Students’ awareness of the student health center’s sexual health services at a southeast public university

Abstract

Objective: To determine whether university students are aware of the sexual health services offered by the student health center. Participants: 522 undergraduate students at a southeast public university. Methods: Students were given a list of 19 sexual health services and tests and were instructed that for each one to check “offered,” “not offered,” or “I'm not sure.” Results: Students were generally unaware that the health center offered testing for a variety of sexually transmitted infections (13-27.4% aware), the Gardasil vaccine for human papillomavirus (HPV) (15.5% aware), the IUD (8.8% aware), emergency contraception (18.6% aware), and breast (24.9% aware) and pelvic examinations (16.5% aware). The only exceptions were for free male condoms (63% aware) and women's awareness of birth control pills (55.3% aware) and pregnancy testing (50.3% aware). Nearly half the students were not aware that parents/guardians could not obtain health center medical records without the student's permission. Conclusions: Student health centers cannot be effective in reducing unwanted pregnancies and the spread of STIs if students are unaware of the services provided. Health centers must do a better job of educating students.

Keywords:

• College
• student health centers
• sexual health
• health promotion
• access to care

About three-fourths of individuals in the United States have engaged in sexual activity by age 20.¹ In a 2016 survey, the American College Health Association (ACHA) found that 43% of college students had engaged in vaginal intercourse and 41% in oral-genital sex in the previous month.² Three-fourths of college students have had at least one sexual partner in the last year³ and about two-thirds of college-age people have had sex with a person they were not dating.⁴ Unprotected sexual intercourse can result in both sexually transmitted infections (STIs) and unplanned pregnancies.

At least 20 million Americans will contract a sexually transmitted infection this year, adding to the over 100 million existing cases.⁵ The highest rates of STIs are among people aged 15 to 24 years. College students are included in this high-risk age group. In a survey of 148 U.S. colleges, 6.6% of women at 4-year institutions, and 5.3% at 2-year institutions, tested at the student health center were positive for chlamydia.⁶ In another national survey, only 20.2% of college women and 7.7% of college men had been tested for STIs in the previous year.⁷

Contraceptive techniques are readily available in the United States, yet the teenage pregnancy rate in the United States is the highest among developed countries.⁸ Nearly half of all pregnancies in the U.S. are unintended.⁹ Again, this includes college students. At community colleges, almost 1 in 10 students who drop out do so because of unplanned births.¹⁰ Most of these students do not complete their education.

College health centers represent one of the first opportunities for health professionals to interact with many young, single adults who are at high risk for sexual health issues.¹¹ Almost all colleges have provided student health centers since the 1980s,¹² and today nearly all provide integrated (physical and mental health) primary care.¹³ Two of the goals of the ACHA’s Healthy Campus 2020 initiative were a decrease in the number of college students testing positive for STIs and an increase in the use of condoms.¹⁴ Only about half of sexually active college students “always” or “mostly” use condoms.²

College health centers can help to increase students’ use of condoms and other types of birth control, and decrease the prevalence of STIs. However, little is known about college students’ awareness of the sexual health services provided by campus health centers. In a recent study, nearly half of students at a Los Angeles college were not aware that they could get an HPV vaccine at the health center.¹⁵ In another study, more than half of students at two Midwestern universities were not aware that physician assistants and nurse-practitioners at the health centers could diagnose illnesses and prescribe medications.¹⁶

The present study was exploratory. The purpose was to determine how knowledgeable undergraduate students were about a wide variety of sexual health services offered by the campus health center, including testing for STIs, birth control, and breast and pelvic examinations. The study also evaluated students’ perceptions of the health center’s attempts to educate students about the services.

Methods

Setting

The student health facility, Redfern Health Center, is located on campus and offers medical, pharmacy, radiology and lab services (including a women’s clinic) as well as counseling and psychological services. The center is staffed by physicians, nurse-practitioners, pharmacists, pharmacy technicians, psychologists and counselors. Redfern Health Center provides testing for seven STIs (gonorrhea, chlamydia, syphilis, herpes, hepatitis A, hepatitis B, human immunodeficiency virus (HIV)), and the Gardasil vaccine for HPV. Four types of contraception are also offered (male condoms for free, birth control pill, IUD, emergency contraception). Redfern Health Center also provides breast and pelvic examinations and pregnancy testing. New students are first educated about provided services during a session of a university-mandatory introductory course. Redfern Health Center has a website where available services can be found and also attempts to inform students of these services by information sessions, fliers, social media advertisements, and digital bulletins.

Sample

Participants were undergraduate students enrolled in a human sexuality course offered by the Department of Psychology at Clemson University during the Spring 2020 semester. The course is not required by any major.

Instrument

The questionnaire was developed by the investigators. It was administered in paper-and-pencil form at the beginning of one class period. After some initial demographic questions, students were given a list of 19 services and tests and were instructed that for each one to check one of three boxes: “offered,” “not offered,” and “I’m not sure.” Four of the services listed were not offered by Redfern Health Center at the time of the investigation. During verbal instructions, it was emphasized that they should not guess. Students were asked two additional questions on a 7-point Likert scale (1 = not at all, 4 = somewhat, 7 = extremely well): (1) “How familiar are you with the sexual health and sexual education services at Redfern?,” and (2) “How well do you feel that you have been educated about the sexual health resources at Redfern?” A third question was answered by “Yes,” “No,” or “Unsure”: “My parents/guardians can see my medical examination and laboratory history at Redfern without my consent.” Sexual experience was ascertained by asking “Have you ever engaged in consensual oral, vaginal, or anal intercourse?” A nonsense question was inserted among these to check whether participants were responding robotically. Responses were entered into Excel. With use of a small sample (n = 20), test-retest reliability (one day apart) of responding to the sexual service items was .95 or greater for each item. The study was approved by the university’s Institutional Review Board (IRB), with consent determined by voluntary participation.

Results

The questionnaire was distributed to 539 students. Fourteen students chose not to participate, and three others were eliminated for responding robotically to the nonsense question. The final sample was 522 students. Eighty percent of female students were sexually experienced, as were 84.2% of men. The mean (±SD) age was 19.49 ± 1.34 years (excluding one 61-year-old outlier). Other demographics are provided in Table 1.

Table 1. Demographics of the sample of 522 undergraduate students.

	Number	Percentage of sample
Gender
Men	133	25.5%
Women	389	74.5%
Ethnicity
Caucasian	434	83.6%
African American	36	6.9%
Hispanic	9	1.7%
Asian	13	2.5%
Mixed race	27	5.2%
Sexual orientation
Heterosexual	491	94.4%
Homosexual	6	1.2%
Bisexual	23	4.4%
Academic year
First year	267	51.4%
Second year	119	22.9%
Third year	74	14.3%
Fourth year +	59	11.4%

Guessing, as indicated by an incorrect answer, was minimal, with only the answers about the IUD (4.8% incorrect), trichomoniasis (7.9% incorrect), and the birth control patch/ring/implant (10% incorrect) above 2.5% incorrect (see Table 2). For STIs and the HPV vaccine, the percentage of students who knew that testing was offered never exceeded 27.4% (chlamydia). This was significantly below the chance level in all cases (p < .001; χ² tests). Similar results were found for the IUD and emergency contraception. Nearly half the students (46.1%) were aware that they could obtain birth control pills, but “free condoms” was the only birth control service for which a significant number of students were aware (63%, χ² = 34.8, df = 1, p < .01). Over 75% of students were not aware that they could get breast and pelvic examinations at the Redfern Health Center, and 54.1% were unaware that pregnancy testing was available. About half (54.5%) of the students were aware that parents/guardians are not allowed to see medical records without the student’s consent. The raw data may be found in a data repository at osf.io/74hq3/.

Table 2. Percentage of 522 university students who responded “Offered,” “Not offered,” or “I’m not sure” to sexual health services offered at the student health center.

Service	Offered	Not Offered	I’m not sure
Chlamydia	27.4%	0	72.6%
Gonorrhea	25.0%	0	75.0%
Hepatitis A	12.9%	0	87.1%
Hepatitis B	12.8%	0	87.2%
Hepatitis C (not offered)	5.0%	1.5%	93.5%
Herpes	25.3%	0	74.7%
HIV	18.6%	0.6%	80.8%
HPV (not offered)	0.8%	15.9%	83.3%
Gardasil vaccine	15.5%	0.6%	83.9%
Syphilis	21.0%	0.2%	78.9%
Trichomoniasis (not offered)	7.9%	0.2%	92.0%
Free condoms	63.0%	0.6%	36.4%
Birth control pill	46.1%	1.0%	53.0%
Birth control patch/ring/implant (not offered)	10.0%	3.6%	86.4%
IUD	8.8%	4.8%	86.4%
Emergency contraception	18.6%	2.3%	79.1%
Breast exams	24.9%	0.6%	74.5%
Pap smears/Pelvic exams	16.5%	2.5%	81.0%
Pregnancy testing and referrals	45.9%	0	54.1%

Some statistically significant differences were found when comparing men’s and women’s responses. A greater proportion of women than men were aware that Redfern Health Center offered the birth control pill (55.3% vs. 18.3%, χ² = 53.87% df = 1, p < .001), IUD (11.1% vs. 2.3%, χ² = 9.52, p < .005), emergency contraception (21.6% vs. 9.1%, χ² = 10.37, p < .005), breast examinations (27.3% vs. 18.3%, χ² = 4.46, p < .05), pelvic examinations and Pap smears (19% vs. 9.1%, χ² = 7.08, p < .01) and pregnancy testing and referrals (50.3% vs. 32.8%, χ² = 12.02, p < .001). A greater proportion of men than women were aware that free male condoms were available (76.5% vs. 58.4%, χ² = 13.95, p < .001).

The proportion of sexually experienced students significantly exceeded inexperienced students for awareness of testing for chlamydia (30.7% vs. 14.2%, χ² = 11.55, df = 1, p < .001), gonorrhea (28% vs. 13.3%, χ² = 9.62, p < .005), herpes (28.3% vs. 14.2%, χ² = 8.86, p < .005), HIV (21% vs. 9.4%, χ² = 7.49, p < .01), and syphilis (23.5% vs. 11.4%, χ² = 7.33, p < .01).

On the 7-point Likert scales (1 = unfamiliar to 7 = extremely familiar), the mean rating was 2.53 for “How familiar are you with the sexual health and sexual education services at Redfern?,” 2.11 for “How well do you feel that you have been educated about the sexual health resources available at Redfern?,” and 2.50 for “How well of an effort do you feel Redfern makes to educate students on available resources?”

Discussion

With the exception of free condoms and women’s awareness of birth control pills and pregnancy testing, only a small minority of students were aware of any sexual health services offered at the student health center. The portion of one class devoted to sexual health during the new student introductory course was inadequate in educating students about sexual health services offered at the health center, and the students gave low ratings to the health center’s subsequent attempts to educate them (mean of 2.50 out of 7). More attention must be given to educating students about sexual health services offered on campus.

Only about 20% of the students were sexually inexperienced, but those students might have little motivation on their own to learn about sexual health resources offered at Redfern Health Center.¹⁷ The generally lower costs of the health center’s services (e.g., condoms and spermicides are free) and the easy accessibility (the nearest major hospital is 45 min away) might be appealing to some sexually experienced students. However, even among sexually experienced students there are barriers that prevent them from using, or even inquiring about, the sexual health services offered at the student health center. The foremost concern of many students is confidentiality, e.g., what others might think of them.^7,18 In the present study, 16 students said that they would not go to Redfern Health Center for treatment of STIs because they were “afraid of judgement.” Nearly half the students believed that parents/guardians might be able to access medical histories without the student’s permission.

Previous research on students’ awareness of sexual health services offered at student health centers has been minimal. A study at a west coast college found that many students were unaware they could obtain the Gardasil vaccine at the student health center.¹⁵ A study conducted in the Midwest found that most students did not understand the role of health center personnel.¹⁶ These studies were limited in scope, but support the present finding that college students are generally unaware of student health centers’ sexual health services. That presents a serious problem because a previous study found that the most successful strategy for recruiting college students to be tested for STIs was to target places where they normally seek health care.¹⁹ However, when student health centers launch a campaign to reach students it can be effective in bringing students to the health center for testing of STIs.²⁰

Conclusions

It is not enough that college student health centers are well staffed and offer numerous sexual health services. If college students are unaware of the sexual health services offered at health centers, then steps must be taken to increase awareness and overcome barriers to using the center. Health centers must do a better job of educating students about the services offered, and guaranteeing students that medical records are not available to parents/guardians without the student’s permission. By reaching a greater number of students, the prevalence of STIs and unintended pregnancies on college campuses can be greatly reduced.

Limitations

The results are limited to a single university. The large number of female participants is typical of the female/male ratio in most university human sexuality courses.²¹ The number of ethnic and sexual minority students in the study were too small for meaningful comparisons. Social desirability bias is always a concern for self-reported sexual behaviors/attitudes,²² but if it was a factor in the present study, then even fewer students than reported were actually aware of the various sexual health services.

Conflict of interest disclosure

The authors have no conflicts of interest to report.

Additional information

Funding

No funding was used to support this research and/or the preparation of the manuscript.