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Exploring College Students' Sexual and Reproductive Health Literacy

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Title: Exploring College Students' Sexual and Reproductive Health Literacy
Language: English
Authors: Vamos, Cheryl A. (ORCID 0000-0003-0227-514X), Thompson, Erika L. (ORCID 0000-0002-7115-0001), Logan, Rachel G. (ORCID 0000-0001-7686-5754), Griner, Stacey B. (ORCID 0000-0002-2774-5841), Perrin, Karen M., Merrell, Laura K. (ORCID 0000-0003-0226-6454), Daley, Ellen M. (ORCID 0000-0003-3020-295X)
Source: Journal of American College Health. 2020 68(1):79-88.
Availability: Taylor & Francis. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
Peer Reviewed: Y
Page Count: 10
Publication Date: 2020
Document Type: Journal Articles
Reports - Research
Education Level: Higher Education
Postsecondary Education
Descriptors: College Students, Literacy, Sexuality, Health Behavior, Grounded Theory, Contraception, Student Attitudes, Patients, Intervention, Health Services, Prevention, Sexually Transmitted Diseases, Information Sources, Barriers, Language Usage, Life Style, Correlation, Trust (Psychology), Access to Information, Visual Aids, Symptoms (Individual Disorders), Peer Relationship, Information Technology, Pregnancy, Student Characteristics
Geographic Terms: Florida
DOI: 10.1080/07448481.2018.1515757
ISSN: 0744-8481
Abstract: Objective: To assess college students' sexual and reproductive health (SRH) literacy experiences, specific to contraception use and STI prevention. Participants: In Spring 2015, participants (n = 43) from a large institution participated in six focus groups (two male and four females groups). Methods: Focus groups were guided by the health literacy domains (access; understand; appraise; apply); data were analyzed in MaxQDA using the constant comparative method. Results: The Internet was the most commonly "accessed" source for SRH information. Participants discussed facilitators (eg, use of visuals) and barriers (eg, medical jargon) to "understanding" information; and personal lifestyle, advice from family/friends, symptoms, and sexual partners as "appraisal" factors. Participants "applied" information by communicating with friends/providers and seeking healthcare. However, findings were not linear nor mutually exclusive, representing the interaction of health literacy skills. Conclusion: Findings suggest that a patient-centered intervention capitalizing on technology and trusted individuals (providers/peer educators) may facilitate college students' SRH literacy.
Abstractor: As Provided
Entry Date: 2020
Accession Number: EJ1239714
Database: ERIC
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  Value: <anid>AN0141151497;acl01jan.20;2020Jan13.03:44;v2.2.500</anid> <title id="AN0141151497-1">Exploring college students' sexual and reproductive health literacy </title> <p>Objective: To assess college students' sexual and reproductive health (SRH) literacy experiences, specific to contraception use and STI prevention. Participants: In Spring 2015, participants (n = 43) from a large institution participated in six focus groups (two male and four females groups). Methods: Focus groups were guided by the health literacy domains (access; understand; appraise; apply); data were analyzed in MaxQDA using the constant comparative method. Results: The Internet was the most commonly accessed source for SRH information. Participants discussed facilitators (eg, use of visuals) and barriers (eg, medical jargon) to understanding information; and personal lifestyle, advice from family/friends, symptoms, and sexual partners as appraisal factors. Participants applied information by communicating with friends/providers and seeking healthcare. However, findings were not linear nor mutually exclusive, representing the interaction of health literacy skills. Conclusion: Findings suggest that a patient-centered intervention capitalizing on technology and trusted individuals (providers/peer educators) may facilitate college students' SRH literacy.</p> <p>Keywords: Community health; health education; counseling</p> <hd id="AN0141151497-2">Introduction</hd> <p>College students are at a unique risk for adverse sexual and reproductive health outcomes, including unintended pregnancy and sexually transmitted infections (STIs) due to their high rates of risky sexual behavior (eg, inconsistent condom use, multiple partners).[[<reflink idref="bib1" id="ref1">1</reflink>]] Women ages 20–24 have the highest unintended pregnancy rates of any age group at 81 per 1,000 women,[<reflink idref="bib5" id="ref2">5</reflink>] and the Centers for Disease Control and Prevention (CDC) reports that between 2001 and 2006, the proportion of pregnancies that were unintended increased from 59 to 64% among women 20–24 years.[<reflink idref="bib6" id="ref3">6</reflink>] Long-term consequences associated with young adult pregnancy include decreased probability of completing postsecondary education, decreased economic well-being, and increased reliance on public benefits and services.[<reflink idref="bib7" id="ref4">7</reflink>],[<reflink idref="bib8" id="ref5">8</reflink>]</p> <p>Moreover, STIs also occur at higher rates in the college-age population than any other age across the lifespan, with CDC estimates reporting that the 15–24 year old age group contracts about half of all new STIs annually.[<reflink idref="bib9" id="ref6">9</reflink>] Specifically, women 20–24 had the highest rate of reported chlamydia cases for either sex of any age group (3,779 per 100,000) and men 20–24 had the highest rate of reported gonorrhea cases at 616.8 per 100,000, regardless of sex or age group.[<reflink idref="bib9" id="ref7">9</reflink>] STIs have serious long-term health consequences for both men and women and, when left untreated, can lead to infertility, reproductive health concerns, chronic pelvic/abdominal pain, and increased susceptibility to HIV infection.[<reflink idref="bib10" id="ref8">10</reflink>],[<reflink idref="bib11" id="ref9">11</reflink>] Moreover, the CDC highlighted women in their 2016 STD Surveillance Report, making note of women's increased risk and impacts on maternal and fetal outcomes.[<reflink idref="bib9" id="ref10">9</reflink>]</p> <p>The lack of knowledge and skills required to engage in preventative health behaviors related to sexual health can significantly contribute to a cascade of negative future health outcomes.[<reflink idref="bib4" id="ref11">4</reflink>],[<reflink idref="bib7" id="ref12">7</reflink>] This knowledge and skill is part of a person's health literacy. Health literacy is defined as the ability to <emph>access, understand, appraise, and apply</emph> health information in order to make an informed health decision.[<reflink idref="bib12" id="ref13">12</reflink>] These skills enable a person to make informed choices, reduce health risks, increase preventive and wellness behavior, and assist in navigating the health system. Adolescence and young adulthood is an opportune period to improve sexual and reproductive health literacy skills as this population develops cognitive abilities, advances skills to process information, acquires more responsibilities for their own health, and cultivates new health behaviors and habits.[[<reflink idref="bib13" id="ref14">13</reflink>]] Health literacy can improve short- and long-term health outcomes and young adults who are health literate have better outcomes across a range of health issues.[<reflink idref="bib13" id="ref15">13</reflink>],[<reflink idref="bib15" id="ref16">15</reflink>]</p> <p>The consequences of low health literacy can result in poor sexual health decisions and delays or difficulties in seeking care.[<reflink idref="bib16" id="ref17">16</reflink>] Adolescents and young adults generally have good health, and thus may not fully understand the importance of preventive healthcare visits, particularly after the onset of sexual activity.[<reflink idref="bib17" id="ref18">17</reflink>] Health literacy would afford the understanding and competence to seek health services in the absence of symptoms.[<reflink idref="bib17" id="ref19">17</reflink>] One study found that adolescent women who participated in risky sexual behavior believed they were not susceptible to acquiring an STI, influencing their intentions to seek preventive health services.[<reflink idref="bib18" id="ref20">18</reflink>] Additionally, low health literacy may affect one's ability to comprehend written information on STIs.[<reflink idref="bib19" id="ref21">19</reflink>] Furthermore, it has been found that adolescents and young adults with high health literacy were more likely to seek preventive services such as HIV testing.[[<reflink idref="bib20" id="ref22">20</reflink>]] Health literacy also has pronounced implications for unintended pregnancies with women with lower health literacy being more likely to have unplanned pregnancies.[<reflink idref="bib23" id="ref23">23</reflink>] With high rates of sexual activity among this age group, it is paramount that adolescents and young adults have adequate health literacy to facilitate sexual health decision-making.</p> <p>College students often rely on misinformation about sexual activity and contraception use.[<reflink idref="bib10" id="ref24">10</reflink>] These myths, alongside the higher rates of negative outcomes associated with sexual activity, may stem from barriers to accessing sexual and reproductive healthcare including a lack of resources for information and service providers.[<reflink idref="bib11" id="ref25">11</reflink>] Subsequently, the Healthy Campus 2020 initiative, developed by the American College Health Association, has specific objectives targeting this need: (<reflink idref="bib1" id="ref26">1</reflink>) increase information about pregnancy and STI prevention distributed by institutions; (<reflink idref="bib2" id="ref27">2</reflink>) increase clinical screening tests for chlamydia and HIV; and (<reflink idref="bib3" id="ref28">3</reflink>) decrease unintended pregnancies and positive chlamydia tests.[<reflink idref="bib24" id="ref29">24</reflink>]</p> <p>While previous literature has found that low health literacy is correlated with poor sexual health decision-making among college students, little research has looked qualitatively at the factors influencing individuals' experiences across health literacy domains when considering sexual health prevention strategies. Additionally, this study extends current research in acknowledging that knowledge alone is not sufficient, as a multidimensional application of health literacy is needed to account for the complex set of skills needed for informed decision making.</p> <p>In order to develop innovative, patient-centered interventions to promote sexual and reproductive health during this critical period in the life course, a greater understanding of college students' perceived barriers and facilitators to sexual and reproductive health literacy is needed. Therefore, the purpose of this study was to assess college students' self-perceived sexual and reproductive health literacy, specifically focused on contraception use and STI prevention.</p> <hd id="AN0141151497-3">Methods</hd> <p></p> <hd id="AN0141151497-4">Participants</hd> <p>This paper presents methods and data as a subset of a larger mixed-methods study aimed at developing and evaluating a patient-centered health literacy intervention. The target population for this study was students at a large, southeastern university in the US. Focus groups were chosen to encourage in-depth discussion and elicit a peer exchange regarding health literacy experiences.[<reflink idref="bib25" id="ref30">25</reflink>] Based on the sample size and appropriate focus group sizes,[<reflink idref="bib26" id="ref31">26</reflink>] there were two focus groups with males and four focus groups with females. Females were oversampled because community partners identified this group as a priority population. In addition, we aimed to have a diverse student representation thus recruited students from various disciplines, academic year (eg, undergraduate/graduate) student status (eg, domestic/international), and racial, ethnic, religious, and sociocultural backgrounds. The inclusion criteria were (<reflink idref="bib1" id="ref32">1</reflink>) 18 years and older; (<reflink idref="bib2" id="ref33">2</reflink>) current student; and (<reflink idref="bib3" id="ref34">3</reflink>) able to read/speak English.</p> <hd id="AN0141151497-5">Recruitment</hd> <p>To guide study activities, a Student Advisory Group was formed and members' connections on and around campus were leveraged to augment recruitment efforts. An undergraduate researcher assisted in online recruitment efforts by posting on social media sites, and emailing listservs, student organizations, and course instructors. Flyers were posted on bulletin boards in the student center, in various colleges and departments on campus, and given to students at a weekly social "market" event outside the student center. Interested students were directed to a brief online Qualtrics survey to determine eligibility. All focus groups took place at an on-campus facility to ease transportation burden.</p> <hd id="AN0141151497-6">Procedure</hd> <p>This study was approved by the University of South Florida's Institutional Review Board and all participants provided informed consent. Prior to the focus group, participants completed a demographic survey and received a $25 gift card. Each focus group was moderated by the primary investigator, trained in qualitative research. The groups were audio-recorded and lasted approximately 90 min.</p> <hd id="AN0141151497-7">Instruments</hd> <p>The focus group guide used the European Health Literacy Project's (HLS-EU) definition of health literacy, which includes four domains that can influence sexual and reproductive health skills and decision-making: (<reflink idref="bib1" id="ref35">1</reflink>) access; (<reflink idref="bib2" id="ref36">2</reflink>) understand; (<reflink idref="bib3" id="ref37">3</reflink>) appraise; and (<reflink idref="bib4" id="ref38">4</reflink>) apply.[<reflink idref="bib12" id="ref39">12</reflink>] The focus group guide also contained vignettes specific to contraceptive and STI prevention to help elicit participant experiences. For example, one of the vignettes presented the following scenario: "<emph>A female student has started a new sexual relationship with a male partner and is thinking about starting a method of birth control to prevent pregnancy</emph>." Participants were then asked a series of questions to guide the discussion about health literacy skills and experiences that this individual may encounter. Participants were also asked to reflect on their perception of the student experience of obtaining sexual and reproductive health services in general and from the on-campus clinic (Table 1).</p> <p>Table 1. Focus group guide questions on health literacy</p> <p> <ephtml> <table><thead><tr><td>Health literacy domain</td><td>Definition</td><td>Sample questions</td></tr></thead><tbody valign="top"><tr><td>Access</td><td>Where people find information</td><td>Where do you think she/he would <bold>find information</bold> about pregnancy prevention?</td></tr><tr><td>Understand</td><td>What facilitates comprehension of information</td><td>Once the student found information about pregnancy prevention, what types of things would make it <bold>easy</bold> to understand the information?</td></tr><tr><td>Appraise</td><td>How people evaluate information</td><td>What factors might this student <bold>consider</bold> when <bold>deciding</bold> which information to use?</td></tr><tr><td>Apply</td><td>What people decide to do with information</td><td>Now thinking of the information and resources we just discussed, how would people you know <bold>use</bold> similar information and resources?</td></tr></tbody></table> </ephtml> </p> <hd id="AN0141151497-8">Data analysis</hd> <p>A professional transcriptionist transcribed each focus group verbatim. Research team members, skilled in qualitative data analysis, reviewed results independently in the following steps: (<reflink idref="bib1" id="ref40">1</reflink>) created a coding guide based on health literacy domains; (<reflink idref="bib2" id="ref41">2</reflink>) coded data in MaxQDA,[<reflink idref="bib27" id="ref42">27</reflink>] a qualitative data management and analysis software system using the coding guide and the constant comparative method; (<reflink idref="bib3" id="ref43">3</reflink>) compared codes between two coders, and adjusted how categories/codes were assigned after coming to consensus; and (<reflink idref="bib4" id="ref44">4</reflink>) sorted passages by category and reviewed for recurring themes and diversity in responses. Researchers agreed on themes and statements to be included in the findings. The quality and contribution of data were evaluated through the four domains of trustworthiness: credibility, dependability, confirmability, and transferability.[<reflink idref="bib25" id="ref45">25</reflink>]</p> <hd id="AN0141151497-9">Results</hd> <p>Across the six focus groups, a total of 43 students participated (Table 2). Four focus groups included females (<emph>n</emph> = 30; 70%) and two focus groups included males (<emph>n</emph> = 13; 30%). Most students were undergraduate (42%), but also masters-level (21%), doctoral candidates (2%), and professional degrees (21%). Most participants identified as Caucasian (58%) and heterosexual (72%). A smaller proportion identified as an international student (9%) or a student with a disability (5%). The mean age of participants was 22.6 years (SD =3.8 years). Major themes that emerged from the data with regards to pregnancy prevention (ie, contraception use) and STI prevention are described below by health literacy domain.</p> <p>Table 2. Participant demographics of students in focus groups (<emph>n</emph> = 43)</p> <p> <ephtml> <table><thead><tr><td>Characteristic</td><td><italic>N</italic></td><td>%</td></tr></thead><tbody valign="top"><tr><td><bold>Gender</bold></td><td /><td /></tr><tr><td>Female</td><td char=".">30</td><td char=".">70</td></tr><tr><td>Male</td><td char=".">13</td><td char=".">30</td></tr><tr><td>International student status</td><td char=".">4</td><td char=".">9</td></tr><tr><td><bold>Degree level</bold><xref ref-type="table-fn" rid="tfn1">a</xref></td><td /><td /></tr><tr><td>Undergraduate</td><td char=".">18</td><td char=".">42</td></tr><tr><td>Masters</td><td char=".">9</td><td char=".">21</td></tr><tr><td>Professional</td><td char=".">9</td><td char=".">21</td></tr><tr><td>Doctorate</td><td char=".">1</td><td char=".">2</td></tr><tr><td><bold>Race/ethnicity</bold></td><td /><td /></tr><tr><td>Caucasian</td><td char=".">25</td><td char=".">58</td></tr><tr><td>Asian</td><td char=".">6</td><td char=".">14</td></tr><tr><td>African American</td><td char=".">6</td><td char=".">14</td></tr><tr><td>Hispanic/Latino</td><td char=".">6</td><td char=".">14</td></tr><tr><td><bold>Sexual orientation</bold><xref ref-type="table-fn" rid="tfn1">a</xref></td><td /><td /></tr><tr><td>Heterosexual</td><td char=".">31</td><td char=".">72</td></tr><tr><td>Bisexual</td><td char=".">4</td><td char=".">9</td></tr><tr><td>Gay/Lesbian</td><td char=".">3</td><td char=".">7</td></tr><tr><td>Student with a disability</td><td char=".">2</td><td char=".">5</td></tr><tr><td>Age (mean, st dev)</td><td char=".">22.6</td><td char=".">3.8</td></tr></tbody></table> </ephtml> </p> <p>1 Total may not equal 100% due to nonresponse from participants.</p> <hd id="AN0141151497-10">Access</hd> <p> <bold>Access: contraception information.</bold> When asked how they found information about contraception and preventing pregnancy, participants cited a variety of sources including: Internet, friends, family, student health clinics, university staff such as residential advisors and orientation staff, university organizations, and other health care providers. The source that was most commonly cited (and the first source to be mentioned) was the Internet. Participants utilized the Internet because of its availability, particularly its capability with smartphones, and noted that the Internet offered an increased level of privacy compared to other information sources. They also said it allowed them to research information to decide if a healthcare appointment is needed and facilitated access to information while waiting for a healthcare appointment. Despite these benefits, most participants realized that the credibility of information found on the Internet could not always be guaranteed, and that using reliable sources, such as Planned Parenthood, Bedsider, WebMD, and Mayo Clinic, were favorable.</p> <p>The internet you don't have to really talk to anyone so it's like [...], all the privacy, I guess, you need. You can ask as many questions as you want, you just don't know how credible the answers are gonna be. (FG 1, Female 5) Female 5)</p> <p>Friends, and to a lesser extent family, were also used for information about contraception because of their personal experience. Participants used friends and family for their knowledge on types of contraception and associated side effects. However, some participants noted that friends and family members may have misinformation, while others hesitated to talk to family members (eg, mothers) out of fear that they may be judged.</p> <p>If I should go to my friend, I would understand it clearer because she has experienced it before. So, I could relate to it because I will be free with her to express that. And I think she's more mature. (FG 3, Female 13)</p> <p>Also, family. If you're really close with your family – you can talk to them about what they've used in the past – like, siblings and parents, if you want to. (FG 1, Female 2)</p> <p>Contraception information sources that participants reported using to a lesser degree were campus health clinics, residential advisors and orientation staff, university organizations (eg, campus ministry and Greek life), and off-campus healthcare providers. Participants noted that they did not use healthcare providers often for information because they felt that they had limited time in an appointment setting (Table 3).</p> <p>Table 3. Summary of themes by health literacy domain and sexual and reproductive health behavior</p> <p> <ephtml> <table><thead><tr><td /><td>Access</td><td>Understand</td><td>Appraise</td><td>Apply</td></tr></thead><tbody valign="top"><tr><td><bold>Contraception</bold></td><td>Internet, friends, college campus, healthcare providers</td><td>Friend's personal experiences Diagrams, decision-aids, and infographics Providers' medical jargon as barrier; clear and simple language desired</td><td>Family/religion Match with lifestyle Advice from family and friends Partners</td><td>Communicating with friends Making appointments with healthcare providers</td></tr><tr><td><bold>STI prevention</bold></td><td>Internet Only providers if there was a symptom</td><td>Selected use of STI statistics Select use of STI visuals Providers' medical jargon as barrier; clear and simple language desired</td><td>Symptoms of STI Partners</td><td>Seeking STI testing Discussing STI status with partners</td></tr></tbody></table> </ephtml> </p> <p>I would feel like I'm taking time away from their schedule and they might not appreciate me coming in just to ask about that. (FG 6, Male 1)</p> <p>I'd be more inclined to bring it up if I was there for another purpose and just say, "Hey, I actually have some questions," but I'm not going to make an appointment just to sit and ask questions and wait forever in a doctor's office and potentially not get any answers that I wanted. (FG 6, Male 2)</p> <p> <bold>Access: STI information.</bold> Similar to contraception information sources, the most common source of STI information was the Internet. The Internet was used as a confidential source of information about symptoms of STIs, which informed whether they would further seek healthcare services. When prompted, participants noted that they would seek information from their romantic partners, but only if they were comfortable with them.</p> <p>I think you would have to be really comfortable, especially if they're just starting to date and that might not be a comfortable conversation. (FG 6, Male 1)</p> <hd id="AN0141151497-11">Understand</hd> <p> <bold>Understand: contraception information</bold>. Participants discussed information characteristics that facilitated their understanding of pregnancy and STI prevention. For pregnancy prevention, hearing a friend's personal experiences using contraception helped them understand their options. In addition, participants explained how the use of diagrams, decision-aids, and infographics helped them understand the efficacy and side effects of different contraceptives.</p> <p>A chart format is helpful for that kind of thing, especially for birth control because there's so many different types it can kind of be overwhelming. So you can...have the type and then maybe like the pros and the cons of each type or like what kind of lifestyle fits in best with this, like oh, if you don't think you'll remember to take a pill every day maybe you should get a patch, or something like that. (FG 2, Female 1)</p> <p> <bold>Understand: STI information</bold>. With regards to STI information, participants reported various elements that made it easier or harder for them to understand. Some participants felt that statistics about incidence and prevalence of STIs helped to promote better risk perception, while others found them confusing and unnecessary. For some, visuals of the symptoms of STIs were alarming in their graphic nature, but necessary to help them understand signs and symptoms; whereas other participants did not connect with these images and found them vulgar.</p> <p>When I see videos in the doctor's office – I don't really look at them. I'd rather experience it than see it on screen 'cause it's completely – it's a different thing. Even though it's the same room, same hallway, I just don't connect it. It has to be simple, precise. Maybe like a sentence. (FG 1, Female 4)</p> <p>Finally, the issue that was most frequently discussed as impacting participants' understanding of both contraception and STI information was the jargon used by medical professionals. Participants strongly desired for healthcare providers to speak in plain language.</p> <p>The language. Like if it's a lot of medical terms that have really long words that I can't even pronounce then I'm going to be like, "I don't know what this is. I feel like I'm going to die." (FG 3, Female 5).</p> <p>Also if you're going to a provider, if the provider uses day to day words rather than very specialized jargon it becomes a lot more easier and also not intimidating as the person receiving health service. (FG 4, Female 9)</p> <hd id="AN0141151497-12">Appraise</hd> <p> <bold>Appraise: contraception information</bold>. Participants considered numerous factors that play a role in decision-making for pregnancy prevention. The most commonly described factors were related to: religion and/or culture, personal lifestyle, and advice of friends and family.</p> <p>Participants discussed how culture and religion could influence how students consider and judge the information that is presented to them. For example, participants felt that premarital sex was strongly discouraged in many cultures and that even the use of medically indicated contraceptives would be viewed as hypocritical. Participants also felt that if someone from a strict religious background were to engage in nonmarital sex, they may not use contraceptives or condoms to not 'double sin,' putting themselves at risk for poor health.</p> <p>I feel like they're telling you to be abstinent; it isn't really that smart? Because you could get pregnant if you do it once because you don't know about the other methods. I don't know if that makes sense. (FG 2, Female 3)</p> <p>Lifestyle was also an important consideration for whether information about preventing pregnancy was applicable to them. Specifically, participants recognized that it was important to match the type of contraceptive to one's daily routine. For instance, some contraception may need to be taken daily, compared to a long-acting reversible contraceptive (LARC) method, such as an intrauterine device (IUD) or implant, which requires a one-time provider insertion or removal visit. Participants explained how college students often have many competing demands and little consistency within their daily schedules, making the responsibility of remembering to take a daily oral contraceptive challenging. Another consideration discussed was whether a person wanted to use contraception to suppress their menstrual cycle.</p> <p>If we go back to evaluating not just cost, but also like if it's birth control, how easy or hard it is to take – if it's something...where I have to take it every day at the same time, that might be harder if you're a college student who is possibly working or has classes at different times every day. (FG 4, Female 6)</p> <p>Participants also used friends and family as a sounding board to appraise if a contraceptive method was appropriate and to understand others' experiences using different methods. However, some participants noted that this could be somewhat limiting if family and friends were only familiar with a few contraception options. Further, once a decision is made, some participants used their friends and family to reinforce their decision.</p> <p>You analyze yourself and then you talk to people once you kind of have your decision made. You talk to friends and family and see – and solidify your decision. (FG 3, Female 8)</p> <p>Other themes included how participants appraised information related to their romantic/sexual partner and the costs or insurance related to obtaining contraception. When prompted to consider whether partners influenced the use of contraceptive information, participants noted that the length or seriousness of a relationship was key in their decision-making. Participants also discussed how contraception may be embarrassing or difficult to discuss with a partner, even if they were in a close, open relationship, and ultimately the decision was their own.</p> <p>Even if we do have a close relationship it's something where I believe that's a personal decision for me because he's not taking the pills, he's not getting the shot, the patch, whatever it is. So, I think it's a very independent decision. (FG 3, Female 12)</p> <p> <bold>Appraise: STI information</bold>. Regarding evaluating information about STIs, only two themes emerged regarding participants' appraisal process of how the information might apply to them: sexual or romantic partners and symptoms. Similar to contraception, participants felt that the length and seriousness of their relationship was an important consideration. Additionally, participants decided if information about STIs applied to them depending upon whether the symptoms they were experiencing matched with those described in the information source. Both the number and severity of the symptoms (or the possible outcomes) had the potential to prompt further action.</p> <p>A lot of people fail to recognize they have something like syphilis because it doesn't hurt and it goes away. They still have it. They're just not in an active outbreak, so they're like, "Oh, out of sight, out of mind. I'm good. Let's move on." (FG 6, Male 6)</p> <hd id="AN0141151497-13">Apply</hd> <p> <bold>Apply: contraception information.</bold> Participants primarily applied information that they found, understood, and was applicable to them in two ways: to communicate with (<reflink idref="bib1" id="ref46">1</reflink>) friends or with (<reflink idref="bib2" id="ref47">2</reflink>) healthcare providers. For instance, participants often shared information with friends and other peers for the specific purpose of sharing new and interesting information.</p> <p>After receiving and thinking about the information, participants made appointments with a healthcare provider to discuss contraceptive options. Further, they recognized the importance of being honest about past and current sexual and reproductive health behaviors, and other medications or health concerns that may impact treatment and medical decision-making.</p> <p>Being open with any other medical providers you may have about what you're actively doing or not doing because you know you could get sick with something else and the treatment they may provide may counteract whatever birth control method you're using. (FG 4, Female 5)</p> <p> <bold>Apply: STI information.</bold> Participants reported that they often discussed STI information and sought out treatment with healthcare providers. Although most participants noted the need to seek testing or possible treatment, some believed that they did not need to communicate with a healthcare provider about prevention as they felt that knowing how to use a condom was enough to prevent STI infection.</p> <p>If I was concerned about getting STIs, I feel like go buy condoms, that's the way to do it so I don't think I need to google information about that. And I don't want to go to a healthcare provider to learn about condoms because I already know about them. (FG 3, Female 4)</p> <p>Participants also reflected on the prospect of discussing STIs with their romantic and sexual partners. As reported above in the appraise domain, discussion with partners, though not common, was dependent on the type of relationship they were in and whether it was casual or long-term in nature. Some participants noted that they would ask for evidence of STI testing, whereas most of the other participants expressed that they would feel embarrassed to do so or did not want their partners to think that they were judging them.</p> <p>It's very hard to ask those questions without potentially seeming like you're passing judgment. (FG 6, Male 2)</p> <p>To circumvent this, several participants discussed how they would delicately ask about their partner's previous sexual history, condom use, and fidelity.</p> <p>I think it's more history that's discussed, so indirectly yes, but they focus more on the history rather than specifically saying, "Have you ever had an STI?" (FG 6, Male 1)</p> <hd id="AN0141151497-14">Discussion</hd> <p>This study aimed to explore college students' sexual and reproductive health literacy. Findings revealed rich thoughts and experiences specific to accessing, understanding, appraising, and applying contraception and STI information among a sample of students attending a large metropolitan university. Overwhelmingly, the most common source of sexual and reproductive health information was the Internet. While participants reported that friends and healthcare providers were sources of information for contraception, STI information-seeking had less emphasis on social networks. Previous research demonstrated that the Internet can be an accurate source for sexual health information, but young adults need guidance on best approaches for searching this type of content.[<reflink idref="bib28" id="ref48">28</reflink>]</p> <p>Regarding understanding sexual health information, participants reported wanting select statistics to understand the epidemiology of these outcomes (eg, unintended pregnancy; STIs) as well as visual referents to aid their comprehension. Specifically, due to the range of contraceptive methods available, decision-aids and diagrams can be useful when considering a method.[<reflink idref="bib29" id="ref49">29</reflink>] Participants also identified providers' use of medical jargon as a barrier to their understanding, and thus providers are recommended to utilize "universal health literacy precautions" as a model to clearly communicate in a patient-centered manner with every individual.[<reflink idref="bib30" id="ref50">30</reflink>]</p> <p>Appraisal skills are critical for making informed decisions regarding STI and pregnancy prevention.[<reflink idref="bib31" id="ref51">31</reflink>] This is especially true in light of the fact that the Internet and peers, where misinformation is often encountered, are common sources of information. Participants reported a range of factors that influenced how they processed this information, including personal lifestyle, interactions with family and friends, and presence of symptoms as cues to action. While social networks can be valuable for learning about contraceptive methods, negative information (eg, side effects) is more likely to be discussed than positive attributes.[<reflink idref="bib29" id="ref52">29</reflink>] For both pregnancy and STI prevention, romantic and sexual partners were part of this appraisal process, since their partner's opinions or the type of relationship could influence subsequent decision-making.[<reflink idref="bib32" id="ref53">32</reflink>]</p> <p>The last domain of the health literacy process involves application, such as communicating or using the information gathered. When asked about what would happen after they or the target population (college students) accessed and considered information/services that they encountered, participants focused on "communication" as the major behavioral outcome. Participants reported that they would discuss their options with their friends or healthcare providers. However, only when considering STI prevention (and not pregnancy prevention), did participants state actual healthcare seeking behaviors. This is a critical finding for the health literacy process since communication with a healthcare provider can set the stage for shared decision-making regarding these topics.[<reflink idref="bib29" id="ref54">29</reflink>] Providers can share patient-centered information based on patients' sexual behaviors, values, and needs if a good rapport is established.[<reflink idref="bib33" id="ref55">33</reflink>] Furthermore, since most participants reported receiving information from the Internet or friend and family, providers can address inaccurate information gathered from those sources. Fostering access to and open patient–provider communication in a nonjudgmental manner is critical to encourage college students to discuss their sexual and reproductive health needs and concerns.</p> <p>Findings highlight that college students may have different health literacy strengths, and these can vary by topic (eg, pregnancy vs STI prevention). In this study, participants focused on the testing and treating of STIs, rather than primary prevention through condom use. Students downplayed the importance of STI prevention and reported seeking care only when they thought they had an STI or were experiencing symptoms, thus indicating that they made health decisions based on this perceived susceptibility and severity. Therefore, students could benefit from more information or skill-building around evaluating their risk for negative sexual and reproductive health outcomes to inform decision-making. Future efforts should target college students' risk perception of STIs, highlight the importance of primary (eg, monogamy, condom use) and secondary (eg, screening) prevention behaviors prior to experiencing a symptom, and provide education on the long-term consequences of STIs. On the other hand, since unintended pregnancies can lead to a life commitment to raising a child, students may be more concerned with preventing this outcome, and as a result be more active in executing health literacy skills. It may also be that given college students' stage of life and focus on receiving a degree, avoiding an unintended pregnancy becomes more critical.[<reflink idref="bib32" id="ref56">32</reflink>]</p> <p>These findings provide insight into college students' sexual and reproductive health literacy and serve as valuable formative research to guide future intervention development. Although the Internet was identified as the most common source for information, family, friends, and healthcare providers were also often discussed as playing a role, and thus a hybrid intervention combining technology and important referents could be promising. Previous research demonstrated that a peer educator sexual health intervention improved college students' sexual health knowledge compared to only visiting health-related websites.[<reflink idref="bib34" id="ref57">34</reflink>] In addition, future interventions should not only deliver medically accurate information that is specific to students' health concerns and needs but also foster critical skill development in evaluating and communicating these issues to sexual partners and healthcare providers. Such development and testing of a hybrid, patient-centered intervention that utilizes technology and in-person communication strategies holds potential in improving college students' sexual and reproductive health literacy. These efforts could assist students in navigating through their sexual and reproductive health-related information, questions, and needs. Future research should also quantitatively examine students' sexual and reproductive health literacy skills, and measure the potential effectiveness of a hybrid, patient-centered intervention.</p> <p>It is important to note that experiences and skills across the health literacy domains are not necessarily linear or mutually exclusive and healthy literacy can be considered both a process and an outcome.[<reflink idref="bib35" id="ref58">35</reflink>] For example, students often discussed the interplay of communicating with friends (apply), searching the Internet for information (access), judging information quality and how it applies to their personal circumstances (appraise) in a cyclical manner.</p> <hd id="AN0141151497-15">Comment</hd> <p></p> <hd id="AN0141151497-16">Limitations</hd> <p>This study should be considered in the context of its limitations and strengths. First, the data comes from a convenience sample of students at one university and may not be generalizable to all students at this institution or other institutions across the US due to the small sample size. Furthermore, we kept this exploratory study open to all college students given the epidemiology of unintended pregnancy and STI rates (eg, women ages 20–24 years have the highest unintended pregnancy rate,[<reflink idref="bib5" id="ref59">5</reflink>] and women and men ages 20–24 years have the highest rates of chlamydia and gonorrhea, respectively[<reflink idref="bib9" id="ref60">9</reflink>]). Nonetheless, diverse individuals across student degree levels (undergraduate vs. graduate) may have different sexual and reproductive health literacy needs and experiences. Thus, even though the mean age was relatively young (22.6 years), this sample does include adults who are older than the traditional undergraduate college population and thus this study sample is not generalizable to college student populations across the US. Moreover, additional research may need to further assess unique populations needs, such as those identifying as a sexual or gender minority. In addition, recruitment bias may be present as only those who were interested or comfortable in discussing sexual and reproductive health information may have agreed to participate. Additionally, although participants received a vignette of a student wanting STI or contraception information to reduce the stigma of individual behaviors in a focus group setting, the responses may not necessarily reflect true individual beliefs or practices for sexual health prevention. Furthermore, some recall bias may have been present given the fluidity of the timeline in which participants may have been reflecting on with regards to their current and previous sexual and reproductive health literacy experiences during the focus group discussions.</p> <p>This study is novel in its recognition that health literacy is more than just knowledge, but a complex system of interacting skills that individuals need to use in a variety of situations including their intimate relationships and the clinical setting. While traditional health literacy studies often consider its use only in the setting of disease management, a public health theoretical framework, as employed by this study, recognizes the multidimensional nature of health literacy across health care, disease prevention, and health promotion contexts, and facilitates the transferability of study findings to other populations.[<reflink idref="bib12" id="ref61">12</reflink>] Examining the complex skills of health literacy in this emerging population is critical for improving sexual health outcomes of adolescents and college students across the life course.</p> <hd id="AN0141151497-17">Conclusion</hd> <p>This study examined college students' sexual and reproductive health literacy with regards to contraception use and STI prevention. Students discussed their experiences in accessing, understanding, appraising, and using information to make a decision that is best for them. Findings suggest that a hybrid intervention that capitalizes on using both technology and informed individuals (peers, providers) to deliver patient-centered information and skills may help to increase college students' sexual and reproductive health decision-making. Fostering health literacy skills among college students not only has the potential to decrease unintended pregnancy and STI rates among this priority population but could also extend to other preventative behaviors impacting health across the life course.</p> <hd id="AN0141151497-18">Acknowledgments</hd> <p>We are extremely grateful for the time, participation, and collaboration provided by University research participants and collaborators.</p> <hd id="AN0141151497-19">Conflict of interest disclosure</hd> <p>The authors have no conflicts of interest to report. 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  Data: Exploring College Students' Sexual and Reproductive Health Literacy
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  Data: <searchLink fieldCode="AR" term="%22Vamos%2C+Cheryl+A%2E%22">Vamos, Cheryl A.</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0003-0227-514X">0000-0003-0227-514X</externalLink>)<br /><searchLink fieldCode="AR" term="%22Thompson%2C+Erika+L%2E%22">Thompson, Erika L.</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0002-7115-0001">0000-0002-7115-0001</externalLink>)<br /><searchLink fieldCode="AR" term="%22Logan%2C+Rachel+G%2E%22">Logan, Rachel G.</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0001-7686-5754">0000-0001-7686-5754</externalLink>)<br /><searchLink fieldCode="AR" term="%22Griner%2C+Stacey+B%2E%22">Griner, Stacey B.</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0002-2774-5841">0000-0002-2774-5841</externalLink>)<br /><searchLink fieldCode="AR" term="%22Perrin%2C+Karen+M%2E%22">Perrin, Karen M.</searchLink><br /><searchLink fieldCode="AR" term="%22Merrell%2C+Laura+K%2E%22">Merrell, Laura K.</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0003-0226-6454">0000-0003-0226-6454</externalLink>)<br /><searchLink fieldCode="AR" term="%22Daley%2C+Ellen+M%2E%22">Daley, Ellen M.</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0003-3020-295X">0000-0003-3020-295X</externalLink>)
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  Data: <searchLink fieldCode="SO" term="%22Journal+of+American+College+Health%22"><i>Journal of American College Health</i></searchLink>. 2020 68(1):79-88.
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  Data: Taylor & Francis. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
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  Data: <searchLink fieldCode="DE" term="%22College+Students%22">College Students</searchLink><br /><searchLink fieldCode="DE" term="%22Literacy%22">Literacy</searchLink><br /><searchLink fieldCode="DE" term="%22Sexuality%22">Sexuality</searchLink><br /><searchLink fieldCode="DE" term="%22Health+Behavior%22">Health Behavior</searchLink><br /><searchLink fieldCode="DE" term="%22Grounded+Theory%22">Grounded Theory</searchLink><br /><searchLink fieldCode="DE" term="%22Contraception%22">Contraception</searchLink><br /><searchLink fieldCode="DE" term="%22Student+Attitudes%22">Student Attitudes</searchLink><br /><searchLink fieldCode="DE" term="%22Patients%22">Patients</searchLink><br /><searchLink fieldCode="DE" term="%22Intervention%22">Intervention</searchLink><br /><searchLink fieldCode="DE" term="%22Health+Services%22">Health Services</searchLink><br /><searchLink fieldCode="DE" term="%22Prevention%22">Prevention</searchLink><br /><searchLink fieldCode="DE" term="%22Sexually+Transmitted+Diseases%22">Sexually Transmitted Diseases</searchLink><br /><searchLink fieldCode="DE" term="%22Information+Sources%22">Information Sources</searchLink><br /><searchLink fieldCode="DE" term="%22Barriers%22">Barriers</searchLink><br /><searchLink fieldCode="DE" term="%22Language+Usage%22">Language Usage</searchLink><br /><searchLink fieldCode="DE" term="%22Life+Style%22">Life Style</searchLink><br /><searchLink fieldCode="DE" term="%22Correlation%22">Correlation</searchLink><br /><searchLink fieldCode="DE" term="%22Trust+%28Psychology%29%22">Trust (Psychology)</searchLink><br /><searchLink fieldCode="DE" term="%22Access+to+Information%22">Access to Information</searchLink><br /><searchLink fieldCode="DE" term="%22Visual+Aids%22">Visual Aids</searchLink><br /><searchLink fieldCode="DE" term="%22Symptoms+%28Individual+Disorders%29%22">Symptoms (Individual Disorders)</searchLink><br /><searchLink fieldCode="DE" term="%22Peer+Relationship%22">Peer Relationship</searchLink><br /><searchLink fieldCode="DE" term="%22Information+Technology%22">Information Technology</searchLink><br /><searchLink fieldCode="DE" term="%22Pregnancy%22">Pregnancy</searchLink><br /><searchLink fieldCode="DE" term="%22Student+Characteristics%22">Student Characteristics</searchLink>
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  Data: <searchLink fieldCode="DE" term="%22Florida%22">Florida</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1080/07448481.2018.1515757
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  Label: ISSN
  Group: ISSN
  Data: 0744-8481
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Objective: To assess college students' sexual and reproductive health (SRH) literacy experiences, specific to contraception use and STI prevention. Participants: In Spring 2015, participants (n = 43) from a large institution participated in six focus groups (two male and four females groups). Methods: Focus groups were guided by the health literacy domains (access; understand; appraise; apply); data were analyzed in MaxQDA using the constant comparative method. Results: The Internet was the most commonly "accessed" source for SRH information. Participants discussed facilitators (eg, use of visuals) and barriers (eg, medical jargon) to "understanding" information; and personal lifestyle, advice from family/friends, symptoms, and sexual partners as "appraisal" factors. Participants "applied" information by communicating with friends/providers and seeking healthcare. However, findings were not linear nor mutually exclusive, representing the interaction of health literacy skills. Conclusion: Findings suggest that a patient-centered intervention capitalizing on technology and trusted individuals (providers/peer educators) may facilitate college students' SRH literacy.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2020
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1239714
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1239714
RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1080/07448481.2018.1515757
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 10
        StartPage: 79
    Subjects:
      – SubjectFull: College Students
        Type: general
      – SubjectFull: Literacy
        Type: general
      – SubjectFull: Sexuality
        Type: general
      – SubjectFull: Health Behavior
        Type: general
      – SubjectFull: Grounded Theory
        Type: general
      – SubjectFull: Contraception
        Type: general
      – SubjectFull: Student Attitudes
        Type: general
      – SubjectFull: Patients
        Type: general
      – SubjectFull: Intervention
        Type: general
      – SubjectFull: Health Services
        Type: general
      – SubjectFull: Prevention
        Type: general
      – SubjectFull: Sexually Transmitted Diseases
        Type: general
      – SubjectFull: Information Sources
        Type: general
      – SubjectFull: Barriers
        Type: general
      – SubjectFull: Language Usage
        Type: general
      – SubjectFull: Life Style
        Type: general
      – SubjectFull: Correlation
        Type: general
      – SubjectFull: Trust (Psychology)
        Type: general
      – SubjectFull: Access to Information
        Type: general
      – SubjectFull: Visual Aids
        Type: general
      – SubjectFull: Symptoms (Individual Disorders)
        Type: general
      – SubjectFull: Peer Relationship
        Type: general
      – SubjectFull: Information Technology
        Type: general
      – SubjectFull: Pregnancy
        Type: general
      – SubjectFull: Student Characteristics
        Type: general
      – SubjectFull: Florida
        Type: general
    Titles:
      – TitleFull: Exploring College Students' Sexual and Reproductive Health Literacy
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: Vamos, Cheryl A.
      – PersonEntity:
          Name:
            NameFull: Thompson, Erika L.
      – PersonEntity:
          Name:
            NameFull: Logan, Rachel G.
      – PersonEntity:
          Name:
            NameFull: Griner, Stacey B.
      – PersonEntity:
          Name:
            NameFull: Perrin, Karen M.
      – PersonEntity:
          Name:
            NameFull: Merrell, Laura K.
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          Name:
            NameFull: Daley, Ellen M.
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      – BibEntity:
          Dates:
            – D: 01
              M: 01
              Type: published
              Y: 2020
          Identifiers:
            – Type: issn-print
              Value: 0744-8481
          Numbering:
            – Type: volume
              Value: 68
            – Type: issue
              Value: 1
          Titles:
            – TitleFull: Journal of American College Health
              Type: main
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