1. Johnson-Mallard, Versie PhD(c), MSN, ARNP
  2. Lengacher, Cecile A. RN, PhD
  3. Kromrey, Jeffrey D. PhD
  4. Campbell, Doris W. PhD, ARNP, FAAN
  5. Jevitt, Cecilia M. CNM, PhD
  6. Daley, Ellen PhD
  7. Schmitt, Karla PhD

Article Content

Sexually transmitted infections (STIs) are a major threat to public health. Without intervention, experts predict dramatic increases in cases.1 Research on both knowledge and perceived risk of STIs among women of childbearing age is very limited. Because of the rising number of human immunodeficiency virus (HIV) infections and other STIs among this patient population, health directives should include behavioral interventions with the aim of empowering women with increased knowledge as well as an increased perception of risk of STIs.

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

Positive behavior changes are plausible with STI prevention messages and services for at-risk women by means of nurse-directed interventions with the intention of enhancing perceived risk as well as increasing knowledge of STIs in women.2-4 The purpose of this study was to test the effects of an educational/behavioral intervention on knowledge and perceived risk of STIs in women of childbearing age.


Background and Significance

The rates of incidence of STIs such as syphilis, herpes simplex virus (HSV), gonorrhea, and chlamydia have increased dramatically in heterosexual women.5,6 Women are diagnosed with two-thirds of the estimated 12 million new cases of STIs annually in the United States. After only a single exposure, women are twice as likely as men to acquire infections from pathogens causing gonorrhea, chlamydia infection, hepatitis B, and chancroid.3,7 Chlamydia is a leading cause of reproductive morbidity in women.3 Moreover, acquired immune deficiency syndrome (AIDS) surveillance data indicate that young people between the ages of 13 and 24 account for a larger proportion of HIV cases than AIDS cases, and the number of female youth becoming HIV infected exceeds that of males.5


Sexually transmitted infections are of particular distress among women because of the potential for acute and life-threatening complications during pregnancy.8-10 Other than HIV, exposure to STIs such as Chlamydiatrachomatis, Neisseriagonorrhoeae, syphilis, HSV, and bacterial vaginosis during pregnancy has been associated with undesirable pregnancy outcomes.6 Each year, an estimated 20,000 infants are born to women who test positive for the hepatitis B surface antigen (HbsAg). Fetal death secondary to premature delivery, pneumonia, and sepsis can occur as a result of HbsAg infection. Untreated syphilis during pregnancy can lead to stillbirths, neonatal deaths, and infant disorders such as deafness, neurologic impairment, and bone deformities.10


Many cultures and religions have an expectation of marriage and mutual monogamy during pregnancy. An expectation of monogamy sometimes contradicts teaching STI prevention and condom use. Therefore, STI prevention during pregnancy has focused on screening for particular STIs. However, STI incidence and prevalence are particularly high among young adults and pregnant females.11,12 Adolescents who are pregnant may be at especially high risk because of their sexual history, likely reduction in condom use, which may be viewed as unnecessary because of pregnancy, and the fact that pregnancy results in additional physiologic vulnerability to STIs.11 Manlove et al12 reported that 33% of births to women of all ages in the United States occur outside of marriage and 79% of births to teens are outside of marriage. Women need to know their STI risk and to learn prevention techniques, especially those without assurances of mutual monogamy.


Study Design

An experimental study was designed to determine whether participating in an educational program has a positive effect on knowledge and perceived risk of STIs. A two-group randomized control pretest/posttest research design was used to analyze whether a significant increase in knowledge and perceived risk of STI would be seen in the educational intervention group when compared with the control group. In addition, the reliability of two instruments was measured: the Sexually Transmitted Infection Knowledge Survey (STIKS) and the Perceived Risk of Sexually Transmitted Infection Survey, which were developed in 1998 to measure knowledge and perceived risk of women in their childbearing years.


Data analysis was based on two hypotheses:


(H1): There will be significant increases in knowledge of STIs in the educational intervention group compared with the control group.


(H2): There will be significant increases in perceived risk of STIs in the educational intervention group compared with the control group.


Analysis of variance (ANOVA) was used to test the hypotheses and compare changes in knowledge and perceived risk between the two groups. Sexually transmitted infection knowledge and perceived risk group comparisons were made between the intervention and control groups before the educational/behavior intervention and after the educational/behavior intervention to address whether the educational/behavior intervention had an effect on knowledge and perceived risk.



The sample included 104 women attending two universities. Sample size was selected using power analysis based on a medium effect size requiring a minimum sample of 88. The overall mean age of the sample was 21 years. Of the 104 participants, 44.2% (n = 46) identified themselves as African-American, 45.2% (n = 47) as Caucasian, 4.8% (n = 5) as Hispanic, and 5.8% (n = 6) defined their race as "other".



Sexually Transmitted Infection Knowledge Survey (STIKS)-a 29-item multiple choice survey. The questions addressed prevention, transmission, treatment, and symptoms of STIs. The questions were grouped according to general knowledge relating to STI prevention, possible transmission from mother to child, cognitive awareness relating to prevention of STIs during pregnancy and ability to identify general understanding of treatment planning for STIs. Content validity was computed to be .93. Each item on the survey was scored "1" for correct responses and "0" for incorrect responses. The estimate of reliability (Cronbach's alpha) for STIKS was 0.76. Potential scores on this instrument could range from 0 to 29 with higher scores indicative of greater STI knowledge.


Perceived Risk of Sexually Transmitted Infection Survey-a five-item instrument, using a five-point Likert scale. The estimate of reliability (Cronbach's alpha) for the Perceived Risk of Sexually Transmitted Infection Survey was .71. A higher range on the scale indicated a higher perceived risk for contracting an STI.



Permission to conduct the study was obtained from the Institutional Review Board for Human Subjects of the universities. The schools' deans and the professors of each class also granted permission to use their students as study subjects. Each participant was given a written description of the study and assured that participation was voluntary. Procedures for the protection and privacy of human subjects were followed throughout the study.


The principal investigator solicited potential sample study participants: women 18 to 48 years of age, able to speak, read, and write English at the seventh grade level, and who were willing to participate in the intervention and the follow-up posttest. Study participants were recruited from a sample of students in a baccalaureate level nursing program. These students had not yet been exposed to any formal nursing class lectures about STIs. The surveys were completed in a comfortable setting with the principal investigator monitoring, providing assistance, and helping to ensure confidentiality of responses.


Participants were randomized (using a table of random numbers) to either the intervention group or the control group during the preintervention phase. Both sets of participant groups were asked to complete the Demographic Data Form, STIKS, and the Perceived Risk of Sexually Transmitted Infection Survey two times-at baseline and 1 week after the intervention. Measurements from the control group were used to compare outcomes of the educational/behavioral intervention as well as to test the reliability of STIKS and the Perceived Risk of Sexually Transmitted Infection Survey.


Description of the Intervention

The educational intervention was designed from empirical standards and guidelines from the Centers for Disease Control and Prevention.13 The principal investigator performed the intervention using an educational presentation including discussion and PowerPoint slides. The PowerPoint presentation depicted condoms, dental dams, and instructions on their proper use. The intervention was supplemented with an informational brochure that experimental subjects were encouraged to review at least three times each week. The supplemented information was intended to relate changes in STI knowledge and safer sex behavior by reinforcing information introduced in the presentation and discussion. Specifically, the directives of the intervention were to increase STI knowledge, encourage adoption of preventive behaviors (limiting number of sex partners), and to increase women's perceptions of their risk of STIs and their need for incorporation of healthy sexual behaviors.


A structured discussion and answer session was conducted in an open forum about STIs. To increase knowledge regarding STIs, explanations were provided about the potential sequelae of undiagnosed and untreated STIs. The study conductors emphasized the importance of condom use (female or male), choosing an appropriate sex partner, monogamy, dental dam or saran wrap use to shield the vulva area during oral sex, and potential adverse effects of anal/rectal sex. The potential effects of STIs on pregnant women and their fetus, as well as the importance of safer sex practices during pregnancy were also addressed. Structured lecture and discussion were supplemented with slides depicting condoms, dental dams, and spermicidal agents used to decrease potential risk of STI transmission from partner to partner and from mother to fetus.



The mean age of the sample was 21 years (range from 19 to 39 years). Demographic factors (such as age, ethnicity, and children) were approximately equivalent in the two groups (see Table: "Demographic Characteristics"). The mean age for initiating sexual intercourse was 15 years old. The leading method of family planning was oral contraceptives (48.9%; n = 51). Condom use was reported by 45.2% (n = 47) of the women. However, it was not statistically clear whether condom use was being identified in conjunction with or as a birth control method.

Table. Demographic C... - Click to enlarge in new windowTable. Demographic Characteristics

In response to a question on sexual partner behavior, 42.4% (n = 44) of participants reported one sex partner, 15.3% (n = 16) reported two sex partners, and 5.7% (n = 6) reported three sex partners (see Table: "Self-Reported Sexual Behaviors"). Women were asked to report past incidence of diagnosed STI. Eighty-three percent (n = 87) reported previous episodes of STIs. Women were specifically asked whether they had difficulty asking their sex partner to use a condom. Ninety-one percent (n = 95) of the women reported difficulty asking their sex partners to use a condom.

Table. Self-Reported... - Click to enlarge in new windowTable. Self-Reported Sexual Behaviors

The experimental group received the educational/behavior intervention 1 week after pretest. Both groups received the posttest 2 weeks after pretest. In testing the first hypothesis (H1), a group mean difference was noted in the intervention group after being exposed to the educational/behavior intervention. Overall, the group mean (M = 26.1 SD +/- 2.6) for the intervention group was higher, indicating greater knowledge about STIs at posttest compared with the control group mean at posttest (M = 21.0 SD +/- 2.3).


The educational/behavioral intervention resulted in statistical significance between group differences at posttest regarding STI knowledge and perceived risk for women receiving the educational/behavioral intervention F (1,102) = 109, p < .0001, indicating the brief (30-minute) educational/ behavioral intervention had an effect on the experimental group.


In testing the second hypothesis (H2), the results revealed a significant main effect in group mean (M = 4.0 SD +/- 1.0) at posttest for perceived risk of STIs in women exposed to the intervention compared to the control group mean at posttest (M = 7.9 SD +/- 2.3). The interaction effect suggests differential changes between the two groups. The interaction effect of the perceived risk mean revealed that the treatment group changed rather substantially between pretest and posttest, but only a modest change for the control group was noted (see Table: "Mean and Standard Deviations for Perceived Risk at Pretest and Posttest").

Table. Mean and Stan... - Click to enlarge in new windowTable. Mean and Standard Deviations for Perceived Risk at Pretest and Posttest

Analysis of variance was used to further examine the pretest and posttest scores and the STI education intervention (see Table: "Posttest of Intervention Effect on Knowledge and Perceived Risk"). The interaction between the time of assessment (pretest vs posttest) and the group was statistically significant for knowledge, F (1,102) = 97.74, p < .0001; F (1,102) = 53.41, and p < .0001 for perceived risk.

Table. Posttest of I... - Click to enlarge in new windowTable. Posttest of Intervention Effect on Knowledge and Perceived Risk

Areas of Future Research

The findings of this study may assist advanced practice nurses in anticipating questions where answers may not appear exceedingly evident. Educating women about STIs could include brief interventions such as explaining literature in a simple and direct manner, as well as fostering a trusting patient/provider relationship throughout the health-seeking encounter. These findings add to the growing body of literature that says patient/provider encounters are brief and communication of health-promoting concepts must be conveyed clearly and with brevity. It cannot be assumed that women previously seen by healthcare providers received informative instructions targeted at increasing knowledge and preventive behavior for STIs. Patients require information along with appropriate treatment. Helping the patient to understand an STI diagnosis is important in allaying possible fears. Also, the findings indicate the importance of advanced practice nurses in reinforcing STI information during clinical encounters with patients. Advanced practice nurses and women are challenged to recognize critical points in at-risk situations such as exposure to STIs. Women need to understand that STIs contribute greatly to morbidity associated with reproductive health, including pelvic inflammatory disease, infertility, ectopic pregnancy, chronic pelvic pain, compromised birth outcomes, and cervical cancer. Advanced practice nurses are in a variety of healthcare settings and should ensure that their patients have a good understanding of treatment options and relevant health education information related to STIs. This study tested a nursing intervention and may influence women's health by eliminating knowledge gaps and adding to evidence-based practice. Creative nurse-directed interventions could give power to women who gain the knowledge to perceive STI risks and to take personal action at circumventing high-risk behaviors. The results confirmed that brief educational interventions related to STIs and targeted at increasing knowledge could be effective. This study corroborates previous investigations that found that brief educational interventions can influence knowledge of STIs.3,14




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