. Note. Values enclosed in parentheses represent mean square errors. 4. Williams SS, Norris AE, Bedor MM. Sexual relationships, condom use, and *p < .05. concerns about pregnancy, HIV/AIDS, and other sexually transmitted dis- eases. Clin Nurse Spec. 2003;17(2):89-94. 5. Stoner BP,Whittington WLH, Aral SO, Hughes JP, Handsfield H, Holmes K. Avoiding risky sex partners: perception of partners’ risks v partners’ self re- I Areas of Future Research ported risks. Sex Transm Infect. 2003;79(3):197-201. The findings of this study may assist advanced practice nurses 6. Von Sadovszky V, Keller M, McKinney K. College students’ perceptions and practices of sexual activities in sexual encounters. J Nurs Scholarsh. in anticipating questions where answers may not appear ex- 2002;34(2):133-138. ceedingly evident. Educating women about STIs could in- 7. Mehta SD, Erbelding EJ, Zenilman JM, Rompalo AM. Gonorrhea reinfec- tion in heterosexual STD clinic attendees: longitudinal analysis of risks for clude brief interventions such as explaining literature in a first reinfection. Sex Transm Infect. 2003;79(2):124-128. simple and direct manner, as well as fostering a trusting pa- 8. Ickovics JR, Niccolai LM, Lewis JB, Kershaw TS, Ethier KA. High postpartum tient/provider relationship throughout the health-seeking rates of sexually transmitted infections among teens: pregnancy as a window of opportunity for prevention. Sex Transm Infect. 2003;79(6):469-473. encounter. These findings add to the growing body of liter- 9. Mahon BE, Rosenman MB, Graham MF, Fortenberry JD. Postpartum ature that says patient/provider encounters are brief and Chlamydia trachomatis and Neisseria gonorrhoeae infections. Am J Obstet Gynecol. 2002;186(6):1320-1325. communication of health-promoting concepts must be con- 10. Mathews C, Guttmacher SJ, Coetzee N, et al. Evaluation of a video based veyed clearly and with brevity. It cannot be assumed that health education strategy to improve sexually transmitted disease partner women previously seen by healthcare providers received in- notification in South Africa. Sex Transm Infect. 2002;78(1):53-57. 11. Niccolai LM, Ethier KM, Kershaw TS, Lewis JB, Ickovics JR. Pregnant ado- formative instructions targeted at increasing knowledge and lescents at risk: sexual behaviors and sexually transmitted disease preva- preventive behavior for STIs. Patients require information lence. Am J Obstet Gynecol. 2003;188(1):63-70. 12. Manlove J, Terry-Humen E, Papillo A, Franzetta K, Williams S, Ryan S. Pre- along with appropriate treatment. Helping the patient to un- venting teenage pregnancy, childbearing, and sexually transmitted diseases: derstand an STI diagnosis is important in allaying possible what research shows. Washington, DC. Child Trends. 2002;1-14. fears. Also, the findings indicate the importance of advanced 13. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines. MMWR Recomm Rep. 2002;51(RR-6):1-78. practice nurses in reinforcing STI information during clini- 14. Johnson BT, Carey MP, Marsh KL, Levin KD, Scott-Sheldon LAJ. Interven- cal encounters with patients. Advanced practice nurses and tions to reduce sexual risk for the human immunodeficiency virus in ado- lescents, 1985-2000: a research synthesis. Arch Pediatric Adolescent Med. women are challenged to recognize critical points in at-risk 2003;157(4):381-388. situations such as exposure to STIs. Women need to under- stand that STIs contribute greatly to morbidity associated ABOUT THE AUTHORS At the University of South Florida, Dr. Johnson-Mallard is a Post Doctoral Fel- with reproductive health, including pelvic inflammatory dis- low, Dr. Lengacher is a Full Professor, Dr. Kromrey is a Full Professor, Dr. Camp- ease, infertility, ectopic pregnancy, chronic pelvic pain, com- bell is a Professor Emeritus of Nursing, Dr. Jevitt is an Assistant Professor, and Dr. Daley is an Assistant Professor. Dr. Schmitt is Chief at the Bureau of Sexu- promised birth outcomes, and cervical cancer. Advanced ally Transmitted Disease, Tallahassee, FL.

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