Exploring psychosocial predictors of STI testing in University students

Exploring psychosocial predictors of STI testing in University students Background: To explore university students’ Sexually Transmitted Infection (STI) testing knowledge, psychosocial and demographic predictors of past STI testing behaviour, intentions to have an STI test, and high risk sexual behaviour, to inform interventions promoting STI testing in this population. Methods: A cross-sectional, quantitative online survey was conducted in March 2016, recruiting university students from North East Scotland via an all-student email. The anonymous questionnaire assessed student demographics (e.g. sex, ethnicity, age), STI testing behaviours, sexual risk behaviours, knowledge and five psychological constructs thought to be predictive of STI testing from theory and past research: attitudes, perceived susceptibility to STIs, social norms, social fear and self-efficacy. Results: The sample contained 1294 sexually active students (response rate 10%) aged 18–63, mean age = 23.61 (SD 6.39), 888 (69%) were female. Amongst participants, knowledge of STIs and testing was relatively high, and students held generally favourable attitudes. 52% reported ever having an STI test, 13% intended to have one in the next month; 16% reported unprotected sex with more than one ‘casual’ partner in the last six months. Being female, older, a postgraduate, longer UK residence, STI knowledge, perceived susceptibility, subjective norms, attitudes and self-efficacy all positively predicted past STI testing behaviour (p < 0.01). Perceived susceptibility to STIs and social norms positively predicted intentions to have an STI test in the next month (p < 0.05); perceived susceptibility also predicted past high-risk sexual behaviour (p < 0.01). Conclusions: Several psychosocial predictors of past STI testing, of high-risk sexual behaviour and future STI intentions were identified. Health promotion STI testing interventions could focus on male students and target knowledge, attitude change, and increasing perceived susceptibility to STIs, social norms and self-efficacy towards STI-testing. Keywords: Sexual health, Students, Health promotion, Sexually transmitted infections, Testing, Psychosocial determinants Background diagnosis and treatment of STIs can reduce the incidence Sexually Transmitted Infections (STIs) are a significant and complications associated with the disease by reducing public health problem. In England there were nearly half onward transmission of infection to sexual contacts [3, 4]. a million new diagnoses of STIs in 2015 alone [1]. If not Proactive approaches to STI testing tend to use popula- treated, STIs can lead to serious long-term health sequelae tion registers to invite individuals from a target population such as pelvic inflammatory disease and infertility [1]. The for screening; in opportunistic approaches individuals are impact of STIs is greatest in young people under 25 years offered testing whilst attending health services for other old [1], including university students, who, are most likely reasons [5]. Some European countries have national STI to be exposed to key risk factors such as multiple sexual testing programmes, however uptake rates are generally partners and unprotected sexual intercourse [2]. When low [6]. Results from a recent large survey in the UK [7] used correctly and consistently, condoms are the most suggested that although rates of chlamydia testing in effective means of preventing an STI. Prompt testing, early young adults aged 16–25 are increasing [8], the level still falls below the 35% of population needed to reduce preva- lence of STIs [9]. Many young people are not attending * Correspondence: hollymartinsmith3@gmail.com NHS Grampian, Public Health Directorate, Aberdeen, UK Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Martin-Smith et al. BMC Public Health (2018) 18:664 Page 2 of 9 STI testing services and so effective efforts to encourage persons decision to have an STI test from qualitative testing uptake are required. and quantitative research [12, 24]. To date a limited number of studies have explored the Application of these theories and sociological factors psychosocial determinants of STI testing in a university in exploring STI testing behaviours have resulted in setting. Traditional STI research has shown that STI somewhat inconsistent and fragmented findings [11–13]. testing rates can vary substantially according to age, gen- Furthermore, sexual health promotion interventions and der, ethnicity, education level as well as STI-related know- communications are not always based on careful analysis ledge and systemic factors [10]. More recent research has of the evidence around predictors of behaviour: one explored more complex social and psychological factors study of safer sex leaflets found most messages targeted such as perceived norms and perceived susceptibility in- knowledge about condoms rather than information about formed by health psychology theories [11–13] and found perceived attitudes even though the latter was more these to be significant predictors of behaviour. strongly correlated with actual condom use [25]. Indeed, according to the Theory of Planned Behaviour Building on this evidence is important to gain a further [14] a person’s behaviour depends on their ‘behavioural understanding of social and psychological factors influen- beliefs’, or attitudes, relating to possible outcomes of the cing STI testing behaviour, particularly to inform practice behaviour, their ‘normative beliefs’ about significant others’ for those working in settings with high proportions of expectations about their behaviour, which can create under 25 year olds, such as universities. The objectives of perceived social pressure (subjective norms) and ‘con- this study were to: trol beliefs’ about the power of barriers to performing the behaviour, which creates perceived behavioural con- 1) Explore university students’ STI testing knowledge, trol. Positive attitudes, subjective norms and perceived psychosocial and demographic factors and behaviours. behavioural control lead to stronger intention and thus 2) Understand which psychosocial and demographic likelihood of behaviour change. This theory has been ap- factors predict STI testing, intentions and sexual plied to explain sexual behaviours such as condom use [15] risk behaviour. and more recently in understanding barriers to STI testing [12]. Later versions of the model and meta-analyses also Ultimately, this aimed to inform effective interventions acknowledge the additive effect of descriptive norms, or for promoting STI testing in university students. individuals’ beliefs about what others’ do, which may be especially important for younger populations and for health risk behaviours [16, 17]. Methods The Health Belief Model [18] proposed alternative Design constructs including perceived susceptibility or vulner- A quantitative cross-sectional survey study using an ability to a condition (such as an STI), perceived severity anonymous, self-administered online survey developed if it occurred, perceived benefits of taking preventative following a review of the literature. The questionnaire action (e.g. STI testing) and beliefs about barriers to this was developed systematically using theory-based psycho- action. This model has also been applied to explain con- logical constructs found to be predictive of behaviour in dom use [19] and only recently to understanding the fac- previous research, and where possible, using validated tors impacting a person’s decision to take an STI test [12]. measures and scores (see Additional file 1 for further de- Social Cognitive Theory [20] emphasises self-efficacy tail on definitions and measures and Additional file 2 for (one’s confidence to perform behaviour) in determining the full questionnaire). Questions assessed students’ sexual which behaviour a person chooses to perform, their health behaviours, intentions to attend an STI test in persistence in the face of obstacles and how well they the next month, demographic characteristics (age, sex, will perform that behaviour. Increased self-efficacy is ethnic background, year of study and number of years also thought to be one mediator of the link between de- living in the UK), STI knowledge and the five theory-based scriptive norms and behaviour, the idea that ‘if similar psychosocial constructs (perceived susceptibility, social people to me do X, then I must be able to do it too’ norms, attitudes, social fear and self-efficacy). The [21]. The role of self-efficacy has been applied to ex- questionnaire was piloted with a convenience sample of plain the initiation and maintenance of many health be- seven health psychology researchers and students and haviours including alcohol consumption [22]; physical minor amendments were made. The main behavioural activity [23], and many others; again infrequently in outcome variables were STI testing history (ever), in- STI testing [12]. tentions to attend an STI test in the next month and In addition social factors (such as social fear based on sexual risk behaviour (defined in this study as unpro- sociological research of stigma and fear of negative con- tected (no condom) sex with two or more sexual part- sequences) has been identified to impact on a young ners in the last six months). Martin-Smith et al. BMC Public Health (2018) 18:664 Page 3 of 9 Setting any item, so for parsimony descriptive norms was removed This study was conducted among students in a North from the analysis. East Scotland University in March 2016. Results Participants Participants A total of 1600 students participated (response rate 10%), Eligible participants were all sexually active registered 297 were excluded due to sexually inactivity and 9 were undergraduate and postgraduate students in all faculties excluded owing to not completing over 50% of the survey. in a North East Scotland University in March 2016 The final analyses were performed on 1294 individuals. Of (16,435 students). these, 69% (888/1294) were female and the mean age was Participants were invited to complete the survey via an 23.68 years (standard deviation, SD 6.44, range 18–63). email that was sent to all the students from the university The response rate was higher for female undergraduates with a link to the online survey questionnaire. Participa- from a white ethnic background compared to official uni- tion was voluntary, anonymous and required online con- versity records on the overall female student population. sent. Students were introduced to the topic and advised of Table 1 shows the characteristics of study participants. the voluntary and anonymous nature of the study, their right to withdraw, and to researcher contact details. An opt-in checkbox indicated participants’ informed consent. Objective 1: Student knowledge, psychosocial and Only participants who indicated that they had ever been demographic factors surrounding STI testing sexually active were included in the final analysis. The survey was live for two weeks, during which time two Knowledge of STIs/STI-testing In the 14-item (true/ reminder emails were sent to facilitate recruitment. false) STI/STI-Testing knowledge section, the median number of correctly answered questions was 10.0 (IQR 9.0–12.0). Male students (median = 11.0, IQR = 8.0–13.0 Statistical analyses had greater STI/STI-Testing knowledge than female The submitted anonymous surveys were coded numeric- students (median = 10.0, IQR = 9.0–12.0) however this ally, scores for individual items were summed into compos- was not found to be a statistically significant difference ite scores based on previous research (full details of data (U = 174,242.5, z = −.619, p = .53). Similarly white students treatment can be found in Additional file 1), and analysis (median = 11.0, IQR = 9.0–12.0), students who had lived in was performed using SPSS (version 20.0). the UK more than 5 years (median = 11.0, IQR = 9.0–11.0) To further explore sample characteristics in relation and undergraduate students (median = 11.0, IQR = to population characteristics, we examined differences 9.0–12.0) had greater STI/STI-Testing knowledge than between our sample with the university student popula- non-white students (median = 9.0, IQR = 6.0–12.0), stu- tion, using demographic data on ethnicity, age and sex dents who had lived in the UK 0–5 years (median = 9.0, from the University records office, using Chi-square tests. IQR = 7.0–11.0) and postgraduate students (median = Data were assessed for normal distribution using 10.0, IQR = 7.0–12.0), and these differences were found to Shapiro-Wilk test of normality. Where data were not be statistically significant (p <.001). normally distributed, the median and interquartile range (IQR) was reported. Chi-square tests and Mann Whitney U tests examined differences, means ranks were investigated Psychosocial factors surrounding STIs and STI testing when differently shaped distributions of the independent Overall, participant direct and indirect attitudes were variable occurred. Odds Ratios (OR) with associated 95% favourable towards STI testing (Median = 31.0, IQR = confidence intervals (95% CI) were used to measure the 28.0–32.0 and Median = 42.0, IQR = 39.0–46.0 respect- association between two attributes. Logistic regression ively). In terms of the other psychosocial variables, social models were then used to assess which psychosocial fear towards STI testing and perceptions of susceptibility (including knowledge and demographic) factors predicted to an STI were low (Median = 16.0, IQR = 10.0–24.0) past STI testing, sexual risk behaviour and intentions to at- and (Median = 4.0, IQR = 4.0–5.0) respectively. Percep- tend STI testing in the next month. Cronbach’salpha was tion of social pressure (subjective norms) and confidence used to assess the internal consistency of items within each (self-efficacy) to attend an STI test were moderate construct of psychosocial measures, with >.07 taken as ad- (Median = 4.0, IQR = − 15.0–20.0) and (Median = 38.0, equate consistency. Cronbach alpha coefficients were all IQR = 31.0–47.0 15.0) respectively. The median score above 0.7 except for the descriptive norms scale [α = .59]. for descriptive norms towards STI testing was moderate There was poor inter-item correlation between the three (Median = 8.0, IQR = 6.0–9.0). Table 1 includes median question items (r =0.11–0.52) making up this scale and and interquartile ranges for participants’ scores on the little improvement in Cronbach’s alpha with the deletion of psychosocial variables. Martin-Smith et al. BMC Public Health (2018) 18:664 Page 4 of 9 Table 1 Participant characteristics and median and interquartile range scores for each psychosocial variable Demographics Psychosocial variablesMedian (IQR) Overall N(%) Overall Knowledge Susceptibility Subjective norms Descriptive norms Direct Attitudes Indirect attitudes Social fear Self-Efficacy Median (IQR) Age 18–25 999 (77) 22 (20–25) 11.0 (9.0–12.0) 4.0 (4.0–5.0) 5.0 (12.0–22.0) 8.0 (6.0–9.0) 31.0 (28.0–33.0) 42.0 (39.0–46.0) 17.0 (11.0–25.0) 38.0 (31.0–46.0) 25 or more 282 (21) 11.0 (8.0–12.0) 4.0 (4.0–5.0) 0.0 (−20.0–18.5) 7.0 (6.0–9.0) 31.0 (28.0–32.0) 43.0 (38.0–46.0) 15.0 (10.0–22.0) 38.0 (32.0–48.0) Sex Male 401 (31) / 11.0 (8.0–13.0) 4.0 (4.0–5.0) 4.0 (−12.0–19.0) 7.0 (6.0–9.0) 30.0 (27.0–32.0) 42.0 (38.0–45.0 16.0 (10.0–23.0) 38.0 (33.0–48.0) Female 888 (69) 10.0 (9.0–12.0) 4.0 (4.0–5.0) 4.0 (−16.0–22.0) 8.0 (7.0–9.0) 31.0 (29.0–33.0) 43.0 (39.0–46.0) 17.0 (10.0–25.0) 37.0 (31.0–46.0) Ethnicity White 1129 (87) / 11.0 (9.0–12.0) 4.0 (4.0–5.0) 5.0 (−14.0–22.0) 8.0 (7.0–9.0) 31.0 (28.0–32.0) 42.0 (39.0–46.0) 16.0 (10.0–24.0) 38.0 (32.0–47.0) Mixed Multiple 23 (2) 9.0 (6.0–12.0) 4.0 (4.0–5.0) 0.0 (−16.0–14.5) 7.0 (6.0–8.5) 31.0 (27.0–33.0) 43.0 (38.0–47.0) 17.0 (10.0–24.5) 36.0 (28.0–43.0) Asian 73 (6) Black n <5 African 31 (2) Other 30 (2) Years in UK 0–5 456 (35) 19 (3.0–21.0) 9.0 (7.0–11.0) 4.0 (4.0–5.0) 0.0 (− 15.0–20.0) 7.0 (6.0–9.0) 31.0 (29.0–33.0) 43.0 (39.0–47.0) 15.0 (9.5–23.0) 38.0 (31.0–47.0) More than 5 838 (65) 11.0 (9.0–11.0) 4.0 (4.0–6.0) 6.0 (−14.0–22.0) 8.0 (7.0–9.0) 31.0 (28.0–32.0) 42.0 (38.0–45.0) 17.0 (11.0–25.0) 38.0 (32.0–46.0) Year of study Undergraduate 968 (75) / 11.0 (9.0–12.0) 4.0 (4.0–6.0) 5.0 (−13.0–22.0) 8.0 (7.0–9.0) 31.0 (38.0–32.0) 42.0 (39.0–46.0) 17.0 (11.0–24.0) 38.0 (23.0–46.0) Post graduate 325 (25) 10.0 (7.0–12.0) 4.0 (4.0–5.0) 0.0 (−17.0–17.0) 7.0 (6.0–9.0) 31.0 (28.0–33.0) 43.0 (38.0–46.0) 16.0 (10.0–24.0) 36.0 (31.0–47.0) Overall 10.0 (9.0–12.0) 4.0 (4.0–5.0) 4.0 (−15.0–20.0) 8.0 (6.0–9.0) 31.0 (28.0–32.0) 42.0 (39.0–46.0) 16.0 (10.0–24.0) 38.0 (31.0–47.0) Median (IQR) Range of possible scores 0–14 4–20 −40 − +40 3–15 8–35 11–55 8–40 12–60 Martin-Smith et al. BMC Public Health (2018) 18:664 Page 5 of 9 Behaviour Fifty two percent (678) of students who com- Sexual behaviour Table 4 below shows that pleted the survey reported having ever had an STI test, socio-demographic variables had no statistically sig- 20.5% (266) reported having had an STI test in the last nificant effect on high risk sexual behaviour in the six months, 13% (166) indicated an intention to attend past six months, defined as having had unprotected an STI test in the next month and 16% (181) reported (no condom) sex with multiple sexual partners (two or unprotected sex with more than one casual partner in more) in the last six months. Perceived susceptibility last six months. and subjective norms were the only predictors of past risky behaviour. For every one-unit increase in suscep- tibility and subjective norms score, students were 33 Objective 2: Psychosocial factors predicting university and 1% more likely to have engaged in risky behaviour students’ past STI testing behaviours, intentions to attend in the past, respectively. an STI test and sexual risk behaviours Discussion Past STI testing Results of regression analysis showed This study assessed knowledge, psychosocial and demo- that females and students aged 25 or over, postgraduates graphic factors and behaviours surrounding STI testing and students who had been in the UK for more than 5 and explored theoretically-relevant psychosocial predic- years were more likely to have had an STI test in the past. tors of past STI testing, intentions to attend an STI test Similarly knowledge, perceived susceptibility, subjective and high risk sexual behaviour in a student population norms, direct and indirect attitudes and self-efficacy were in Scotland, United Kingdom. all predictors of past STI testing behaviour. High scores Participants had a relatively high level of knowledge of on these variables meant students were more likely to STIs and STI testing and younger students (18–25 years), have had an STI test in the past (Table 2). undergraduate and students who have lived in the UK for over 5 years statistically significantly answered more Intentions to go for an STI test Furthermore, ethnicity, knowledge questions correctly. perceived susceptibility and social norms predicted inten- Approximately half of participants reported ever at- tions to get tested in the next month with white students tending an STI test, similar to the proportion of women being less likely to express an intention to get an STI than reporting having had a chlamydia test in the national those of other ethnicities, and high perceived susceptibility survey [7]. Similar to other studies, women and students and subjective norms meaning students were more likely over 25 years old were more likely to report having been to express intention to get tested (Table 3). tested for STIs [12], confirming that under 25 s may Table 2 Results of logistic regression of past STI testing behaviour (n = 1212) Variable Odds ratio 95% CI p value Demographics Age 18–25 Reference 25 or more 1.522 1.019–2.273 p = .040 Sex Male Reference Female 2.134 1.599–2.847 p < .001 Ethnicity Non White Reference White 1.107 0.718–1.796 p = .645 Number of years in UK 0–5 Reference More than 5 0.706 0.521–0.957 p = .025 Year of study Undergraduate Reference Post graduate 1.551 1.053–2.285 p = .026 Psychosocial Knowledge 1.254 1.185–1.326 p < .001 Susceptibility 1.076 1.022–1.134 p = .006 Subjective norms 1.014 1.008–1.020 p < .001 Direct attitudes 1.037 1.000–1.075 p = .048 Indirect attitudes 1.063 1.030–1.097 p < .001 Social Fear 1.000 0.982–1.018 p = .972 Self-Efficacy 1.042 1.027–1.057 p < .001 Intention 1.027 0.667–1.581 P = .901 Martin-Smith et al. BMC Public Health (2018) 18:664 Page 6 of 9 Table 3 Results of logistic regression of intentions to have an STI test in the next month (n = 1212) Variable Odds ratio 95% CI p value Demographics Age 18–25 Reference 25 or more 1.446 0.825–2.536 p = .198 Gender Male Reference Female 0.889 0.590–1.340 p = .575 Ethnicity Non White Reference White 0.425 0.246–0.735 p = .002 Number of years in UK 0–5 Reference More than 5 0.913 0.588–1.417 p = .685 Year of study Undergraduate Reference Post graduate 0.637 0.355–1.141 p = .129 Psychosocial Knowledge 1.005 0.927–1.090 p = .901 Susceptibility 1.236 1.174–1.300 p < .001 Subjective norms 1.024 1.015–1.034 p < .001 Direct attitudes 1.052 0.990–1.118 p = .100 Indirect attitudes 1.030 0.985–1.078 p = .194 Social Fear 1.002 0.976–1.030 p = .869 Self-Efficacy 1.007 0.987–1.028 p = .484 Past STI testing 1.078 0.696–1.670 p = .735 indeed be a ‘high-risk’ group. Women over 25 in particu- Our study showed that knowledge was also a predictor lar may generally have more opportunity for STI testing of past STI testing behaviour. Similar findings have been given cervical screening and other contact with health reported by some studies [26, 27]. In contrast to one care providers for reproductive health issues. Postgradu- study in Australia [12] that reported no link between ates and students who had lived in the UK for more than knowledge of STI and risk behaviour. A growing consen- 5 years were also more likely to have had an STI test. sus suggests that increasing knowledge is necessary but Table 4 Results of logistic regression of sexual risk behaviour i.e. Unprotected (no condom) and multiple sexual partners (2 or more) in the last 6 months (n = 1104) Variable Odds ratio 95% CI p value Demographics Age 18–25 Reference 25 or more 0.656 0.355–1.212 p = .178 Sex Male Reference Female 0.854 0.574–1.269 p = .434 Ethnicity Non White Reference White 0.579 0.324–1.034 p = .065 Number of years in UK 0–5 Reference More than 5 1.243 0.801–1.930 p = .333 Year of study Undergraduate Reference Post graduate 0.591 0.325–1.073 p = .084 Psychosocial Knowledge 1.044 0.965–1.130 p = .284 Susceptibility 1.331 1.258–1.408 p < .001 Subjective norms 1.011 1.002–1.019 p = .018 Direct attitudes 1.001 0.950–1.054 p = .974 Indirect attitudes 1.009 0.966–1.054 p = .684 Social Fear 1.012 0.987–1.039 p = .348 Self-Efficacy 1.007 0.987–1.028 p = .488 Martin-Smith et al. BMC Public Health (2018) 18:664 Page 7 of 9 not sufficient for behaviour change, given other complex factors to increase uptake of STI testing. Firstly marketing factors that contribute to health-seeking behaviour (e.g. campaigns that deliver health messages have been found self-efficacy, social norms and socio-structural factors) to positively impact on changing health behaviours [33]. [28]. Other less strongly positive associated predictors of Peer-led screening uses peer education to promote posi- STI testing included high perceptions of susceptibility, tive social norms and positive attitudes through modelling high social pressure (subjective norms) to attend STI and normalising [34]. A role-modelling intervention could testing, with favourable direct and indirect attitudes and involve displaying video messages around campuses with high confidence to attend a test. These findings are in- students sharing their experiences of going for an STI test consistent with previous studies, perhaps due to differ- to increase self-efficacy and finally utilising social net- ences in methodology and culture. It emphasises the works within universities by recruiting advocates who complex nature of sexual health behaviours such as STI could spread behaviour change recommendations to their testing cementing the need for diverse initiatives to peers. Furthermore since younger, undergraduate, male tackle this public health problem. students were found to be less likely to have attended test- Few students intended to attend an STI test in the ing, it is feasible that these interventions could focus on next month (13%). Similar to other studies, intention to this sub group of students to help encourage more young participate in STI testing among students in this popula- people to have an STI test. tion was driven by perceived susceptibility and subjective Overall, this cross-sectional study contributes to the body norms [11–13] and multiple partners [29] however other of evidence on factors that impact STI testing behaviours research [30, 31] identified variables such as perceived and demonstrates the complexity of social and psycho- behavioural control, self-identity, motivation and cues to logical factors that impact on STI testing behaviours; action as important predictors of intentions. This high- further research to validate the findings using a pro- lights the possible need to further explore intentions spective longitudinal study is required. within this population including variables not assessed in the survey. Strengths and limitations A small number of students reported engagement in The current study is the first of its kind in this population sexual risk behaviour in the past (16%). in Scotland, adding to the limited body of evidence in this The finding that high scores of susceptibility for an topic area. It is strengthened by the systematic develop- STI and social pressure to attend an STI test meant ment of the survey allowing for a wide range of factors to students were more likely to have engaged in past risky be assessed including demographic, behavioural and psy- behaviour is important. It suggests students accurately chosocial factors regarding STI testing. Moreover this judged themselves to be susceptible, whilst feeling so- study attracted a relatively large sample size comparing cial pressure to attend an STI test if they’dtaken arisk. favourably with other small-scale cross-sectional studies. In comparison previous reviews, explored determinants However there are several limitations, not least that the of sexual risk behaviour, but with inconsistent results. Some cross-sectional design allows only for statistically signifi- identified attitudes, behavioural intentions and behavioural cant associations between behaviour and their potential skills as correlates of sexual behaviours [32]. The ma- determinants. Cross-sectional surveys use self-reports of jority of this research was based on correlation data behaviour, risking recall and reporting bias. Participation from cross-sectional studies which is limited as tempor- bias may also have occurred if some people may be more ality is unable to be established. In light of the above, willing than others to participate in this sensitive topic, current theoretical models of sexual risk behaviour war- and given the online nature of the survey although most if rant further investigation and possible adaptation. not all students would be likely to be able to access a Since a range of psychosocial and demographic factors computer. Like many other surveys, males aged 18–25 were associated with STI testing, sexual health promo- were under-represented, which could affect validity and tion interventions could benefit from targeting specific generalizability of the findings. Ceiling and floor effects student groups and by addressing relevant psychosocial occurred when measuring some of the psychosocial factors. Some recommendations that interventions may variables, limiting the range of data reported leading to address in their design are as follows 1) promote and non-normally distributed data. Fortunately, the analyt- strengthen positive norms around testing to build on ical test used in this study did not require normally dis- health promotion, 2) address young people’s perceptions tributed data,and as thesamplesizeinthisstudy was of personal risk of contracting an STI, 3) promote and fairly large the negative effect of this response bias is strengthen positive attitudes towards STI testing, 4) in- reduced. The 10% response rate was larger than the 7% crease confidence to attend STI testing. There are several reported in another university-based sexual health practical intervention ideas based on previous research study [35]: other comparable online sexual health ques- that could be applied to focus on these key psychosocial tionnaire studies have not tended to report response Martin-Smith et al. BMC Public Health (2018) 18:664 Page 8 of 9 rates and yield smaller overall sample sizes [13, 36]. Author’s contributions HMS was involved in the conception and design of the work data collection, Our response rate was naturally smaller than the more data analysis and interpretation, drafting the manuscript, revising the representative UK-wide national survey The National manuscript and final approval of the version to be published. EB and EO Survey of Sexual Attitudes and Lifestyles [7], who are supervised the conception and design of the work, data analysis and interpretation, critical revision of the manuscript and final approval of the resourced to visit potential participants in their home version to be published. All authors read and approved the final manuscript. and offer monetary incentives for participation. We were not able to assess the predictive effect of descrip- Ethics and consent to participate Ethical approval for the study was granted by the College Ethics Review tive norms, despite this being a potentially important Board at the University of Aberdeen (ethical approval number: CERB/2015/ influence on young people’s behaviour [17]asinternal 11/1235). Consent to participate was obtained at the beginning of the consistency was poor with low inter-item correlation. Fur- online survey, participants read a description of the study before clicking a button to indicate their consent to participate. ther exploratory work would be useful to better understand which are the key referent groups for university stu- Competing interests dents, if descriptive norms vary substantially. Never- The authors declare that they have no competing interests. theless, this study adds to our understanding of several theory-based psychological factors associated with Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in high-risk behaviours and STI testing in this important published maps and institutional affiliations. student population: further replication on a national scalewould nowbeuseful. Author details 1 2 NHS Grampian, Public Health Directorate, Aberdeen, UK. Division of Medical Education, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK. Conclusions This study found several demographic and psychosocial Received: 17 November 2017 Accepted: 23 May 2018 factors influencing STI testing behaviour, high-risk sexual behaviour and future intentions towards STI testing. Per- References ceptions of risks and social pressure are important factors 1. 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Erens B, Phelps A, Clifton S, Mercer CH, Tanton C, Hussey D, Sonnenberg P, (DOCX 16 kb) Macdowall W, Field N, Datta J, Mitchell K. Methodology of the third British Additional file 2: STI Screening Questionnaire. This file provides the full National Survey of sexual attitudes and lifestyles (Natsal-3). Sex Transm questionnaire used to survey participants. (DOCX 76 kb) Infect. 2013 Nov 25:sextrans–2013. 8. Woodhall SC, Soldan K, Sonnenberg P, Mercer CH, Clifton S, Saunders P, da Silva F, Alexander S, Wellings K, Tanton C, Field N. Is chlamydia screening Abbreviations and testing in Britain reaching young adults at risk of infection? Findings CI: Confidence Interval; IQR: Interquartile Range; OR: Odds Ratio; SD: Standard from the third National Survey of sexual attitudes and lifestyles (Natsal-3). Deviation; STI: Sexually Transmitted Infection Sex Transm Infect. 2016 May 1;92(3):218–27. 9. Normansell R, Drennan VM, Oakeshott P. 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Exploring psychosocial predictors of STI testing in University students

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Medicine & Public Health; Public Health; Medicine/Public Health, general; Epidemiology; Environmental Health; Biostatistics; Vaccine
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Abstract

Background: To explore university students’ Sexually Transmitted Infection (STI) testing knowledge, psychosocial and demographic predictors of past STI testing behaviour, intentions to have an STI test, and high risk sexual behaviour, to inform interventions promoting STI testing in this population. Methods: A cross-sectional, quantitative online survey was conducted in March 2016, recruiting university students from North East Scotland via an all-student email. The anonymous questionnaire assessed student demographics (e.g. sex, ethnicity, age), STI testing behaviours, sexual risk behaviours, knowledge and five psychological constructs thought to be predictive of STI testing from theory and past research: attitudes, perceived susceptibility to STIs, social norms, social fear and self-efficacy. Results: The sample contained 1294 sexually active students (response rate 10%) aged 18–63, mean age = 23.61 (SD 6.39), 888 (69%) were female. Amongst participants, knowledge of STIs and testing was relatively high, and students held generally favourable attitudes. 52% reported ever having an STI test, 13% intended to have one in the next month; 16% reported unprotected sex with more than one ‘casual’ partner in the last six months. Being female, older, a postgraduate, longer UK residence, STI knowledge, perceived susceptibility, subjective norms, attitudes and self-efficacy all positively predicted past STI testing behaviour (p < 0.01). Perceived susceptibility to STIs and social norms positively predicted intentions to have an STI test in the next month (p < 0.05); perceived susceptibility also predicted past high-risk sexual behaviour (p < 0.01). Conclusions: Several psychosocial predictors of past STI testing, of high-risk sexual behaviour and future STI intentions were identified. Health promotion STI testing interventions could focus on male students and target knowledge, attitude change, and increasing perceived susceptibility to STIs, social norms and self-efficacy towards STI-testing. Keywords: Sexual health, Students, Health promotion, Sexually transmitted infections, Testing, Psychosocial determinants Background diagnosis and treatment of STIs can reduce the incidence Sexually Transmitted Infections (STIs) are a significant and complications associated with the disease by reducing public health problem. In England there were nearly half onward transmission of infection to sexual contacts [3, 4]. a million new diagnoses of STIs in 2015 alone [1]. If not Proactive approaches to STI testing tend to use popula- treated, STIs can lead to serious long-term health sequelae tion registers to invite individuals from a target population such as pelvic inflammatory disease and infertility [1]. The for screening; in opportunistic approaches individuals are impact of STIs is greatest in young people under 25 years offered testing whilst attending health services for other old [1], including university students, who, are most likely reasons [5]. Some European countries have national STI to be exposed to key risk factors such as multiple sexual testing programmes, however uptake rates are generally partners and unprotected sexual intercourse [2]. When low [6]. Results from a recent large survey in the UK [7] used correctly and consistently, condoms are the most suggested that although rates of chlamydia testing in effective means of preventing an STI. Prompt testing, early young adults aged 16–25 are increasing [8], the level still falls below the 35% of population needed to reduce preva- lence of STIs [9]. Many young people are not attending * Correspondence: hollymartinsmith3@gmail.com NHS Grampian, Public Health Directorate, Aberdeen, UK Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Martin-Smith et al. BMC Public Health (2018) 18:664 Page 2 of 9 STI testing services and so effective efforts to encourage persons decision to have an STI test from qualitative testing uptake are required. and quantitative research [12, 24]. To date a limited number of studies have explored the Application of these theories and sociological factors psychosocial determinants of STI testing in a university in exploring STI testing behaviours have resulted in setting. Traditional STI research has shown that STI somewhat inconsistent and fragmented findings [11–13]. testing rates can vary substantially according to age, gen- Furthermore, sexual health promotion interventions and der, ethnicity, education level as well as STI-related know- communications are not always based on careful analysis ledge and systemic factors [10]. More recent research has of the evidence around predictors of behaviour: one explored more complex social and psychological factors study of safer sex leaflets found most messages targeted such as perceived norms and perceived susceptibility in- knowledge about condoms rather than information about formed by health psychology theories [11–13] and found perceived attitudes even though the latter was more these to be significant predictors of behaviour. strongly correlated with actual condom use [25]. Indeed, according to the Theory of Planned Behaviour Building on this evidence is important to gain a further [14] a person’s behaviour depends on their ‘behavioural understanding of social and psychological factors influen- beliefs’, or attitudes, relating to possible outcomes of the cing STI testing behaviour, particularly to inform practice behaviour, their ‘normative beliefs’ about significant others’ for those working in settings with high proportions of expectations about their behaviour, which can create under 25 year olds, such as universities. The objectives of perceived social pressure (subjective norms) and ‘con- this study were to: trol beliefs’ about the power of barriers to performing the behaviour, which creates perceived behavioural con- 1) Explore university students’ STI testing knowledge, trol. Positive attitudes, subjective norms and perceived psychosocial and demographic factors and behaviours. behavioural control lead to stronger intention and thus 2) Understand which psychosocial and demographic likelihood of behaviour change. This theory has been ap- factors predict STI testing, intentions and sexual plied to explain sexual behaviours such as condom use [15] risk behaviour. and more recently in understanding barriers to STI testing [12]. Later versions of the model and meta-analyses also Ultimately, this aimed to inform effective interventions acknowledge the additive effect of descriptive norms, or for promoting STI testing in university students. individuals’ beliefs about what others’ do, which may be especially important for younger populations and for health risk behaviours [16, 17]. Methods The Health Belief Model [18] proposed alternative Design constructs including perceived susceptibility or vulner- A quantitative cross-sectional survey study using an ability to a condition (such as an STI), perceived severity anonymous, self-administered online survey developed if it occurred, perceived benefits of taking preventative following a review of the literature. The questionnaire action (e.g. STI testing) and beliefs about barriers to this was developed systematically using theory-based psycho- action. This model has also been applied to explain con- logical constructs found to be predictive of behaviour in dom use [19] and only recently to understanding the fac- previous research, and where possible, using validated tors impacting a person’s decision to take an STI test [12]. measures and scores (see Additional file 1 for further de- Social Cognitive Theory [20] emphasises self-efficacy tail on definitions and measures and Additional file 2 for (one’s confidence to perform behaviour) in determining the full questionnaire). Questions assessed students’ sexual which behaviour a person chooses to perform, their health behaviours, intentions to attend an STI test in persistence in the face of obstacles and how well they the next month, demographic characteristics (age, sex, will perform that behaviour. Increased self-efficacy is ethnic background, year of study and number of years also thought to be one mediator of the link between de- living in the UK), STI knowledge and the five theory-based scriptive norms and behaviour, the idea that ‘if similar psychosocial constructs (perceived susceptibility, social people to me do X, then I must be able to do it too’ norms, attitudes, social fear and self-efficacy). The [21]. The role of self-efficacy has been applied to ex- questionnaire was piloted with a convenience sample of plain the initiation and maintenance of many health be- seven health psychology researchers and students and haviours including alcohol consumption [22]; physical minor amendments were made. The main behavioural activity [23], and many others; again infrequently in outcome variables were STI testing history (ever), in- STI testing [12]. tentions to attend an STI test in the next month and In addition social factors (such as social fear based on sexual risk behaviour (defined in this study as unpro- sociological research of stigma and fear of negative con- tected (no condom) sex with two or more sexual part- sequences) has been identified to impact on a young ners in the last six months). Martin-Smith et al. BMC Public Health (2018) 18:664 Page 3 of 9 Setting any item, so for parsimony descriptive norms was removed This study was conducted among students in a North from the analysis. East Scotland University in March 2016. Results Participants Participants A total of 1600 students participated (response rate 10%), Eligible participants were all sexually active registered 297 were excluded due to sexually inactivity and 9 were undergraduate and postgraduate students in all faculties excluded owing to not completing over 50% of the survey. in a North East Scotland University in March 2016 The final analyses were performed on 1294 individuals. Of (16,435 students). these, 69% (888/1294) were female and the mean age was Participants were invited to complete the survey via an 23.68 years (standard deviation, SD 6.44, range 18–63). email that was sent to all the students from the university The response rate was higher for female undergraduates with a link to the online survey questionnaire. Participa- from a white ethnic background compared to official uni- tion was voluntary, anonymous and required online con- versity records on the overall female student population. sent. Students were introduced to the topic and advised of Table 1 shows the characteristics of study participants. the voluntary and anonymous nature of the study, their right to withdraw, and to researcher contact details. An opt-in checkbox indicated participants’ informed consent. Objective 1: Student knowledge, psychosocial and Only participants who indicated that they had ever been demographic factors surrounding STI testing sexually active were included in the final analysis. The survey was live for two weeks, during which time two Knowledge of STIs/STI-testing In the 14-item (true/ reminder emails were sent to facilitate recruitment. false) STI/STI-Testing knowledge section, the median number of correctly answered questions was 10.0 (IQR 9.0–12.0). Male students (median = 11.0, IQR = 8.0–13.0 Statistical analyses had greater STI/STI-Testing knowledge than female The submitted anonymous surveys were coded numeric- students (median = 10.0, IQR = 9.0–12.0) however this ally, scores for individual items were summed into compos- was not found to be a statistically significant difference ite scores based on previous research (full details of data (U = 174,242.5, z = −.619, p = .53). Similarly white students treatment can be found in Additional file 1), and analysis (median = 11.0, IQR = 9.0–12.0), students who had lived in was performed using SPSS (version 20.0). the UK more than 5 years (median = 11.0, IQR = 9.0–11.0) To further explore sample characteristics in relation and undergraduate students (median = 11.0, IQR = to population characteristics, we examined differences 9.0–12.0) had greater STI/STI-Testing knowledge than between our sample with the university student popula- non-white students (median = 9.0, IQR = 6.0–12.0), stu- tion, using demographic data on ethnicity, age and sex dents who had lived in the UK 0–5 years (median = 9.0, from the University records office, using Chi-square tests. IQR = 7.0–11.0) and postgraduate students (median = Data were assessed for normal distribution using 10.0, IQR = 7.0–12.0), and these differences were found to Shapiro-Wilk test of normality. Where data were not be statistically significant (p <.001). normally distributed, the median and interquartile range (IQR) was reported. Chi-square tests and Mann Whitney U tests examined differences, means ranks were investigated Psychosocial factors surrounding STIs and STI testing when differently shaped distributions of the independent Overall, participant direct and indirect attitudes were variable occurred. Odds Ratios (OR) with associated 95% favourable towards STI testing (Median = 31.0, IQR = confidence intervals (95% CI) were used to measure the 28.0–32.0 and Median = 42.0, IQR = 39.0–46.0 respect- association between two attributes. Logistic regression ively). In terms of the other psychosocial variables, social models were then used to assess which psychosocial fear towards STI testing and perceptions of susceptibility (including knowledge and demographic) factors predicted to an STI were low (Median = 16.0, IQR = 10.0–24.0) past STI testing, sexual risk behaviour and intentions to at- and (Median = 4.0, IQR = 4.0–5.0) respectively. Percep- tend STI testing in the next month. Cronbach’salpha was tion of social pressure (subjective norms) and confidence used to assess the internal consistency of items within each (self-efficacy) to attend an STI test were moderate construct of psychosocial measures, with >.07 taken as ad- (Median = 4.0, IQR = − 15.0–20.0) and (Median = 38.0, equate consistency. Cronbach alpha coefficients were all IQR = 31.0–47.0 15.0) respectively. The median score above 0.7 except for the descriptive norms scale [α = .59]. for descriptive norms towards STI testing was moderate There was poor inter-item correlation between the three (Median = 8.0, IQR = 6.0–9.0). Table 1 includes median question items (r =0.11–0.52) making up this scale and and interquartile ranges for participants’ scores on the little improvement in Cronbach’s alpha with the deletion of psychosocial variables. Martin-Smith et al. BMC Public Health (2018) 18:664 Page 4 of 9 Table 1 Participant characteristics and median and interquartile range scores for each psychosocial variable Demographics Psychosocial variablesMedian (IQR) Overall N(%) Overall Knowledge Susceptibility Subjective norms Descriptive norms Direct Attitudes Indirect attitudes Social fear Self-Efficacy Median (IQR) Age 18–25 999 (77) 22 (20–25) 11.0 (9.0–12.0) 4.0 (4.0–5.0) 5.0 (12.0–22.0) 8.0 (6.0–9.0) 31.0 (28.0–33.0) 42.0 (39.0–46.0) 17.0 (11.0–25.0) 38.0 (31.0–46.0) 25 or more 282 (21) 11.0 (8.0–12.0) 4.0 (4.0–5.0) 0.0 (−20.0–18.5) 7.0 (6.0–9.0) 31.0 (28.0–32.0) 43.0 (38.0–46.0) 15.0 (10.0–22.0) 38.0 (32.0–48.0) Sex Male 401 (31) / 11.0 (8.0–13.0) 4.0 (4.0–5.0) 4.0 (−12.0–19.0) 7.0 (6.0–9.0) 30.0 (27.0–32.0) 42.0 (38.0–45.0 16.0 (10.0–23.0) 38.0 (33.0–48.0) Female 888 (69) 10.0 (9.0–12.0) 4.0 (4.0–5.0) 4.0 (−16.0–22.0) 8.0 (7.0–9.0) 31.0 (29.0–33.0) 43.0 (39.0–46.0) 17.0 (10.0–25.0) 37.0 (31.0–46.0) Ethnicity White 1129 (87) / 11.0 (9.0–12.0) 4.0 (4.0–5.0) 5.0 (−14.0–22.0) 8.0 (7.0–9.0) 31.0 (28.0–32.0) 42.0 (39.0–46.0) 16.0 (10.0–24.0) 38.0 (32.0–47.0) Mixed Multiple 23 (2) 9.0 (6.0–12.0) 4.0 (4.0–5.0) 0.0 (−16.0–14.5) 7.0 (6.0–8.5) 31.0 (27.0–33.0) 43.0 (38.0–47.0) 17.0 (10.0–24.5) 36.0 (28.0–43.0) Asian 73 (6) Black n <5 African 31 (2) Other 30 (2) Years in UK 0–5 456 (35) 19 (3.0–21.0) 9.0 (7.0–11.0) 4.0 (4.0–5.0) 0.0 (− 15.0–20.0) 7.0 (6.0–9.0) 31.0 (29.0–33.0) 43.0 (39.0–47.0) 15.0 (9.5–23.0) 38.0 (31.0–47.0) More than 5 838 (65) 11.0 (9.0–11.0) 4.0 (4.0–6.0) 6.0 (−14.0–22.0) 8.0 (7.0–9.0) 31.0 (28.0–32.0) 42.0 (38.0–45.0) 17.0 (11.0–25.0) 38.0 (32.0–46.0) Year of study Undergraduate 968 (75) / 11.0 (9.0–12.0) 4.0 (4.0–6.0) 5.0 (−13.0–22.0) 8.0 (7.0–9.0) 31.0 (38.0–32.0) 42.0 (39.0–46.0) 17.0 (11.0–24.0) 38.0 (23.0–46.0) Post graduate 325 (25) 10.0 (7.0–12.0) 4.0 (4.0–5.0) 0.0 (−17.0–17.0) 7.0 (6.0–9.0) 31.0 (28.0–33.0) 43.0 (38.0–46.0) 16.0 (10.0–24.0) 36.0 (31.0–47.0) Overall 10.0 (9.0–12.0) 4.0 (4.0–5.0) 4.0 (−15.0–20.0) 8.0 (6.0–9.0) 31.0 (28.0–32.0) 42.0 (39.0–46.0) 16.0 (10.0–24.0) 38.0 (31.0–47.0) Median (IQR) Range of possible scores 0–14 4–20 −40 − +40 3–15 8–35 11–55 8–40 12–60 Martin-Smith et al. BMC Public Health (2018) 18:664 Page 5 of 9 Behaviour Fifty two percent (678) of students who com- Sexual behaviour Table 4 below shows that pleted the survey reported having ever had an STI test, socio-demographic variables had no statistically sig- 20.5% (266) reported having had an STI test in the last nificant effect on high risk sexual behaviour in the six months, 13% (166) indicated an intention to attend past six months, defined as having had unprotected an STI test in the next month and 16% (181) reported (no condom) sex with multiple sexual partners (two or unprotected sex with more than one casual partner in more) in the last six months. Perceived susceptibility last six months. and subjective norms were the only predictors of past risky behaviour. For every one-unit increase in suscep- tibility and subjective norms score, students were 33 Objective 2: Psychosocial factors predicting university and 1% more likely to have engaged in risky behaviour students’ past STI testing behaviours, intentions to attend in the past, respectively. an STI test and sexual risk behaviours Discussion Past STI testing Results of regression analysis showed This study assessed knowledge, psychosocial and demo- that females and students aged 25 or over, postgraduates graphic factors and behaviours surrounding STI testing and students who had been in the UK for more than 5 and explored theoretically-relevant psychosocial predic- years were more likely to have had an STI test in the past. tors of past STI testing, intentions to attend an STI test Similarly knowledge, perceived susceptibility, subjective and high risk sexual behaviour in a student population norms, direct and indirect attitudes and self-efficacy were in Scotland, United Kingdom. all predictors of past STI testing behaviour. High scores Participants had a relatively high level of knowledge of on these variables meant students were more likely to STIs and STI testing and younger students (18–25 years), have had an STI test in the past (Table 2). undergraduate and students who have lived in the UK for over 5 years statistically significantly answered more Intentions to go for an STI test Furthermore, ethnicity, knowledge questions correctly. perceived susceptibility and social norms predicted inten- Approximately half of participants reported ever at- tions to get tested in the next month with white students tending an STI test, similar to the proportion of women being less likely to express an intention to get an STI than reporting having had a chlamydia test in the national those of other ethnicities, and high perceived susceptibility survey [7]. Similar to other studies, women and students and subjective norms meaning students were more likely over 25 years old were more likely to report having been to express intention to get tested (Table 3). tested for STIs [12], confirming that under 25 s may Table 2 Results of logistic regression of past STI testing behaviour (n = 1212) Variable Odds ratio 95% CI p value Demographics Age 18–25 Reference 25 or more 1.522 1.019–2.273 p = .040 Sex Male Reference Female 2.134 1.599–2.847 p < .001 Ethnicity Non White Reference White 1.107 0.718–1.796 p = .645 Number of years in UK 0–5 Reference More than 5 0.706 0.521–0.957 p = .025 Year of study Undergraduate Reference Post graduate 1.551 1.053–2.285 p = .026 Psychosocial Knowledge 1.254 1.185–1.326 p < .001 Susceptibility 1.076 1.022–1.134 p = .006 Subjective norms 1.014 1.008–1.020 p < .001 Direct attitudes 1.037 1.000–1.075 p = .048 Indirect attitudes 1.063 1.030–1.097 p < .001 Social Fear 1.000 0.982–1.018 p = .972 Self-Efficacy 1.042 1.027–1.057 p < .001 Intention 1.027 0.667–1.581 P = .901 Martin-Smith et al. BMC Public Health (2018) 18:664 Page 6 of 9 Table 3 Results of logistic regression of intentions to have an STI test in the next month (n = 1212) Variable Odds ratio 95% CI p value Demographics Age 18–25 Reference 25 or more 1.446 0.825–2.536 p = .198 Gender Male Reference Female 0.889 0.590–1.340 p = .575 Ethnicity Non White Reference White 0.425 0.246–0.735 p = .002 Number of years in UK 0–5 Reference More than 5 0.913 0.588–1.417 p = .685 Year of study Undergraduate Reference Post graduate 0.637 0.355–1.141 p = .129 Psychosocial Knowledge 1.005 0.927–1.090 p = .901 Susceptibility 1.236 1.174–1.300 p < .001 Subjective norms 1.024 1.015–1.034 p < .001 Direct attitudes 1.052 0.990–1.118 p = .100 Indirect attitudes 1.030 0.985–1.078 p = .194 Social Fear 1.002 0.976–1.030 p = .869 Self-Efficacy 1.007 0.987–1.028 p = .484 Past STI testing 1.078 0.696–1.670 p = .735 indeed be a ‘high-risk’ group. Women over 25 in particu- Our study showed that knowledge was also a predictor lar may generally have more opportunity for STI testing of past STI testing behaviour. Similar findings have been given cervical screening and other contact with health reported by some studies [26, 27]. In contrast to one care providers for reproductive health issues. Postgradu- study in Australia [12] that reported no link between ates and students who had lived in the UK for more than knowledge of STI and risk behaviour. A growing consen- 5 years were also more likely to have had an STI test. sus suggests that increasing knowledge is necessary but Table 4 Results of logistic regression of sexual risk behaviour i.e. Unprotected (no condom) and multiple sexual partners (2 or more) in the last 6 months (n = 1104) Variable Odds ratio 95% CI p value Demographics Age 18–25 Reference 25 or more 0.656 0.355–1.212 p = .178 Sex Male Reference Female 0.854 0.574–1.269 p = .434 Ethnicity Non White Reference White 0.579 0.324–1.034 p = .065 Number of years in UK 0–5 Reference More than 5 1.243 0.801–1.930 p = .333 Year of study Undergraduate Reference Post graduate 0.591 0.325–1.073 p = .084 Psychosocial Knowledge 1.044 0.965–1.130 p = .284 Susceptibility 1.331 1.258–1.408 p < .001 Subjective norms 1.011 1.002–1.019 p = .018 Direct attitudes 1.001 0.950–1.054 p = .974 Indirect attitudes 1.009 0.966–1.054 p = .684 Social Fear 1.012 0.987–1.039 p = .348 Self-Efficacy 1.007 0.987–1.028 p = .488 Martin-Smith et al. BMC Public Health (2018) 18:664 Page 7 of 9 not sufficient for behaviour change, given other complex factors to increase uptake of STI testing. Firstly marketing factors that contribute to health-seeking behaviour (e.g. campaigns that deliver health messages have been found self-efficacy, social norms and socio-structural factors) to positively impact on changing health behaviours [33]. [28]. Other less strongly positive associated predictors of Peer-led screening uses peer education to promote posi- STI testing included high perceptions of susceptibility, tive social norms and positive attitudes through modelling high social pressure (subjective norms) to attend STI and normalising [34]. A role-modelling intervention could testing, with favourable direct and indirect attitudes and involve displaying video messages around campuses with high confidence to attend a test. These findings are in- students sharing their experiences of going for an STI test consistent with previous studies, perhaps due to differ- to increase self-efficacy and finally utilising social net- ences in methodology and culture. It emphasises the works within universities by recruiting advocates who complex nature of sexual health behaviours such as STI could spread behaviour change recommendations to their testing cementing the need for diverse initiatives to peers. Furthermore since younger, undergraduate, male tackle this public health problem. students were found to be less likely to have attended test- Few students intended to attend an STI test in the ing, it is feasible that these interventions could focus on next month (13%). Similar to other studies, intention to this sub group of students to help encourage more young participate in STI testing among students in this popula- people to have an STI test. tion was driven by perceived susceptibility and subjective Overall, this cross-sectional study contributes to the body norms [11–13] and multiple partners [29] however other of evidence on factors that impact STI testing behaviours research [30, 31] identified variables such as perceived and demonstrates the complexity of social and psycho- behavioural control, self-identity, motivation and cues to logical factors that impact on STI testing behaviours; action as important predictors of intentions. This high- further research to validate the findings using a pro- lights the possible need to further explore intentions spective longitudinal study is required. within this population including variables not assessed in the survey. Strengths and limitations A small number of students reported engagement in The current study is the first of its kind in this population sexual risk behaviour in the past (16%). in Scotland, adding to the limited body of evidence in this The finding that high scores of susceptibility for an topic area. It is strengthened by the systematic develop- STI and social pressure to attend an STI test meant ment of the survey allowing for a wide range of factors to students were more likely to have engaged in past risky be assessed including demographic, behavioural and psy- behaviour is important. It suggests students accurately chosocial factors regarding STI testing. Moreover this judged themselves to be susceptible, whilst feeling so- study attracted a relatively large sample size comparing cial pressure to attend an STI test if they’dtaken arisk. favourably with other small-scale cross-sectional studies. In comparison previous reviews, explored determinants However there are several limitations, not least that the of sexual risk behaviour, but with inconsistent results. Some cross-sectional design allows only for statistically signifi- identified attitudes, behavioural intentions and behavioural cant associations between behaviour and their potential skills as correlates of sexual behaviours [32]. The ma- determinants. Cross-sectional surveys use self-reports of jority of this research was based on correlation data behaviour, risking recall and reporting bias. Participation from cross-sectional studies which is limited as tempor- bias may also have occurred if some people may be more ality is unable to be established. In light of the above, willing than others to participate in this sensitive topic, current theoretical models of sexual risk behaviour war- and given the online nature of the survey although most if rant further investigation and possible adaptation. not all students would be likely to be able to access a Since a range of psychosocial and demographic factors computer. Like many other surveys, males aged 18–25 were associated with STI testing, sexual health promo- were under-represented, which could affect validity and tion interventions could benefit from targeting specific generalizability of the findings. Ceiling and floor effects student groups and by addressing relevant psychosocial occurred when measuring some of the psychosocial factors. Some recommendations that interventions may variables, limiting the range of data reported leading to address in their design are as follows 1) promote and non-normally distributed data. Fortunately, the analyt- strengthen positive norms around testing to build on ical test used in this study did not require normally dis- health promotion, 2) address young people’s perceptions tributed data,and as thesamplesizeinthisstudy was of personal risk of contracting an STI, 3) promote and fairly large the negative effect of this response bias is strengthen positive attitudes towards STI testing, 4) in- reduced. The 10% response rate was larger than the 7% crease confidence to attend STI testing. There are several reported in another university-based sexual health practical intervention ideas based on previous research study [35]: other comparable online sexual health ques- that could be applied to focus on these key psychosocial tionnaire studies have not tended to report response Martin-Smith et al. BMC Public Health (2018) 18:664 Page 8 of 9 rates and yield smaller overall sample sizes [13, 36]. Author’s contributions HMS was involved in the conception and design of the work data collection, Our response rate was naturally smaller than the more data analysis and interpretation, drafting the manuscript, revising the representative UK-wide national survey The National manuscript and final approval of the version to be published. EB and EO Survey of Sexual Attitudes and Lifestyles [7], who are supervised the conception and design of the work, data analysis and interpretation, critical revision of the manuscript and final approval of the resourced to visit potential participants in their home version to be published. All authors read and approved the final manuscript. and offer monetary incentives for participation. We were not able to assess the predictive effect of descrip- Ethics and consent to participate Ethical approval for the study was granted by the College Ethics Review tive norms, despite this being a potentially important Board at the University of Aberdeen (ethical approval number: CERB/2015/ influence on young people’s behaviour [17]asinternal 11/1235). Consent to participate was obtained at the beginning of the consistency was poor with low inter-item correlation. Fur- online survey, participants read a description of the study before clicking a button to indicate their consent to participate. ther exploratory work would be useful to better understand which are the key referent groups for university stu- Competing interests dents, if descriptive norms vary substantially. Never- The authors declare that they have no competing interests. theless, this study adds to our understanding of several theory-based psychological factors associated with Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in high-risk behaviours and STI testing in this important published maps and institutional affiliations. student population: further replication on a national scalewould nowbeuseful. Author details 1 2 NHS Grampian, Public Health Directorate, Aberdeen, UK. Division of Medical Education, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK. Conclusions This study found several demographic and psychosocial Received: 17 November 2017 Accepted: 23 May 2018 factors influencing STI testing behaviour, high-risk sexual behaviour and future intentions towards STI testing. Per- References ceptions of risks and social pressure are important factors 1. 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BMC Public HealthSpringer Journals

Published: May 29, 2018

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