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Chlamydia Infection: Population Specific Risk Factors for Female University Students

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PAGE 1

CHL AMYDI A I NFE CTI ON: POPUL ATI ON SPECI FI C RI SK FACTORS FOR FEMAL E UNI VERSI TY STUDENTS By TAMI L YNN TH OMAS A DI SSER TATI ON PRESENTED TO THE G RADUATE SCHOOL OF T HE UNI VERSI TY OF FL ORI DA I N PARTI AL FUL FI L L MENT OF T HE REQUI REMENTS FOR THE DE GREE OF DOCTOR OF PHI L OSOPHY UNI VERSI TY OF FL ORI DA 2006

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Copy rig ht 2006 by Tami L y nn Thomas

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This dissertation is dedicated to the stude nts at the University of F lorida a n d t o m y m a t e r n a l g r a n d f a t h e r T h o m a s E d w a r d G e n t r y.

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iv ACKNOWL EDGMENTS I thank my chair Dr. Sharle en Simpson, for believing in me and enc ourag ing me I am g rate ful to my committee member s, Dr. Donna Nef f, Dr. Sandr a Sey mour, and Dr Nabih Asa l, for their kindne ss, encour ag ement, patienc e, and f aith. I would like to thank the fa culty in the College of Nursing for their support and enc ourag ement. I am thankful f o r t h e p r o f e s s i o n a l i s m a n d p a t i e n c e o f D r Je n n i f e r E l d e r D r A n n H o r g a s a n d D r Jo Sni de r. I a m a lso tha nk fu l to Dr H us se in Y a ra nd i f or his re vie w o f m y da ta a na ly sis This resea rch c ould not have bee n completed with out the support of the administration, me dic a l st a ff n ur se s a nd se c re ta ri a l st a ff of the Un ive rs ity of F lor ida St ud e nt H e a lth Care Ce nter. Most of all I thank my children, Rober t Timothy Eng elber th and Hele n Renee Eng elber th, for being my strong est supporters. I must also acknowledg e my car eer mentors and pe rsonal inspirations, Dr. De e Willi ams, Dr. Ma uree n Keller -Wood, and Dr. Char les Wood. They understood me, e ncoura g ed me, a nd saw my potential when I had doubts.

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v TAB L E OF CONTENTS P age A C K N O W L E D G M E N T S ................................................ iv L I S T O F T A B L E S ..................................................... vii L I S T O F F I G U R E S ..................................................... ix A B S T R A C T ........................................................... x CHAPTER 1 B A C K G R O U N D A N D S I G N I F I C A N C E .................................. 1 Chlamy dia I nfec tion Rates and Risks to Young Women . . . . . . . . . . . 1 E p i d e m i o l o g y o f C h l a m y d i a ............................................ 4 T h e o r e t i c a l F r a m e w o r k ................................................ 8 S u m m a r y .......................................................... 10 2 L I T E R A T U R E R E V I E W .............................................. 12 P a t h o b i o l o g i c a l P e r s p e c t i v e s ........................................... 12 S o c i o c u l t u r a l P e r s p e c t i v e s ............................................. 14 B e h a v i o r a l P e r s p e c t i v e s ............................................... 19 T h e o r e t i c a l A p p l i c a t i o n a n d R a t i o n a l e ................................... 21 S u m m a r y .......................................................... 25 3 R E S E A R C H I M P L E M E N T A T I O N ..................................... 26 R e s e a r c h D e s i g n ..................................................... 26 D a t a C o l l e c t i o n M e t h o d s .............................................. 31 A n a l y s i s o f Q u e s t i o n n a i r e D a t a ......................................... 31 E t h i c a l C o n s i d e r a t i o n s ................................................ 32 S u m m a r y .......................................................... 32 4 F I N D I N G S ......................................................... 33 I n t r o d u c t i o n ........................................................ 33 I n f e c t i o n R a t e s ...................................................... 34 Q u e s t i o n n a i r e A n a l y s i s ............................................... 37 R e s e a r c h Q u e s t i o n F i n d i n g s............................................ 41 S u m m a r y .......................................................... 48

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vi 5 D I S C U S S I O N A N D I M P L I C A T I O N S ................................... 50 R e s e a r c h P u r p o s e .................................................... 50 D i s c u s s i o n ......................................................... 50 The Sig nificanc e and Re visions to t he Campus Chlamy dia Model . . . . . . . 59 L i m i t a t i o n s ......................................................... 62 R e c o m m e n d a t i o n s f o r F u t u r e R e s e a r c h ................................... 62 C o n t r i b u t i o n t o N u r s i n g S c i e n c e ........................................ 63 C o n c l u s i o n ......................................................... 64 A P P E N D IX A C H L A M Y D I A Q U E S T I O N N A I R E ..................................... 66 B POSI TI VE CHL AMYDI A RESUL TS BY MON TH . . . . . . . . . . . . 71 C DEMOGRAPHI C CHARACTERI STI CS FOR POSI TI VE CHL AMYDI A R E S U L T S ......................................................... 72 R E F E R E N C E S ........................................................ 73 B I O G R A P H I C A L S K E T C H .............................................. 81

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vii L I ST OF TAB L ES T ab l e p age 1-1 Chlamy dia, re ported c ases a nd rate s per 100,000 f emales a g es 16-19 in the U n i t e d S t a t e s ...................................................... 1 1-2 Chlamy dia, re ported c ases a nd rate s per 100,000 f emales a g es 20-24 in the U n i t e d S t a t e s ...................................................... 2 1-3 Number of case s and incidenc e ra tes of chla my dia per 100,000 in women a g e s 1 7 2 4 i n F l o r i d a ............................................... 2 1-4 Chlamy dia positivit y in women 15 by testing site in F lorida . . . . . . . 2 15 Re su lts fr om t he Am e ri c a n Co lle g e He a lth As so c ia tio n s ur ve y of pr ov ide rs Ra te s o f c hla my dia (C Z ) i n me n, wo me n, tho se pr e se nti ng wi th s y mpt oms (p os iti ve s) a nd tho se pr e se nti ng wi tho ut ( a sy mpt oma tic po sit ive s) . . . . . . 3 31 Exa mpl e s o f q ue sti on s u se d in the Con do m U se Se lf -E ff ic a c y Sc a le . . . . . 29 41 Chl a my dia inf e c tio n d a ta fo r s tud e nts wh o a c c e ss s e rv ic e s a t th e Un ive rs ity o f F l o r i d a S t u d e n t H e a l t h C a r e C e n t e r ................................. 34 42 De mog ra ph ic c ha ra c te ri sti c s f or stu de nts te sti ng po sit ive fo r c hla my dia i n f e c t i o n ......................................................... 35 4-3 Chlamy dia infec tion rates as r eporte d by the ACHA a nd the Univer sity of F l o r i d a S t u d e n t H e a l t h C a r e C e n t e r ................................... 37 44 De mog ra ph ic c ha ra c te ri sti c s o f s tud y pa rt ic ipa nts . . . . . . . . . . . . 39 4-5 Fr equenc y of condom use a nd highrisk drinking . . . . . . . . . . . . 39 4 -6 S u m m ar y m ea s u re s o f v ar i ab l es age n u m b er o f p ar t n er s h i gh ri s k d ri n k i n g, drink occ asions, drinking and having sex, and CUSES score s . . . . . . . 40 4-7 Fr equenc y and per cent of sexual activities, behavior, sexually transmitted infec tion (STI ), and g y necolog ic complaint . . . . . . . . . . . . . . 42 4-8 The diff ere nce in mea n rank of the number of sexual partners . . . . . . . 45

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vii i 4-9 Goodness of f it complete model for the logistic re g ression to deter mine combined ef fec ts of condom use self -ef fica cy scale score s, number of se x ual partne rs, hig h-risk drinking and sexual risk taking on those with a g y n e c o l o g i c c o m p l a i n t .............................................. 46 410 An a ly sis of ma ximum lik e lih oo d e sti ma te s f or log ist ic re g re ssi on to de te rm ine c omb ine d e ff e c ts o f c on do m us e se lf -e ff ic a c y sc a le sc or e s, number of se x ual par tners, hig h-risk drinking and sexual risk taking on t h o s e w i t h a g y n e c o l o g i c c o m p l a i n t ................................... 47 411 Od ds ra tio e sti ma te s f or the pa ra me te rs of the c omp le te d mo de l to de te rm ine c omb ine d e ff e c ts o f c on do m us e se lf -e ff ic a c y sc a le sc or e s, number of se x ual par tners, hig h-risk drinking and sexual risk taking on t h o s e w i t h a g y n e c o l o g i c c o m p l a i n t ................................... 48 4-12 Analy sis of max imum li kelihood estimates deter mining combined e ffe cts of c on do m us e se lf -e ff ic a c y sc a le sc or e s, nu mbe r o f s e xua l pa rt ne rs h ig hri sk drinking and sexual risk taking on those with a g y necolog ic complaint . . . 48

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ix L I ST OF F I GURES Fi gu re p age 1 1 T h e e p i d e m i o l o g i c t r i a n g l e ........................................... 7 1-2 A model of socia l cog nitive theory (B andura 1986) depic ting c onstruct g ro up s in c ir c le s a nd the int e ra c tiv e re la tio ns hip a mon g the g ro up s w ith b i d i r e c t i o n a l a r r o w s ................................................. 9 2-1 Proposed Campus Chlamy dia Model ada pted from B andura s (1997) se lfe f f i c a c y t h e o r y .................................................... 23 4-1 Perce nt of subjects with and without g y necolog ic complaint diag nosed and trea ted for se x ually transmitted infec tion . . . . . . . . . . . . . . . 44 4-2 A compar ison of subjects with and without g y necolog ic complaints trea ted more than onc e for sexually transmitted infec tion . . . . . . . . . . . . 44

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x AB STR AC T Abstrac t of Dissertation Prese nted to the Gra duate School of the Unive rsity of F lorida in Partial Fulf illment of the Requirements for the Deg ree of Doc tor of Philosophy CHL AMYDI A I NFE CTI ON: POPUL ATI ON SPECI FI C RI SK FACTORS FOR FEMAL E UNI VERSI TY STUDENTS By Tami L y nn Thomas Aug ust 2006 Chair: Sharlee n Simps on Major De partment: Nursing Genital chla my dia infec tion is i ncre asing on a national leve l resulting in millions in health ca re c osts. Chl amy dia re lated morbidity includes pelvic infla mmatory disease, chlamy dia prostatitis for men, a nd in some case s infertility Despite de cade s of primary a nd se c on da ry pr e ve nti on me a su re s, inc lud ing the dis tr ibu tio n o f f re e c on do ms, he a lth e du c a tio n p ro g ra ms, a nd ine xpe ns ive tr e a tme nt, na tio na lly a nd loc a lly g e nit a l c hla my dia infec tion rates have risen in y oung women. The purpose of this resea rch w as to document ra tes of g enital chlamy dia infec tion in m a le a nd fe ma le un ive rs ity stu de nts wh o a c c e ss h e a lth c a re se rv ic e s a t a un ive rs ity student health ca re c enter and desc ribe possible population specif ic risk fa ctors for fema le university students. First, re ported c ases of g enital chlamy dia wer e tra cked a nd demog raphic s calc ulated with the coope ration of the la boratory manag er a t the rese arc h site. I ncidenc e ra tes wer e hig her tha n national ra tes, 5.8% ver sus 3.8%. Those infe cted wer e more likely to be fe male, living in a partments off campus, 20 y ear s old, and white.

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xi Then, fe male univer sity students who acc essed se rvice s at the student hea lth care cente r we re r ecr uited using a n instit utional review board a pproved f ly er to c omplete an a no ny mou s q ue sti on na ir e to g a the r d a ta on hig h r isk dr ink ing be ha vio rs s e xua l r isk ta kin g g y ne c olo g ic c omp la int s, c on do m us e a nd c on do m us e se lf -e ff ic a c y T his sa mpl e of fe male students was pr edominantly junior and senior c lass level. The y repor ted highrisk drinking and sexual risk-taking behavior s at rate s g rea ter than 67% The mea n number of se x ual par tners for those students completing the questionnaire was 1.6 in the pa st y e a r. Th e nu mbe r o f s e xua l pa rt ne rs ma y a lso pr e dic t th e lik e lih oo d o f a g y ne c olo g ic complaint, g rea ter sexual activity and subseque nt sex ually transmitted infec tion. Further an al y s i s d em o n s t ra t ed n o re l at i o n s h i p s b et we en h i gh -r i s k d ri n k i n g, s ex u al ri s k t ak i n g, a nd c on do m us e se lf e ff ic a c y sc a le sc or e s. T h i s re s ea rc h d em o n s t ra t es t h e n ee d fo r p re v en t i o n ef fo rt s t h ro u gh c omp re he ns ive se xua lit y e du c a tio n a nd re pr od uc tiv e he a lth se rv ic e s o n a un ive rs ity campus. F urther r esea rch is planne d to examine the impact of the tra nsition t o a un ive rs ity c a mpu s li fe in c lud ing so c ioc ult ur a l f a c tor s su c h a s p e e r g ro up su bc ult ur e s, g ender based pow er issues, hig h-risk drinking and sexual risk taking

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1 CH APT ER 1 B AC KG RO UN D A ND SI GN I F I CA NC E Chlamy dia is an oblig ate ba cter ia that enter s the vag ina during sexual contact causing milli ons of infec tions annually for wome n under a g e 25 (K elly 2003; Centers for Di se a se Con tr ol a nd Pr e ve nti on 2 00 4) U ntr e a te d in fe c tio ns inv a de the fe ma le endoce rvica l epithelium and fallopian tubes with subseque nt health ca re c osts ex cee ding $3 bil lio n p e r y e a r ( Ar a l, 2 00 2; H olm e s, 19 94 ; Sta mm, 20 04 ). Va g ue sy mpt oms including bur ning upon ur ination, pelvic pain and va g inal bleeding may be pre sent, but asy mptomatic infection is common (Weir, 2004). Mild sy mptoms, or lack there of, lea ve the se y ou ng wo me n a t r isk fo r c hla my dia re la te d mo rb idi ty mo st s pe c if ic a lly p e lvi c inflammatory disease ( PI D). Chlamy dia PI D ca n lead to infe rtility (Stamm, 2004). Unfortuna tely inexpensive and eff ective tr eatment is often de lay ed bec ause of vag ue or absent sy mptoms (Hu, Hook & G oldie, 2004). Chlam ydia In fection Rates and Risks to Youn g Wom en The Center s for Disea se Control and Preve ntion (CDC) reports incr easing rate s of c hla my dia na tio na lly in w ome n a g e d 1 6 to 24 fr om 1 99 9 to 20 03 (C e nte rs fo r D ise a se Control and Prevention, 2004; Tables 11 and 1-2) Table 11. Chlamy dia, re ported c ases a nd rate s per 100,000 f emales a g es 16-19 in the United States Fe males ag es 16-19 y ear s 1999 2000 2001 2002 2003 Cases 277,376 231,167 249,269 257,428 266,175 Rates 2,329.2 2,352.5 2,531.3 2,599.0 2,687.3 (CDC, 2004)

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2 Table 12. Chlamy dia, re ported c ases a nd rate s per 100,000 f emales a g es 20-24 in the United States Fe males ag es 20-24 1999 2000 2001 2002 2003 Cases 185,058 199,257 226,992 238,406 252,936 Rates 2,033.9 2,129.1 2,357.0 2,417.1 2,564.4 (CDC, 2004). These da ta indicate a steady rise in the ra tes of chla my dia in this ag e g roup, an inc re a se fr om 1 85 ,0 58 fo r w ome n a g e s 2 0 to 24 in 1 99 9 to 25 2, 96 3 in 20 03 T he se incre ases oc cur in the pr esenc e of pr imary and sec ondary preve ntion measures inc luding educa tion, condom distributi on, and ef fec tive trea tment. The CDC postulates that incre asing rate s of chlamy dia may be a r esult of primary and sec ondary preve ntion failure s (U. S. Depa rtment of He alth and Human Ser vices, 2000). I n Florida the re ported c ases a nd rate s per 100,000 f or women ha ve incr ease d from 1999 to 2003 (CDC, 2004; Table 13). Women in Florida a re not scr eene d for chlamy dia as a standard of car e in many primary healthca re se ttings. Cases ha ve incre ased f rom 25,957 in 1999 to 34,581 in 2003. The infec tion rates continue to c limb, de sp ite he a lth e du c a tio n e ff or ts a nd ine xpe ns ive e ff e c tiv e tr e a tme nt. Ta ble 14 r e pr e se nts scre ening rate s for wome n in Florida a nd substantiates the conc ern tha t seconda ry preve ntion measures ma y have f ailed or a t least that scre ening must increase Table 13. Number of case s and incidenc e ra tes of chla my dia per 100,000 in women ag es 17 in Florida State repor tingF lorida Yea r 1999 2000 2001 2002 2003 Rate per 100,000 population 321.5 335.4 365.9 396.9 404.8 Cases 25957 27562 30647 33902 34581 (Center s for Disea se Control and Preve ntion, 2004). Table 14. Chlamy dia positivit y in women 15 by testing site in F lorida Testing Site Number of clinics Number te sted Perce nt found positive Fa mily planning 28 16131 4.1% STD clinics 25 4220 10.3 Prenata l clinics 13 3494 5.2 Ot he r N/ A N/ A N/ A (CDC, 2004)

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3 Current scr eening of women in F lorida may not be ade quate. The data r efle ct that c hla my dia wa s d ia g no se d in a sy mpt oma tic pa tie nts re g a rd le ss o f s e tti ng wi th t he hig he st rate of positivity occur ring in STD clinics. These sites do not include a ny population sp e c if ic ins tit uti on s su c h a s st ud e nt h e a lth c a re se rv ic e s o n a ny c a mpu s in F lor ida T his fac t is the rationale supporting this two-fold rese arc h purpose a nd the re sear ch questions. The Ame rica n College Hea lth Association 2004 Annual Pap Tests and STI Survey repr esents finding s with lower than e x pecte d rate s of chlamy dia in y oung women and hig her tha n expected ra tes in y oung men (Ame rica n College Hea lth Association [ACH A], 20 05 ; T a ble 15) T he a uth or s o f t he Am e ri c a n Co lle g e He a lth As so c ia tio n d a ta caution that these results may not be ac cura te, as provide rs re ported only the number of asy mptomatic case s if known, and c ited results as being imprecise ( ACHA, 2005). The curr ent ra tes of chla my dia infec tion rates for students who acc ess the Univer sity of Florida Student Health Care Center a re unknow n as of January 2006. These da ta make the a rg ume nt t ha t c hla my dia sc re e nin g fo r y ou ng wo me n o n c oll e g e c a mpu se s is no t on ly desired but imper ative. Ta ble 15. Re su lts fr om t he Am e ri c a n Co lle g e He a lth As so c ia tio n s ur ve y of pr ov ide rs Ra te s o f c hla my dia (C Z ) i n me n, wo me n, tho se pr e se nti ng wi th s y mpt oms (p os iti ve s) a nd tho se pr e se nti ng wi tho ut ( a sy mpt oma tic po sit ive s) Total Posit ive % positive As y mpt oma tic positive % of positive a sy mpt oma tic Undiffe rentiate d CZ 108602 4289 3.95 604 14.1 % Fe males with CZ 72565 2649 3.65 387 14.6% Males with CZ 13948 1110 7.96 131 11.8% (ACHA, 2005)

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4 Epide m iol og y o f Chl am ydi a The e pidemiology of chla my dia is depende nt on severa l fac tors. As descr ibed by Donovan ( 2004, p. 545) t h ey ar e t h e f o l l o wi n g: Sex ual mix ing pa tterns modera ted by protec tive behavior s Th e tr a ns mis sio n a nd pa tho g e nic ity of c hla my dia Demog raphic s Reporting prac tices of he althcar e provide rs I mplications of persona l judgment Normative be havior Social conditions Dec isions to s eek tr eatment There is no curre nt routine scre ening for c hlamy dia for stude nts who acc ess hea lth care se rv ic e s a t th e Un ive rs ity of F lor ida Stu de nt H e a lth Ca re Ce nte r. Chl a my dia sc re e nin g is offe red, but testing for c hlamy dia and other sexually transmitted infec tions is ex pensive, m o re t h an $ 1 0 0 p er t es t Be ca u s e i n cr ea s i n g ra t es o f c h l am y d i a i n fe ct i o n i n t h i s age g roup per sist on the state and national leve l, rates f or fe male students ac cessing the University of F lorida Student Hea lth Care Center should be eva luated. I n fac t, the epidemiolog y of chla my dia war rants re g ular scr eening of this population. Bec ause of these statistics, even in a n environment of limited re source s and controlled c osts, budge t allocations for chlamy dia scre ening must be considere d. Sex ual ac tivity along with other risk behavior ssuch as bing e drinking undera g e drinking sexual activity while using alcohol, and se x ual contac t without the use of bar rier me thodscontributes to the sprea d of thi s in fe c tio n a nd su g g e sts tha t th e se be ha vio rs or ri sk fa c tor s b e e xami ne d a nd the ir rela tionships ex plored (D onovan, 2004; Ross, 2002; Von Sadovsky Keller & McKinney 2002). Sexual Activity Sex ual ac tivity is a g roup of be haviors that includes pe nile vag inal intercour se, mutual masturbation, petting, or al sex, anal sex, penile vag inal intercour se, and se x ual

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5 e xpe ri me nta tio n w ith ob je c ts a nd div e rs e fo rm s o f l ub ri c a tio n ( Ros s, 20 02 ). Se xua l r isk taking is a subset of these behavior s that put an individual at risk for infe ction or abuse The most common form of se x ual risk taking is penile vag inal intercour se without the use of a condom (Gr ady & G illam, 2003). Adverse outcomes of se x ual risk taking include unwa nted pre g nancy and incr ease d rate s of sexually transmitted diseases (C oo pe r, 20 04 ). No t su rp ri sin g ly s e xua l r isk ta kin g is a lso a sso c ia te d w ith hig hri sk drinking in resea rch studies that e x plore c olleg e student beha vior (L aB rie, Schiff man, & Early wine, 2002; L icca rdone, 2003) Hig hRi sk D r inkin g Hi gh -r i s k d ri n k i n g i s d ef i n ed as u n d er age d ri n k i n g an d b i n ge d ri n k i n g. Bi n ge d ri n k i n g i s d ef i n ed b y re s ea rc h er s as fi v e o r m o re d ri n k s at o n e o cc as i o n (D ej o n g & L ang ford, 2002) Resear cher s repor t the adver se outcomes f or hig h-risk drinking as incre ased r ates of se x ually transmitted diseases, se x ual assault, batter y proper ty damag e, and eve n loss of life (Santelli, L owry Br ener & Robin, 2000; Sipkin, Grady Bissett, & Gi lla m, 2 00 3) Se xua l r isk ta kin g a nd hig hri sk dr ink ing se e m to ha ve a te mpo ra l e ff e c t, which mea ns that when sexual risk taking and hig h-risk drinking occur transmission rates incre ase f or chla my dia and other sexually transmitted diseases ( Chronister & McWhirter, 20 03 ; F oxma n e t a l., 20 00 ; K ir by 2 00 2) Re se a rc h s tud ie s a lso ind ic a te tha t se xua l r isk taking and hig h-risk drinking are some of the most preva lent exploratory behavior s prac ticed by fema le students (Wechsler et al., 2002). Transition to Cam pus Culture The a djustment to college offe rs cha lleng es re fer red to in re sear ch litera ture a s developmenta l transitions (Far row & Arnold, 2003). The se deve lopmental transitions are fr e qu e ntl y c ha ra c te ri zed by po pu la tio n s pe c if ic be ha vio rs T he y inc lud e the de sir e to

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6 h av e i n t i m at e e m o t i o n al an d s ex u al re l at i o n s h i p s u n d er age al co h o l u s e, b i n ge d ri n k i n g, sexual risk taking, a nd inclusion in social functions (F arr ow & Arnold, 2003; L icca rdone, 2003). Chlamy dia infec tion rates must be explored in the context of these deve lopmental transitioning be haviors as the y are products of pe rsonal dec ision making that include be ha vio rs a nd de c isi on s to se e k tr e a tme nt. Epi dem iologic Met hodol ogy Epidemiologic methodology incorpora tes population specific information and addre sses the ca usality and assoc iation of disease Epidemiologic causa lity includes associate d risks and re lationships between a disease a nd the ca uses of the disea se. Ep ide mio log ic c a us a lit y is a c omp le x inte ra c tio n o f i nf e c tio us or no nin fe c tio us a g e nts environmenta l and host fac tors that implies a direct r elationship among an ag ent, an e nv ir on me nta l or ho st f a c tor a nd a dis e a se (E va ns 1 97 8) F e a tur e s o f d ise a se c a us a lit y we re de sc ri be d b y Ev a ns in 1 97 8; t he y a re the fo llo wi ng : The ra te of pre valenc e is hig her in the e x posed population than in a none x posed population. Expo su re to t he inf e c tio us a g e nt i s mo re c omm on in t ho se dia g no se d th a n th os e wi tho ut t he ill ne ss. I ncidenc e ra tes should be hig her in those e x posed than those not exposed. Expo su re to t he su sp e c te d in fe c tio us a g e nt s ho uld pr e c e de sig ns a nd sy mpt oms Spe c if ic sig ns a nd sy mpt oms sh ou ld e xist. Expe ri me nta l r e pr od uc tio n o f t he dis e a se sh ou ld e xist. I n o the r w or ds th e dis e a se can be replica ted in labora tory setting. Eliminating the infe ctious ag ent should decr ease the incidenc e of the illness, and preve ntion or modification of sig ns and sy mptoms shoul d decr ease or eliminate the prese nce of the illness (Evans, p. 254, 1978).

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7 Host Disease Environment In contrast, a statistical association between a specific disease and a possible risk factor does not imply a causal relationship (Last, 2001). Statistical associations can be direct, indirect, or spurious (Gordis, 2000) Statistical analysis incorporated with epidemiologic method can determine direct, indirect or spurious associations. This analysis is essential in defining the interaction among host, pathogen, and environment. The classic epidemiological triangle graphically represents this interaction among host, pathogen, and environment, explaining the e tiology and epidemiology of both infectious and chronic disease (Mausner & Krammer, 1985; Figure 1-1). Figure 1-1.The epidemiologic triangle But epidemiologic causality as an indicator of disease prevalence is different from statistical and biological causality because it begins with the determination of the number of disease cases in a certain population (Rothman, 1976). For example, in the venue of public health and clinical practice, the choice of a treatment is based on physical assessment, available treatment and the known causality of the infection or disease (Rothman, Greenland, & Walker, 1980). Determining the causality or associated risk factors for acquiring chlamydia in the speci fic population of female university students requires review of current infection rates of chlamydia for these students. The epidemiology of chlamydia on a university campus includes disease causality and identification of associated risk factors.

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8 Genital chla my dia infec tion is di rec tly cause d by transmission during se x ual c on ta c t. P op ula tio n s pe c if ic a sso c ia te d r isk fa c tor s su c h a s c on do m us e h ig hri sk dr ink ing a nd se xua l r isk ta kin g ma y ha ve a dir e c t, i nd ir e c t, o r s pu ri ou s a sso c ia tio n w ith c hla my dia inf e c tio n r a te s. An a ly se s to de te rm ine wh e the r p op ula tio n a sso c ia te d r isk fa c tor s w e re a sso c ia te d w ith c hla my dia inf e c tio n o r s e e kin g c a re fo r a g y ne c olo g ic complaint are an esse ntial part of this rese arc h. Theoretic al F ram ework A theore tical fra mework pr ovides an e x planation and c larity for the r esea rch a nd its findings. The c hoice of theory is based on litera ture re view and a mplifies the purpose, questions and ra tionale for the rese arc h. Choice of Th eory Soc ia l Co g nit ive Th e or y (S CT) po stu la te s th a t he a lth -p ro te c tiv e be ha vio r r e su lts from a pr ocess of cog nitive appra isal with an integ ration of infor mation about disease, the ou tc ome s o f h e a lth be ha vio r d e c isi on ma kin g a nd the int e ra c tio n o f t he e nv ir on me nt, also descr ibed as socia l influence s (B andura 1986; Fig ure 12). Social Cog nitive Theory c on str uc ts a re a lso c on g ru e nt w ith nu rs ing the or y be c a us e the y a dd re ss e nv ir on me nt, behavior and per sonal aspec ts of behavior chang e in a dy namic re ciproc al re lational intercha ng e. I have c onstructed a g raphic repr esenta tion of Social Cognitive The ory (B andura 1986), which is similar to the Epidemiolog ic Triang le, using a triang ular model and including environment a s a major c onstruct (F igur e 1-2) Th e re su lt o f t his int e g ra te d p ro c e ss i s se lf -e ff ic a c y or a n e sti ma te of ho w w e ll a person will cope with a situation that moderates be havior (B andura 1990). Self-e ffica cy is a me a su ra ble c on str uc t w ith pr e dic tiv e po we r, pa rs imo ny a nd re lia bil ity (Wu lf e rt & Wan 1 99 5) T he c on str uc t pr ov e d to be so us e fu l it s o wn un iqu e the or y de ve lop e d. Th is

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9 Behavioral Capability Expectations Expectancies Self Control Self-Efficacy Reinforcement Observational Learning Emotional Coping Responses Reciprocal Determinism Situation Environment Personal Factors Environment Behavior theory provides a framework to explain the importance of a young womans choice of sexual behaviors (Few, 1997; Leganger, Kraft, & Roysamb, 2000; Sherwin, 1992). Figure 1-2.A model of social cognitive theory (Bandura, 1986) depicting construct groups in circles and the interactive relationship among the groups with bidirectional arrows Leganger and colleagues (2000) also reported that self-efficacy predicts behavior change because of its influence on individual decisions. Therefore, if a female college student exercises self-efficacy, she will determine for herself what her choices are about use of condoms or the amount of alcohol she consumes. Research findings suggest that a female college students choices for sexual health may depend on three key factors: selfefficacy, condom use, and perceived social support (Chronister & McWhirter, 2003). Self-efficacy Theory or SET, is the logical choice for this research because of its predictive value for behavior change and behavior maintenance (Bandura, 1977b, 1990).

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10 More spe cifica lly self-e ffica cy theory provides a r esea rch f rame work to examine incidence rate s of chlamy dia and the r elationships among condom use, sexual risk taking a nd hig hri sk dr ink ing in f e ma le un ive rs ity stu de nts by pr ov idi ng a the or e tic a l ba sis to explore the beha viors of these stude nts in relation to infection ra tes of chla my dia. P ur pos e Th e pu rp os e of thi s r e se a rc h w a s to de te rm ine c ur re nt i nfection rates of chlamydia in the student population that acc esses ser vices a t the University of F lorida Student Hea lth Care Center and to deter mine rela tionships among condom use self-e ffica cy score s in female stude nts, high-r isk drinking, se x ual risk taking and the c urre nt incidence rate s of chlamy dia infec tion. Re se ar c h Que st ion s What is t he re lationship among c ondom use self-e ffica cy scale score s and sexual risk taking behavior and hig h-risk drinking among the fe male colleg e students who acc ess servic es at a university student health ca re c enter ? What are the differ ence s in the number of se x ual par tners and the amount of hig hrisk drinking betwee n those who did and did not eng ag e in hig h-risk sexual a c t i v i t y? What are the combined ef fec ts of condom use self -ef fica cy scale score s, number of sexual partners, hig h-risk drinking and sexual risk taking behavior s on those with a g y ne c olo g ic a l c omp la int ? Summ ary This first chapte r provides ba ckg round informa tion on chlamy dia ra tes, the signific ance of this problem, and a choice of a the oretica l frame work. The impacts of condom use a nd population specific r isk factor sincluding hig h-risk drinking sexual risk taking and a stude nts decision to seek tr eatment f or a g y necolog ic complaintar e fa c tor s in re du c ing tr a ns mis sio n r a te s o f g e nit a l c hla my dia inf e c tio n ( B a rt h, Coo l, Do wn s, Swi tze r, & F isc hh of f, 20 02 ). Ep ide mio log ic me tho d p ro vid e s a fo un da tio n to

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11 examine population specific r isk factor s to determine c ausality and tra nsmissi on of c hla my dia inf e c tio n. Th e imp or ta nc e of a n in te g ra te d r e se a rc h s tud y us ing e pid e mio log ic method and theor y is ex plained with the purpose and re sear ch questions identified.

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12 CH APT ER 2 L I TERATURE REVI EW Cur re nt l ite ra tur e pr of fe rs thr e e re se a rc h p e rs pe c tiv e s r e la tiv e to c hla my dia infec tion and its relationship with condom use, sexual risk taking, hig h-risk drinking and colleg e students. These perspe ctives ar e pathobiolog ic, sociocultura l and beha vioral. The following para g raphs pr ovide a r eview of curr ent per spectives, a summary of cur rent rese arc h literature and the r ationale f or the theor y choice with proposed model as the fra mework f or this resea rch. P athobiol ogical P erspec tives Chl a my dia inf e c tio n is ty pic a lly stu die d f ro m a pa tho bio log ic a l vi e wp oin t. T his perspe ctive desc ribes a pa thoge n and host interac tion as the key to preva lence and incidence rate s (Stamm, 2001). Resear ch desc ribes tra nsmissi on emphasizing the vulnera bility of the va g ina as a host for infec tion (Colli er e t al., 1995; Dry den, Wil kinson, Redman, & Miller, 1994; Elkins & Cox 1974; Hooton et al., 2000; Os te rb e rg A sp e va ll, Gr ill ne r, & Pe rs so n, 19 96 ). Ha lti ng the sp re a d o f c hla my dia inf e c tio n b y pr e sc ri bin g se xua l a bs tin e nc e e xclu siv e ly is u nr e a lis tic a s a bs tin e nc e is a persona l behaviora l choice. Students choose to be sexually active f or many rea sons and condom use may be spora dic. Acc ording to resea rche rs at the Cente rs for D isease Control and Preve ntion (CDC, 2004) using c ondoms without fail is t he only behavior besides abstinence that can c ontrol chlamy dia transmission. A students persona l sex ual choice s aff ect c onsistent condom use. These choice s are in turn influence d by sociocultural a nd behavior al fa ctors and ma y become risk fac tors for wome n ag es 16 to 24.

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13 Chl a my dia inf e c tio n r e se a rc h id e nti fi e s a g e of the ind ivi du a l a s th e mos t important risk fac tor for a cquiring chlamy dia infec tion (United States Preventive Service s Task F orce [US PTF], 2002, CDC, 2004). Other associa ted risks wer e mar ital status, rac e, number of sexual partner s, cer vical ec topy history of infec tion with a sex ual ly tr ans mi tt ed d is ease and in con si st ent us e of c on do ms (C DC 2 00 4; US P TF, 20 02 ). Ne w d a ta fr om t he Ce nte rs fo r D ise a se Con tr ol a nd Pr e ve nti on in the fi rs t national re prese ntative study looking a t preva lence rate s in women ag es 14 to 39, ind ic a te tha t a lmo st 1 ou t of e ve ry 20 wo me n w e re re po rt e d to ha ve c hla my dia (C DC 2005). I n 2004, the Centers f or Disea se Control repor ted the cost of c hlamy dia infec tion and re lated morbidities at 374.6 million dol lars annua lly in the United States with an a nn ua l in c ide nc e ra te of 1. 5 mi lli on c a se s ( Wei r, 20 04 ). Th e re ha s b e e n a ste a dy inc re a se in infection ra tes since 1984 c omplicated by a 70% a sy mptomatic case rate (CDC, 2004; USP TF 2 00 2) T he Di vis ion of Se xua lly Tr a ns mit te d D ise a se s a t th e Ce nte rs fo r D ise a se Control and Prevention desc ribes seve ral c halleng es to the identifica tion and trea tment of this disease. One challeng e is the limitation of having only case repor ts to moni tor trends i n ch l am y d i a, i n co n s i s t en cy i n ca s e r ep o rt i n g l aw s an d a l ac k o f r o u t i n e s cr ee n i n g. Unfortuna tely in Florida, infe ction rate s remain hig h beca use chla my dia scre ening is not routine at most fema le annua l gy necolog ical exams. This puts women under the a g e of twenty at a c onsiderable risk (CDC, 2004). Hu and a ssociates (2004) conclude d that the persistent rise in c hlamy dia ra tes is a direc t response to fa ilures in primary and sec ondary preve ntion effor ts in the public health are na. The United States Preventa tive Task F orce re po rt s th a t in fe c tio n r a te s se e m to de c lin e wh e n la rg e -s c a le sc re e nin g a nd tr e a tme nt i s implemented (USPTF, 2002)

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14 Since primary preve ntion effor ts focus on educ ation, and sec ondary eff orts focus on scre ening and tre atment, the cost of sc ree ning a nd trea tment has bee n the topic of rese arc h and ca se studies. The c ost of trea tment for a pr imary infec tion is an important considera tion in an environment of c ost containment and rising presc ription costs. Recent c lin ic a l pr a c tic e lit e ra tur e ind ic a te s th a t tr e a tme nt o f c hla my dia inf e c tio n w ith do xy c y c lin e or a zith ro mic in i s e ff e c tiv e (A dim or a 2 00 2) D oxy c y c lin e tr e a tme nt i s curr ently $10.10 per r eg imen at the Univer sity of F lorida Student Hea lth Care Center (UF SHCC) and azithromicin follows closely behind at a c ost of $38.00 per r eg imen. Ef fe c tiv e tr e a tme nt i s n ot c os t pr oh ibi tiv e a t th e UF SHC C f or mos t st ud e nts The stre ng th of curr ent pathobiolog ical re sear ch is its specific a cknowledg ment of vag ueness or lack of sy mptoms wit h this infection and the r ecog nition of the so c ioc ult ur a l im pli c a tio ns (B re ne r & Go wd a 2 00 1) Pa tho bio log ic re se a rc h li te ra tur e is lim ite d in tha t it ha s n ot a dd re sse d th is s pe c if ic po pu la tio n, fe ma le un ive rs ity stu de nts who may or may not seek medic al trea tment for a va g ue g y necolog ic complaint. Whether the fa ilu re is i n p ri ma ry pr e ve nti on e ff or ts t ha t in vo lve e du c a tio n o r s e c on da ry e ff or ts that include costly scre ening and tre atment, fe male colleg e students re main at c on sid e ra ble ri sk fo r a c qu ir ing thi s in fe c tio n. F e ma le c oll e g e or un ive rs ity stu de nts embra ce a n attitude of invulnera bility a desire for be longing and intimate re lationships (Arne tt, 2004). Sociocultural Pe rspect ives Sociocultural per spectives must include population-a ssociated r isks including g e nd e r, a g e e thn ic ity r e sid e nc e s e xua l r isk ta kin g h ig hri sk dr ink ing a nd the ir respe ctive re lationships with each other Sex ual risk taking is a subset of these behavior s tha t pu t a n in div idu a l a t r isk fo r i nf e c tio n o r a bu se T he mos t c omm on fo rm of se xua l r isk

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15 taking is penile vag inal intercour se without the use of a condom (Gr ady & G illam, 2003). Hi g hri sk dr ink ing is d e fi ne d a s u nd e ra g e dr ink ing a nd bin g e dr ink ing B ing e dr ink ing is define d by rese arc hers a s five or more drinks at one oc casion (D ejong & L ang ford, 2002). This specif ic re sear ch litera ture e x amines the socia l pressure s of pee r g roups such as sorority pledg ing, da ting e vents and a thletics that directly influence sexual risk taking and hig h-risk drinking (Wechsler et al., 2002). A dditional resea rch litera ture de scribes t h e i n t er p er s o n al an d b eh av i o ra l i m p l i ca t i o n s fr o m s ex u al ri s k t ak i n g ac t i v i t y o n a c o l l ege campuse s; supporting c onsideration of the sociocultural e nvironment as a pr edictor of hig hri sk a c tiv iti e s ( Gu rm a n & B or zek ow sk i, 2 00 4) I nc on sis te nt c on do m us e is a persistent trend in se x ual beha viors for c olleg e and unive rsity students acc ompanied by a lc oh ol u se (B a y -C he ng 2 00 3) A dd iti on a l r e se a rc h n ote s th a t in c on sis te nt c on do m us e is highly corr elated w ith high-r isk drinking ( Albarr acin, Kumka le, & J ouhnson, 2004). Condom use is a persona l choice of sexual behavior influenc ed by associate d sociocultural f actor s. These f actor s include g ender -base d power rela tionships and peer g roup expectations. Malefema le power rela tionships are par t of g ender expectations and sociocultural influe nces tha t determine c ondom use and influenc e disea se transmission (G ome z & Va n O ss M a rt in, 19 96 ). Th e so c ioc ult ur a l e nv ir on me nt o f t he un ive rs ity campus may influence a fe male students c hoice to see k trea tment for sy mptoms of a se xua lly tr a ns mit te d d ise a se A n u nd e rs ta nd ing of the se so c ioc ult ur a l f a c tor s ma y a lso assist in the ex amination of population associa ted risk fa ctors and in the de velopment of eff ective inter ventions to decre ase c hlamy dia infec tion rates. Specific r esea rch on c olleg e students examined condom use, hig h-risk drinking and sexual risk taking deter mined that behavior al interve ntions were the most effe ctive me tho d o f d e c re a sin g ra te s o f s e xua lly tr a ns mit te d in fe c tio ns (H ir oza wa 2 00 1) H e a lth

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16 educa tion prog rams on univer sity and colleg e ca mpuses focus on e ducating students as a n in te rv e nti on a nd a pr ima ry pr e ve nti on me a su re a g a ins t nu me ro us ill ne sse s ( Col lin s, Duport, & Nag le, 2003 ). De veloping eff ective inter ventions to promote healthy behavior s spawned r esea rch studies that identified pe rson-e nvironment interac tion as an integ ral c oncept in this endea vor (Ma rtinelli, 1999). The intera ction betwee n person a nd e nv ir on me nt i s e sse nti a l to c on sid e r w he n r e se a rc hin g thi s sp e c if ic po pu la tio n: s tud e nts who intera ct in the sociocultura l environment of a colleg e or unive rsity campus. Hig hrisk drinking and sexual risk taking occur simult aneously as routine student be havior (Cooper, 2004) Resear ch litera ture notes that r isk behaviors a ppear in this new so c ioc ult ur a l e nv ir on me nt, c a mpu s li vin g a s st ud e nts ma ke the tr a ns iti on fr om h ome to campus life ( Renn & Arnold, 2003). R es ea rc h er s d es cr i b e t h e t ra n s i t i o n fr o m h o m e t o at t en d i n g a u n i v er s i t y o r c o l l ege as a c h al l en ge f o r m o s t y o u n g wo m en (F ar ro w & Ar n o l d 2 0 0 3 ). T h e c u l t u re o f a co l l ege campus is re plete with g ender and powe r issues. Examples include formation of ma le /f e ma le re la tio ns hip s a nd a c a de mic pr e ssu re s im po se d b y pr of e sso rs T he se situations in t hemselves a re not ha rmful, but making decisions on unfa miliar topics and navig ating the conse quence s and potentially neg ative situations is a challeng e for y oung fe ma le stu de nts M a kin g de c isi on s a bo ut s e xua l r isk ta kin g a nd inc re a sin g se xua l a c tiv ity is common for women in this ag e g roup (Smith, 2003). I ndividual conce rns about phy sical sy mptoms i n response to actively eng ag ing in intimate sexual activity are influence d by social expectations and pe rce ption of socio cultural or c ampus culture issues (B err y 2004). The de sire to establish intimate rela tionships wit h the appr oval of a nd a dh e re nc e to p e e r g ro up e xpe c ta tio ns ha s a c on sid e ra ble inf lue nc e on the fe ma le stu de nt. Stu de nts mus t e xer c ise ind e pe nd e nt c ho ic e s p os sib ly fo r t he fi rs t ti me in t he ir

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17 liv e s. Re a l or pe rc e ive d p ow e r i nf lue nc e s a re c ri tic a l to the ir pe rc e pti on s a nd c ho ic e s. Power re lationships are pa rt of g ender and socioc ultural expectations aff ecting condom us e a nd dis e a se tr a ns mis sio n b e c a us e the y inv olv e fe ma le s a nd ma le s ( Go me z & Va n O ss Martin, 1996). The ne g ative outcome of ignor ing a vag ue sy mptom or gy necolog ic complaint ma y be a by pr od uc t of a so c ioc ult ur a l e xpe c ta tio n. Th e so c ioc ult ur a l e xpe c ta tio n th a t a fe ma le wh o b e lie ve s h e r p a rt ne r i s f a ith fu l, d e c lin e s c on do m us e a nd wi ll n ot s e e k e a rl y trea tment for a g y necolog ic complaint. I n many instances ther e is a strug g le betwe en condom use a nd the desire of the fe male student to be pa rt of a c ouple, which may mean sex wit hout condom. Sex ual ac tivity is affe cted by power in interpersona l relationships during the neg otiation of condom use (F ew, 1997) Studies on sex ually transmitted diseases de scribe a moment, when a y oung wo ma n d e c ide s h ow w he n, a nd wi th w ho m sh e sh a re s se xua l a c tiv ity T his mom e nt i s sh a pe d b y he r s oc ioc ult ur a l e nv ir on me nt ( B e rr y 2 00 4; K e nn e y 2 00 0) T he re is a c on ne c tio n a mon g pe rs on b e ha vio r c ho ic e a nd ou tc ome tha t is a re pe a te d tr e nd in t he se studies. For e x ample if the e x pecta tion is t o have a boy friend, a n important part of soc ial a c c e pta nc e on c a mpu s, thi s ma y imp ly tha t se x is a n e xpe c te d. Ha vin g se x with ou t a condom is a demonstra tion of the students trust in her pa rtner ( Davidson-Ha rden, F isher, & D avidson, 2000). This conne ction is evidence d by a linear rela tionship among pe rson, behavior choice and outcome. T he student make s a choic e, has se lf-ef fica cy or lac k of se lf e ff ic a c y u se s a c on do m or de c lin e s to us e a c on do m, a nd the re su lt i s a sp e c if ic health outcome. Resear ch that addr esses the soc iocultural per spectives of male fe male intera ction addre sses the fa ct that not using a condom leave s the fema le vulnera ble to infec tion. The

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18 persistenc e of a partne r say ing, Every thing is okay may lead to the pe rce ption that there is low risk or no risk (Smith, 2003). I n eff ect, the f emale stude nt wants to believe the re is n o r isk be c a us e sh e wa nts to t ru st t ha t he r l ov e r w ou ld n ot d e c e ive he r j us t to have se x (Da vidson-Har den et a l., 2000). The pe rce ption of risk and infec tion are not signific ant cor rela tes. Fe eling that she is not at risk does not protec t the individual from inf e c tio n ( Ka lic hma n e t a l., 20 02 ). Th e stu de nt s r e a liza tio n th a t sh e is v uln e ra ble to infec tion is si g nificant be cause it affe cts the per ception of pr esenting sy mptoms and the decision to seek me dical tre atment (Opr endek & Malca rne, 1997) Th e inf lue nc e of so c ia l po we r u po n c on do m us e is s ig nif ic a nt, a s r e po rt e d in re se a rc h o n a c qu ir e d im mun e de fi c ie nc y sy nd ro me (A I DS) ; w he the r p e e rs us e c on do ms can a ffe ct individual condom use (Alba rra cin et al., 2004) Personal conc erns a bout vag inal irritation or burning upon urination are often c ompeting a g ainst the desire to deny previous sexual activity The pre sence of a g y necolog ical complaint or a vag ue sy mptom may be dismissed and medica l treatment de lay ed. Sex ual ac tivity and the de cision to use condoms are part of the sociocultural dy namic of tra nsitioni ng from living a t home to campus life, be coming sexually active, a nd ta kin g se xua l r isk s. Pos se ssi ng a c on do m a nd us ing it c or re c tly a re tw o d ist inc tly differ ent situations. Many times a condom is car ried a nd not used due to g ender expectations, what y oung men expect from their fema le par tners, and w hat y oung women may fee l their partne rs expect from them. The se expectations ar e also a lluded to as power issues or social pre ssures (A rnett, 2004). The stre ng ths of sociocultural r esea rch litera ture is a r ecog nition of the integ ration and impact of sociocultural influe nces, pe er pr essure to be in rela tionships, participation in h ig hri sk dr ink ing a nd se xua l r isk ta kin g T he lim ita tio n to thi s r e se a rc h li te ra tur e is that, althoug h the information is well docume nted, no re sear ch has e valuated a

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19 c omp a ri so n o f t he se be ha vio rs wi th c hla my dia inf e c tio n o r a g y ne c olo g ic c omp la int in this specific population. Behavioral Pe rspect ives Pitt s and collea g ues (Pitts, McMaster, Mang wiro, & Wooll iscroft, 1999) demonstrated tha t individual behavior and the sociocultural e nvironment deter mine whether trea tment is sought. B ehavior al re sear ch supports this finding a nd sug g ests that studies frame d by Social Cognitive The ory (SCT; Bandur a, 1977b), using the construc t of se lf -e ff ic a c y a re va lua ble pr e dic tor s f or be ha vio rs tha t in fl ue nc e se xua l he a lth (Tre mblay & F rig on, 2004; Tulloch, McCaul, Miltenberg er, & Smy th, 2004). C h l am y d i a i n fe ct i o n an d co rr el at ed p o p u l at i o n s p ec i fi c r i s k b eh av i o rs fo r c o l l ege students have not bee n published in curre nt resea rch litera ture, but condom use by y oung adults has. Condom use is hy pothesized to predict sexually transmitted infec tion rates and must be examined as population spec ific risk fa ctor for disease tr ansmission (Hirozawa 2001). Resea rch using health belief models, rea soned ac tion, and social cog nitive frame works indicate that condom use is best explored in rela tion to sex ual neg otiation (Wul fer t & Wan, 1995). Since the sexual neg otiating pr ocess is af fec ted by drinking drinking behavior s must be expl ored in re lation to condom use. Study data in colleg e student populations descr ibe a r elationship betwee n ag e at first drunkenne ss, and unplanned a nd unprotec ted sex (Hingson, H err en, Winter, & Wechsler, 2003) The e arlier drinking starts, the more likely unplanned a nd unprotec ted se x will oc c ur Re se a rc h c on fi rm s th a t pa tte rn s o f h ig hri sk dr ink ing sta rt pr ior to transitioning to ca mpus life and may actua lly esca late whe n students beg in their studies (Von Sadovsky et al., 2002). Studies also support the pre mise that highrisk drinking has

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20 ma ny po or ou tc ome s, inc lud ing inc re a se d s e xua lly tr a ns mit te d in fe c tio n r a te s, bo dil y injury and eve n death ( Staton et al., 1999). This sobering information furthe r illustrates the influenc e of c ampus culture, pe er gro u p s an d s o ci o cu l t u ra l ex p ec t an ci es o n ra t es o f p ar t i ci p at i o n i n h i gh -r i s k d ri n k i n g. Perce ived expectations of alc ohol use or alc ohol expectancies, in other words the soc ial expectations to drink or pee r pre ssure to drink, ar e sig nificant influenc es on students and their dec isions to participate in hig h-risk drinking Hig h-risk drinking which is define d as d ri n k i n g fi v e o r m o re d ri n k s o n an o cc as i o n i s l i n k ed t o s ex u al ri s k t ak i n g, inc on sis te nt c on do m us e a nd the a bs e nc e of ba rr ie r m e tho ds to p re ve nt t he se xua lly transmitted infec tions (L aB rie e t al., 2002). Over all, behavior and condom use rese arc h support the nee d for f urther study on a tti tud e s a bo ut t he ini tia tio n o f c on do m us e (D a vid so nHa rd e n e t a l., 20 00 ). Stu de nts attitudes about the informa tion they rec eive is cr ucial. Nur se re sear cher s repor t that even in t he c on te xt of a lif e -t hr e a te nin g ill ne ss, the stu de nts a c c e pta nc e of inf or ma tio n is para mount to the subsequent follow throug h or pra ctice of health promoting activities (Collins et al., 2003). Be cause infec tion rates ar e incr easing in the prese nce of primary p re v en t i o n a s t u d y t o ex am i n e f re q u en cy o f c o n d o m u s e b y s t u d en t s i s es s en t i al C o l l ege students repe atedly put themselves at risk by prac ticing unhe althy behavior such as sexual risk taking a nd highrisk drinking (Rozmus Evans, Wy sochansky & Mixon, 2 0 0 5 ). Ot h er ex am p l es ar e s m o k i n g, u s i n g i l l ega l d ru gs u n d er age d ri n k i n g, b i n ge drinking having sex wit h unknown par tners, and ha ving se x while under the influenc e of alcohol or dr ug s (Von Ah, Ebe rt, Ng amvitroj, Park, & DuckHee 2004). The stre ng th of thi s p e rs pe c tiv e in t he lit e ra tur e re vie w i s th a t it pr ov ide s a ba sis of re se a rc h th a t su pp or ts the se le c tio n o f r e se a rc h q ue sti on s. B ut t he lim ita tio n to thi s sp e c if ic g ro up of lit e ra tur e is

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21 the dea rth of re sear ch foc used on spec ific beha viors and g y necolog ic complaints or diag nosis of sexually transmitted infec tion and subsequent disea se transmission. The or e ti c al A pplic at ion and R at ion ale Self -Eff icacy Theory The c onstruct of self -ef fica cy derive d from socia l cog nitive theory (B andura 19 97 b) is w e ll t e ste d a nd ha s su c h r e lia bil ity fo r p re dic tin g he a lth be ha vio r t ha t it ha s it s own theore tical model. The the ory of selfeff icac y has fr amed studies that examined psy cholog ical aspe cts of ac ademic a chieve ment (Maddux & Stanley 1986; Multon, Br own, & L ent, 1991), c linical are as such a s depre ssion (Davis & Yates, 1982) social s k i l l s (M o e & Ze i s s 1 9 8 2 ), as s er t i v en es s (Lee, 1 9 8 3 1 9 8 4 ), p ai n co n t ro l (M an n i n g & Wri g ht, 19 83 ), a nd he a lth be ha vio rs (O L e a ry 1 98 5; P e nd e r, Mu rd a ug h, & Pa rs on s, 2002). This rese arc h foundation provides a suitable fra mework f or chla my dia infec tion rese arc h involving beha vioral and soc iocultural fa ctors. Self-ef fica cy involves the deve lopment of social, cog nitive, and beha vioral capa biliti es that must be org anized and tar g eted into a c ourse of action (B andura 1977b). Fe male univer sity students are adapting to campus life a nd desire to be succe ssful and competent. Competent func tioning in life re quires a sy nthesis of skills i n cog nitive, social, and be haviora l are as. The f emale unive rsity student is adapting and for ming be ha vio rs fo r h e r l if e wi th e xpe c ta tio ns of po sit ive ou tc ome s. F or e xamp le if sh e stu die s, she make s excellent g rade s that will result in a rewa rding car eer Self-ef fica cy theory involves three ma in constructs: person, be havior, a nd outcome as a ffe cted by eff icac y expectations and outcome e x pecta tions (Ba ndura, 1977a ). The f ollowing pa rag raphs descr ibe these ke y constructs a nd the re lational statements.

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22 Ke y Constructs Self-ef fica cy theory is a linear mode l with the construct of pe rson as the star ting point (rig ht-hand side of the model in Fig ure 21). Person is def ined as a human being who wishes to ac complish a beha vior cha ng e. The construct of behavior is defined a s a c tio ns tha t w ill a ff e c t th e fi na l c on str uc t of the ou tc ome or the ind ivi du a l s d e c isi on to perf orm, expend eff ort and pe rsist to achieve the re quisite behavior. The outcome, is the succe ssful completion of the re quired be havior or the desired be havior c hang e (B andura 1977b, 1997). Effic acy expectations are a g roup of c oncepts that impac t personal be havior a nd are influence d by perf ormanc e attainment, vica rious experience verba l persuasion, a nd phy siologic a rousal. Where as outcome e x pecta tions are c oncepts that foc us on persona l beliefs, that de sired beha vior cha ng e will be ac hieved ( Ba ndura, 1977a 1990). Relational Statem ents The re lationships among the thr ee ma jor construc ts of self-e ffica cy theory are un idi re c tio na l a nd lin e a r. Pe rs on dir e c tly a ff e c ts b e ha vio r, thu s b e ha vio r d ir e c tly imp a c ts outcome. Eff icac y expectations and outcome e x pecta tions have no direc t linear rela tionship among the ma jor construc ts, but are shown a s influencing both behavior a nd ou tc ome (t he br ok e n li ne s in F ig ur e 21; B a nd ur a 19 97 ; F itzg e ra ld, 19 91 ). Th is m od e l, e pid e mio log ic me tho do log y a nd re vie w o f t he c ur re nt s ta te of re se a rc h in c hla my dia fra me the two-f old purpose and que stions developed for this resea rch. Ra ti ona le Th e us e of se lf -e ff ic a c y the or y a s a fr a me wo rk fo r t his re se a rc h is log ic a l be c a us e of its pr e dic tiv e va lue in h e a lth be ha vio r c ha ng e a nd ma int e na nc e I t c a n a ssi st i n

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23 The Campus Environment Peer Group Subcultures Sexual Risk Taking High Risk Drinking Person Behavior Outcome Condom Use Female University Students Negative Chlamydia Screening Efficacy Ex p ectation Outcome Ex p ectation I can use condoms, not use condoms or choose abstinence Since I use condoms or practice abstinence I will not be infected with chlamydia. I will not have a gynecologic complaint describing the relationships among individuals, their specific behaviors, and a desired outcome. Therefore, the person, the female student entering the university setting, experiencing transitions and interacting with the environmental, develops expectancies. These expectancies include whether she can influence her own condom use, drinking patterns, and sexual behavior. Figure 2-1.Proposed Campus Chlamydia Model adapted from Banduras (1997) self-efficacy theory The chosen behavior will then directly affect the outcome. A choice to not use condoms, participate in binge drinking, and sexual risk taking may predict chlamydia positivity or the decision to seek treatment for a gynecological complaint. Since chlamydia has subtle symptoms the individual may not seek treatment and may then

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24 su ff e r p e lvi c inf la mma tor y dis e a se a nd /or inf e rt ili ty T he pr op os e d Ca mpu s Ch la my dia Model is adapted f rom self-e ffica cy theory The pe rson (fe male univer sity student) may or may not use condoms and the de sired outcome is a neg ative chla my dia scre en (F igur e 2-1) Subst r uc te d Co nst r uc ts and R e lat ion ship s Th e su bs tr uc te d th e or e tic a l f ra me wo rk be g ins wi th f e ma le un ive rs ity stu de nts There is a direc t relationship to behavior, spe cifica lly condom use without fail or abstinence The be havior is influenc ed by eff icac y expectations, denoted by a broke n line. When using c ondoms consistently or pra cticing abstinence the student ac hieves the outcome beha vior, a ne g ative chla my dia scre en. Outcome expectations are that if she prac tices consistent condom use or abstinence ; she avoids a c hlamy dia positive scre en, pa y ing fo r t re a tme nt m or bid ity of su bs e qu e nt p e lvi c inf la mma tor y dis e a se a nd po ssi ble s t e r i l i t y. Fa ilure to use condoms a nd the fa ilure to demonstrate self-e ffica cy puts the student at g rea ter risk for infec tion. The absenc e of c ondom use leads to infe ction, and condom use is the only measure other than a bstinence tha t preve nts transmission (Pinkerton, Abra mson, & Tur k, 1998). To mea sure c ondom use self-e ffica cy the Con do m U se Se lf -E ff ic a c y Sc a le wa s d e ve lop e d ( B ra ff or d & B e c k, 19 91 ). Th is t oo l, which y ields a condom use se lf-ef fica cy score will be used to measur e the students se lfeff icac y in using a condom. Carr y ing a condom and using a condom with selfeff icac y are two differ ent situations for the fe male univer sity student. The propose d Campus Chlamy dia Model will provide a f rame work to examine the impact of soc iocultural fac tors such as c lass standing and re sidency along with behaviora l fac tors like condom us e se lf e ff ic a c y c on do m us e a nd hig hri sk dr ink ing on c hla my dia inf e c tio n r a te s.

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25 Sta tis tic a l a na ly sis a nd fi nd ing s ma y su pp or t or re fu te the mod e l a nd wi ll b e dis c us se d in Chapter 5. Summ ary This literature r eview a ddresse s pathobiologic al, environme ntal, and beha vioral aspec ts of the phenomenon of rising r ates of c hlamy dia in y oung women who a ttend a colleg e or unive rsity I t describe s the theory of selfeff icac y introduces the pr oposed Ca mpu s Ch la my dia Mo de l to de sc ri be the ph e no me no n o f i nc re a sin g c hla my dia infec tion, and provides a f rame work for rese arc h.

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26 CH APT ER 3 RESEARC H I MPL EMENTATI ON Th is c ha pte r d e sc ri be s th e re se a rc h s tud y a nd its imp le me nta tio n. Th e tw ofo ld purpose of this resea rch w as to deter mine curr ent incidenc e ra tes of chla my dia in the student population that acc esses ser vices a t the University of F lorida Student Hea lth Care Ce nte r a nd to d e te rm ine re la tio ns hip s a mon g c on do m us e se lf -e ff ic a c y sc or e s in fe ma le students, high r isk drinking, se x ual risk taking and the c urre nt incidence rate s of chlamy dia infec tion. Rese arch De sign A desc riptive crosssectional study method was c hosen bec ause this appr oach g ather s information from one population at a g iven point in tim e using a conve nience sample (Hulley et al., 2001). Results from a chlamy dia questionnaire completed by fema le students wer e ana ly zed and then cur rent c hlamy dia infec tion rates as r eporte d by labora tory rec ords wer e eva luated. P owe r Ana lys is a nd Sam ple Siz e Est im at ion s Clin ic ia ns of te n tr e a t a g y ne c olo g ic c omp la int ra the r t ha n te st f or a se xua lly transmitted infec tion because of cost to the student. I t is much chea per in many instances to treat with a pr escr iption than to pay the cost of testing and tre atment. The use of the bin omi a l de pe nd e nt v a ri a ble g y ne c olo g ic c omp la int a c c ou nts fo r t his pr a c tic e T his dummy varia ble expresses either the abse nce or prese nce of a g y necolog ic complaint descr ibed as y east infe ction, bacte rial vag inosis, chlamy dia, g onorrhe a, her pes, or HPV.

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27 He a lth c a re pr ov ide rs ma y se e on a ve ra g e 10 to 2 0 p a tie nts on a g ive n d a y T he sa mpl e size re qu ir e d to de te c t st a tis tic a l si g nif ic a nc e ba se d o n r e sp on se s f ro m th e c hla my dia questionnaire pilot was a chieve d. Three hundred twe nty -five que stionnaires we re collecte d. Only those that had leg ible response s and we re c omplete wer e used f or analy sis, a total of 285. Th e pr e dic te d s a mpl e size of thi s d e sc ri pti ve stu dy re lie d o n a re a so na ble confide nce be cause no hy pothesis testing oc curr ed (H ulley et al., 2001). A ssuming that 30 % o f t he fe ma le stu de nts c omi ng to a un ive rs ity c lin ic ha ve a g y ne c olo g ic a l c omp la int ap p ro x i m at el y 8 1 s u b j ec t s we re re q u i re d i f t h e e s t i m at e i s t o fa l l wi t h i n 1 0 p er ce n t age points of the true propor tion with 95% confidenc e. On the othe r hand, ba sed on a formulation of 80% pow er, a medium critical e ffe ct size of 0.30, and a sig nificanc e leve l of 0. 05 fo r a tw ota ile d te st, a sa mpl e of 10 6 s ub je c ts w a s d e e me d s uf fi c ie nt t o a dd re ss the re la tio ns hip be tw e e n c a te g or ic a l va ri a ble s. F or te sti ng the dif fe re nc e in o utc ome varia bles, g iven the median e ffe ct size and 80% powe r, 62 subjects pe r g roup we re sufficie nt. Finally to determine the corr elation betwe en the outcome varia bles, g iven a me diu m e ff e c t si ze a nd 80 % p ow e r, 82 su bje c ts w e re re qu ir e d to a dd re ss t he re la tio ns hip questions. The Gpowe r computer softwar e (Er dfelde r, F aul, & Buc hner, 1996) was used to calcula te the re quired sample size. Se tt ing and Su bj e c t R e c r uit m e nt Th e Un ive rs ity of F lor ida Stu de nt H e a lth Ca re Ce nte r i s f ull y sta ff e d w ith pe rs on ne l to me e t th e he a lth c a re ne e ds of tho se stu de nts re qu ir ing wo me n s h e a lth ex am i n at i o n s co u n s el i n g o n b i rt h co n t ro l m et h o d s s ex u al l y t ra n s m i t t ed d i s ea s e t es t i n g, and wa lk-in appointments as nee ded. I t has also bee n the site of pre vious resea rch. The

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28 Student Health Care Center a t the University of F lorida and its satellite clinics ser ve the health ca re ne eds of a pproxi mately 27,000 fema le students annually The main c ampus and sate llite clinics provide similar service s with private ar eas to complete hea lth hist ory information and c onfer with the health ca re pr oviders about confide ntial conce rns. Approve d fly ers invited the students to par ticipate in this study and an e x planation of the study s purpose a nd instructions were attache d to the front of chlamy dia questionnaire Instrum ents Chlam ydia q uestionnai re. The student volunteer subject wa s g iven a c over le tter explaining the purpose of the study a selfrepor t chlamy dia questionnaire A questionnaire inc luding de mogr aphic infor mation, questions on sex ual beha vior, hig hrisk drinking trea tment for sexually transmitted diseases, a nd the Condom Use SelfEffic acy Scale ( Appendix A) was used to g ather rese arc h data. This combined questionnaire sc ale include s the 28 items developed a nd validated by rese arc hers a t the University of Mar y land named the Condom Use Self-Eff icac y Scale ( Br aff ord & Be ck, 1991). This instrument was used to c ollect data on c ondom use, hig h-risk drinking be ha vio rs a nd se xua l r isk ta kin g I te ms w e re e ith e r f ill -i nthe -b la nk or mul tip le response s with answer s to cirlce. Condom U se Self-Ef fi cacy Scale Th e Con do m U se Se lf -E ff ic a c y Sc a le (CUSES) is based on selfeff icac y theory (B andura 1997b) and w as used to study cog nitive and beha vioral pre dictors of sexually transmitted diseases in a dolesce nt and y oung adults (Sieving e t al., 1997). I t was deve loped from be haviora l theory and has be e n te ste d f or re lia bil ity a nd va lid ity I t ha s a pr ov e n Cr on ba c h s a lph a of 0. 91 a nd te strete st corre lation equaling 0.81 (B raf ford & Be ck, 1991). The CUSES resear ch

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29 co m p l et ed at u n i v er s i t i es i n t h e M i d we s t v er i fi ed i t s re l i ab i l i t y d em o n s t ra t i n g a Cronbach s alpha of .94 f or the sca le and a reliable application to colleg e student re se a rc h ( Pe te rs on & Ga ba ny 2 00 1) E a c h it e m on the sc a le re qu ir e s th e stu de nt t o c ir c le a n it e m on a 5po int re sp on se fo rm a t r a ng ing fr om str on g ly dis a g re e (s c or e d a s 1 ) t o "strong ly ag ree ( score d as 5) in this rese arc h. The scor ing is re verse d on items 8, 9, 10, 15, 16, 17, and 18. The score s for e ach item a re the n summed y ielding a total score r a n g i n g f r o m 0 1 4 0 w i t h h i g h e r s c o r e s i n d i c a t i n g g r e a t e r c o n d o m u s e s e l f e f f i c a c y. Table 31 provides a sa mple of the que stions included. I n studies focused on the development of the condom use se lf eff icac y scale by Br aff ord & Be ck (1991) a hig h CUSES s core emer g ed as pr edictor of chang e in sexual risk behavior an indicator for spe cific he alth educa tion topics such as applica tion of condoms and a dditional resea rch to support these finding s (Satha, Ha nna, & Rodcumdee, 20 05 ; Sie vin g e t a l., 19 97 ). I n p a rt ic ula r, Pe te rs on & Ga ba ny ( 2 00 1) fo un d th a t st ud e nts a t th e ir mid we ste rn un ive rs ity wh o r e po rt e d u sin g c on do ms c on sis te ntl y du ri ng the la st 30 day s score d statistically signific antly highe r on the CUSES. Ta ble 31. Exa mpl e s o f q ue sti on s u se d in the Con do m U se Se lf -E ff ic a c y Sc a le Str on g ly disag ree Disag ree Undec ided Ag ree Str on g ly ag ree I fee l confident that I could re member to c a rr y a c on do m w ith me sh ou ld I need one I fe e l c on fi de nt i n my a bil ity to discuss condom usag e with any partne r I might have Th e se re su lts a re me a nin g fu l be c a us e c on do m us e re qu ir e s so me te c hn ic a l sk ill a nd ma y re qu ir e ne g oti a tin g wi th a re sis ta nt p a rt ne r o n s ome oc c a sio ns T he sc a le integ rate s condom use neg otiation, confidenc e about a pply ing c ondoms, and using c o n d o m s w h i l e d r i n k i n g o r u s i n g m a r i j u a n a ( B r a f f o r d & B e c k 1 9 9 1 ; P e t e r s o n & G a b a n y,

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30 2001). The pur pose of using the CUSES was to evaluate repor ted condom use se lfeff icac y in those students who completed the que stionnaire. Resea rch e valuating and utilizing this tool noted that convenience sampling and self-report were listed as lim ita tio ns to t he too l; d e sp ite thi s r e po rt th e tool has demonstrated reliability (B raf ford & Be ck, 1991; Cecil & Pinkerton, 1998; Peterson & Gaba ny 2001). Condom use selfeff icac y is integr al to this resea rch be cause condom use is identified a s the key preve ntative measur e to stop the sprea d of chla my dia (USPTF, 2002) D a t a A na ly s is o f L a bo r a t o r y R e v ie w Chlamy dia infec tion rates we re de termined fr om reporte d finding s from the Student Health Care Center s laborator y manag er. The labora tory manag er sig ned a confide ntiality ag ree ment prior to re sear ch implementation. Then, a fter r eview of positive chlamy dia test results, provided de identified data that assisted in determining g ender residenc e, and r einfe ction for students ac cessing health ca re se rvice s at the Un ive rs ity of F lor ida Stu de nt H e a lth Ca re Ce nte r. Pos iti ve la bo ra tor y te sts wi th deidentified da ta conf irming Chlamy dia infec tion were collecte d from labor atory finding s. These r aw da ta wer e tra nsfer red to a log on a password pr otected c omputer file. Th is f ile wa s th e n tr a ns fe rr e d to a sta tis tic a l a na ly sis da ta sh e e t f or fu tur e a na ly sis (Appe ndices B and C). Ra te s c a lc ula te d f ro m 20 05 ind ic a te d th a t la bo ra tor y re su lts of se xua lly tr a ns mit te d d ise a se da ta re ve a l a 7% inc ide nc e ra te of c hla my dia inf e c tio n in fe ma le s. These r ates a re c onsistent with increasing trends and a re a lmost t wice a s high a s rates repor ted by the Amer ican Colleg e He alth Association (ACHA, 2005) They wer e compar ed to the ca se ra tes repor ted by the Alac hua County Hea lth Depar tment, the F lor ida De pa rt me nt o f H e a lth a nd na tio na l pr e va le nc e ra te s f or wo me n a g e s 1 8 to 24 to

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31 deter mine whether rate s for fe male students ac cessing health ca re se rvice s at the University of F lorida Student Hea lth Care Center wer e consistent with cur rent rising rate s repor ted locally statewide, a nd nationally Da ta Co lle c ti on M e th ods Com ple te d a no ny mou s q ue sti on na ir e s f ro m vo lun te e r s ub je c ts w e re us e d to g ather data a nd as a stra teg y to ensure a ccur ate se lf-re port for se x ual ac tivity condom use, and hig h risk drinking These que stionnaires we re c ollected a t the University of Florida Student Health Care Center c linic on the main campus. A le tter of e x planation was a ttached to the f ront of the que stionnaire that explained the purpose of the study and pr ov ide d c on ta c t in fo rm a tio n a nd ins tr uc tio ns fo r c omp le tin g the qu e sti on na ir e St ud e nts completed the que stionnaires and pla ced the m in an envelope These e nvelopes we re collecte d on a daily basis by the principa l investiga tor. Questionnaire s were collecte d until the number of subjec ts require d for statistical ana ly sis was met. The time per iod for raw data c ollection was a pproxi mately 3 wee ks. Th e qu e sti on na ir e inf or ma tio n w a s e nte re d o n a sta tis tic a l pr og ra m va ri a ble da ta sheet to fa cilitate ana ly sis at a later date. The computer use d was pa ssword protec ted and data we re loc ked in a f iling ca binet behind a locke d door to ensure confide ntiality Analysis of Questionn aire Dat a Desc riptive statistics were used to obtain the summary measure s for a ll data, including a descr iption of the sample cha rac teristics. Desc riptive statistics included means, media ns, rang e, and sta ndard de viations for continuous var iables. Categ orica l v ar i ab l es we re s t at i s t i ca l l y re p re s en t ed i n fr eq u en cy d i s t ri b u t i o n s p er ce n t age distributions and g raphic al illustrations. A p -value of less than 0.05 wa s considere d sta tis tic a lly sig nif ic a nt.

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32 For the eva luations of the re sear ch questions, Wilcox on rank sum test wa s used when two g roups wer e compa red. Spea rman c orre lation analy sis was used to deter mine the cor rela tion between the varia bles. Analy sis of fre quency was utiliz ed to deter mine the rela tionship between c ateg orica l variable s. Finally logistic re g ression ana ly sis was used to e xplor e po te nti a l di ff e re nc e s in pr e dic tor va ri a ble s b e tw e e n th os e wi th a nd wi tho ut a g y ne c olo g ic a l c omp la int Et hic al C ons ide r at ion s University students are a re adily acc essible hea lth population and are considere d vulnera ble bec ause of economic a nd power rela tionship i ssues betwe en prof essors and students. There fore no rese arc h implementation of any kind was done until the study pr oto c ol w a s r e vie we d a nd a pp ro ve d b y the I ns tit uti on a l Re vie w B oa rd a t th e Un ive rs ity of F lorida and the medical dire ctor of the University of F lorida Student Hea lth Care Center. Re c ru itm e nt w a s c omp le te d w ith sp e c ia l c on c e rn fo r t he stu de nts v uln e ra bil ity a nd a c c e ssi bil ity H e a lth c a re wa s p ro vid e d to stu de nts re g a rd le ss o f t he ir pa rt ic ipa tio n in the study and no medica l treatment wa s denied a t any time if they ref used to participa te. Al l r e sp on se s w e re a no ny mou s a nd c on fi de nti a l, a nd the re vie w o f c hla my dia c a se re po rt ing wa s d on e wi tho ut i de nti fi e rs H e a lth I ns ur a nc e Por ta bil ity a nd Ac c ou nta bil ity Act (H I PAA) g uidelines wer e obser ved. Summ ary This chapter explained the rese arc h study desig n, including da ta collec tion, power analy sis and sample size estimation, recr uitment, inst ruments, and e thical consider ations to implement the resea rch.

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33 CH APT ER 4 FI NDI NGS Introduction Re se ar c h P ur pos e The purpose of this resea rch w as to deter mine curr ent infec tion rates of chlamy dia in the student population that acc esses ser vices a t the University of F lorida Student Health Care Center a nd to determine relationships among condom use selfeff icac y score s in female stude nts, high-r isk drinking, se x ual risk taking and the c urre nt incidence rate s of chlamy dia infec tion. Re se ar c h Que st ion s What is t he re lationship among c ondom use self-e ffica cy response s and sexual risktaking behavior and hig h-risk drinking among the fe male colleg e students who acc ess servic es at a university student health ca re c enter ? What are the differ ence s in the number of se x ual par tners and the amount of hig hrisk drinking betwee n those who did and did not eng ag e in hig h-risk sexual a c t i v i t y? What are the combined ef fec ts of condom use self -ef fica cy scale score s, number of sexual partners, hig h-risk drinking and sexual risk taking behavior s on those with a g y ne c olo g ic a l c omp la int ? I n th is c ha pte r, inf e c tio n r a te s o f c hla my dia fo r t ho se stu de nts wh o a c c e ss service s at the Univer sity of F lorida Student Hea lth Care Center (UF SHCC) are descr ibed, the sample c hara cter istics of those fema le students who completed the chlamy dia questionnaire are descr ibed, and the r esea rch que stions are a ddresse d.

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34 Inf ect ion Rates I nfec tion rates for students who acc ess the UF SHCC were c alculate d from de ide nti fi e d d a ta pr ov ide d b y the la bo ra tor y ma na g e r. Th e inc ide nc e of c hla my dia infec tion for these students for the ca lendar y ear 2005 and ra tes for January 2006 are provided in Table 4-1. This table re prese nts an incre asing trend in infec tion rates base d on the number of students tested and the time of y ear A bre akdown of perc entag es betwee n males and f emales w as unava ilable prior to Jul y 2005. Rates among males and fema les are varia ble, and this may be a r esult of incre ased sc ree ning done by healthca re pr ov ide rs du e to t he a va ila bil ity of ur ine sc re e nin g te sts a t a re du c e d c os t. Table 41. Chlamy dia infec tion data for stude nts who acc ess servic es at the U niversity of Florida Student Health Care Center Month/Year To ta l st ud e nts te ste d/N P er ce n t age positive total/(N) P er ce n t age positive fema le/(N) P er ce n t age positive male/(N) J anuar y 2006 235 5.1 (12) 1.3 (3) 3.8 (9) Dec ember 2005 208 7.8 (16) 5.2 (11) 2.4 (5) November 2005 235 6.4 (15) 3.0 (8) 2.9 (7) October 2005 290 6.5 (18) 3.7 (11) 2.8 (7) September 2005 389 5.4 (21) 2.6 (10) 2.8 (11) Aug ust 2005 152 5.2 (8) 2.0 (3) 3.2 (5) J uly 2005 149 7.4 (11) 2.7 (4) 4.7 (7) J une 2005 120 3.3 (4) * May 2005 154 3.2 (5) * April 2005 245 4.5 (11) * Marc h 2005 263 6.1 (16) * Fe bruar y 2005 238 9.2 (22) * J anuar y 2005 285 7.0 (20) * M iss ing da ta U na va ila ble Table 42 illust rate s the demog raphic char acte ristics of students testing positive and notes the me an ag e as 20, w ith females testing positive 70% versus male s at 30%. The e thnicity of those testing positive were white at 25%, B lack a t 21.4%, Hispanic a t 12 .9 %, a nd As ia n a t 4. 3% N o r e pe a t in fe c tio ns we re no te d. Th e ma jor ity of the stu de nts

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35 who tested positive g ave a n apar tment addre ss as their re sidence with dormitories the next frequent and a fra ternity or sorority house as the lowe st reporte d place of re sidence Th e a ve ra g e de mog ra ph ic c ha ra c te ri sti c s o f t ho se wh o te ste d p os iti ve fo r c hla my dia inf e c tio n w e re 20 y e a rs of a g e f e ma le w hit e a nd re sid ing in a n a pa rt me nt o ff c a mpu s. This demog raphic information and the c ase r ates we re not a vailable pr eviously Ta ble 42. De mog ra ph ic c ha ra c te ri sti c s f or stu de nts te sti ng po sit ive fo r c hla my dia infec tion Demog raphic Fr equenc y /Perce nt Ag e (20) 18.0% Gende r Fe male (56) 70.0% Male (31) 30.0% E t h n i c i t y* Whit e (20) 25.0% Bla ck (16) 21.4% Hispanic (9) 12.9% Asian (3) 4.3% Residence Offcampus a partment (56) 75.7% On-c ampus dormitory (11) 14.3% On-c ampus sorority /frate rnity house (1) 1.4% Offcampus home (6) 8.5% M iss ing da ta Chlam ydia In cidence Rat es for 2004 This rate w as re ported a s 3.8% by the Amer ican Colleg e He alth Association and is considere d the national ave rag e (A CHA, 2005). Responding student health ca re c enter s had enr ollment siz e ra ng ing f rom 836 to 51,827, with a mean size of 15,049 (A CHA, 20 05 ). Un fo rt un a te ly in 20 04 no da ta we re c oll e c te d o r e va lua te d f or g e nit a l c hla my dia inf e c tio n in stu de nts wh o a c c e sse d s e rv ic e s a t th e UF SHC C.

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36 Incidence Rate s for 2005 The incide nce r ate of chlamy dia infec tion for students who ac cesse d health ca re service s at UF SHCC was calcula ted using the total number of ne w ca ses diag nosed divided by the total number of pe rsons at risk. The de nominator, persons a t risk, were tho se ind ivi du a ls i de nti fi e d b y he a lth c a re pr ov ide rs wh o w e re a t r isk fo r c hla my dia infec tion. These ra tes wer e ca lculated a t 5.8% for 2005 f or the UF SHCC. The rates for the Amer ican Colleg e He alth Association have not been published for 2005; these ra tes might also incr ease Incidence Rate s for 2006 Chlamy dia infec tion rates for students who acc ess servic es at the U F SHCC thus far in 2006 y ield a ra te of 5.1%. I nfec tion rates fr om the first few months of 2006 do not nece ssarily ref lect the a vera g e infe ction rate of chla my dia for the entire y ear Subsequent analy sis of these ra tes will be completed w hen data from all months are available Com parisons of National and State Dat a I n c omp a ri so n to the na tio na l da ta pr ov ide d b y the Am e ri c a n Co lle g e He a lth Association, the infe ction rate s for students who a cce ss service s at the UF SHCC are 1.5 times the national ave rag e of 3.9% This is consistent with t he infe ction rate s repor ted by the Alac hua County Hea lth Depar tment (Florida Depa rtment of He alth, 2006). The compar isons are note d in Table 4-3. Ta ble 43 p ro vid e s a c omp a ri so n b e tw e e n r e po rt e d c hla my dia inf e c tio n in students who acc ess hea lth care at a c olleg e or unive rsity student health ca re c enter in the United States and the r eporte d infec tions of chlamy dia at the UF SHCC. These rate s are compar able be cause of the methodolog y used to ana ly ze perc entag es. To ar rive a t the rate s, those testing positive we re divided by the total students tested (P. Davis-Smith,

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37 pe rs on a l c omm un ic a tio n, Ap ri l 5, 20 06 ). I n c on tr a st, sta tis tic s f ro m th e Al a c hu a c ou nty health depa rtment are repor ted by case only Reporting of chla my dia is require d by law in F lor ida (F lor ida De pa rt me nt o f H e a lth 2 00 6) T he nu mbe r o f c a se s o f c hla my dia infec tion in Alachua c ounty has more tha n doubled in 9 y ear s, from 480 in 1995 to 1134 in 2004 (Florida Depa rtment of He alth, 2006). Table 43. Chlamy dia infec tion rates as r eporte d by the ACHA a nd the Univer sity of Florida Student Health Care Center Reporting ag ency Yea r Perce nt of c hla my dia infec tions repor ted/(N) Perce ntag e of fema les/(N) Perce ntag e of males/(N) Am e ri c a n Co lle g e He a lth Association* 2004 3.9 3.6 7.9 University of F lorida Student Hea lth Care Center 2005 5.8 (158) 3.2 (87) 2.6 (71) R e p o r t e d i n p e r c e n t s o n l y. Que st ion nai r e Ana lys is Sam ple Characte ristics The que stionnaire wa s offe red to fe male students who accessed care at the UF SHCC for any rea son. During a 3-w eek pe riod, 328 questionnaire s were collecte d. Qu e sti on na ir e s th a t w e re c omp le te a nd le g ibl e we re us e d f or a na ly sis T he sa mpl e c on sis te d o f 2 85 qu e sti on na ir e s. De mog ra ph ic c ha ra c te ri sti c s a lso we re de ri ve d f ro m th is questionnaire; de tails of these c hara cter istics are illustrated in Ta ble 4-4. The ag es ra ng ed from 18 to 31 y ear s with the mean a g e of 20.81 y ear s (SD = 1.85, Media n = 21 y ear s). The majority of students (74%) wer e Cauc asian, a nd resided of f ca mpus, 78.2%. Senior students made up the lar g est perc entag e of subjec ts, 27.02%. Va r iab le s The va riables se lected f or ana ly sis were deter mined from a liter ature revie w of the epidemiolog y of g enital chlamy dia infec tion. I ndepende nt variable s were ag e,

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38 nu mbe r o f s e xua l pa rt ne rs c on do m us e se lf -e ff ic a c y sc a le (C USE S) sc or e s, se xua l r isk ta kin g a nd hig h r isk dr ink ing T he de pe nd e nt v a ri a ble g y ne c olo g ic c omp la int a du mmy varia ble, re flec ted either the pre sence or abse nce of a diag nosis or treatment of c hla my dia g on or rh e a h e rp e s, HPV y e a st i nf e c tio n, or ba c te ri a l va g ini tis T his depende nt variable was c hosen bec ause of the fre quent pra ctice by health ca re pr oviders to t re a t st ud e nts ra the r t ha n te sti ng fo r S TI du e to c os t c on c e rn s. F re qu e ntl y tr e a tme nt i s ch ea p er t h an t es t i n g. Hig h-risk drinking was de fined a s five or more drinks on one occ asion and deter mined by response s from subjects noting how many occa sions in the past y ear they had five or more dr inks and how many alcoholic dr inks they consumed on e ach oc casion. For the purposes of this resea rch, se x ual risk taking was de fined a s inconsistent or a bs e nc e of c on do m us e du ri ng se xua l c on ta c t. T his wa s c a lc ula te d f ro m r e sp on se s to questions that asked how of ten the subjec t used condoms. I nitial analy sis of the i n d e p e n d e n t v a r i a b l e s i n c l u d e d f r e q u e n c i e s a n d o t h e r m e a s u r e s o f c e n t r a l t e n d e n c y. Ta ble 44 d isp la y s th e de mog ra ph ic c ha ra c te ri sti c s o f s tud y pa rt ic ipa nts in t his descr iptive resea rch. Discussion Table 45 provides desc riptive statistics of three va riables. The mean a g e for the sample size is 20 with a SD of + or 1.8 y ear s. Thirty -one pe rce nt of the student volunteer subjec ts reporte d they never participa ted in highrisk drinking in the past 12 months. Conversely 68% of the stude nt volunteer subjec ts reporte d they had par ticipated in highrisk drinking (more tha n 5 drinks at a sitting) The hig hest repor ted fre quency of c on sis te nt c on do m us e wa s 2 9% of the tim e ; 27 % reported never using condoms. This ind ic a te s th a t st ud e nts pa rt ic ipa te in h ig hri sk se xua l be ha vio r b y no t us ing c on do ms ev er y t i m e d u ri n g s ex at l ea s t 7 1 % o f t h e t i m e. Summary measure s of the var iables ag e,

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39 nu mbe r o f s e xua l pa rt ne rs h ig hri sk dr ink ing n umb e r o f o c c a sio ns to d ri nk in t he pa st 2 wee ks, the number of drinks on these oc casions, the number of times students were drinking and having sex, and the CUSES score s are listed in Table 4-6. Table 44. Demog raphic char acte ristics of study participa nts (n = 285) Var iable Fr equenc y (N) Perce nt Et hn ic ity Cauca sian 211 74.04 Hispanic 33 11.58 Afric an Amer ican 23 8.06 Asian 9 3.16 Other 9 3.16 Residence On-c ampus dormitory 53 18.60 On-c ampus sorority /frate rnity 9 3.16 Offcampus a partment 208 72.98 OffcampusL iving a t home 15 5.26 Class standing Fr eshman 50 17.54 Sophomore 42 14.74 J unior 62 21.75 Senior 77 27.02 Gra duate Student 54 18.95 Table 45. Fr equenc y of condom use a nd highrisk drinking Var iable Fr equenc y (%) Fr equenc y of condom use in the la st 12 months Neve r 77 (27.02) 20% of the time 42 (14.74) 50% of the time 42 (14.74) 70% of the time 41 (14.4) Alway s 83 (29.1) Fr eq u en cy o f h i gh ri s k d ri n k i n g (5 or more drinks on one occ asion) Z ero 90 (31.6) 1 28 (8.5) 2 20 (6.1) 3 15 (4.6) 4 4 (1.2) 5-10 53 (25.8) 11-20 38 (11.5)

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40 T ab l e 4 -6 S u m m ar y m ea s u re s o f v ar i ab l es age n u m b er o f p ar t n er s h i gh ri s k d ri n k i n g, drink occ asions, drinking and having sex, and CUSES score s (N = 285) Var iable Mean SD Median Minimum Maxi mum Ag e 20.81 1.85 21 18 31 Number of sexual partners 1.64 1.64 1 0 10 Hig h-risk drinking 12.82 25.65 3 0 180 Number of drinking occa sions 2.20 7.33 1 0 120 Drinks 3.28 6.72 3 0 93 Drinking and having sex 6.45 13.90 1 0 100 CUSES 93.91 18.13 98 28 140 I n the past 12 months, students reported the y participa ted in highrisk drinking an av er age o f 1 2 8 t i m es W h i ch m ea n s t h ey p ar t i ci p at ed i n h i gh -r i s k d ri n k i n g o n av er age once a month. As indicated by the median va lue, more tha n 50% of the stude nts practiced highrisk drinking three times in the past 12 months. I n the past 2 we eks, they indicated that they chose to drink a n aver ag e of 2.20 oc casions and ha d an ave rag e of 3.28 dr inks on the se oc c a sio ns T his ind ic a te s th a t hi g hri sk dr ink ing is c omm on pr a c tic e fo r t ho se s t u d e n t s w h o p a r t i c i p a t e d i n t h e s t u d y. Se xua l r isk ta kin g wa s a lso c omm on in t his g ro up T he stu de nts re po rt e d th a t in the past 12 months they consumed a lcohol and simultaneously eng ag ed in a se x ual activity an ave rag e of 6.45 oc casions and ha d an ave rag e of 1.64 pa rtners in the pa st 12 mon ths T he se be ha vio rs wo uld wa rr a nt c on do m us e B ut, a s r e fl e c te d in Ta ble 45, thi s is not common practice The Condom Use SelfEffic acy Scale ( CUSES) scores re flec t an unexpected finding The mea n total score f or condom use se lf-ef fica cy was 93.91, ref lective of a moder ate a mount of self-e ffica cy and the e x pecta tion was that score s would be much lowe r bec ause c ondom use was low. F re qu e nc y a nd pe rc e nt o f t he pr e se nc e of a g y ne c olo g ic c omp la int s e xua l a c tiv ity and beha viors, comfort in discussing diag nosis of an STI with a par tner, a nd diag nosis of

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41 e ith e r a n ST I y e a st i nf e c tio n, or ba c te ri a l va g ini tis a re lis te d in Ta ble 47. Th e re su lts ind ic a te d th a t, 2 9. 12 % o f t he stu de nts in t he sa mpl e ha d a g y ne c olo g ic a l c omp la int When they wer e aske d about condom use, 29.12% alway s used condoms. The ma jority of the students in the sample (69.82% ) indicate d that they wer e ver y comforta ble asking their par tners about se eking trea tment for a se x ually transmitted infec tion. Also, 51.58% ind ic a te d th a t th e y we re ve ry c omf or ta ble dis c us sin g the ir dia g no sis of a se xua lly transmitted infec tion with their partner s. I n this sample of students, five we re dia g nosed and tre ated f or chla my dia (1.75%) and 2.81% of the students have be en tre ated more than once for c hlamy dia. Rese arch Question F ind ings Re se ar c h Que st ion 1 What is t he re lationship among c ondom use self-e ffica cy response s, sexual riskta kin g be ha vio r, a nd hig hri sk dr ink ing a mon g the fe ma le c oll e g e stu de nts wh o a c c e ss service s at a univer sity student health ca re c enter ? To addre ss Resear ch Que stion 1, W ilcox on rank sum test and Spea rman corr elation ana ly sis were utiliz ed. The re w ere no signific ant diffe renc es in mean r ank CU SES s c or e s b e tw e e n th os e wh o e ng a g e d in hig hri sk be ha vio r a nd tho se wh o d id n ot. There was a signific ant diffe renc e in mean r ank CUSES scores be tween those with and without a g y necolog ical complaint (p = 0.0291). Ana ly sis using Spear man cor rela tion coef ficient indica ted that the cor rela tion among CUSES score s, ag e, number of sexual pa rt ne rs n umb e r o f t ime s p ra c tic ing hig hri sk dr ink ing n umb e r o f d ri nk ing oc c a sio ns number of dr inks on eac h occa sion, and number of times drinking a nd having sex were statistically nonsignific ant.

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42 Table 47. Fr equenc y and per cent of sexual activities, behavior, sexually transmitted infec tion (STI ), and g y necolog ic complaint (N = 285) Va ri a ble F re qu e nc y Pe rc e nt Gy necolog ical complaint Yes 83 29.12 No 202 70.88 Condom Use Neve r 77 27.02 20% of the time 42 14.74 50% of the time 42 14.74 70% of the time 41 14.39 Alway s 83 29.12 Petting Yes 189 66.32 No 96 33.68 Masturbating Yes 143 50.18 No 142 49.82 Ora l Sex Yes 209 73.34 No 76 26.66 I nte rc ou rs e Yes 137 48.07 No 148 51.93 Anal Sex Yes 11 3.86 No 274 96.14 Gende r of pa rtners Male 267 93.68 Fe male 10 3.51 Both 8 2.81 Asking partne r about see king tr eatment Uncomfor table 22 7.72 Somewhat comfor table 18 6.32 Modera tely comforta ble 46 16.14 Ver y comforta ble 199 69.82 Comfort in discussing an STI with a par tner Uncomfor table 45 15.79 Somewhat comfor table 42 14.74 Modera tely comforta ble 51 17.89 Ver y comforta ble 147 51.58

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Table 47. Continued. 43 Va ri a ble F re qu e nc y Pe rc e nt Diag nosed and tre ated f or Chlamy dia 5 1.75 Gonorrhe a 5 1.75 Her pes 7 2.46 HPV 12 4.21 Yea st infection 47 16.50 Ba cter ial vag inosis 11 3.86 None 198 69.47 Trea ted more tha n once f or Chlamy dia 8 2.81 Gonorrhe a 6 2.11 Her pes 3 1.05 HPV 5 1.75 Yea st infection 38 13.33 Ba cter ial vag inosis 7 2.46 None 218 76.49 Analy sis of fre quency (chi-squa re a naly sis) indicated that ther e we re sig nificant rela tionships between having a g y necolog ical complaint and g ender of par tner (chi-squa re = 9.95, p = 0. 00 69 ). Th a t is a mon g tho se wi th a g y ne c olo g ic a l c omp la int 4.48% indicate d they eng ag ed in sexual activity with the same sex, where as only 1.2% of those with no g y necolog ical complaint indicate d they had a sa me sex relationship. There was a signific ant diffe renc e betwe en having a g y necolog ical complaint and be ing diag nosed and tre ated ( p = 0.0001). A mong those with gy necolog ical complaints, 2.41% wer e diag nosed with chlamy dia ver sus 1.52% with no g y necolog ical complaint (F igur e 4-1). I n addition, there w as a sig nificant diff ere nce be tween ha ving a g y necolog ical complaint and those students trea ted more tha n once f or sexually a tra nsmitt ed infe ction ( p = 0.0001). A mong those with a g y necolog ical complaint, 6.02% w ere trea ted more than once for c hlamy dia ver sus 1.51% of those with no g y necolog ical complaint (F igur e 4-2).

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44 Fig ure 41. Perce nt of subjects with and without g y necolog ic complaint diag nosed and tre ated f or sexually transmitted infec tion F ig ur e 42. A c omp a ri so n o f s ub je c ts w ith a nd wi tho ut g y ne c olo g ic c omp la int s trea ted more tha n once f or sexually transmitted infec tion

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45 Re se ar c h Que st ion 2 What are the differ ence s in the number of se x ual par tners and the amount of hig hr i s k d r i n k i n g b e t w e e n t h o s e w h o d i d a n d d i d n o t e n g a g e i n h i g h r i s k s e x u a l a c t i v i t y? Due to the ske wness of the data, r eports fr om 0 to gr eate r than 150, the Wilcox on rank sum test, instead of a two-sa mple t test, was used to addr ess Resea rch Q uestion 2. The re sults indi cate d that the diffe renc es in mean r ank of numbe r of times pra cticing highrisk drinking number of dr inking oc casions, number of drinks on ea ch occ asion, a nd nu mbe rs of tim e s d ri nk ing a nd ha vin g se x amo ng tho se wh o e ng a g e d in hig hri sk sexual activity and those who did not, we re statistically nonsignific ant. Howe ver, the re we re sig nif ic a nt d if fe re nc e s in me a n r a nk of the nu mbe r o f s e xua l pa rt ne rs be tw e e n th os e who did and did not eng ag e in hig h-risk sexual activity (Table 4-8). Ta ble 4-8 demonstrates tha t with an incre ase in the numbe r of se x ual par tners, the a mount and kinds of sexual activity incre ase. The ref ore those stude nts who have a n incre ased numbe r of sexual partner s have a lso eng ag ed in more dive rse se x ual ac tivity such as a nal sex or oral sex. Table 48. The diff ere nce in mea n rank of the number of sexual partners ( N = 285) Var iable (N) Mean Rank Z Value P-Value M as t u rb at i n g* No 141 129.24 2.35 0.0092 Yes 143 155.57 O r a l s e x* No 74 95.01 6.23 0.0001 Yes 209 158.64 I nte rc ou rs e No 148 128.96 3.00 0.0027 Yes 137 155.90 Anal sex No 274 140.87 2.36 0.0092 Yes 11 196.05 Gy necolog ical complaint No 202 132.32 3.70 0.0002 Yes 83 169.00 *M iss ing da ta

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46 Re se ar c h Que st ion 3 What are the combined ef fec ts of condom use self -ef fica cy scale score s, number of pa rt ne rs h ig hri sk dr ink ing a nd se xua l r isk -t a kin g be ha vio rs on tho se wi th g y ne c olo g ic a l c omp la int s? L og ist ic re g re ssi on wa s u se d to a dd re ss R e se a rc h Q ue sti on 3. F ir st, a log ist ic reg ression wa s utili zed to determined c ombined eff ects of c ondom use self-e ffica cy score s, number of pa rtners, dr inking a lcoholic beve rag es, and hig h risk sexual behaviors on those with a g y necolog ical complaint. Ta ble 4-9 lists various criter ia for a ssessing model fit throug h the quality of the e x planatory capa city of the model; for likelihood ratio, scor e statistic, and Wald statistics, thi s is done by testing w hether the explanatory va ri a ble s a re joi ntl y sig nif ic a nt r e la tiv e to t he c hisq ua re dis tr ibu tio n. Al l of the se statistics are a nalog ous to the overa ll F test for the model para meters in a linea r reg ression setting The p -value s for the c hi-square of L ikelihood Ratio, P ear son (Score ), and Wald are all signific ant at a 0.05 le vel indicating that the explanatory varia bles are joi ntl y sig nif ic a nt i n p re dic tin g the g y ne c olo g ic a l c omp la int Table 49. Goodness of f it complete model for the logistic re g ression to deter mine combined ef fec ts of condom use self -ef fica cy scale score s, number of se x ual partne rs, hig h-risk drinking and sexual risk taking on those with a g y necolog ic complaint Test Chi-square DF P-value L ikelihood ratio 27.7899 12 0.0059 Score 28.0611 12 0.0054 Wald 23.5284 12 0.0236 Wit h satisfac tory g oodness of fit, it is appropria te to examine the para meter e sti ma te s f ro m th e mod e l. T a ble 410 lis ts t he e sti ma te d mo de l pa ra me te rs a nd the ir standard e rror s.

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47 Ta ble 410 An a ly sis of ma ximum lik e lih oo d e sti ma te s f or log ist ic re g re ssi on to de te rm ine c omb ine d e ff e c ts o f c on do m us e se lf -e ff ic a c y sc a le sc or e s, number of se x ual par tners, hig h-risk drinking and sexual risk taking on those with a g y necolog ic complaint Parame ter DF Estimate Standard e rror Wal d chi-squar e P-value I nterc ept 1 -4.2613 1.9662 4.6972 0.0302 CUSES s core 1 -0.0052 0.0084 0.3797 0.5377 Ag e 1 0.137 0.0799 2.9411 0.0864 Number of sexual partners 1 0.3151 0.0972 10.5191 0.0012 Drinking and having sex 1 -0.0063 0.0127 0.2469 0.6193 Hig h risk drinking 1 0.0008 0.0064 1.546 0.2137 Number of drinking occa sions 1 -0.0086 0.0259 0.1106 0.7395 Drinks 1 0.0309 0.0237 1.7026 0.1919 Petting 1 -0.1575 0.347 0.206 0.6499 Masturbating 1 0.233 0.3904 0.3562 0.5506 Ora l sex 1 0.502 0.4331 1.344 0.2463 I nterc ourse 1 -0.2552 -0.3767 0.4587 0.4982 Anal sex 1 0.0399 0.7242 0.003 0.9561 Ta ble 411 sh ow s th e od ds ra tio s o f t he pa ra me te rs in t he c omp le te mod e l. O nly the od ds ra tio of the nu mbe r o f s e xua l pa rt ne rs (1 .3 7) wa s st a tis tic a lly sig nif ic a nt s inc e its 95% conf idence interval did not include one Ba sed on the c alculate d odds ratio, the odds of those with g y necolog ical complaints would incre ase by a fa ctor of 1.37 times for eac h partne r. F or eve ry five pa rtners, the odds ratio would incre ase to 4.83 times (2.71828 ). 5(0.3151) D Step ty pe (stepw ise proce dure, f orwa rd selec tion, and backw ard e limination) log ist ic re g re ssi on wa s u se d to ob ta in t he op tim a l mo de l. T he re su lts ind ic a te d th a t on ly the number of sexual partners sig nificantly discriminated betwe en those with and w ithout g y necolog ical complaints (c hi-square = 13.90, p = 0.0002, Ta ble 4-12).

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48 Ta ble 411 Od ds ra tio e sti ma te s f or the pa ra me te rs of the c omp le te d mo de l to de te rm ine c omb ine d e ff e c ts o f c on do m us e se lf -e ff ic a c y sc a le sc or e s, number of se x ual par tners, hig h-risk drinking and sexual risk taking on those with a g y necolog ic complaint Ef fe c t Poi nt e sti ma te 95 % Wa ld c on fi de nc e lim its CUSES S core s 0.995 0.979 1.011 Ag e 1.147 0.981 1.341 Number of sexual partners 1.370 1.133 1.658 Drinking and having sex 0.998 0.969 1.019 Hig h risk drinking 1.008 0.995 1.021 Number of drinking occa sions 0.991 0.942 1.043 Drinks 1.031 0.985 1.080 Petting 0.854 0.433 1.686 Masturbating 1.262 0.587 2.713 Ora l sex 1.652 0.707 3.861 I nterc ourse 0.775 0.370 1.621 Anal sex 1.041 0.252 4.303 Table 412. Analy sis of max imum li kelihood estimates deter mining combined e ffe cts of c on do m us e se lf -e ff ic a c y sc a le sc or e s, nu mbe r o f s e xua l pa rt ne rs h ig hri sk drinking and sexual risk taking on those with a g y necolog ic complaint Pa ra me te r DF Es tim a te Standard err or Wal d c hisquare P-value Odds ra tio I nterc ept 1 -1.4577 0.2098 48.2613 <.0001 Number of sexual partners 1 0.3319 0.089 13.8988 0.0002 1.394 Summ ary This chapter summarized the finding s from the statistical ana ly sis of the chlamy dia questionnaire and the incide nce r ates for chlamy dia infec tion for students who a c c e ss s e rv ic e s a t th e UF SHC C. I nc ide nc e ra te inf or ma tio n a lso wa s c omp a re d to national and state data. The study provided de mogr aphic infor mation to administ rative and medica l staff a t the UF SHCC that was not ava ilable in the past. Subsequent dis c us sio ns on the a dmi nis tr a tiv e le ve ls a t th e UF SHC C a re fo c us e d o n im pr ov e me nts in clinical pra ctice a nd chlamy dia scre ening

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49 Qu e sti on na ir e da ta ind ic a te d th a t hi g hri sk dr ink ing a nd se xua l r isk ta kin g pe rs ist i n t o t h e j u n i o r a n d s e n i o r c l a s s ye a r s f o r t h o s e s t u d e n t s w h o p a r t i c i p a t e d i n t h e s t u d y. Condom use self-e ffica cy scale score s were modera te for stude nts who are prac ticing highrisk drinking and sexual risk taking A statistical rela tionship was expl ored a mong co n d o m u s e s el fef fi ca cy s ca l e s co re s h i gh -r i s k d ri n k i n g, an d s ex u al ri s k t ak i n g. Although no sta tisti cal r elationship was found be tween the condom use self -ef fica cy sc a le sc or e s, hig hri sk dr ink ing a nd se xua l r isk ta kin g it is a la rm ing to n ote tha t bo th highrisk drinking and sexual risk taking are repor ted at ra tes g rea ter than 65% Fur ther, those fema le students with more than one sexual partner in the pa st y ear repor ted more fr e qu e nt a nd va ri e d s e xua l a c tiv ity F ina lly in de te rm ini ng be ha vio rs tha t mi g ht p re dic t a g y ne c olo g ic c omp la int o nly the nu mbe r o f s e xua l pa rt ne rs wa s st a tis tic a lly sig nif ic a nt. I mplications of these finding s are discussed in Chapter 5.

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50 CH APT ER 5 DI SCUS SI ON AND I MPL I CATI ONS Re se ar c h P ur pos e The purpose of this resea rch w as to deter mine curr ent infec tion rates of chlamy dia in the student population who ac cesse s service s at the Univer sity of F lorida Stu de nt H e a lth Ca re Ce nte r a nd to d e te rm ine re la tio ns hip s b e tw e e n c on do m us e self-e ffica cy scale score s in female stude nts, high-r isk drinking, se x ual risk taking and curr ent ra tes of chla my dia infec tion. Discussion Infe c ti on R at e s o f Chl am ydi a Th is r e se a rc h e xami ne d, fo r t he fi rs t ti me th e re po rt e d c a se s o f c hla my dia infec tion in st udents who ac cess the U niversity of F lorida Student Hea lth Care Center (U F SHC C) T he da ta re fl e c t a fl uc tua tin g bu t st e a dy inc re a se in i nc ide nc e ra te s f or the se students. I n the past y ear 2005 rate s were calc ulated at 5.8% National ra tes repor ted by the Amer ican Colleg e He alth Association (ACHA) wer e 3.8% f or the y ear 2004 (ACHA, 2005). Methodolog y to calcula te these r ates is the same (P. Davis-Smith, personal c omm un ic a tio n, Ap ri l 5, 20 06 ). B ut, c a uti on sh ou ld b e ta ke n in g e ne ra lizin g the se re su lts as not all colleg es and unive rsities repor ting to the ACHA have a simil ar student body population. Also, the ACHA re ports that the per centa g e of those inf ecte d are twice a s lik e ly to b e ma le (A CH A, 20 05 ). I n c on tr a st, the g e nd e r p e rc e nta g e of tho se mos t infec ted at the UF SHCC i s female

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51 Statist ics repor ted by the Flor ida Depa rtment of He alth also ref lect ca se ra tes for y oung fema les almost six times gr eate r than the r ates for y oung men; 26,145 in female s ag es 15 to 24 versus 4,857 in males a g es 12 to 24 for 2004 ( Florida Depa rtment of Hea lth, 2006). An incre ase in the numbe r of f emale stude nts testing positive may be ex p l ai n ed b y t h e v o l u m e o f f em al e s t u d en t s s cr ee n ed b y p ra ct i t i o n er s i n t h e w o m en 's health ca re te am. B ut increa sed scr eening does not explain persistence in incr easing repor ts of chlamy dia infec tion. Those students who tested positive for chlamy dia wer e most commonly fema le, Cauca sian, 25 y ear s of ag e, and r esiding in an apa rtment off c ampus. Whil e ther e is no sp e c if ic de mog ra ph ic da ta lis te d f or c hla my dia inf e c tio n in un ive rs ity or c oll e g e stu de nts national, state, a nd county ag encie s have de mogr aphics on fe males in the compa rative ag e ra ng e of 18 to 24 y ear s. National data ref lect that blac k fema les ag es 16 to 19 have the hig hest rate s of chlamy dia at this point, 49.53% of all repor ted ca ses (CDC, 2005; Florida Depa rtment of He alth, 2006). State of F lorida and A lachua County rate s consistently repor t highe r ca ses in fema les, 16 to 24 (Flor ida Depa rtment of He alth, 2006). I nc re a se d c a se s o f c hla my dia inf e c tio n w ith a dis pr op or tio n o f f e ma le to m a le c a se s a re sig nif ic a nt. I t g ive s d ir e c tio n f or fu tur e re se a rc h th a t mi g ht i nc lud e a do ub le arm study to look at the compar isons between a g roup of students who a cce ss scree ning service s under c urre nt prac tices and those w ho might see k out scree ning unde r a ne w scre ening policy The re sear ch could de scribe dif fer ence s in males and fe males who see k testing a nd which scr eening policy provides the most ac cess to ser vices for both ge nders. Chang es in clinical pra ctice ma y also be a ffe cted. Curr ently students make an appointment, see a nurse a nd then see a provide r bef ore a scre ening test is ordere d and

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52 the n th e stu de nt r e c e ive s th e sc re e nin g te st. Th is r e se a rc h in fo rm a tio n o n c hla my dia c a se rate s and the c omparisons with national data c an launc h a cha ng e in clinical pr actice and scre ening policy Gene rating an improved pr otocol for sc ree ning stude nts who may have a g y necolog ic complaint and de sire scr eening is highly desirable This improved protocol would consist of strea mlined acc ess for stude nts. They could g o direc tly to the labora tory a nd re qu e st a sc re e nin g te st. L a bo ra tor y pe rs on ne l ma y c ho os e to k e e p r e po rt s o f c a se rate s logg ed so eva luation of g ender residenc e and r ace can dir ect f uture scr eening policy and clinica l prac tice. The chang e in policy is alrea dy in the discussion and pla nn ing sta g e s a t U F SHC C. Re se ar c h Que st ion 1 Wha t is the re la tio ns hip a mon g c on do m us e se lf e ff ic a c y sc a le (C USE S) sc or e s, se xua l r isk -t a kin g be ha vio r, a nd hig hri sk dr ink ing in f e ma le c oll e g e stu de nts wh o a c c e ss service s at a univer sity student health ca re c enter ? The re sults of statist ical ana ly sis demonstrated that ther e we re no r elationships among CUSES s core s, sexual risk taking, and hig h-risk drinking This result challeng es pr e vio us re se a rc h th a t in dic a te s a re la tio ns hip is u su a lly pr e se nt b e tw e e n s e xua l r isk taking and hig h-risk drinking The CUSES scores r efle cted a modera te amount of self-e ffica cy and this also challeng es the log ic of a high or modera te score resulting in a predic ted cha ng e in beha vior. Fe male students, who ag ree d to complete the c hlamy dia questionnaire wer e asked I n the past 12 months I have use d condoms: Neve r, 20% of the time, 50% of the time, 70% of the time, or a lway s. At lea st 27.02% of the students indicate d that they never used condoms and, c onverse ly 29.12% alwa y s used condoms while e ng ag ing in a sexual activity in the past 12 months. The mean total scor e for condom use self -ef fica cy

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53 wa s 9 3. 91 in dic a tin g a mod e ra te kn ow le dg e of po te nti a l be ne fi t of c on do m us e T he se da ta su g g e st t ha t, d e sp ite kn ow le dg e a bo ut c on do m us e s tud e nts do no t us e c on do ms without fail and put themselves a t risk for ac quiring not only chlamy dia but many other kinds of sexually transmitted infec tions. But there are no statistical relationships among CUSES s core s, highrisk drinking and sexual risk taking Risk factors doc umented in cur rent re sear ch litera ture for sexually transmitted dis e a se s, inc lud ing c hla my dia a re c on do m us e s e xua l r isk ta kin g a nd hig hri sk dr ink ing T he mos t c omm on fo rm of se xua l r isk ta kin g is p e nil e va g ina l in te rc ou rs e wi tho ut t he us e of a c on do m ( Gr a dy & Gi lla m, 2 00 3) I nc on sis te nt c on do m us e is a persistent trend in se x ual beha viors for c olleg e and unive rsity students acc ompanied by a lc oh ol u se (B a y -C he ng 2 00 3) A dd iti on a l r e se a rc h n ote s th a t in c on sis te nt c on do m us e is highly corr elated w ith high-r isk drinking ( Albarr acin e t al., 2004). Hi gh -r i s k d ri n k i n g i s d ef i n ed as u n d er age d ri n k i n g an d b i n ge d ri n k i n g. Bi n ge d ri n k i n g i s d ef i n ed b y re s ea rc h er s as fi v e o r m o re d ri n k s at o n e o cc as i o n (D ej o n g & L ang ford, 2002) Current re sear ch litera ture e x amines the socia l pressure s of pee r g roups su c h a s so ro ri ty ple dg ing d a tin g e ve nts a nd a thl e tic s th a t di re c tly inf lue nc e se xua l r isk taking and hig h-risk drinking (Wechsler et al., 2002). A dditional resea rch litera ture de sc ri be s th e int e rp e rs on a l a nd be ha vio ra l im pli c a tio ns fr om s e xua l r isk -t a kin g a c tiv ity on college campuses, supporting consideration of the sociocultural environment as a predic tor of hig h-risk ac tiviti es (Gur man & Bor zekowski, 2004). The impac t of the campus c ulture may impact beha vior more than pr evious rese arc h could demonstrate So, a lth ou g h s tud e nts ma y de mon str a te a mod e ra te a mou nt o f c on do m us e self-e ffica cy this does not translate into a beha vior. I f it did, the expectation would be a ve ry low me a n o n th e CU SES s c or e s. Th e fi nd ing s in dic a te tha t po pu la tio n s pe c if ic ri sk

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54 fa c tor s f or c hla my dia inf e c tio n mu st i nc lud e oth e r f a c tor s th a t ha ve no t be e n e xami ne d in the context of colleg e hea lth. The signif icanc e of the se re sults is discussed fur ther unde r imp lic a tio ns Re se ar c h Que st ion 2 What are the differ ence s in the number of se x ual par tners and the amount of h i g h r i s k d r i n k i n g b e t w e e n t h o s e w h o d i d a n d d i d n o t e n g a g e i n h i g h r i s k s e x u a l a c t i v i t y? Un iva ri a te sta tis tic s w e re us e d to e va lua te se xua l r isk ta kin g in r e sp on se to questions that asked the numbe r of se x ual par tners ea ch fe male had in the pa st y ear ty pes of sexual behavior the y eng ag ed in, and the numbe r of oc casions they wer e drinking and having sex. The results repor t students were drinking and having sex an avera g e of 6.45 oc c a sio ns in the pa st 1 2 mo nth s. Th e me a n n umb e r o f s e xua l pa rt ne rs wa s 1 .6 4. B ut, the re we re no sig nif ic a nt r e la tio ns hip s a mon g nu mbe r o f s e xua l pa rt ne rs h ig hri sk dr ink ing a nd se xua l r isk ta kin g T his da ta is c on tr a ry to o the r r e se a rc h. Re se a rc h in colleg e hea lth has repor ted a c orre lation among the sprea d of sexually transmitted infec tions, alcohol use, and e ng ag ing in se x (L aB rie e t al., 2002; L icca rdone, 2003) Many rese arc hers be lieve this is due to the eff ects of a lcohol, specific ally decr ease d inhibiti on in a population that routinely prac tices risk taking (Wechsler et al., 2002). S ex u al ac t i v i t y al o n g wi t h o t h er ri s k b eh av i o rs s u ch as b i n ge d ri n k i n g, u n d er age drinking sexual activity while using alcohol, and se x ual contac t without the use of ba rr ie r m e tho ds c on tr ibu te s to the sp re a d o f s e xua lly tr a ns mit te d in fe c tio ns a nd su g g e sts that these be haviors or r isk factor s be examined and their r elationships expl ored (D on ov a n, 20 04 ; Ro ss, 20 02 ; V on Sa do vs ky e t a l., 20 02 ). No t su rp ri sin g ly s e xua l r isk taking is also associated w ith high-r isk drinking in other rese arc h studies that expl ore colleg e student beha vior (L aB rie e t al., 2002; L icca rdone, 2003) .

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55 The implications of these f inding a re multifac eted a nd complicated by study lim ita tio ns dis c us se d la te r i n th is c ha pte r. On e ra tio na le fo r t he re su lts is t he inf ini te possibili ty of re lationship ty pes that occ ur during this ti me per iod for y oung people. Whil e fe ma le stu de nts ma y pr e fe r a n e xclu siv e se xua l r e la tio ns hip ma ny ma le stu de nts do no t. T he he a lth of the me n w ith wh om t he se y ou ng wo me n a re ha vin g se x is c ru c ia l. They may sprea d g enital chlamy dia to many partne rs if they are not diag nosed and tr e a te d. Dr ink ing a nd se xua l e xpe c ta tio ns of me n a nd the su bs e qu e nt e ff e c ts o n th e ir fe ma le pa rt ne rs c a nn ot b e ig no re d. Yo un g me n in thi s a g e g ro up ma y ha ve lim ite d a c c e ss to sex ual and r eproduc tive health re source s (Guttmache r I nstitut e, 2006). This void of information impacts sexual behavior a nd health choic es. Young men pra cticing sexual risk taking not only put their partne rs at risk but their own he alth status can be compromised (G uttmacher I nstitut e). This impli cation g ener ates que stions for additional rese arc h. One r esea rch question might ask wha t kinds of sex ual expectations do men discuss with their par tners and wha t kinds of sex ual re lationships do they desire? How are the se expectations c omm un ic a te d? The se qu e sti on s, in t he c on te xt of ri g or ou s r e se a rc h me tho do log y w ou ld provide infor mation on what other r isk factor s impact fema le university students and su bs e qu e nt i nf e c tio n r a te s o n a un ive rs ity or c oll e g e c a mpu s. Re se ar c h Que st ion 3 Wha t a re the c omb ine d e ff e c ts o f c on do m us e se lf -e ff ic a c y sc a le (C USE S) sc or e s, nu mbe r o f s e xua l pa rt ne rs h ig hri sk dr ink ing a nd se xua l r isk ta kin g be ha vio rs on tho se wi th a g y ne c olo g ic c omp la int ? This gr oup of data was e x amined using logistic re g ression. Results indicated that only the number of sexual partners sig nificantly discriminated betwe en those with and

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56 those without a g y necolog ical complaint (c hi-square = 10.52, p = 0.0012) This finding ind ic a te s th a t th e nu mbe r o f s e xua l pa rt ne rs ma y pr e dic t th e lik e lih oo d o f a g y ne c olo g ic c omp la int A CU SES s c or e h ig hri sk dr ink ing a nd se xua l r isk ta kin g do no t se e m to pr e dic t a g y ne c olo g ic c omp la int or a c hla my dia inf e c tio n. Con ve rs e ly th e inc re a se in sexual partners may predic t a pre dispositi on to a g y necolog ic compliant. Hopef ully the fema le student would seek tr eatment if she is sy mptomatic or at risk. B ut seeking medical trea tment is not alway s the dec ision made by the student, espec ially if sy mptoms are vag ue or tra nsient. Dec isions to s eek tr eatment a nd live independe ntly are part of transitioning to ca mpus life. Fe male students make e rrone ous decisions as they transition to t his ne w l if e a nd de ve lop lif e ma na g e me nt s kil ls. R es ea rc h er s d es cr i b e t h e t ra n s i t i o n fr o m h o m e t o at t en d i n g a u n i v er s i t y o r c o l l ege as a c halleng e for most y oung women (F arr ow & Arnold, 2003). Students may lear n for the first time how to manag e time, ac ademic de adlines, financ ial obliga tions, and social events. The re is a ste ep lea rning curve and a c ampus culture c an be ove rwhe lming. The culture of a colleg e ca mpus is replete with g ender and powe r issues also. Examples include for mation of male/fe male re lationships and aca demic pre ssures imposed by profe ssors. These situations in themselves ar e not har mful, but making de cisions on un fa mil ia r t op ic s a nd na vig a tin g the c on se qu e nc e s a nd po te nti a lly ne g a tiv e sit ua tio ns is a challeng e for y oung fema le students. Making decisions about sexual risk taking and incre asing sexual activity is common for women in this ag e g roup (Smith, 2003). I nd ivi du a l c on c e rn s a bo ut p hy sic a l sy mpt oms in r e sp on se to a c tiv e ly e ng a g ing in int ima te se xua l a c tiv ity a re inf lue nc e d b y so c ia l e xpe c ta tio ns a nd pe rc e pti on of so c io cultural or c ampus culture issues ( Be rry 2004). F or some students, a va g ue sy mptom may be an indica tor of sexual activity and an e mbarra ssment. They do not seek medic al

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57 c a re Co nv e rs e ly s ome stu de nts ma y se e k c a re imm e dia te ly T he de sir e to e sta bli sh intimate relationships with the approva l of and a dhere nce to pe er g roup expectations has a conside rable influence on the fe male student. F emale stude nts may fea r being stigmatized or dirty by seeking trea tment; they are less desirable or at risk of be ing le ft out of the pee r g roup (Opr endek & Malca rne, 1997) Real or pe rce ived power influence s are critica l to their perc eptions and choic es. These power rela tionships are par t of g ender a nd so c ioc ult ur a l e xpe c ta tio ns a ff e c tin g c on do m us e a nd dis e a se tr a ns mis sio n b e c a us e they involve fema les and male s (Gomez & V an Oss Mar tin, 1996). The ne g ative outcome of ignor ing a vag ue sy mptom or gy necolog ic complaint ma y be a by pr od uc t of a so c ioc ult ur a l e xpe c ta tio n. Th e so c ioc ult ur a l e xpe c ta tio n th a t a fema le who believe s her pa rtner is fa ithful, declines condom use and will not need trea tment for a g y necolog ic complaint. I n many instances ther e is a strug g le betwe en condom use a nd the desire of the fe male student to be pa rt of a c ouple, which may mean sex wit hout condom. The ne g otiation of condom use is aff ecte d by power in interpersona l rela tionships (Few, 1997) Studies on sex ually transmitted diseases de scribe a moment when a y oung woman decide s how, when, a nd with whom she share s sexual activity This moment is shaped by her soc iocultural environme nt (Be rry 2004; Kenney 2000). Ther e is a c onnection betwee n person, be havior c hoice, a nd outcome. F or example, if the expectation is to have a boy friend, a n important part of soc ial acc eptanc e on ca mpus, this m ay imply that sex and drinking are expected. Ha ving se x without a condom is a demonstra tion of the student' s trust in her par tner (D avidson-Ha rden e t al., 2000). Resear ch that addr esses the soc iocultural per spectives of male-f emale inter action addre sses the fa ct that not using a condom leave s the fema le vulnera ble to infec tion. The

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58 persistenc e of a partne r say ing, Every thing is okay ma y lead to the pe rce ption that there is l ow ri sk or no ri sk (S mit h, 20 03 ). I n e ff e c t, t he fe ma le stu de nt w a nts to b e lie ve the re is no risk beca use she wa nts to trust t hat her lover would not dec eive he r just to have sex (Da vidson-Har den et a l., 2000).The pe rce ption of risk and infec tion are not sig nificant corr elates. F eeling that she is not at risk does not protec t the individual from infec tion (K a lic hma n e t a l., 20 02 ). Th e stu de nt' s r e a liza tio n th a t sh e is v uln e ra ble to i nf e c tio n is sig nif ic a nt b e c a us e it a ff e c ts t he pe rc e pti on of pr e se nti ng sy mpt oms a nd the de c isi on to se e k me dic a l tr e a tme nt ( Op re nd e k & Ma lc a rn e 1 99 7) I f t he stu de nt d oe s n ot t hin k s he is vulnera ble, the pre sence of a g y necolog ical complaint or a vag ue sy mptom may be dismiss ed and me dical tre atment delay ed. Over all, behavior and condom use rese arc h support the nee d for f urther study on a tti tud e s a bo ut t he ini tia tio n o f c on do m us e (D a vid so nHa rd e n e t a l., 20 00 ). Stu de nts attitudes about the informa tion they rec eive a re c rucia l. Nurse r esea rche rs re port that e ve n in the c on te xt of a lif e -t hr e a te nin g ill ne ss, the stu de nts a c c e pta nc e of inf or ma tio n is para mount to the subsequent follow throug h or pra ctice of health promoting activities (Collins et al., 2003). College students repe atedly put themselves at risk by prac ticing unhealthy behavior such as se x ual risk taking and hig h-risk drinking (Rozmus et al., 2 0 0 5 ). Ot h er ex am p l es ar e s m o k i n g, u s i n g i l l ega l d ru gs u n d er age d ri n k i n g, b i n ge drinking having sex wit h unknown par tners, and ha ving se x while under the influenc e of alcohol or dr ug s (Von Ah e t al., 2004). These results demonstrate that the number of se xua l pa rt ne rs ma y pr e dic t a g y ne c olo g ic c omp la int a nd wh e n a fe ma le stu de nt s e e s a pr ov ide r f or a g y ne c olo g ic c omp la int s c re e nin g sh ou ld b e of fe re d. No re se a rc h to da te has provided this data in such specif ic terms.

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59 The Si gnif icance and Revisions to the Cam pus Chlam ydia Model Im plic at ion s o f Re se ar c h Re sult s The pre sence of primar y and sec ondary preve ntion measures ( health educ ation, distribution of free condoms, enc ourag ing STI scre ening and inexpensive trea tment) and incre asing rate s of re ported c hlamy dia infec tion is concerning The e x pecta tion is t hat these ra tes would be much lowe r than na tional rates or at minimum, i nfec tion would be de c re a sin g A stu dy to d e te rm ine pr e va le nc e of the c hla my dia inf e c tio n o n th is u niv e rs ity campus would be helpful to direc t scree ning pr og rams, compr ehensive sexual and repr oductive hea lth education, ea rlier tre atment, and diag nosis of not only chlamy dia but other sexually transmitted infec tions. The statistical ana ly sis indicated that only the number of sexual partners s i g n i f i c a n t l y d i s c r i m i n a t e d b e t w e e n t h o s e w i t h a n d w i t h o u t g y n e c o l o g i c a l c o m p l a i n t s If fema le students only seek tre atment in the pre sence of a g y necolog ical complaint, and thi s o c c ur s o nly wi th t ho se wh o p ra c tic e se x with mul tip le pa rt ne rs th e n ma ny stu de nts are at risk for inf ection. Va g ue sy mptoms i ncluding burning upon urination, pelvic pa in, and vag inal bleeding may be pre sent, but asy mptomatic infection is common (Weir, 2004). Mild sy mptoms, or lack there of, lea ve these y oung women at r isk for chla my diar e l a t e d m o r b i d i t y m o s t s p e c i f i c a l l y p e l v i c i n f l a m m a t o r y d i s e a s e ( P ID ) C h l a m y d i a P ID can le ad to infer tilit y (Stamm, 2004). Unfortuna tely inexpensive and eff ective tr eatment is often delay ed bec ause of the vag ue or a bsent sy mptoms previously mentioned (Hu e t al., 2004). T h e C o n d o m Us e S el fef fi ca cy S ca l e h as b ee n a v al u ab l e t o o l o n co l l ege campuse s. This was the ra tionale for inc luding it in the Campus Chlamy dia Model develope d in Chapter 2. Unf ortunately students who score d modera tely well on the

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60 Con do m U se Se lf -e ff ic a c y Sc a le sti ll e ng a g e d in se xua l r isk ta kin g a nd hig hri sk drinking A sec ondary analy sis of the individual CUSES items would refle ct individual response s of the subjec ts reg arding sexual neg otiation, comfort using a condom whe n us ing a lc oh ol o r d ru g s, a nd the me c ha nic s o f a pp ly ing a c on do m. T his inf or ma tio n c ou ld the n im pr ov e he a lth e du c a tio n p ro g ra ms b y ta rg e tin g the g a ps in e du c a tio n. Th is w ou ld positively aff ect pr imary preve ntion measures. A s e c on da ry a na ly sis ma y a lso pr ov ide dir e c tio n to he lp n ur se s b e tte r e du c a te students in a sociocultural e nvironment wher e sexual risk taking and hig h-risk drinking continue into junior and senior c lass levels. Resea rch on r isk reduction interve ntions of sexually transmitted infec tions report that skill-based inter ventions are most effe ctive (Jemmot t, J emmott, Bra verma n, & F ont, 2005). These skill-based interve ntions invol ve the ac tual application of c ondoms on anatomical models. Role play ing tha t includes ne g oti a tin g c on do m us e is a lso inc lud e d. I f t his sk ill -b a se d in te rv e nti on wa s u se d, ma le stu de nts a lso sh ou ld b e ta rg e te d f or e du c a tio n to no t on ly re du c e ra te s o f c hla my dia infec tion but to pos sibly instil l positi ve attitudes about c ondom use (Pinkerton, Holtgr ave, & J emmott, 2000). Cam pus Chlam ydia Model The pre sent rese arc h finding s void the model prese nted in Chapter 1. The expectation was that c lear statistical findings would support that the inde pendent varia bles of hig h-risk drinking and sexual risk taking predic t a positive chlamy dia scre en, a diag nosis of a sexually transmitted infec tion, or g y necolog ic complaint. Then, c on ve rs e ly a hig h c on do m us e se lf -e ff ic a c y sc or e wo uld pr ov ide a ne g a tiv e c hla my dia sc re e n, no dia g no sis of se xua lly tr a ns mit te d in fe c tio n, a nd a bs e nc e of a g y ne c olo g ic complaint.

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61 This was not the ca se. The sta tisti cal f indings indica ted that the cor rela tion betwee n CUSES s core s, ag e, number of sexual partner s, number of times pra cticing highrisk drinking number of dr inking oc casions, number of drinks on ea ch occ asion, a nd nu mbe rs of dr ink ing a nd ha vin g se x we re sta tis tic a lly no t si g nif ic a nt. Th e re su lts ind ic a te d th a t th e dif fe re nc e s in me a n r a nk of nu mbe r o f t ime s h a vin g fi ve dr ink s, number of dr inking oc casions, number of drinks on ea ch occ asion, and number s of drinking and having sex between those who e ng ag ed in hig h-risk sexual activity and those who did not were statistically not significa nt. Howeve r, there wer e sig nificant dif fe re nc e s in me a n r a nk of the nu mbe r o f s e xua l pa rt ne rs be tw e e n th os e wh o d id a nd did not eng ag e in hig h-risk sexual activity This is logica l as fema le students who ar e not eng ag ed in sexual risk-taking behavior s would not have a n incre ase in number of sexual partne rs. I t was expected tha t clear evidenc e supported by statistics would reflec t the positive linear re lationship between pe rson, beha vior, and outcome aff ecte d indirectly by eff icac y expectation and outcome e x pecta tions. But that was not the c ase. The CUSES score s from the students, who re prese nt the person in the model, did not have a dire ct c or re la tio n w ith be ha vio r, us ing or no t us ing c on do ms. But in this specific a g e g roup, fe male univer sity students, other fa ctors such a s peer subcultures, g ender -powe r issues, and tra nsitioni ng to colleg e may impact the students so strongly that self-e ffica cy is affe cted, a nd these a dditional factors should be studied to determine their eff orts on sexual risk-taking be havior in this gr oup. Transitioning to campus life may be a popula tion specific r isk factor beca use of the influenc e this transition has on health beha vior choice s. The choic e of a sexual p a r t n e r o r h i g h r i s k d r i n k i n g m a y b e i m p a c t e d b y p e e r g r o u p s u b c u l t u r e s C o n v e r s e l y,

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62 se xua l r isk ta kin g ma y inf lue nc e a fe ma le un ive rs ity stu de nt s c ho ic e in p e e r g ro up s. Gende r-ba sed powe r issues ca n influence students in their choice s of risk taking be ha vio r. Th e inf lue nc e of a ma le pa rt ne r c a n a ff e c t c on do m us e U np ro te c te d s e x puts b o t h p a r t n e r s a t r i s k b u t m a y a l s o b e a p l e d g e o f t r u s t f o r e i t h e r p a r t y. Lim it at ion s L imitations of the c hlamy dia questionnaire data may be one r eason f or this lack of consistent re sults with previous resea rch. A dded questionnaire items were develope d by the re sear cher based on litera ture re view and pr evious rese arc h. The a ddition of another tool in combination with t he Condom Use Self-e ffica cy Scale ( CUSES) mi g ht y ield differ ent re sults or results consistent with previous finding s. What the data does ref lect is the nee d for f urther study The use of a qualitative methodolog ic study may explain inconsist ency of these f indings a nd the lack of statistical support for the c ampus chlamy dia model. Rec om m endations f or F uture Re searc h A c on ne c tio n b e tw e e n th e tr a ns iti on to c a mpu s c ult ur e a nd the su bs e qu e nt h e a lth be ha vio r c ho ic e s f or stu de nts is p ro ba ble A qu a lit a tiv e re se a rc h s tud y c ou ld a sk sp e c if ic qu e sti on s a bo ut r e la tio ns hip s f or me d d ur ing the fr e sh me n a nd so ph omo re y e a rs to explore sexualit y rela tionships, and risk factors w ith attention to sex ual risk taking and highrisk drinking Since sexual risk taking a nd highrisk drinking have a lrea dy been ide nti fi e d in the lit e ra tur e a s r isk fa c tor s f or se xua lly tr a ns mit te d in fe c tio ns th e ir interac tion with adaptation to peer subcultures a nd g ender -base d power issues may addre ss ga ps in curre nt resea rch litera ture. Qua litative resea rch, in pa rticular na rra tive analy sis, would elicit personal ac counts or stories fr om the students that may provide further valuable inf ormation reg arding risk behavior s. Narr ative ana ly sis from persona l

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63 interviews would pr ovide insight into the life a nd culture of the students, exploring and answe ring questions found in this resear ch (Patton, 2002; Reissman, 1993). Th e na rr a tiv e sto ri e s o f s e xua lit y r e la tio ns hip s, a nd ri sk be ha vio rs of fe ma le fr e sh me n a nd so ph omo re s c ou ld b e tr a ns c ri be d a nd the n th e ma tic c a te g or ie s d e ve lop e d to answe r the re sear ch questions (Ry an & Be rnar d, 2003). F or example, an e x planation of why fema le students of junior class standing still persist in highrisk drinking and sexual ri sk ta kin g de sp ite pr ima ry a nd se c on da ry pr e ve nti on me a su re s. Th is r e se a rc h d id n ot u se a ny qu a lit a tiv e me tho do log y li mit ing so me of the fi nd ing s a nd ra isi ng mor e qu e sti on s. A p re va le nc e stu dy a t th e Un ive rs ity of F lor ida wo uld a lso be he lpf ul t o c omp le te a picture of this phenomenon. A pr evale nce of an infe ction is studied by convenie nce sampling ove r a shor t period of time (L ast, 2001). The true pre valenc e of the disease ma y chang e medica l and nursing prac tice at the U F SHCC. This could increa se scr eening and improve the likelihood of ea rly trea tment. An additional limitation t o this study was the f ocus exclusively on women. Re se a rc he rs ha ve no te d th a t th e inf lue nc e of me n o n w ome n' s se xua l be ha vio r i s su bs ta nti a l in thi s a g e g ro up (A rn e tt, 20 04 ). F ur the r, e xpe rt s w a rn tha t me n a re se xua lly a c tiv e fo r a t le a st 1 0 y e a rs be fo re be ing ma rr ie d, on a ve ra g e a nd tha t on ly 14 % o f t he se men re port they had see n a hea lth care provider f or a se x ual or re productive he alth issue (G u t t m ac h er I n s t i t u t e, 2 0 0 6 ). R es ea rc h t h at fo cu s es o n t h e r o l e o f m en i n wo m en 's sexualit y along with the repr oductive and se x ual hea lth needs of men is ne eded to f ill the g aps in defining population specific r isk factor s for c hlamy dia infec tion. Contribution to Nursin g Science This resea rch c ontributes to the body of nursing scienc e by providing new i n fo rm at i o n o n p o s s i b l e r i s k fa ct o rs an d d i re ct i o n s fo r f u t u re re s ea rc h T h es e f i n d i n gs

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64 indicate that c omprehe nsive repr oductive hea lth and sexual health educa tion with an inc re a se in c hla my dia sc re e nin g on c oll e g e a nd un ive rs ity c a mpu se s is ne e de d. Va lua ble information on chlamy dia infec tion rates, demog raphic s of those infec ted, and compar isons to national and state data provide nurse s with valuable infor mation they ne e d to c a re fo r t he c oll e g e he a lth po pu la tio n. Nu rs e s in te ra c t w ith c oll e g e or un ive rs ity students at cruc ial moments when students are attempting to tra nsition t o colleg e life, a university campus, make persona l health choice s, and see k medical c are This resea rch provides informa tion that may improve these ve ry cruc ial interac tions, fostering positive health beha viors for a lifetime. Conclusion The purpose of this study was to dete rmine the c urre nt incidence rate s of chlamy dia in the student population that acc ess servic es at the U niversity of F lorida Stu de nt H e a lth Ca re Ce nte r. Se c on d, to d e te rm ine the re la tio ns hip s b e tw e e n c on do m us e self-e ffica cy scale score s in female stude nts, high-r isk drinking, se x ual risk taking and the cur rent incide nce r ates of g enital chlamy dia infec tion. This resear ch wa s not designe d to t e st a hy po the sis bu t to pr ov ide a mor e a c c ur a te pic tur e of wh a t ma y be oc c ur ri ng in the hea lth of female students on a university campus. A more detailed pictur e wa s sought be c a us e c ur re nt p ri ma ry a nd se c on da ry me a su re s o f p re ve nti on ha ve fa ile d to de c re a se repor ted ca ses of c hlamy dia infec tion in thi s population. I ncidenc e ra tes of chla my dia infec tion for all students who ac cess se rvice s at UF SHCC are hig her tha n nationally repor ted ra tes. Self-e ffica cy is a signif icant pre dictor of he a lth be ha vio rs bu t ma y be imp a c te d s o s tr on g ly by the tr a ns iti on to a c a mpu s c ult ur e it scar cely aff ects c ondom use. The scor es fr om CUSES had no appa rent re lationship with hi g h-risk drinking or se xua l r isk ta kin g D e sp ite a re a so na ble de g re e of se lf -e ff ic a c y us ing c on do ms, fe ma le

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65 students continue, eve n at junior class standing to participate in highrisk drinking and sexual risk taking. The number of se x ual par tners wa s the only signific ant pre dictor of whether a fe male student had a g y necolog ic complaint. Fe male students re ported on aver ag e 1.64 par tners in the past y ear The picture of wha t is occurr ing in the he alth of these y oung women is unclea r, and c hlamy dia infec tion is i ncre asing Fo rt u n at el y p o l i cy ch an ges ar e a l re ad y b ei n g d i s cu s s ed at UF S HC C t o ch an ge clinical pra ctice a nd scre ening policies as a r esult of this resea rch. This re sear ch has ma de a n im pa c t di re c tly on the liv e s o f s tud e nts B ut, fu rt he r r e se a rc h is ne e de d to deter mine other population spec ific risk fa ctors that influenc e the pr evale nce of c hla my dia inf e c tio n in fe ma le un ive rs ity stu de nts a nd the ir ma le c la ssm a te s. Re se a rc h to promote cha ng es in hea lth policy and nursing prac tice could make the diffe renc e in the l i v es o f a l l s t u d en t s T h i s re s ea rc h wa s j u s t a b egi n n i n g.

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66 APPENDI X A CH L AM YD I A Q UE STI ON NA I RE Please c omplete the following information. Where a blank is prese nt put the number that c or re sp on ds or lis t y ou r r a c e a s y ou re po rt it f or the Un ive rs ity of F lor ida Re g ist ra r s Of fi c e Ci rc le the a ns we r t ha t be st d e sc ri be s y ou a nd y ou r e xpe ri e nc e s. 1. Ag e ____ 2. Ethnicity circ le one: White Hispanic Bla ck Asian Other 3. Cla ss S ta nd ing c ir c le on e : Fr eshman Sophomore J unior Senior Gra d Student 4. Re sid e nc e c ir c le on e : On -c a mpu s d or mit or y On -C a mpu s so ro ri ty ho us e Of f C a mpu s Ap a rt me nt Of f c a mpu s liv ing a t ho me 5. The number of sexual partner s I have ha d in the last 12 months _____________. 6. I have e ng ag ed in the following sexual behaviors in the past 12 months, please c ircle: Petting (touc hing of the g enitals or bre asts with clothing of f or on) Masturbating Ora l Sex Sex ual I nterc ourse Anal Sex 7. My pa rt ne rs a re str ic tly : Ma le F e ma le B oth 8. I n th e pa st 1 2 mo nth s I ha ve us e d c on do ms: Ne ve r 20 %o f t he tim e 50 % o f t he tim e 70 % o f t he tim e Al wa y s 9. I n th e pa st 1 2 mo nth s, the nu mbe rs of oc c a sio ns I c on su me d a lc oh ol a nd e ng a g e d in sexual activity at the same time or during the same oc casion we re _________________. 10. I n the past 12 months, I have ha d 5 drinks (one be er = 1 drink, one shot = 1 dr ink, one g lass of wine = 1 drink) or more the following number of times ________. 11. The number of occ asions in the past two wee ks I chose to drink ____________. 12. The number of drinks (one beer = 1 drink, one shot = 1 drink, one g lass of wine = 1 drink) I had on ea ch occ asion __________________________________________.

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67 13. My comfort with asking my partne r about see king tr eatment if the y wer e diag nosed wi th a se xua lly tr a ns mit te d in fe c tio n: Un c omf or ta ble Som e wh a t Co mf or ta ble Mo de ra te ly Com fo rt a ble Ve ry Com fo rt a ble 14 My c omf or t w ith dis c us sin g a dia g no sis of a se xua lly tr a ns mit te d in fe c tio n in my se lf wi th m y c ur re nt p a rt ne r i s: Un c omf or ta ble Som e wh a t Co mf or ta ble Mo de ra te ly Com fo rt a ble Ve ry Com fo rt a ble 15. I have be en diag nosed in the past or I am cur rently being trea ted for: Chl a my dia Go no rr he a He rp e s H PV Y e a st I nf e c tio n B a c te ri a l V a g ini tis None 1 6 I h av e b ee n t re at ed m o re t h an o n ce fo r t h e f o l l o wi n g : Chl a my dia Go no rr he a He rp e s H PV Y e a st I nf e c tio n B a c te ri a l V a g ini tis None Condom U se Self-eff icacy Scale (B raf ford & Be ck, 1991) These que stions ask about y our own fe eling s about using c ondoms in specific situations. Please re spond even if y ou are not sex ually active or have ne ver use d (or ha d a par tner who used) c ondoms. I n such ca ses indicate how y ou think y ou would fee l in such a situation. 1. I fee l confident in my ability to put a condom on my self or my partne r S t r o n g l y D i s a g r e e U n d e c i d e d A g r e e S t r o n g l y Disag ree Ag ree 2. I fee l confident I could purc hase c ondoms without feeling embar rasse d. S t r o n g l y D i s a g r e e U n d e c i d e d A g r e e S t r o n g l y Disag ree Ag ree 3. I fee l confident I could re member to c arr y a condom with me should I need one S t r o n g l y D i s a g r e e U n d e c i d e d A g r e e S t r o n g l y Disag ree Ag ree 4. I fee l confident in my ability to discuss condom usag e with any partne r I might have. S t r o n g l y D i s a g r e e U n d e c i d e d A g r e e S t r o n g l y Disag ree Ag ree 5. I fee l confident in my ability to sugg est using c ondoms with a new pa rtner. S t r o n g l y D i s a g r e e U n d e c i d e d A g r e e S t r o n g l y Disag ree Ag ree

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68 6. I fee l confident I could sug g est using a condom without my partne r fe eling "dise ased." S t r o n g l y D i s a g r e e U n d e c i d e d A g r e e S t r o n g l y Disag ree Ag ree 7. I fe e l c on fi de nt i n my ow n o r m y pa rt ne r' s a bil ity to m a int a in a n e re c tio n w hil e us ing a c on do m. S t r o n g l y D i s a g r e e U n d e c i d e d A g r e e S t r o n g l y Disag ree Ag ree 8.* I would fee l embarr assed to put a c ondom on my self or my partne r. S t r o n g l y D i s a g r e e U n d e c i d e d A g r e e S t r o n g l y Disag ree Ag ree 9.* I f I wer e to sug g est using a condom to a par tner, I would fee l afra id that he or she would reje ct me. S t r o n g l y D i s a g r e e U n d e c i d e d A g r e e S t r o n g l y Disag ree Ag ree 10 .* I f I we re un su re of my pa rt ne r' s f e e lin g s a bo ut u sin g c on do ms, I wo uld no t su g g e st using one S t r o n g l y D i s a g r e e U n d e c i d e d A g r e e S t r o n g l y Disag ree Ag ree 1 1 I f e e l c o n f i d e n t i n m y a b i l i t y t o u s e a c o n d o m c o r r e c t l y. S t r o n g l y D i s a g r e e U n d e c i d e d A g r e e S t r o n g l y Disag ree Ag ree 12. I would fee l comfortable discussing c ondom use with a potential sexual partner be fo re we e ve r h a d a ny se xua l c on ta c t (e.g ., hug g ing, kissing car essing etc.) S t r o n g l y D i s a g r e e U n d e c i d e d A g r e e S t r o n g l y Disag ree Ag ree 13. I fee l confident in my ability to persuade a par tner to ac cept using a condom whe n we ha ve interc ourse. S t r o n g l y D i s a g r e e U n d e c i d e d A g r e e S t r o n g l y Disag ree Ag ree 14. I fee l confident I could g rac efully remove and dispose of a condom af ter sexual intercour se. S t r o n g l y D i s a g r e e U n d e c i d e d A g r e e S t r o n g l y Disag ree Ag ree

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69 15.* I f my partne r and I wer e to try to use a c ondom and did not succe ed, I would fee l e mba rr a sse d to tr y to u se on e a g a in ( e .g ., no t be ing a ble to u nr oll c on do m, p utt ing it on backw ards or awkwa rdness). S t r o n g l y D i s a g r e e U n d e c i d e d A g r e e S t r o n g l y Disag ree Ag ree 16. *I would not fee l confident sug g esting using c ondoms with a new pa tner be cause I would be af raid he or she would think I ve had a pa st homosex ual experienc e. S t r o n g l y D i s a g r e e U n d e c i d e d A g r e e S t r o n g l y Disag ree Ag ree 17. *I would not fee l confident sug g esting using c ondoms with a new pa rtner be cause I would be af raid he or she would think I have a sexually transmitted disease. S t r o n g l y D i s a g r e e U n d e c i d e d A g r e e S t r o n g l y Disag ree Ag ree 18. *I would not fee l confident sug g esting using c ondoms with a new pa rtner be cause I would be af raid he or she would think I thought they had a se x ually transmitted disease. S t r o n g l y D i s a g r e e U n d e c i d e d A g r e e S t r o n g l y Disag ree Ag ree 19. I would fee l comfortable discussing c ondom use with a potential sexual partner befor e we ever eng ag ed in interc ourse. S t r o n g l y D i s a g r e e U n d e c i d e d A g r e e S t r o n g l y Disag ree Ag ree 20 I fe e l c on fi de nt i n my a bil ity to i nc or po ra te pu tti ng a c on do m on my se lf or my p a r t n e r i n t o f o r e p l a y. S t r o n g l y D i s a g r e e U n d e c i d e d A g r e e S t r o n g l y Disag ree Ag ree 21. I fee l confident that I could use a condom with a par tner without brea king the mood." S t r o n g l y D i s a g r e e U n d e c i d e d A g r e e S t r o n g l y Disag ree Ag ree 2 2 I f e e l c o n f i d e n t i n m y a b i l i t y t o p u t a c o n d o m o n m ys e l f o r m y p r t n e r q u i c k l y. S t r o n g l y D i s a g r e e U n d e c i d e d A g r e e S t r o n g l y Disag ree Ag ree 23. I fee l confident I could use a condom during intercour se without reduc ing a ny se xua l se ns a tio ns S t r o n g l y D i s a g r e e U n d e c i d e d A g r e e S t r o n g l y Disag ree Ag ree

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70 24. I fee l confident that I would reme mber to use a condom eve n afte r I have be en d ri n k i n g. S t r o n g l y D i s a g r e e U n d e c i d e d A g r e e S t r o n g l y Disag ree Ag ree 25. I fee l confident that I would reme mber to use a condom eve n if I wer e hig h. S t r o n g l y D i s a g r e e U n d e c i d e d A g r e e S t r o n g l y Disag ree Ag ree 26 I f m y pa rt ne r d idn t w a nt t o u se a c on do m du ri ng int e rc ou rs e I c ou ld e a sil y convince him or her that it was ne cessa ry to do so. S t r o n g l y D i s a g r e e U n d e c i d e d A g r e e S t r o n g l y Disag ree Ag ree 2 7 I f e e l c o n f i d e n t t h a t I c o u l d u s e a c o n d o m s u c c e s s f u l l y. S t r o n g l y D i s a g r e e U n d e c i d e d A g r e e S t r o n g l y Disag ree Ag ree 28. I fee l confident I could stop to put a condom on my self or my prtner e ven in the heat of passion. S t r o n g l y D i s a g r e e U n d e c i d e d A g r e e S t r o n g l y Disag ree Ag ree item reve rse sc ored

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71 APPENDI X B POSI TI VE CHL AMYDI A RESUL TS BY MON TH Data g ather ing instrument use d to rec ord re ported c ases of chlamy dia in students who acc ess servic es fr om the University of F lorida Student Hea lth Care Center via labora tory re c or ds M on t h / Y ear r eport ed Jan 99 F eb 99 M ar 99 A pr 99 M ay 99 June 99 J u ly 99 A ug 99 Se pt 99 O ct 99 N ov 99 D ec 99 F em al es M al es T ot al 3871 7 3874 8 3877 6 3880 7 3883 7 3886 8 3889 8 3892 9 Se pt 00 O ct 00 N ov 00 D ec 00 F em al es M al es T ot al 3871 7 3874 8 3877 6 3880 7 3883 7 3886 8 3889 8 3892 9 Se pt 01 O ct 01 N ov 01 D ec 01 F em al es M al es T ot al 3871 8 F eb 02 3877 7 3880 8 3883 8 3886 9 3889 9 3893 0 Se pt 02 3899 1 N ov 02 3905 2 F em al es M al es T ot al 3871 9 3875 0 3877 8 3880 9 3883 9 3887 0 3890 0 3893 1 Se pt 03 3899 2 N ov 03 3905 3 F em al es M al es T ot al

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72 APPENDI X C DEMOGRAPHI C CHARACTERI STI CS FOR POSI TI VE CHL AMYDI A RESUL TS Data c ollection log f or re view of c hlamy dia ca ses re ported by labora tory results form the labora tory at the Univer sity of F lorida Student Hea lth Care Center Case number Ag e Sex Ethnicity Repea t infection Residence J an 99 # 1 J an 99 # 2 J an 99 # 3 J an 99 # 4 J an 99 # 5 J an 99 # 6 Continue asnee ded I nformation on this data shee t will be rec orded a s follows. A number will sig nify ag e, sex will be noted as 0 for male and 1 f or fe male and e thnicity will be repor ted as 0 for Cauca sian, 1 for A frica n Americ an, 3 for Hispanic, 4 for Asian, 5 for Native Ame rica n, 6 for nonwhite othe r. Repea t infection will be indicate d as 0 for no and 1 for y es and residenc e will be re corde d as 1 for on-ca mpus dormitory 2 for oncampus soror ity or fra ternity house, 3 for offcampus a partment/house a nd 4 for of f-c ampus home.

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81 B I OG RA PHI CA L SKE TCH Ms. Thomas g radua ted from Saint Petersbur g J unior College in 1979 with an associate deg ree in nursing sc ience and an a ssociate s deg ree in social arts. She re ceive d a bac helor' s deg ree in nursing sc ience from the Unive rsity of F lorida in 1996 and a ma ste r' s d e g re e in n ur sin g sc ie nc e fr om t he Un ive rs ity of F lor ida in 1 99 8. Ms. Th oma s' ex p er t i s e i n cl u d es 1 8 y ea rs o f c l i n i ca l n u rs i n g ex p er i en ce i n m at er n al n ew b o rn n u rs i n g, neonata l intensive car e, adult cr itical car e, and a dvance d prac tice nursing Advanc ed p r a c t i c e a r e a s i n c l u d e g e n e r a l p e d i a t r i c s p e d i a t r i c f o r e n s i c s a d o l e s c e n t g yn e c o l o g y, colleg e hea lth, primary car e, and w omen' s repr oductive hea lth. She has also enric hed her car eer with 8 y ear s of prog ressive ma nag ement experienc e, including clinical supervision, cha rg e nurse roles, and dir ector levels. She has g arne red 6 y ear s of re sear ch during her c are er inc luding c oordination of an N I H funde d study clinical trials, and e p i d e m i o l o g i c r e s e a r c h E p i d e m i o l o g y i s M s T h o m a s s m i n o r c o u r s e o f s t u d y. Presently Ms. Thomas serve s as a r esea rch a ssociate a nd site coordinator for the Ad dic tiv e a nd He a lth B e ha vio rs Re se a rc h I ns tit ute a nd a s a n a dv a nc e d r e g ist e re d n ur se prac titioner at the Univer sity of F lorida Student Hea lth Care Center


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Title: Chlamydia Infection: Population Specific Risk Factors for Female University Students
Physical Description: Mixed Material
Copyright Date: 2008

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Holding Location: University of Florida
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CHLAMYDIA INFECTION: POPULATION SPECIFIC RISK FACTORS FOR
FEMALE UNIVERSITY STUDENTS















By

TAMI LYNN THOMAS


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA


2006

































Copyright 2006

by

Tami Lynn Thomas

































This dissertation is dedicated to the students at the University of Florida
and to my maternal grandfather, Thomas Edward Gentry.















ACKNOWLEDGMENTS

I thank my chair, Dr. Sharleen Simpson, for believing in me and encouraging me.

I am grateful to my committee members, Dr. Donna Neff, Dr. Sandra Seymour, and Dr.

Nabih Asal, for their kindness, encouragement, patience, and faith. I would like to thank

the faculty in the College of Nursing for their support and encouragement. I am thankful

for the professionalism and patience of Dr. Jennifer Elder, Dr. Ann Horgas, and Dr. Jo

Snider. I am also thankful to Dr. Hussein Yarandi for his review of my data analysis.

This research could not have been completed with out the support of the administration,

medical staff, nurses and secretarial staff of the University of Florida, Student Health

Care Center.

Most of all I thank my children, Robert Timothy Engelberth and Helen Renee

Engelberth, for being my strongest supporters. I must also acknowledge my career

mentors and personal inspirations, Dr. Dee Williams, Dr. Maureen Keller-Wood, and

Dr. Charles Wood. They understood me, encouraged me, and saw my potential when I

had doubts.


















TABLE OF CONTENTS

Page

ACKNOWLEDGMENTS .................................. ............ iv

LIST OF TABLES ..................................................... vii

LIST OF FIGURES .......... .. ...................... .. .......... ix

ABSTRACT ............ ............................................. x

CHAPTER

1 BACKGROUND AND SIGNIFICANCE .................................. 1

Chlamydia Infection Rates and Risks to Young Women ....................... 1


Epidemiology of Chlamydia .......
Theoretical Framework ...........
Sum m ary ....................

2 LITERATURE REVIEW ..........

Pathobiological Perspectives .......
Sociocultural Perspectives .........
Behavioral Perspectives ...........
Theoretical Application and Rationale
Sum m ary ....................

3 RESEARCH IMPLEMENTATION .

Research Design ...............
Data Collection Methods ..........
Analysis of Questionnaire Data .....
Ethical Considerations .......... .
Sum m ary ....................

4 FINDINGS ...................

Introduction ....................
Infection Rates ..................
Questionnaire Analysis ...........
Research Question Findings ........
Sum m ary ....................


. . . . . . . . . . 8
.......................... ..........10

........................ ..........12

. . . . . . . . . 12
........................ ..........14
.......................... ..........19
. . . . . . . . . 2 1
....................................25

....................................26

....................................26
......................... ...........31
. . . . . . . . . 3 1
. . . . . . . . . 3 2
....................................32

....................................33

....................................33
....................................34
. . . . . . . . . 3 7
..................................41
......................... ...........48










5 DISCUSSION AND IMPLICATIONS ................................. 50

Research Purpose ............. ..................... ............. 50
Discussion ........... ............................................ 50
The Significance and Revisions to the Campus Chlamydia Model .............. 59
Limitations .................. ....................... ............. 62
Recommendations for Future Research ................ ................ 62
Contribution to Nursing Science .................................... 63
Conclusion ............ ............................................ 64

APPENDIX

A CHLAMYDIA QUESTIONNAIRE .................................. 66

B POSITIVE CHLAMYDIA RESULTS BY MONTH ........................ 71

C DEMOGRAPHIC CHARACTERISTICS FOR POSITIVE CHLAMYDIA
RESULTS ............... ............................ .72

REFERENCES .............. ............................ .73

BIOGRAPHICAL SKETCH ............... .......................... 81















LIST OF TABLES

Table page

1-1 Chlamydia, reported cases and rates per 100,000 females ages 16-19 in the
United States ........... ......................................... 1

1-2 Chlamydia, reported cases and rates per 100,000 females ages 20-24 in the
United States ........... .........................................2

1-3 Number of cases and incidence rates of chlamydia per 100,000 in women
ages 17-24 in Florida .............................................. 2

1-4 Chlamydia positivity in women 15-44 by testing site in Florida ............. .2

1-5 Results from the American College Health Association survey of providers-
Rates of chlamydia (CZ) in men, women, those presenting with symptoms
(positives), and those presenting without (asymptomatic positives) ............ 3

3-1 Examples of questions used in the Condom Use Self-Efficacy Scale .......... 29

4-1 Chlamydia infection data for students who access services at the University
of Florida Student Health Care Center ............................. 34

4-2 Demographic characteristics for students testing positive for chlamydia
infection ....................................................... 35

4-3 Chlamydia infection rates as reported by the ACHA and the University of
Florida Student Health Care Center ............................... 37

4-4 Demographic characteristics of study participants ........................ 39

4-5 Frequency of condom use and high-risk drinking ......................... 39

4-6 Summary measures of variables age, number of partners, high risk drinking,
drink occasions, drinking and having sex, and CUSES scores ............... 40

4-7 Frequency and percent of sexual activities, behavior, sexually transmitted
infection (STI), and gynecologic complaint ............................. 42

4-8 The difference in mean rank of the number of sexual partners ............... 45









4-9 Goodness of fit complete model for the logistic regression to determine
combined effects of condom use self-efficacy scale scores, number of sexual
partners, high-risk drinking, and sexual risk taking on those with a
gynecologic complaint ........................................... 46

4-10 Analysis of maximum likelihood estimates for logistic regression to
determine combined effects of condom use self-efficacy scale scores,
number of sexual partners, high-risk drinking, and sexual risk taking on
those with a gynecologic complaint ................................... 47

4-11 Odds ratio estimates for the parameters of the completed model to
determine combined effects of condom use self-efficacy scale scores,
number of sexual partners, high-risk drinking, and sexual risk taking on
those with a gynecologic complaint ................................... 48

4-12 Analysis of maximum likelihood estimates determining combined effects of
condom use self-efficacy scale scores, number of sexual partners, high-risk
drinking, and sexual risk taking on those with a gynecologic complaint ....... 48















LIST OF FIGURES


Figure page

1-1 The epidemiologic triangle ................ ........................ 7

1-2 A model of social cognitive theory (Bandura, 1986) depicting construct
groups in circles and the interactive relationship among the groups with
bidirectional arrows ......... ......................................9

2-1 Proposed Campus Chlamydia Model adapted from Bandura's (1997) self-
efficacy theory .................................. ............. 23

4-1 Percent of subjects with and without gynecologic complaint diagnosed and
treated for sexually transmitted infection ............................ 44

4-2 A comparison of subjects with and without gynecologic complaints treated
more than once for sexually transmitted infection ..................... .. 44















Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

CHLAMYDIA INFECTION: POPULATION SPECIFIC RISK FACTORS FOR
FEMALE UNIVERSITY STUDENTS

By

Tami Lynn Thomas

August 2006

Chair: Sharleen Simpson
Major Department: Nursing

Genital chlamydia infection is increasing on a national level resulting in millions

in health care costs. Chlamydia related morbidity includes pelvic inflammatory disease,

chlamydia prostatitis for men, and in some cases infertility. Despite decades of primary

and secondary prevention measures, including the distribution of free condoms, health

education programs, and inexpensive treatment, nationally and locally genital chlamydia

infection rates have risen in young women.

The purpose of this research was to document rates of genital chlamydia infection

in male and female university students who access health care services at a university

student health care center and describe possible population specific risk factors for

female university students. First, reported cases of genital chlamydia were tracked and

demographics calculated with the cooperation of the laboratory manager at the research

site. Incidence rates were higher than national rates, 5.8% versus 3.8%. Those infected

were more likely to be female, living in apartments off campus, 20 years old, and white.









Then, female university students who accessed services at the student health care

center were recruited using an institutional review board approved flyer to complete an

anonymous questionnaire to gather data on high risk drinking behaviors, sexual risk

taking, gynecologic complaints, condom use, and condom use self-efficacy. This sample

of female students was predominantly junior and senior class level. They reported

high-risk drinking and sexual risk-taking behaviors at rates greater than 67%. The mean

number of sexual partners for those students completing the questionnaire was 1.6 in the

past year. The number of sexual partners may also predict the likelihood of a gynecologic

complaint, greater sexual activity, and subsequent sexually transmitted infection. Further

analysis demonstrated no relationships between high-risk drinking, sexual risk taking,

and condom use self efficacy scale scores.

This research demonstrates the need for prevention efforts through

comprehensive sexuality education and reproductive health services on a university

campus. Further research is planned to examine the impact of the transition to a

university campus life, including sociocultural factors such as peer group subcultures,

gender based power issues, high-risk drinking, and sexual risk taking.















CHAPTER 1
BACKGROUND AND SIGNIFICANCE

Chlamydia is an obligate bacteria that enters the vagina during sexual contact

causing millions of infections annually for women under age 25 (Kelly, 2003; Centers for

Disease Control and Prevention, 2004). Untreated infections invade the female

endocervical epithelium and fallopian tubes with subsequent health care costs exceeding

$3 billion per year (Aral, 2002; Holmes, 1994; Stamm, 2004). Vague symptoms

including burning upon urination, pelvic pain and vaginal bleeding may be present, but

asymptomatic infection is common (Weir, 2004). Mild symptoms, or lack thereof, leave

these young women at risk for chlamydia related morbidity, most specifically, pelvic

inflammatory disease (PID). Chlamydia PID can lead to infertility (Stamm, 2004).

Unfortunately, inexpensive and effective treatment is often delayed because of vague or

absent symptoms (Hu, Hook & Goldie, 2004).

Chlamydia Infection Rates and Risks to Young Women

The Centers for Disease Control and Prevention (CDC) reports increasing rates of

chlamydia nationally in women aged 16 to 24 from 1999 to 2003 (Centers for Disease

Control and Prevention, 2004; Tables 1-1 and 1-2).

Table 1-1. Chlamydia, reported cases and rates per 100,000 females ages 16-19 in the
United States
Females ages 16-19 years 1999 2000 2001 2002 2003
Cases 277,376 231,167 249,269 257,428 266,175
Rates 2,329.2 2,352.5 2,531.3 2,599.0 2,687.3
(CDC, 2004)







2

Table 1-2. Chlamydia, reported cases and rates per 100,000 females ages 20-24 in the
United States
Females ages 20-24 1999 2000 2001 2002 2003
Cases 185,058 199,257 226,992 238,406 252,936
Rates 2,033.9 2,129.1 2,357.0 2,417.1 2,564.4
(CDC, 2004).

These data indicate a steady rise in the rates of chlamydia in this age group, an

increase from 185,058 for women ages 20 to 24 in 1999 to 252, 963 in 2003. These

increases occur in the presence of primary and secondary prevention measures including

education, condom distribution, and effective treatment. The CDC postulates that

increasing rates of chlamydia may be a result of primary and secondary prevention

failures (U. S. Department of Health and Human Services, 2000).

In Florida, the reported cases and rates per 100,000 for women have increased

from 1999 to 2003 (CDC, 2004; Table 1-3). Women in Florida are not screened for

chlamydia as a standard of care in many primary healthcare settings. Cases have

increased from 25,957 in 1999 to 34,581 in 2003. The infection rates continue to climb,

despite health education efforts and inexpensive effective treatment. Table 1-4 represents

screening rates for women in Florida and substantiates the concern that secondary

prevention measures may have failed or at least that screening must increase.

Table 1-3. Number of cases and incidence rates of chlamydia per 100,000 in women ages
17-24 in Florida
State reporting-Florida
Year 1999 2000 2001 2002 2003
Rate per 100,000 population 321.5 335.4 365.9 396.9 404.8
Cases 25957 27562 30647 33902 34581
(Centers for Disease Control and Prevention, 2004).

Table 1-4. Chlamydia positivity in women 15-44 by testing site in Florida
Testing Site Number of clinics Number tested Percent found positive
Family planning 28 16131 4.1%
STD clinics 25 4220 10.3
Prenatal clinics 13 3494 5.2
Other N/A N/A N/A
(CDC, 2004)









Current screening of women in Florida may not be adequate. The data reflect that

chlamydia was diagnosed in asymptomatic patients regardless of setting with the highest

rate of positivity occurring in STD clinics. These sites do not include any population

specific institutions such as student health care services on any campus in Florida. This

fact is the rationale supporting this two-fold research purpose and the research questions.

The American College Health Association 2004 Annual Pap Tests and STI

Survey represents findings with lower than expected rates of chlamydia in young women

and higher than expected rates in young men (American College Health Association

[ACHA], 2005; Table 1-5). The authors of the American College Health Association data

caution that these results may not be accurate, as providers reported only the number of

asymptomatic cases if known, and cited results as being imprecise (ACHA, 2005). The

current rates of chlamydia infection rates for students who access the University of

Florida Student Health Care Center are unknown as of January 2006. These data make

the argument that chlamydia screening for young women on college campuses is not only

desired but imperative.

Table 1-5. Results from the American College Health Association survey of providers-
Rates of chlamydia (CZ) in men, women, those presenting with symptoms
(positives), and those presenting without (asymptomatic positives)
% Asymptomatic % of positive
Total Positive positive positive asymptomatic
Undifferentiated CZ 108602 4289 3.95 604 14.1 %
Females with CZ 72565 2649 3.65 387 14.6%
Males with CZ 13948 1110 7.96 131 11.8%

(ACHA, 2005)









Epidemiology of Chlamydia

The epidemiology of chlamydia is dependent on several factors. As described by

Donovan (2004, p. 545) they are the following:

* Sexual mixing patterns moderated by protective behaviors
* The transmission and pathogenicity of chlamydia
* Demographics
* Reporting practices of healthcare providers
* Implications of personal judgment
* Normative behavior
* Social conditions
* Decisions to seek treatment

There is no current routine screening for chlamydia for students who access health care

services at the University of Florida Student Health Care Center. Chlamydia screening is

offered, but testing for chlamydia and other sexually transmitted infections is expensive,

more than $100 per test. Because increasing rates of chlamydia infection in this age

group persist on the state and national level, rates for female students accessing the

University of Florida Student Health Care Center should be evaluated. In fact, the

epidemiology of chlamydia warrants regular screening of this population. Because of

these statistics, even in an environment of limited resources and controlled costs, budget

allocations for chlamydia screening must be considered. Sexual activity along with other

risk behaviors-such as binge drinking, underage drinking, sexual activity while using

alcohol, and sexual contact without the use of barrier methods-contributes to the spread

of this infection and suggests that these behaviors or risk factors be examined and their

relationships explored (Donovan, 2004; Ross, 2002; Von Sadovsky, Keller, &

McKinney, 2002).

Sexual Activity

Sexual activity is a group of behaviors that includes penile vaginal intercourse,

mutual masturbation, petting, oral sex, anal sex, penile vaginal intercourse, and sexual









experimentation with objects and diverse forms of lubrication (Ross, 2002). Sexual risk

taking is a subset of these behaviors that put an individual at risk for infection or abuse.

The most common form of sexual risk taking is penile vaginal intercourse without the

use of a condom (Grady & Gillam, 2003). Adverse outcomes of sexual risk taking

include unwanted pregnancy and increased rates of sexually transmitted diseases

(Cooper, 2004). Not surprisingly, sexual risk taking is also associated with high-risk

drinking in research studies that explore college student behavior (LaBrie, Schiffman, &

Earlywine, 2002; Liccardone, 2003).

High-Risk Drinking

High-risk drinking is defined as underage drinking and binge drinking. Binge

drinking is defined by researchers as five or more drinks at one occasion (Dejong &

Langford, 2002). Researchers report the adverse outcomes for high-risk drinking as

increased rates of sexually transmitted diseases, sexual assault, battery, property damage,

and even loss of life (Santelli, Lowry, Brener, & Robin, 2000; Sipkin, Grady, Bissett, &

Gillam, 2003). Sexual risk taking and high-risk drinking seem to have a temporal effect,

which means that when sexual risk taking and high-risk drinking occur transmission rates

increase for chlamydia and other sexually transmitted diseases (Chronister & McWhirter,

2003; Foxman et al., 2000; Kirby, 2002). Research studies also indicate that sexual risk

taking and high-risk drinking are some of the most prevalent exploratory behaviors

practiced by female students (Wechsler et al., 2002).

Transition to Campus Culture

The adjustment to college offers challenges referred to in research literature as

developmental transitions (Farrow & Arnold, 2003). These developmental transitions are

frequently characterized by population specific behaviors. They include the desire to









have intimate emotional and sexual relationships, underage alcohol use, binge drinking,

sexual risk taking, and inclusion in social functions (Farrow & Arnold, 2003; Liccardone,

2003). Chlamydia infection rates must be explored in the context of these developmental

transitioning behaviors as they are products of personal decision making that include

behaviors and decisions to seek treatment.

Epidemiologic Methodology

Epidemiologic methodology incorporates population specific information and

addresses the causality and association of disease. Epidemiologic causality includes

associated risks and relationships between a disease and the causes of the disease.

Epidemiologic causality is a complex interaction of infectious or noninfectious agents,

environmental and host factors that implies a direct relationship among an agent, an

environmental or host factor, and a disease (Evans, 1978). Features of disease causality

were described by Evans in 1978; they are the following:

* The rate of prevalence is higher in the exposed population than in a nonexposed
population.

* Exposure to the infectious agent is more common in those diagnosed than those
without the illness.

* Incidence rates should be higher in those exposed than those not exposed.

* Exposure to the suspected infectious agent should precede signs and symptoms.

* Specific signs and symptoms should exist.

* Experimental reproduction of the disease should exist. In other words, the disease
can be replicated in laboratory setting.

* Eliminating the infectious agent should decrease the incidence of the illness, and
prevention or modification of signs and symptoms should decrease or eliminate the
presence of the illness (Evans, p. 254, 1978).









In contrast, a statistical association between a specific disease and a possible risk

factor does not imply a causal relationship (Last, 2001). Statistical associations can be

direct, indirect, or spurious (Gordis, 2000). Statistical analysis incorporated with

epidemiologic method can determine direct, indirect or spurious associations. This

analysis is essential in defining the interaction among host, pathogen, and environment.

The classic epidemiological triangle graphically represents this interaction among host,

pathogen, and environment, explaining the etiology and epidemiology of both infectious

and chronic disease (Mausner & Krammer, 1985; Figure 1-1).


Host







Disease Environment


Figure 1-1. The epidemiologic triangle

But epidemiologic causality as an indicator of disease prevalence is different from

statistical and biological causality because it begins with the determination of the number

of disease cases in a certain population (Rothman, 1976). For example, in the venue of

public health and clinical practice, the choice of a treatment is based on physical

assessment, available treatment and the known causality of the infection or disease

(Rothman, Greenland, & Walker, 1980). Determining the causality or associated risk

factors for acquiring chlamydia in the specific population of female university students

requires review of current infection rates of chlamydia for these students. The

epidemiology of chlamydia on a university campus includes disease causality and

identification of associated risk factors.









Genital chlamydia infection is directly caused by transmission during sexual

contact. Population specific associated risk factors such as condom use, high-risk

drinking, and sexual risk taking may have a direct, indirect, or spurious association with

chlamydia infection rates. Analyses to determine whether population associated risk

factors were associated with chlamydia infection or seeking care for a gynecologic

complaint are an essential part of this research.

Theoretical Framework

A theoretical framework provides an explanation and clarity for the research and

its findings. The choice of theory is based on literature review and amplifies the purpose,

questions and rationale for the research.

Choice of Theory

Social Cognitive Theory (SCT) postulates that health-protective behavior results

from a process of cognitive appraisal with an integration of information about disease,

the outcomes of health behavior decision making, and the interaction of the environment,

also described as social influences (Bandura, 1986; Figure 1-2). Social Cognitive Theory

constructs are also congruent with nursing theory because they address environment,

behavior, and personal aspects of behavior change in a dynamic reciprocal relational

interchange. I have constructed a graphic representation of Social Cognitive Theory

(Bandura, 1986), which is similar to the Epidemiologic Triangle, using a triangular

model and including environment as a major construct (Figure 1-2).

The result of this integrated process is self-efficacy or an estimate of how well a

person will cope with a situation that moderates behavior (Bandura, 1990). Self-efficacy

is a measurable construct with predictive power, parsimony, and reliability (Wulfert &

Wan, 1995). The construct proved to be so useful its own unique theory developed. This










theory provides a framework to explain the importance of a young woman's choice of

sexual behaviors (Few, 1997; Leganger, Kraft, & Roysamb, 2000; Sherwin, 1992).

Personal Factors




Behavioral
Capability
Expectations
Expectancies
Self Control





Self-Efficacy
Reinforcement
Observational Learning
Emotional Coping Responses
Situation Reciprocal Determinism
Environment





Environment Behavior

Figure 1-2. A model of social cognitive theory (Bandura, 1986) depicting construct
groups in circles and the interactive relationship among the groups with
bidirectional arrows

Leganger and colleagues (2000) also reported that self-efficacy predicts behavior

change because of its influence on individual decisions. Therefore, if a female college

student exercises self-efficacy, she will determine for herself what her choices are about

use of condoms or the amount of alcohol she consumes. Research findings suggest that a

female college student's choices for sexual health may depend on three key factors: self-

efficacy, condom use, and perceived social support (Chronister & McWhirter, 2003).

Self-efficacy Theory or SET, is the logical choice for this research because of its

predictive value for behavior change and behavior maintenance (Bandura, 1977b, 1990).









More specifically, self-efficacy theory provides a research framework to examine

incidence rates of chlamydia and the relationships among condom use, sexual risk taking

and high-risk drinking in female university students by providing a theoretical basis to

explore the behaviors of these students in relation to infection rates of chlamydia.

Purpose

The purpose of this research was to determine current infection rates of chlamydia

in the student population that accesses services at the University of Florida Student

Health Care Center and to determine relationships among condom use self-efficacy

scores in female students, high-risk drinking, sexual risk taking, and the current incidence

rates of chlamydia infection.

Research Questions

* What is the relationship among condom use self-efficacy scale scores and sexual
risk taking behavior and high-risk drinking among the female college students who
access services at a university student health care center?

* What are the differences in the number of sexual partners and the amount of high-
risk drinking between those who did and did not engage in high-risk sexual
activity?

* What are the combined effects of condom use self-efficacy scale scores, number of
sexual partners, high-risk drinking and sexual risk taking behaviors on those with a
gynecological complaint?

Summary

This first chapter provides background information on chlamydia rates, the

significance of this problem, and a choice of a theoretical framework. The impacts of

condom use and population specific risk factors-including high-risk drinking, sexual

risk taking, and a students' decision to seek treatment for a gynecologic complaint-are

factors in reducing transmission rates of genital chlamydia infection (Barth, Cool,

Downs, Switzer, & Fischhoff, 2002). Epidemiologic method provides a foundation to







11

examine population specific risk factors to determine causality and transmission of

chlamydia infection. The importance of an integrated research study using epidemiologic

method and theory is explained with the purpose and research questions identified.















CHAPTER 2
LITERATURE REVIEW

Current literature proffers three research perspectives relative to chlamydia

infection and its relationship with condom use, sexual risk taking, high-risk drinking and

college students. These perspectives are pathobiologic, sociocultural and behavioral. The

following paragraphs provide a review of current perspectives, a summary of current

research literature and the rationale for the theory choice with proposed model as the

framework for this research.

Pathobiological Perspectives

Chlamydia infection is typically studied from a pathobiological viewpoint. This

perspective describes a pathogen and host interaction as the key to prevalence and

incidence rates (Stamm, 2001). Research describes transmission emphasizing the

vulnerability of the vagina as a host for infection (Collier et al., 1995; Dryden,

Wilkinson, Redman, & Miller, 1994; Elkins & Cox, 1974; Hooton et al., 2000;

Osterberg, Aspevall, Grillner, & Persson, 1996). Halting the spread of chlamydia

infection by prescribing sexual abstinence exclusively is unrealistic as abstinence is a

personal behavioral choice. Students choose to be sexually active for many reasons and

condom use may be sporadic. According to researchers at the Centers for Disease Control

and Prevention (CDC, 2004) using condoms without fail is the only behavior besides

abstinence that can control chlamydia transmission. A student's personal sexual choices

affect consistent condom use. These choices are in turn influenced by sociocultural and

behavioral factors and may become risk factors for women ages 16 to 24.









Chlamydia infection research identifies age of the individual as the most

important risk factor for acquiring chlamydia infection (United States Preventive

Services Task Force [USPTF], 2002, CDC, 2004). Other associated risks were marital

status, race, number of sexual partners, cervical ectopy, history of infection with a

sexually transmitted disease and inconsistent use of condoms (CDC, 2004; USPTF,

2002). New data from the Centers for Disease Control and Prevention, in the first

national representative study looking at prevalence rates in women ages 14 to 39,

indicate that almost 1 out of every 20 women were reported to have chlamydia (CDC,

2005).

In 2004, the Centers for Disease Control reported the cost of chlamydia infection

and related morbidities at 374.6 million dollars annually in the United States with an

annual incidence rate of 1.5 million cases (Weir, 2004). There has been a steady increase

in infection rates since 1984 complicated by a 70% asymptomatic case rate (CDC, 2004;

USPTF, 2002). The Division of Sexually Transmitted Diseases at the Centers for Disease

Control and Prevention describes several challenges to the identification and treatment of

this disease. One challenge is the limitation of having only case reports to monitor trends

in chlamydia, inconsistency in case reporting laws, and a lack of routine screening.

Unfortunately in Florida, infection rates remain high because chlamydia screening is not

routine at most female annual gynecological exams. This puts women under the age of

twenty at a considerable risk (CDC, 2004). Hu and associates (2004) concluded that the

persistent rise in chlamydia rates is a direct response to failures in primary and secondary

prevention efforts in the public health arena. The United States Preventative Task Force

reports that infection rates seem to decline when large-scale screening and treatment is

implemented (USPTF, 2002).







14

Since primary prevention efforts focus on education, and secondary efforts focus

on screening and treatment, the cost of screening and treatment has been the topic of

research and case studies. The cost of treatment for a primary infection is an important

consideration in an environment of cost containment and rising prescription costs. Recent

clinical practice literature indicates that treatment of chlamydia infection with

doxycycline or azithromicin is effective (Adimora, 2002). Doxycycline treatment is

currently $10.10 per regimen at the University of Florida Student Health Care Center

(UF SHCC) and azithromicin follows closely behind at a cost of $38.00 per regimen.

Effective treatment is not cost prohibitive at the UF SHCC for most students.

The strength of current pathobiological research is its specific acknowledgment of

vagueness or lack of symptoms with this infection and the recognition of the

sociocultural implications (Brener & Gowda, 2001). Pathobiologic research literature is

limited in that it has not addressed this specific population, female university students,

who may or may not seek medical treatment for a vague gynecologic complaint. Whether

the failure is in primary prevention efforts that involve education or secondary efforts

that include costly screening and treatment, female college students remain at

considerable risk for acquiring this infection. Female college or university students

embrace an attitude of invulnerability, a desire for belonging, and intimate relationships

(Arnett, 2004).

Sociocultural Perspectives

Sociocultural perspectives must include population-associated risks including

gender, age, ethnicity, residence, sexual risk taking, high-risk drinking, and their

respective relationships with each other. Sexual risk taking is a subset of these behaviors

that put an individual at risk for infection or abuse. The most common form of sexual risk







15

taking is penile vaginal intercourse without the use of a condom (Grady & Gillam, 2003).

High-risk drinking is defined as under-age drinking and binge drinking. Binge drinking is

defined by researchers as five or more drinks at one occasion (Dejong & Langford,

2002). This specific research literature examines the social pressures of peer groups such

as sorority pledging, dating events and athletics that directly influence sexual risk taking

and high-risk drinking (Wechsler et al., 2002). Additional research literature describes

the interpersonal and behavioral implications from sexual risk taking activity on a college

campuses; supporting consideration of the sociocultural environment as a predictor of

high-risk activities (Gurman & Borzekowski, 2004). Inconsistent condom use is a

persistent trend in sexual behaviors for college and university students accompanied by

alcohol use (Bay-Cheng, 2003). Additional research notes that inconsistent condom use

is highly correlated with high-risk drinking (Albarracin, Kumkale, & Jouhnson, 2004).

Condom use is a personal choice of sexual behavior influenced by associated

sociocultural factors. These factors include gender-based power relationships and peer

group expectations. Male-female power relationships are part of gender expectations and

sociocultural influences that determine condom use and influence disease transmission

(Gomez & Van Oss Martin, 1996). The sociocultural environment of the university

campus may influence a female student's choice to seek treatment for symptoms of a

sexually transmitted disease. An understanding of these sociocultural factors may also

assist in the examination of population associated risk factors and in the development of

effective interventions to decrease chlamydia infection rates.

Specific research on college students examined condom use, high-risk drinking

and sexual risk taking determined that behavioral interventions were the most effective

method of decreasing rates of sexually transmitted infections (Hirozawa, 2001). Health









education programs on university and college campuses focus on educating students as

an intervention and a primary prevention measure against numerous illnesses (Collins,

Duport, & Nagle, 2003 ). Developing effective interventions to promote healthy

behaviors spawned research studies that identified person-environment interaction as an

integral concept in this endeavor (Martinelli, 1999). The interaction between person and

environment is essential to consider when researching this specific population: students

who interact in the sociocultural environment of a college or university campus. High-

risk drinking and sexual risk taking occur simultaneously as routine student behavior

(Cooper, 2004). Research literature notes that risk behaviors appear in this new

sociocultural environment, campus living, as students make the transition from home to

campus life (Renn & Arnold, 2003).

Researchers describe the transition from home to attending a university or college

as a challenge for most young women (Farrow & Arnold, 2003). The culture of a college

campus is replete with gender and power issues. Examples include formation of

male/female relationships and academic pressures imposed by professors. These

situations in themselves are not harmful, but making decisions on unfamiliar topics and

navigating the consequences and potentially negative situations is a challenge for young

female students. Making decisions about sexual risk taking and increasing sexual activity

is common for women in this age group (Smith, 2003). Individual concerns about

physical symptoms in response to actively engaging in intimate sexual activity are

influenced by social expectations and perception of socio cultural or campus culture

issues (Berry, 2004). The desire to establish intimate relationships with the approval of

and adherence to peer group expectations has a considerable influence on the female

student. Students must exercise independent choices possibly for the first time in their









lives. Real or perceived power influences are critical to their perceptions and choices.

Power relationships are part of gender and sociocultural expectations affecting condom

use and disease transmission because they involve females and males (Gomez & Van Oss

Martin, 1996).

The negative outcome of ignoring a vague symptom or gynecologic complaint

may be a by product of a sociocultural expectation. The sociocultural expectation that a

female who believes her partner is faithful, declines condom use, and will not seek early

treatment for a gynecologic complaint. In many instances there is a struggle between

condom use and the desire of the female student to be part of a couple, which may mean

sex without condom. Sexual activity is affected by power in interpersonal relationships

during the negotiation of condom use (Few, 1997).

Studies on sexually transmitted diseases describe a moment, when a young

woman decides how, when, and with whom she shares sexual activity. This moment is

shaped by her sociocultural environment (Berry, 2004; Kenney, 2000). There is a

connection among person, behavior choice, and outcome that is a repeated trend in these

studies. For example if the expectation is to have a boyfriend, an important part of social

acceptance on campus, this may imply that sex is an expected. Having sex without a

condom is a demonstration of the student's trust in her partner (Davidson-Harden, Fisher,

& Davidson, 2000). This connection is evidenced by a linear relationship among person,

behavior choice, and outcome. The student makes a choice, has self-efficacy or lack of

self efficacy, uses a condom or declines to use a condom, and the result is a specific

health outcome.

Research that addresses the sociocultural perspectives of male female interaction

addresses the fact that not using a condom leaves the female vulnerable to infection. The









persistence of a partner saying, "Everything is okay" may lead to the perception that

there is low risk or no risk (Smith, 2003). In effect, the female student wants to believe

there is no risk because she wants to trust that her lover would not deceive her just to

have sex (Davidson-Harden et al., 2000). The perception of risk and infection are not

significant correlates. Feeling that she is not at risk does not protect the individual from

infection (Kalichman et al., 2002). The student's realization that she is vulnerable to

infection is significant because it affects the perception of presenting symptoms and the

decision to seek medical treatment (Oprendek & Malcarne, 1997).

The influence of social power upon condom use is significant, as reported in

research on acquired immune deficiency syndrome (AIDS); whether peers use condoms

can affect individual condom use (Albarracin et al., 2004). Personal concerns about

vaginal irritation or burning upon urination are often competing against the desire to deny

previous sexual activity. The presence of a gynecological complaint or a vague symptom

may be dismissed and medical treatment delayed.

Sexual activity and the decision to use condoms are part of the sociocultural

dynamic of transitioning from living at home to campus life, becoming sexually active,

and taking sexual risks. Possessing a condom and using it correctly are two distinctly

different situations. Many times a condom is carried and not used due to gender

expectations, what young men expect from their female partners, and what young women

may feel their partners expect from them. These expectations are also alluded to as power

issues or social pressures (Arnett, 2004).

The strengths of sociocultural research literature is a recognition of the integration

and impact of sociocultural influences, peer pressure to be in relationships, participation

in high-risk drinking, and sexual risk taking. The limitation to this research literature is

that, although the information is well documented, no research has evaluated a









comparison of these behaviors with chlamydia infection or a gynecologic complaint in

this specific population.

Behavioral Perspectives

Pitts and colleagues (Pitts, McMaster, Mangwiro, & Woolliscroft, 1999)

demonstrated that individual behavior and the sociocultural environment determine

whether treatment is sought. Behavioral research supports this finding and suggests that

studies framed by Social Cognitive Theory (SCT; Bandura, 1977b), using the construct

of self-efficacy, are valuable predictors for behaviors that influence sexual health

(Tremblay & Frigon, 2004; Tulloch, McCaul, Miltenberger, & Smyth, 2004).

Chlamydia infection and correlated population specific risk behaviors for college

students have not been published in current research literature, but condom use by young

adults has. Condom use is hypothesized to predict sexually transmitted infection rates

and must be examined as population specific risk factor for disease transmission

(Hirozawa, 2001). Research using health belief models, reasoned action, and social

cognitive frameworks indicate that condom use is best explored in relation to sexual

negotiation (Wulfert & Wan, 1995). Since the sexual negotiating process is affected by

drinking, drinking behaviors must be explored in relation to condom use.

Study data in college student populations describe a relationship between age at

first drunkenness, and unplanned and unprotected sex (Hingson, Herren, Winter, &

Wechsler, 2003). The earlier drinking starts, the more likely unplanned and unprotected

sex will occur. Research confirms that patterns of high-risk drinking start prior to

transitioning to campus life and may actually escalate when students begin their studies

(Von Sadovsky et al., 2002). Studies also support the premise that high-risk drinking has









many poor outcomes, including increased sexually transmitted infection rates, bodily

injury, and even death (Staton et al., 1999).

This sobering information further illustrates the influence of campus culture, peer

groups and sociocultural expectancies on rates of participation in high-risk drinking.

Perceived expectations of alcohol use or alcohol expectancies, in other words the social

expectations to drink or peer pressure to drink, are significant influences on students and

their decisions to participate in high-risk drinking. High-risk drinking, which is defined

as drinking five or more drinks on an occasion, is linked to sexual risk taking,

inconsistent condom use, and the absence of barrier methods to prevent the sexually

transmitted infections (LaBrie et al., 2002).

Overall, behavior and condom use research support the need for further study on

attitudes about the initiation of condom use (Davidson-Harden et al., 2000). Students'

attitudes about the information they receive is crucial. Nurse researchers report that even

in the context of a life-threatening illness, the students' acceptance of information is

paramount to the subsequent follow through or practice of health promoting activities

(Collins et al., 2003). Because infection rates are increasing in the presence of primary

prevention, a study to examine frequency of condom use by students is essential. College

students repeatedly put themselves at risk by practicing unhealthy behavior such as

sexual risk taking and high-risk drinking (Rozmus, Evans, Wysochansky, & Mixon,

2005). Other examples are smoking, using illegal drugs, underage drinking, binge

drinking, having sex with unknown partners, and having sex while under the influence of

alcohol or drugs (Von Ah, Ebert, Ngamvitroj, Park, & Duck-Hee, 2004). The strength of

this perspective in the literature review is that it provides a basis of research that supports

the selection of research questions. But the limitation to this specific group of literature is









the dearth of research focused on specific behaviors and gynecologic complaints or

diagnosis of sexually transmitted infection and subsequent disease transmission.

Theoretical Application and Rationale

Self-Efficacy Theory

The construct of self-efficacy derived from social cognitive theory (Bandura,

1997b) is well tested and has such reliability for predicting health behavior that it has its

own theoretical model. The theory of self-efficacy has framed studies that examined

psychological aspects of academic achievement (Maddux & Stanley, 1986; Multon,

Brown, & Lent, 1991), clinical areas such as depression (Davis & Yates, 1982), social

skills (Moe & Zeiss, 1982), assertiveness (Lee, 1983, 1984), pain control (Manning &

Wright, 1983), and health behaviors (O'Leary, 1985; Pender, Murdaugh, & Parsons,

2002). This research foundation provides a suitable framework for chlamydia infection

research involving behavioral and sociocultural factors.

Self-efficacy involves the development of social, cognitive, and behavioral

capabilities that must be organized and targeted into a course of action (Bandura, 1977b).

Female university students are adapting to campus life and desire to be successful and

competent. Competent functioning in life requires a synthesis of skills in cognitive,

social, and behavioral areas. The female university student is adapting and forming

behaviors for her life with expectations of positive outcomes. For example, if she studies,

she makes excellent grades that will result in a rewarding career. Self-efficacy theory

involves three main constructs: person, behavior, and outcome as affected by efficacy

expectations and outcome expectations (Bandura, 1977a). The following paragraphs

describe these key constructs and the relational statements.









Key Constructs

Self-efficacy theory is a linear model with the construct of person as the starting

point (right-hand side of the model in Figure 2-1). Person is defined as a human being

who wishes to accomplish a behavior change. The construct of behavior is defined as

actions that will affect the final construct of the outcome or the individual's decision to

perform, expend effort and persist to achieve the requisite behavior. The outcome, is the

successful completion of the required behavior or the desired behavior change (Bandura,

1977b, 1997).

Efficacy expectations are a group of concepts that impact personal behavior and

are influenced by performance attainment, vicarious experience, verbal persuasion, and

physiologic arousal. Whereas outcome expectations are concepts that focus on personal

beliefs, that desired behavior change will be achieved (Bandura, 1977a, 1990).

Relational Statements

The relationships among the three major constructs of self-efficacy theory are

unidirectional and linear. Person directly affects behavior, thus behavior directly impacts

outcome. Efficacy expectations and outcome expectations have no direct linear

relationship among the major constructs, but are shown as influencing both behavior and

outcome (the broken lines in Figure 2-1; Bandura 1997; Fitzgerald, 1991). This model,

epidemiologic methodology and review of the current state of research in chlamydia

frame the two-fold purpose and questions developed for this research.

Rationale

The use of self-efficacy theory as a framework for this research is logical because

of its predictive value in health behavior change and maintenance. It can assist in









describing the relationships among individuals, their specific behaviors, and a desired

outcome. Therefore, the person, the female student entering the university setting,

experiencing transitions and interacting with the environmental, develops expectancies.

These expectancies include whether she can influence her own condom use, drinking

patterns, and sexual behavior.

The Campus Environment

Peer Group Sexual Risk High Risk
Subcultures Taking Drinking













Students Cndom Ue Chlamydia
SScreening

"I can use "Since I use
condoms, condoms or practice
not use abstinence I will not
condoms or be infected with
choose chlamydia. I will not
abstinence" have a gynecologic
complaint"

Figure 2-1. Proposed Campus Chlamydia Model adapted from Bandura's
(1997) self-efficacy theory

The chosen behavior will then directly affect the outcome. A choice to not use

condoms, participate in binge drinking, and sexual risk taking may predict chlamydia

positivity or the decision to seek treatment for a gynecological complaint. Since

chlamydia has subtle symptoms the individual may not seek treatment and may then









suffer pelvic inflammatory disease and/or infertility. The proposed Campus Chlamydia

Model is adapted from self-efficacy theory. The person (female university student) may

or may not use condoms and the desired outcome is a negative chlamydia screen

(Figure 2-1).

Substructed Constructs and Relationships

The substructed theoretical framework begins with female university students.

There is a direct relationship to behavior, specifically condom use without fail or

abstinence. The behavior is influenced by efficacy expectations, denoted by a broken

line. When using condoms consistently or practicing abstinence, the student achieves the

outcome behavior, a negative chlamydia screen. Outcome expectations are that if she

practices consistent condom use or abstinence; she avoids a chlamydia positive screen,

paying for treatment morbidity of subsequent pelvic inflammatory disease and possible

sterility.

Failure to use condoms and the failure to demonstrate self-efficacy puts the

student at greater risk for infection. The absence of condom use leads to infection, and

condom use is the only measure other than abstinence that prevents transmission

(Pinkerton, Abramson, & Turk, 1998). To measure condom use self-efficacy, the

Condom Use Self-Efficacy Scale was developed (Brafford & Beck, 1991). This tool,

which yields a condom use self-efficacy score, will be used to measure the student's self-

efficacy in using a condom. Carrying a condom and using a condom with self-efficacy

are two different situations for the female university student. The proposed Campus

Chlamydia Model will provide a framework to examine the impact of sociocultural

factors such as class standing and residency along with behavioral factors like condom

use self efficacy, condom use, and high-risk drinking on chlamydia infection rates.







25

Statistical analysis and findings may support or refute the model and will be discussed in

Chapter 5.

Summary

This literature review addresses pathobiological, environmental, and behavioral

aspects of the phenomenon of rising rates of chlamydia in young women who attend a

college or university. It describes the theory of self-efficacy, introduces the proposed

Campus Chlamydia Model to describe the phenomenon of increasing chlamydia

infection, and provides a framework for research.















CHAPTER 3
RESEARCH IMPLEMENTATION

This chapter describes the research study and its implementation. The two-fold

purpose of this research was to determine current incidence rates of chlamydia in the

student population that accesses services at the University of Florida Student Health Care

Center and to determine relationships among condom use self-efficacy scores in female

students, high risk drinking, sexual risk taking, and the current incidence rates of

chlamydia infection.

Research Design

A descriptive cross-sectional study method was chosen because this approach

gathers information from one population at a given point in time using a convenience

sample (Hulley et al., 2001). Results from a chlamydia questionnaire completed by

female students were analyzed and then current chlamydia infection rates as reported by

laboratory records were evaluated.

Power Analysis and Sample Size Estimations

Clinicians often treat a gynecologic complaint rather than test for a sexually

transmitted infection because of cost to the student. It is much cheaper in many instances

to treat with a prescription than to pay the cost of testing and treatment. The use of the

binomial dependent variable, gynecologic complaint, accounts for this practice. This

dummy variable expresses either the absence or presence of a gynecologic complaint

described as yeast infection, bacterial vaginosis, chlamydia, gonorrhea, herpes, or HPV.









Health care providers may see on average 10 to 20 patients on a given day. The sample

size required to detect statistical significance based on responses from the chlamydia

questionnaire pilot was achieved. Three hundred twenty-five questionnaires were

collected. Only those that had legible responses and were complete were used for

analysis, a total of 285.

The predicted sample size of this descriptive study relied on a reasonable

confidence because no hypothesis testing occurred (Hulley et al., 2001). Assuming that

30% of the female students coming to a university clinic have a gynecological complaint,

approximately 81 subjects were required if the estimate is to fall within 10 percentage

points of the true proportion with 95% confidence. On the other hand, based on a

formulation of 80% power, a medium critical effect size of 0.30, and a significance level

of 0.05 for a two-tailed test, a sample of 106 subjects was deemed sufficient to address

the relationship between categorical variables. For testing the difference in outcome

variables, given the median effect size and 80% power, 62 subjects per group were

sufficient. Finally, to determine the correlation between the outcome variables, given a

medium effect size and 80% power, 82 subjects were required to address the relationship

questions. The Gpower computer software (Erdfelder, Faul, & Buchner, 1996) was used

to calculate the required sample size.

Setting and Subject Recruitment

The University of Florida Student Health Care Center is fully staffed with

personnel to meet the health care needs of those students requiring women's health

examinations, counseling on birth control methods, sexually transmitted disease testing,

and walk-in appointments as needed. It has also been the site of previous research. The









Student Health Care Center at the University of Florida and its satellite clinics serve the

health care needs of approximately 27,000 female students annually.

The main campus and satellite clinics provide similar services with private areas

to complete health history information and confer with the health care providers about

confidential concerns. Approved flyers invited the students to participate in this study

and an explanation of the study's purpose and instructions were attached to the front of

chlamydia questionnaire.

Instruments

Chlamydia questionnaire. The student volunteer subject was given a cover letter

explaining the purpose of the study a self-report chlamydia questionnaire. A

questionnaire including demographic information, questions on sexual behavior, high-

risk drinking, treatment for sexually transmitted diseases, and the Condom Use Self-

Efficacy Scale (Appendix A) was used to gather research data. This combined

questionnaire scale includes the 28 items developed and validated by researchers at the

University of Maryland named the Condom Use Self-Efficacy Scale (Brafford & Beck,

1991). This instrument was used to collect data on condom use, high-risk drinking

behaviors, and sexual risk taking. Items were either fill-in-the-blank or multiple

responses with answers to cirlce.

Condom Use Self-Efficacy Scale. The Condom Use Self-Efficacy Scale

(CUSES) is based on self-efficacy theory (Bandura, 1997b) and was used to study

cognitive and behavioral predictors of sexually transmitted diseases in adolescent and

young adults (Sieving et al., 1997). It was developed from behavioral theory and has

been tested for reliability and validity. It has a proven Cronbach's alpha of 0.91 and test-

retest correlation equaling 0.81 (Brafford & Beck, 1991). The CUSES research









completed at universities in the Midwest verified its reliability demonstrating a

Cronbach's alpha of .94 for the scale and a reliable application to college student

research (Peterson & Gabany, 2001). Each item on the scale requires the student to circle

an item on a 5-point response format ranging from "strongly disagree" (scored as 1) to

"strongly agree" (scored as 5) in this research. The scoring is reversed on items 8, 9, 10,

15, 16, 17, and 18. The scores for each item are then summed yielding a total score

ranging from 0-140, with higher scores indicating greater condom use self-efficacy.

Table 3-1 provides a sample of the questions included.

In studies focused on the development of the condom use self efficacy scale by

Brafford & Beck (1991), a high CUSES score emerged as predictor of change in sexual

risk behavior, an indicator for specific health education topics such as application of

condoms and additional research to support these findings (Satha, Hanna, & Rodcumdee,

2005; Sieving et al., 1997). In particular, Peterson & Gabany ( 2001) found that students

at their midwestern university who reported using condoms consistently during the last

30 days scored statistically significantly higher on the CUSES.

Table 3-1. Examples of questions used in the Condom Use Self-Efficacy Scale
Strongly Strongly
disagree Disagree Undecided Agree agree
I feel confident that I could remember
to carry a condom with me should
I need one
I feel confident in my ability to
discuss condom usage with any
partner I might have.

These results are meaningful because condom use requires some technical skill

and may require negotiating with a resistant partner on some occasions. The scale

integrates condom use negotiation, confidence about applying condoms, and using

condoms while drinking or using marijuana (Brafford & Beck, 1991; Peterson & Gabany,









2001). The purpose of using the CUSES was to evaluate reported condom use self-

efficacy in those students who completed the questionnaire. Research evaluating and

utilizing this tool noted that convenience sampling and self-report were listed as

limitations to the tool; despite this report, the tool has demonstrated reliability

(Brafford & Beck, 1991; Cecil & Pinkerton, 1998; Peterson & Gabany, 2001). Condom

use self-efficacy is integral to this research because condom use is identified as the key

preventative measure to stop the spread of chlamydia (USPTF, 2002).

Data Analysis of Laboratory Review

Chlamydia infection rates were determined from reported findings from the

Student Health Care Center's laboratory manager. The laboratory manager signed a

confidentiality agreement prior to research implementation. Then, after review of

positive chlamydia test results, provided deidentified data that assisted in determining

gender, residence, and reinfection for students accessing health care services at the

University of Florida Student Health Care Center. Positive laboratory tests with

deidentified data confirming Chlamydia infection were collected from laboratory

findings. These raw data were transferred to a log on a password protected computer file.

This file was then transferred to a statistical analysis data sheet for future analysis

(Appendices B and C).

Rates calculated from 2005 indicated that laboratory results of sexually

transmitted disease data reveal a 7% incidence rate of chlamydia infection in females.

These rates are consistent with increasing trends and are almost twice as high as rates

reported by the American College Health Association (ACHA, 2005). They were

compared to the case rates reported by the Alachua County Health Department, the

Florida Department of Health, and national prevalence rates for women ages 18 to 24 to









determine whether rates for female students accessing health care services at the

University of Florida Student Health Care Center were consistent with current rising

rates reported locally, statewide, and nationally.

Data Collection Methods

Completed anonymous questionnaires from volunteer subjects were used to

gather data and as a strategy to ensure accurate self-report for sexual activity, condom

use, and high risk drinking. These questionnaires were collected at the University of

Florida Student Health Care Center clinic on the main campus. A letter of explanation

was attached to the front of the questionnaire that explained the purpose of the study, and

provided contact information and instructions for completing the questionnaire. Students

completed the questionnaires and placed them in an envelope. These envelopes were

collected on a daily basis by the principal investigator. Questionnaires were collected

until the number of subjects required for statistical analysis was met. The time period for

raw data collection was approximately 3 weeks.

The questionnaire information was entered on a statistical program variable data

sheet to facilitate analysis at a later date. The computer used was password protected and

data were locked in a filing cabinet behind a locked door to ensure confidentiality.

Analysis of Questionnaire Data

Descriptive statistics were used to obtain the summary measures for all data,

including a description of the sample characteristics. Descriptive statistics included

means, medians, range, and standard deviations for continuous variables. Categorical

variables were statistically represented in frequency distributions, percentage

distributions, and graphical illustrations. Ap-value of less than 0.05 was considered

statistically significant.









For the evaluations of the research questions, Wilcoxon rank sum test was used

when two groups were compared. Spearman correlation analysis was used to determine

the correlation between the variables. Analysis of frequency was utilized to determine the

relationship between categorical variables. Finally, logistic regression analysis was used

to explore potential differences in predictor variables between those with and without a

gynecological complaint.

Ethical Considerations

University students are a readily accessible health population and are considered

vulnerable because of economic and power relationship issues between professors and

students. Therefore, no research implementation of any kind was done until the study

protocol was reviewed and approved by the Institutional Review Board at the University

of Florida and the medical director of the University of Florida Student Health Care

Center.

Recruitment was completed with special concern for the students' vulnerability

and accessibility. Health care was provided to students regardless of their participation in

the study and no medical treatment was denied at anytime if they refused to participate.

All responses were anonymous and confidential, and the review of chlamydia case

reporting was done without identifiers. Health Insurance Portability and Accountability

Act (HIPAA) guidelines were observed.

Summary

This chapter explained the research study design, including data collection, power

analysis and sample size estimation, recruitment, instruments, and ethical considerations

to implement the research.















CHAPTER 4
FINDINGS

Introduction

Research Purpose

The purpose of this research was to determine current infection rates of

chlamydia in the student population that accesses services at the University of Florida

Student Health Care Center and to determine relationships among condom use self-

efficacy scores in female students, high-risk drinking, sexual risk taking, and the current

incidence rates of chlamydia infection.

Research Questions

* What is the relationship among condom use self-efficacy responses and sexual risk-
taking behavior and high-risk drinking among the female college students who
access services at a university student health care center?

* What are the differences in the number of sexual partners and the amount of high-
risk drinking between those who did and did not engage in high-risk sexual
activity?

* What are the combined effects of condom use self-efficacy scale scores, number of
sexual partners, high-risk drinking, and sexual risk taking behaviors on those with a
gynecological complaint?

In this chapter, infection rates of chlamydia for those students who access

services at the University of Florida Student Health Care Center (UF SHCC) are

described, the sample characteristics of those female students who completed the

chlamydia questionnaire are described, and the research questions are addressed.









Infection Rates

Infection rates for students who access the UF SHCC were calculated from

deidentified data provided by the laboratory manager. The incidence of chlamydia

infection for these students for the calendar year 2005 and rates for January 2006 are

provided in Table 4-1. This table represents an increasing trend in infection rates based

on the number of students tested and the time of year. A breakdown of percentages

between males and females was unavailable prior to July 2005. Rates among males and

females are variable, and this may be a result of increased screening done by healthcare

providers due to the availability of urine screening tests at a reduced cost.

Table 4-1. Chlamydia infection data for students who access services at the University of
Florida Student Health Care Center
Percentage Percentage Percentage
Total students positive positive positive
Month/Year tested/N total/(N) female/(N) male/(N)
January 2006 235 5.1(12) 1.3(3) 3.8(9)
December 2005 208 7.8 (16) 5.2 (11) 2.4 (5)
November 2005 235 6.4 (15) 3.0 (8) 2.9 (7)
October 2005 290 6.5(18) 3.7(11) 2.8(7)
September 2005 389 5.4(21) 2.6(10) 2.8(11)
August 2005 152 5.2 (8) 2.0 (3) 3.2 (5)
July 2005 149 7.4(11) 2.7(4) 4.7(7)
June 2005 120 3.3(4) *
May 2005 154 3.2(5) *
April 2005 245 4.5(11) *
March 2005 263 6.1(16) *
February 2005 238 9.2 (22) *
January 2005 285 7.0(20) *
Missing data-Unavailable

Table 4-2 illustrates the demographic characteristics of students testing positive

and notes the mean age as 20, with females testing positive 70% versus males at 30%.

The ethnicity of those testing positive were white at 25%, Black at 21.4%, Hispanic at

12.9%, and Asian at 4.3%. No repeat infections were noted. The majority of the students









who tested positive gave an apartment address as their residence with dormitories the

next frequent and a fraternity or sorority house as the lowest reported place of residence.

The average demographic characteristics of those who tested positive for chlamydia

infection were 20 years of age, female, white, and residing in an apartment off campus.

This demographic information and the case rates were not available previously.

Table 4-2. Demographic characteristics for students testing positive for chlamydia
infection

Demographic Frequency/Percent

Age (20) 18.0%
Gender
Female (56) 70.0%
Male (31) 30.0%
Ethnicity*
White (20) 25.0%
Black (16) 21.4%
Hispanic (9) 12.9%
Asian (3) 4.3%
Residence*
Off-campus apartment (56) 75.7%
On-campus dormitory (11) 14.3%
On-campus sorority/fraternity house (1) 1.4%
Off-campus home (6) 8.5%
* Missing data

Chlamydia Incidence Rates for 2004

This rate was reported as 3.8% by the American College Health Association and

is considered the national average (ACHA, 2005). Responding student health care centers

had enrollment size ranging from 836 to 51,827, with a mean size of 15,049 (ACHA,

2005). Unfortunately, in 2004 no data were collected or evaluated for genital chlamydia

infection in students who accessed services at the UF SHCC.









Incidence Rates for 2005

The incidence rate of chlamydia infection for students who accessed health care

services at UF SHCC was calculated using the total number of new cases diagnosed

divided by the total number of persons at risk. The denominator, persons at risk, were

those individuals identified by healthcare providers who were at risk for chlamydia

infection. These rates were calculated at 5.8% for 2005 for the UF SHCC. The rates for

the American College Health Association have not been published for 2005; these rates

might also increase.

Incidence Rates for 2006

Chlamydia infection rates for students who access services at the UF SHCC thus

far in 2006 yield a rate of 5.1%. Infection rates from the first few months of 2006 do not

necessarily reflect the average infection rate of chlamydia for the entire year. Subsequent

analysis of these rates will be completed when data from all months are available.

Comparisons of National and State Data

In comparison to the national data provided by the American College Health

Association, the infection rates for students who access services at the UF SHCC are 1.5

times the national average of 3.9%. This is consistent with the infection rates reported by

the Alachua County Health Department (Florida Department of Health, 2006). The

comparisons are noted in Table 4-3.

Table 4-3 provides a comparison between reported chlamydia infection in

students who access health care at a college or university student health care center in the

United States and the reported infections of chlamydia at the UF SHCC. These rates are

comparable because of the methodology used to analyze percentages. To arrive at the

rates, those testing positive were divided by the total students tested (P. Davis-Smith,









personal communication, April 5, 2006). In contrast, statistics from the Alachua county

health department are reported by case only. Reporting of chlamydia is required by law

in Florida (Florida Department of Health, 2006). The number of cases of chlamydia

infection in Alachua county has more than doubled in 9 years, from 480 in 1995 to 1134

in 2004 (Florida Department of Health, 2006).

Table 4-3. Chlamydia infection rates as reported by the ACHA and the University of
Florida Student Health Care Center
Percent of
chlamydia
infections Percentage of Percentage of
Reporting agency Year reported/(N) females/(N) males/(N)
American College Health
Association* 2004 3.9 3.6 7.9
University of Florida Student
Health Care Center 2005 5.8 (158) 3.2(87) 2.6(71)
*Reported in percent only.

Questionnaire Analysis

Sample Characteristics

The questionnaire was offered to female students who accessed care at the UF

SHCC for any reason. During a 3-week period, 328 questionnaires were collected.

Questionnaires that were complete and legible were used for analysis. The sample

consisted of 285 questionnaires. Demographic characteristics also were derived from this

questionnaire; details of these characteristics are illustrated in Table 4-4. The ages ranged

from 18 to 31 years with the mean age of 20.81 years (SD = 1.85, Median = 21 years).

The majority of students (74%) were Caucasian, and resided off campus, 78.2%. Senior

students made up the largest percentage of subjects, 27.02%.

Variables

The variables selected for analysis were determined from a literature review of

the epidemiology of genital chlamydia infection. Independent variables were age,









number of sexual partners, condom use self-efficacy scale (CUSES) scores, sexual risk

taking, and high risk drinking. The dependent variable, gynecologic complaint, a dummy

variable, reflected either the presence or absence of a diagnosis or treatment of

chlamydia, gonorrhea, herpes, HPV, yeast infection, or bacterial vaginitis. This

dependent variable was chosen because of the frequent practice by health care providers

to treat students rather than testing for STI due to cost concerns. Frequently, treatment is

cheaper than testing.

High-risk drinking was defined as five or more drinks on one occasion and

determined by responses from subjects noting how many occasions in the past year they

had five or more drinks and how many alcoholic drinks they consumed on each occasion.

For the purposes of this research, sexual risk taking was defined as inconsistent or

absence of condom use during sexual contact. This was calculated from responses to

questions that asked how often the subject used condoms. Initial analysis of the

independent variables included frequencies and other measures of central tendency.

Table 4-4 displays the demographic characteristics of study participants in this

descriptive research.

Discussion

Table 4-5 provides descriptive statistics of three variables. The mean age for the

sample size is 20 with a SD of + or 1.8 years. Thirty-one percent of the student

volunteer subjects reported they never participated in high-risk drinking in the past 12

months. Conversely, 68% of the student volunteer subjects reported they had participated

in high-risk drinking (more than 5 drinks at a sitting). The highest reported frequency of

consistent condom use was 29% of the time; 27% reported never using condoms. This

indicates that students participate in high-risk sexual behavior by not using condoms

every time during sex at least 71% of the time. Summary measures of the variables age,









number of sexual partners, high-risk drinking, number of occasions to drink in the past 2

weeks, the number of drinks on these occasions, the number of times students were

drinking and having sex, and the CUSES scores are listed in Table 4-6.


Table 4-4. Demographic characteristics of study participants (n


285)


Variable Frequency (N) Percent
Ethnicity
Caucasian 211 74.04
Hispanic 33 11.58
African American 23 8.06
Asian 9 3.16
Other 9 3.16
Residence
On-campus dormitory 53 18.60
On-campus sorority/fraternity 9 3.16
Off-campus apartment 208 72.98
Off-campus-Living at home 15 5.26
Class standing
Freshman 50 17.54
Sophomore 42 14.74
Junior 62 21.75

Senior 77 27.02
Graduate Student 54 18.95

Table 4-5. Frequency of condom use and high-risk drinking
Variable Frequency (%)
Frequency of condom use in the last 12 months
Never 77 (27.02)
20% of the time 42 (14.74)
50% of the time 42 (14.74)
70% of the time 41 (14.4)
Always 83 (29.1)
Frequency of high risk drinking
(5 or more drinks on one occasion)
Zero 90 (31.6)
1 28 (8.5)
2 20 (6.1)
3 15 (4.6)
4 4 (1.2)
5-10 53 (25.8)
11-20 38 (11.5)









Table 4-6. Summary measures of variables age, number of partners, high risk drinking,
drink occasions, drinking and having sex, and CUSES scores (N = 285)
Variable Mean SD Median Minimum Maximum
Age 20.81 1.85 21 18 31
Number of sexual partners 1.64 1.64 1 0 10
High-risk drinking 12.82 25.65 3 0 180
Number of drinking occasions 2.20 7.33 1 0 120
Drinks 3.28 6.72 3 0 93
Drinking and having sex 6.45 13.90 1 0 100
CUSES 93.91 18.13 98 28 140

In the past 12 months, students reported they participated in high-risk drinking an

average of 12.8 times. Which means they participated in high-risk drinking on average

once a month. As indicated by the median value, more than 50% of the students practiced

high-risk drinking three times in the past 12 months. In the past 2 weeks, they indicated

that they chose to drink an average of 2.20 occasions and had an average of 3.28 drinks

on these occasions. This indicates that high-risk drinking is common practice for those

students who participated in the study.

Sexual risk taking was also common in this group. The students reported that in

the past 12 months they consumed alcohol and simultaneously engaged in a sexual

activity an average of 6.45 occasions and had an average of 1.64 partners in the past 12

months. These behaviors would warrant condom use. But, as reflected in Table 4-5, this

is not common practice. The Condom Use Self-Efficacy Scale (CUSES) scores reflect an

unexpected finding. The mean total score for condom use self-efficacy was 93.91,

reflective of a moderate amount of self-efficacy, and the expectation was that scores

would be much lower because condom use was low.

Frequency and percent of the presence of a gynecologic complaint, sexual activity

and behaviors, comfort in discussing diagnosis of an STI with a partner, and diagnosis of









either an STI, yeast infection, or bacterial vaginitis are listed in Table 4-7. The results

indicated that, 29.12% of the students in the sample had a gynecological complaint.

When they were asked about condom use, 29.12% always used condoms. The majority of

the students in the sample (69.82%) indicated that they were very comfortable asking

their partners about seeking treatment for a sexually transmitted infection. Also, 51.58%

indicated that they were very comfortable discussing their diagnosis of a sexually

transmitted infection with their partners. In this sample of students, five were diagnosed

and treated for chlamydia (1.75%), and 2.81% of the students have been treated more

than once for chlamydia.

Research Question Findings

Research Question 1

What is the relationship among condom use self-efficacy responses, sexual risk-

taking behavior, and high-risk drinking among the female college students who access

services at a university student health care center?

To address Research Question 1, Wilcoxon rank sum test and Spearman

correlation analysis were utilized. There were no significant differences in mean rank

CUSES scores between those who engaged in high-risk behavior and those who did not.

There was a significant difference in mean rank CUSES scores between those with and

without a gynecological complaint (p = 0.0291). Analysis using Spearman correlation

coefficient indicated that the correlation among CUSES scores, age, number of sexual

partners, number of times practicing high-risk drinking, number of drinking occasions,

number of drinks on each occasion, and number of times drinking and having sex were

statistically nonsignificant.









Table 4-7. Frequency and percent of sexual activities, behavior, sexually transmitted
infection (STI), and gynecologic complaint (N = 285)
Variable Frequency Percent
Gynecological complaint
Yes 83 29.12
No 202 70.88
Condom Use
Never 77 27.02
20% of the time 42 14.74
50% of the time 42 14.74
70% of the time 41 14.39
Always 83 29.12
Petting
Yes 189 66.32
No 96 33.68
Masturbating
Yes 143 50.18
No 142 49.82
Oral Sex
Yes 209 73.34
No 76 26.66
Intercourse
Yes 137 48.07
No 148 51.93
Anal Sex
Yes 11 3.86
No 274 96.14
Gender of partners
Male 267 93.68
Female 10 3.51
Both 8 2.81
Asking partner about seeking treatment
Uncomfortable 22 7.72
Somewhat comfortable 18 6.32
Moderately comfortable 46 16.14
Very comfortable 199 69.82
Comfort in discussing an STI with a partner
Uncomfortable 45 15.79
Somewhat comfortable 42 14.74
Moderately comfortable 51 17.89
Very comfortable 147 51.58









Table 4-7. Continued.

Variable Frequency Percent
Diagnosed and treated for
Chlamydia 5 1.75
Gonorrhea 5 1.75
Herpes 7 2.46
HPV 12 4.21
Yeast infection 47 16.50
Bacterial vaginosis 11 3.86
None 198 69.47

Treated more than once for
Chlamydia 8 2.81
Gonorrhea 6 2.11
Herpes 3 1.05
HPV 5 1.75
Yeast infection 38 13.33
Bacterial vaginosis 7 2.46
None 218 76.49

Analysis of frequency (chi-square analysis) indicated that there were significant

relationships between having a gynecological complaint and gender of partner

(chi-square = 9.95, p = 0.0069). That is, among those with a gynecological complaint,

4.48% indicated they engaged in sexual activity with the same sex, whereas only 1.2% of

those with no gynecological complaint indicated they had a same sex relationship. There

was a significant difference between having a gynecological complaint and being

diagnosed and treated (p = 0.0001). Among those with gynecological complaints, 2.41%

were diagnosed with chlamydia versus 1.52% with no gynecological complaint (Figure

4-1). In addition, there was a significant difference between having a gynecological

complaint and those students treated more than once for sexually a transmitted infection

(p = 0.0001). Among those with a gynecological complaint, 6.02% were treated more

than once for chlamydia versus 1.51% of those with no gynecological complaint (Figure

4-2).



























2.41 1 !


uYE.


0 0o o .
Gnorrhea HPV Bacterial vagin
Chlamydia Herpes Yeast infection
Yes 0 No
Figure 4-1. Percent of subjects with and without gynecologic complaint diagnosed
and treated for sexually transmitted infection


'osis


36.14


30

25

20

15

10
7.23 7.23
6.02 6.02 4.02
5 1.51 3.61 1 i

0 0 o
Gonorrhea HPV Bacterial vaginosis
Chlamydia Herpes Yeast infection
Yes U No

Figure 4-2. A comparison of subjects with and without gynecologic complaints
treated more than once for sexually transmitted infection


50


40


30


20


I


I









Research Question 2

What are the differences in the number of sexual partners and the amount of high-

risk drinking between those who did and did not engage in high-risk sexual activity?

Due to the skewness of the data, reports from 0 to greater than 150, the Wilcoxon

rank sum test, instead of a two-sample t test, was used to address Research Question 2.

The results indicated that the differences in mean rank of number of times practicing

high-risk drinking, number of drinking occasions, number of drinks on each occasion,

and numbers of times drinking and having sex among those who engaged in high-risk

sexual activity and those who did not, were statistically nonsignificant. However, there

were significant differences in mean rank of the number of sexual partners between those

who did and did not engage in high-risk sexual activity (Table 4-8). Table 4-8

demonstrates that with an increase in the number of sexual partners, the amount and

kinds of sexual activity increase. Therefore those students who have an increased number

of sexual partners have also engaged in more diverse sexual activity such as anal sex or

oral sex.

Table 4-8. The difference in mean rank of the number of sexual partners (N = 285)
Variable (N) Mean Rank Z Value P-Value
Masturbating*
No 141 129.24 2.35 0.0092
Yes 143 155.57
Oral sex*
No 74 95.01 6.23 0.0001
Yes 209 158.64
Intercourse
No 148 128.96 3.00 0.0027
Yes 137 155.90
Anal sex
No 274 140.87 2.36 0.0092
Yes 11 196.05
Gynecological complaint
No 202 132.32 3.70 0.0002
Yes 83 169.00
*Missing data









Research Question 3

What are the combined effects of condom use self-efficacy scale scores, number

of partners, high-risk drinking, and sexual risk-taking behaviors on those with

gynecological complaints?

Logistic regression was used to address Research Question 3. First, a logistic

regression was utilized to determined combined effects of condom use self-efficacy

scores, number of partners, drinking alcoholic beverages, and high risk sexual behaviors

on those with a gynecological complaint. Table 4-9 lists various criteria for assessing

model fit through the quality of the explanatory capacity of the model; for likelihood

ratio, score statistic, and Wald statistics, this is done by testing whether the explanatory

variables are jointly significant relative to the chi-square distribution. All of these

statistics are analogous to the overall F test for the model parameters in a linear

regression setting. The p-values for the chi-square of Likelihood Ratio, Pearson (Score),

and Wald are all significant at a 0.05 level indicating that the explanatory variables are

jointly significant in predicting the gynecological complaint.

Table 4-9. Goodness of fit complete model for the logistic regression to determine
combined effects of condom use self-efficacy scale scores, number of sexual
partners, high-risk drinking, and sexual risk taking on those with a
gynecologic complaint
Test Chi-square DF P-value
Likelihood ratio 27.7899 12 0.0059
Score 28.0611 12 0.0054
Wald 23.5284 12 0.0236


With satisfactory goodness of fit, it is appropriate to examine the parameter

estimates from the model. Table 4-10 lists the estimated model parameters and their

standard errors.









Table 4-10. Analysis of maximum likelihood estimates for logistic regression to
determine combined effects of condom use self-efficacy scale scores,
number of sexual partners, high-risk drinking, and sexual risk taking on
those with a gynecologic complaint
Wald
Parameter DF Estimate Standard error chi-square P-value

Intercept 1 -4.2613 1.9662 4.6972 0.0302
CUSES score 1 -0.0052 0.0084 0.3797 0.5377
Age 1 0.137 0.0799 2.9411 0.0864
Number of sexual partners 1 0.3151 0.0972 10.5191 0.0012
Drinking and having sex 1 -0.0063 0.0127 0.2469 0.6193
High risk drinking 1 0.0008 0.0064 1.546 0.2137
Number of drinking 1 -0.0086 0.0259 0.1106 0.7395
occasions
Drinks 1 0.0309 0.0237 1.7026 0.1919
Petting 1 -0.1575 0.347 0.206 0.6499
Masturbating 1 0.233 0.3904 0.3562 0.5506
Oral sex 1 0.502 0.4331 1.344 0.2463
Intercourse 1 -0.2552 -0.3767 0.4587 0.4982
Anal sex 1 0.0399 0.7242 0.003 0.9561

Table 4-11 shows the odds ratios of the parameters in the complete model. Only

the odds ratio of the number of sexual partners (1.37) was statistically significant since its

95% confidence interval did not include one. Based on the calculated odds ratio, the odds

of those with gynecological complaints would increase by a factor of 1.37 times for each

partner. For every five partners, the odds ratio would increase to 4.83 times

(2.718285(0.3151)D).

Step type (stepwise procedure, forward selection, and backward elimination)

logistic regression was used to obtain the optimal model. The results indicated that only

the number of sexual partners significantly discriminated between those with and without

gynecological complaints (chi-square = 13.90, p = 0.0002, Table 4-12).









Table 4-11. Odds ratio estimates for the parameters of the completed model to
determine combined effects of condom use self-efficacy scale scores,
number of sexual partners, high-risk drinking, and sexual risk taking on
those with a gynecologic complaint
Effect Point estimate 95% Wald confidence limits
CUSES Scores 0.995 0.979 1.011
Age 1.147 0.981 1.341
Number of sexual partners 1.370 1.133 1.658
Drinking and having sex 0.998 0.969 1.019
High risk drinking 1.008 0.995 1.021
Number of drinking occasions 0.991 0.942 1.043
Drinks 1.031 0.985 1.080
Petting 0.854 0.433 1.686
Masturbating 1.262 0.587 2.713
Oral sex 1.652 0.707 3.861
Intercourse 0.775 0.370 1.621
Anal sex 1.041 0.252 4.303

Table 4-12. Analysis of maximum likelihood estimates determining combined effects of
condom use self-efficacy scale scores, number of sexual partners, high-risk
drinking, and sexual risk taking on those with a gynecologic complaint
Standard Wald chi- Odds
Parameter DF Estimate error square P-value ratio

Intercept 1 -1.4577 0.2098 48.2613 <.0001
Number of sexual partners 1 0.3319 0.089 13.8988 0.0002 1.394

Summary

This chapter summarized the findings from the statistical analysis of the

chlamydia questionnaire and the incidence rates for chlamydia infection for students who

access services at the UF SHCC. Incidence rate information also was compared to

national and state data. The study provided demographic information to administrative

and medical staff at the UF SHCC that was not available in the past. Subsequent

discussions on the administrative levels at the UF SHCC are focused on improvements in


clinical practice and chlamydia screening.







49

Questionnaire data indicated that high-risk drinking and sexual risk taking persist

into the junior and senior class years for those students who participated in the study.

Condom use self-efficacy scale scores were moderate for students who are practicing

high-risk drinking and sexual risk taking. A statistical relationship was explored among

condom use self-efficacy scale scores, high-risk drinking, and sexual risk taking.

Although no statistical relationship was found between the condom use self-efficacy

scale scores, high-risk drinking and sexual risk taking, it is alarming to note that both

high-risk drinking and sexual risk taking are reported at rates greater than 65%. Further,

those female students with more than one sexual partner in the past year, reported more

frequent and varied sexual activity. Finally, in determining behaviors that might predict a

gynecologic complaint, only the number of sexual partners was statistically significant.

Implications of these findings are discussed in Chapter 5.















CHAPTER 5
DISCUSSION AND IMPLICATIONS

Research Purpose

The purpose of this research was to determine current infection rates of

chlamydia in the student population who accesses services at the University of Florida

Student Health Care Center and to determine relationships between condom use

self-efficacy scale scores in female students, high-risk drinking, sexual risk taking, and

current rates of chlamydia infection.

Discussion

Infection Rates of Chlamydia

This research examined, for the first time, the reported cases of chlamydia

infection in students who access the University of Florida Student Health Care Center

(UF SHCC). The data reflect a fluctuating but steady increase in incidence rates for these

students. In the past year, 2005 rates were calculated at 5.8%. National rates reported by

the American College Health Association (ACHA) were 3.8% for the year 2004 (ACHA,

2005). Methodology to calculate these rates is the same (P. Davis-Smith, personal

communication, April 5, 2006). But, caution should be taken in generalizing these results

as not all colleges and universities reporting to the ACHA have a similar student body

population. Also, the ACHA reports that the percentage of those infected are twice as

likely to be male (ACHA, 2005). In contrast, the gender percentage of those most

infected at the UF SHCC is female.







51

Statistics reported by the Florida Department of Health also reflect case rates for

young females almost six times greater than the rates for young men; 26,145 in females

ages 15 to 24 versus 4,857 in males ages 12 to 24 for 2004 (Florida Department of

Health, 2006). An increase in the number of female students testing positive may be

explained by the volume of female students screened by practitioners in the women's

health care team. But increased screening does not explain persistence in increasing

reports of chlamydia infection.

Those students who tested positive for chlamydia were most commonly female,

Caucasian, 25 years of age, and residing in an apartment off campus. While there is no

specific demographic data listed for chlamydia infection in university or college students,

national, state, and county agencies have demographics on females in the comparative

age range of 18 to 24 years. National data reflect that black females ages 16 to 19 have

the highest rates of chlamydia at this point, 49.53% of all reported cases (CDC, 2005;

Florida Department of Health, 2006). State of Florida and Alachua County rates

consistently report higher cases in females, 16 to 24 (Florida Department of Health,

2006).

Increased cases of chlamydia infection with a disproportion of female to male

cases are significant. It gives direction for future research that might include a double

arm study to look at the comparisons between a group of students who access screening

services under current practices and those who might seek out screening under a new

screening policy. The research could describe differences in males and females who seek

testing and which screening policy provides the most access to services for both genders.

Changes in clinical practice may also be affected. Currently, students make an

appointment, see a nurse and then see a provider before a screening test is ordered and







52

then the student receives the screening test. This research information on chlamydia case

rates and the comparisons with national data can launch a change in clinical practice and

screening policy. Generating an improved protocol for screening students who may have

a gynecologic complaint and desire screening is highly desirable. This improved protocol

would consist of streamlined access for students. They could go directly to the laboratory

and request a screening test. Laboratory personnel may choose to keep reports of case

rates logged so evaluation of gender, residence and race can direct future screening

policy and clinical practice. The change in policy is already in the discussion and

planning stages at UF SHCC.

Research Question 1

What is the relationship among condom use self efficacy scale (CUSES) scores,

sexual risk-taking behavior, and high-risk drinking in female college students who access

services at a university student health care center?

The results of statistical analysis demonstrated that there were no relationships

among CUSES scores, sexual risk taking, and high-risk drinking. This result challenges

previous research that indicates a relationship is usually present between sexual risk

taking and high-risk drinking. The CUSES scores reflected a moderate amount of

self-efficacy, and this also challenges the logic of a high or moderate score resulting in a

predicted change in behavior.

Female students, who agreed to complete the chlamydia questionnaire, were

asked "In the past 12 months I have used condoms: Never, 20% of the time, 50% of the

time, 70% of the time, or always." At least 27.02% of the students indicated that they

never used condoms and, conversely, 29.12% always used condoms while engaging in a

sexual activity in the past 12 months. The mean total score for condom use self-efficacy









was 93.91, indicating a moderate knowledge of potential benefit of condom use. These

data suggest that, despite knowledge about condom use, students do not use condoms

without fail and put themselves at risk for acquiring not only chlamydia but many other

kinds of sexually transmitted infections. But there are no statistical relationships among

CUSES scores, high-risk drinking, and sexual risk taking.

Risk factors documented in current research literature for sexually transmitted

diseases, including chlamydia, are condom use, sexual risk taking, and high-risk

drinking. The most common form of sexual risk taking is penile vaginal intercourse

without the use of a condom (Grady & Gillam, 2003). Inconsistent condom use is a

persistent trend in sexual behaviors for college and university students accompanied by

alcohol use (Bay-Cheng, 2003). Additional research notes that inconsistent condom use

is highly correlated with high-risk drinking (Albarracin et al., 2004).

High-risk drinking is defined as underage drinking and binge drinking. Binge

drinking is defined by researchers as five or more drinks at one occasion (Dejong &

Langford, 2002). Current research literature examines the social pressures of peer groups

such as sorority pledging, dating events, and athletics that directly influence sexual risk

taking and high-risk drinking (Wechsler et al., 2002). Additional research literature

describes the interpersonal and behavioral implications from sexual risk-taking activity

on college campuses, supporting consideration of the sociocultural environment as a

predictor of high-risk activities (Gurman & Borzekowski, 2004). The impact of the

campus culture may impact behavior more than previous research could demonstrate.

So, although students may demonstrate a moderate amount of condom use

self-efficacy, this does not translate into a behavior. If it did, the expectation would be a

very low mean on the CUSES scores. The findings indicate that population specific risk







54

factors for chlamydia infection must include other factors that have not been examined in

the context of college health. The significance of these results is discussed further under

implications.

Research Question 2

What are the differences in the number of sexual partners and the amount of

high-risk drinking between those who did and did not engage in high-risk sexual activity?

Univariate statistics were used to evaluate sexual risk taking in response to

questions that asked the number of sexual partners each female had in the past year, types

of sexual behavior they engaged in, and the number of occasions they were drinking and

having sex. The results report students were drinking and having sex an average of 6.45

occasions, in the past 12 months. The mean number of sexual partners was 1.64. But,

there were no significant relationships among number of sexual partners, high-risk

drinking, and sexual risk taking. This data is contrary to other research. Research in

college health has reported a correlation among the spread of sexually transmitted

infections, alcohol use, and engaging in sex (LaBrie et al., 2002; Liccardone, 2003).

Many researchers believe this is due to the effects of alcohol, specifically decreased

inhibition in a population that routinely practices risk taking (Wechsler et al., 2002).

Sexual activity, along with other risk behaviors such as binge drinking, underage

drinking, sexual activity while using alcohol, and sexual contact without the use of

barrier methods, contributes to the spread of sexually transmitted infections and suggests

that these behaviors or risk factors be examined and their relationships explored

(Donovan, 2004; Ross, 2002; Von Sadovsky et al., 2002). Not surprisingly, sexual risk

taking is also associated with high-risk drinking in other research studies that explore

college student behavior (LaBrie et al., 2002; Liccardone, 2003).









The implications of these finding are multifaceted and complicated by study

limitations discussed later in this chapter. One rationale for the results is the infinite

possibility of relationship types that occur during this time period for young people.

While female students may prefer an exclusive sexual relationship, many male students

do not. The health of the men with whom these young women are having sex is crucial.

They may spread genital chlamydia to many partners if they are not diagnosed and

treated. Drinking and sexual expectations of men and the subsequent effects on their

female partners cannot be ignored. Young men in this age group may have limited access

to sexual and reproductive health resources (Guttmacher Institute, 2006). This void of

information impacts sexual behavior and health choices. Young men practicing sexual

risk taking not only put their partners at risk but their own health status can be

compromised (Guttmacher Institute).

This implication generates questions for additional research. One research

question might ask what kinds of sexual expectations do men discuss with their partners

and what kinds of sexual relationships do they desire? How are these expectations

communicated? These questions, in the context of rigorous research methodology, would

provide information on what other risk factors impact female university students and

subsequent infection rates on a university or college campus.

Research Question 3

What are the combined effects of condom use self-efficacy scale (CUSES) scores,

number of sexual partners, high-risk drinking, and sexual risk taking behaviors on those

with a gynecologic complaint?

This group of data was examined using logistic regression. Results indicated that

only the number of sexual partners significantly discriminated between those with and









those without a gynecological complaint (chi-square = 10.52, p = 0.0012). This finding

indicates that the number of sexual partners may predict the likelihood of a gynecologic

complaint. A CUSES score, high-risk drinking, and sexual risk taking do not seem to

predict a gynecologic complaint or a chlamydia infection. Conversely, the increase in

sexual partners may predict a predisposition to a gynecologic compliant. Hopefully the

female student would seek treatment if she is symptomatic or at risk. But seeking medical

treatment is not always the decision made by the student, especially if symptoms are

vague or transient. Decisions to seek treatment and live independently are part of

transitioning to campus life. Female students make erroneous decisions as they transition

to this new life and develop life management skills.

Researchers describe the transition from home to attending a university or college

as a challenge for most young women (Farrow & Arnold, 2003). Students may learn for

the first time how to manage time, academic deadlines, financial obligations, and social

events. There is a steep learning curve, and a campus culture can be overwhelming. The

culture of a college campus is replete with gender and power issues also. Examples

include formation of male/female relationships and academic pressures imposed by

professors. These situations in themselves are not harmful, but making decisions on

unfamiliar topics and navigating the consequences and potentially negative situations is a

challenge for young female students. Making decisions about sexual risk taking and

increasing sexual activity is common for women in this age group (Smith, 2003).

Individual concerns about physical symptoms in response to actively engaging in

intimate sexual activity are influenced by social expectations and perception of socio

cultural or campus culture issues (Berry, 2004). For some students, a vague symptom

may be an indicator of sexual activity and an embarrassment. They do not seek medical









care. Conversely, some students may seek care immediately. The desire to establish

intimate relationships with the approval of and adherence to peer group expectations has

a considerable influence on the female student. Female students may fear being

stigmatized or dirty by seeking treatment; they are less desirable or at risk of being left

out of the peer group (Oprendek & Malcare, 1997). Real or perceived power influences

are critical to their perceptions and choices. These power relationships are part of gender

and sociocultural expectations affecting condom use and disease transmission because

they involve females and males (Gomez & Van Oss Martin, 1996).

The negative outcome of ignoring a vague symptom or gynecologic complaint

may be a by product of a sociocultural expectation. The sociocultural expectation that a

female who believes her partner is faithful, declines condom use, and will not need

treatment for a gynecologic complaint. In many instances there is a struggle between

condom use and the desire of the female student to be part of a couple, which may mean

sex without condom. The negotiation of condom use is affected by power in interpersonal

relationships (Few, 1997).

Studies on sexually transmitted diseases describe a moment when a young woman

decides how, when, and with whom she shares sexual activity. This moment is shaped by

her sociocultural environment (Berry, 2004; Kenney, 2000). There is a connection

between person, behavior choice, and outcome. For example, if the expectation is to have

a boyfriend, an important part of social acceptance on campus, this may imply that sex

and drinking are expected. Having sex without a condom is a demonstration of the

student's trust in her partner (Davidson-Harden et al., 2000).

Research that addresses the sociocultural perspectives of male-female interaction

addresses the fact that not using a condom leaves the female vulnerable to infection. The







58

persistence of a partner saying, "Everything is okay" may lead to the perception that there

is low risk or no risk (Smith, 2003). In effect, the female student wants to believe there is

no risk because she wants to trust that her lover would not deceive her just to have sex

(Davidson-Harden et al., 2000).The perception of risk and infection are not significant

correlates. Feeling that she is not at risk does not protect the individual from infection

(Kalichman et al., 2002). The student's realization that she is vulnerable to infection is

significant because it affects the perception of presenting symptoms and the decision to

seek medical treatment (Oprendek & Malcame, 1997). If the student does not think she is

vulnerable, the presence of a gynecological complaint or a vague symptom may be

dismissed and medical treatment delayed.

Overall, behavior and condom use research support the need for further study on

attitudes about the initiation of condom use (Davidson-Harden et al., 2000). Students'

attitudes about the information they receive are crucial. Nurse researchers report that

even in the context of a life-threatening illness, the students' acceptance of information is

paramount to the subsequent follow through or practice of health promoting activities

(Collins et al., 2003). College students repeatedly put themselves at risk by practicing

unhealthy behavior such as sexual risk taking and high-risk drinking (Rozmus et al.,

2005). Other examples are smoking, using illegal drugs, underage drinking, binge

drinking, having sex with unknown partners, and having sex while under the influence of

alcohol or drugs (Von Ah et al., 2004). These results demonstrate that the number of

sexual partners may predict a gynecologic complaint, and when a female student sees a

provider for a gynecologic complaint, screening should be offered. No research to date

has provided this data in such specific terms.









The Significance and Revisions to the Campus Chlamydia Model

Implications of Research Results

The presence of primary and secondary prevention measures (health education,

distribution of free condoms, encouraging STI screening, and inexpensive treatment) and

increasing rates of reported chlamydia infection is concerning. The expectation is that

these rates would be much lower than national rates or, at minimum, infection would be

decreasing. A study to determine prevalence of the chlamydia infection on this university

campus would be helpful to direct screening programs, comprehensive sexual and

reproductive health education, earlier treatment, and diagnosis of not only chlamydia but

other sexually transmitted infections.

The statistical analysis indicated that only the number of sexual partners

significantly discriminated between those with and without gynecological complaints. If

female students only seek treatment in the presence of a gynecological complaint, and

this occurs only with those who practice sex with multiple partners, then many students

are at risk for infection. Vague symptoms including burning upon urination, pelvic pain,

and vaginal bleeding may be present, but asymptomatic infection is common (Weir,

2004). Mild symptoms, or lack thereof, leave these young women at risk for chlamydia-

related morbidity, most specifically pelvic inflammatory disease (PID). Chlamydia PID

can lead to infertility (Stamm, 2004). Unfortunately, inexpensive and effective treatment

is often delayed because of the vague or absent symptoms previously mentioned (Hu et

al., 2004).

The Condom Use Self-efficacy Scale has been a valuable tool on college

campuses. This was the rationale for including it in the Campus Chlamydia Model

developed in Chapter 2. Unfortunately, students who scored moderately well on the









Condom Use Self-efficacy Scale still engaged in sexual risk taking and high-risk

drinking. A secondary analysis of the individual CUSES items would reflect individual

responses of the subjects regarding sexual negotiation, comfort using a condom when

using alcohol or drugs, and the mechanics of applying a condom. This information could

then improve health education programs by targeting the gaps in education. This would

positively affect primary prevention measures.

A secondary analysis may also provide direction to help nurses better educate

students in a sociocultural environment where sexual risk taking and high-risk drinking

continue into junior and senior class levels. Research on risk reduction interventions of

sexually transmitted infections report that skill-based interventions are most effective

(Jemmott, Jemmott, Braverman, & Font, 2005). These skill-based interventions involve

the actual application of condoms on anatomical models. Role playing that includes

negotiating condom use is also included. If this skill-based intervention was used, male

students also should be targeted for education to not only reduce rates of chlamydia

infection but to possibly instill positive attitudes about condom use (Pinkerton,

Holtgrave, & Jemmott, 2000).

Campus Chlamydia Model

The present research findings void the model presented in Chapter 1. The

expectation was that clear statistical findings would support that the independent

variables of high-risk drinking and sexual risk taking predict a positive chlamydia screen,

a diagnosis of a sexually transmitted infection, or gynecologic complaint. Then,

conversely, a high condom use self-efficacy score would provide a negative chlamydia

screen, no diagnosis of sexually transmitted infection, and absence of a gynecologic

complaint.









This was not the case. The statistical findings indicated that the correlation

between CUSES scores, age, number of sexual partners, number of times practicing

high-risk drinking, number of drinking occasions, number of drinks on each occasion,

and numbers of drinking and having sex were statistically not significant. The results

indicated that the differences in mean rank of number of times having five drinks,

number of drinking occasions, number of drinks on each occasion, and numbers of

drinking and having sex between those who engaged in high-risk sexual activity and

those who did not were statistically not significant. However, there were significant

differences in mean rank of the number of sexual partners between those who did and did

not engage in high-risk sexual activity. This is logical as female students who are not

engaged in sexual risk-taking behaviors would not have an increase in number of sexual

partners.

It was expected that clear evidence supported by statistics would reflect the

positive linear relationship between person, behavior, and outcome affected indirectly by

efficacy expectation and outcome expectations. But that was not the case. The CUSES

scores from the students, who represent the person in the model, did not have a direct

correlation with behavior, using or not using condoms.

But in this specific age group, female university students, other factors such as

peer subcultures, gender-power issues, and transitioning to college may impact the

students so strongly that self-efficacy is affected, and these additional factors should be

studied to determine their efforts on sexual risk-taking behavior in this group.

Transitioning to campus life may be a population specific risk factor because of

the influence this transition has on health behavior choices. The choice of a sexual

partner or high-risk drinking may be impacted by peer group subcultures. Conversely,









sexual risk taking may influence a female university student's choice in peer groups.

Gender-based power issues can influence students in their choices of risk taking

behavior. The influence of a male partner can affect condom use. Unprotected sex puts

both partners at risk but may also be a pledge of trust for either party.

Limitations

Limitations of the chlamydia questionnaire data may be one reason for this lack

of consistent results with previous research. Added questionnaire items were developed

by the researcher based on literature review and previous research. The addition of

another tool in combination with the Condom Use Self-efficacy Scale (CUSES) might

yield different results or results consistent with previous findings. What the data does

reflect is the need for further study. The use of a qualitative methodologic study may

explain inconsistency of these findings and the lack of statistical support for the campus

chlamydia model.

Recommendations for Future Research

A connection between the transition to campus culture and the subsequent health

behavior choices for students is probable. A qualitative research study could ask specific

questions about relationships formed during the freshmen and sophomore years to

explore sexuality, relationships, and risk factors with attention to sexual risk taking and

high-risk drinking. Since sexual risk taking and high-risk drinking have already been

identified in the literature as risk factors for sexually transmitted infections, their

interaction with adaptation to peer subcultures and gender-based power issues may

address gaps in current research literature. Qualitative research, in particular narrative

analysis, would elicit personal accounts or stories from the students that may provide

further valuable information regarding risk behaviors. Narrative analysis from personal









interviews would provide insight into the life and culture of the students, exploring and

answering questions found in this research (Patton, 2002; Reissman, 1993).

The narrative stories of sexuality, relationships, and risk behaviors of female

freshmen and sophomores could be transcribed and then thematic categories developed to

answer the research questions (Ryan & Bernard, 2003). For example, an explanation of

why female students of junior class standing still persist in high-risk drinking and sexual

risk taking despite primary and secondary prevention measures. This research did not use

any qualitative methodology, limiting some of the findings and raising more questions.

A prevalence study at the University of Florida would also be helpful to complete

a picture of this phenomenon. A prevalence of an infection is studied by convenience

sampling over a short period of time (Last, 2001). The true prevalence of the disease may

change medical and nursing practice at the UF SHCC. This could increase screening and

improve the likelihood of early treatment.

An additional limitation to this study was the focus exclusively on women.

Researchers have noted that the influence of men on women's sexual behavior is

substantial in this age group (Arnett, 2004). Further, experts warn that men are sexually

active for at least 10 years before being married, on average, and that only 14% of these

men report they had seen a health care provider for a sexual or reproductive health issue

(Guttmacher Institute, 2006). Research that focuses on the role of men in women's

sexuality along with the reproductive and sexual health needs of men is needed to fill the

gaps in defining population specific risk factors for chlamydia infection.

Contribution to Nursing Science

This research contributes to the body of nursing science by providing new

information on possible risk factors and directions for future research. These findings









indicate that comprehensive reproductive health and sexual health education with an

increase in chlamydia screening on college and university campuses is needed. Valuable

information on chlamydia infection rates, demographics of those infected, and

comparisons to national and state data provide nurses with valuable information they

need to care for the college health population. Nurses interact with college or university

students at crucial moments when students are attempting to transition to college life, a

university campus, make personal health choices, and seek medical care. This research

provides information that may improve these very crucial interactions, fostering positive

health behaviors for a lifetime.

Conclusion

The purpose of this study was to determine the current incidence rates of

chlamydia in the student population that access services at the University of Florida

Student Health Care Center. Second, to determine the relationships between condom use

self-efficacy scale scores in female students, high-risk drinking, sexual risk taking, and

the current incidence rates of genital chlamydia infection. This research was not designed

to test a hypothesis but to provide a more accurate picture of what may be occurring in

the health of female students on a university campus. A more detailed picture was sought

because current primary and secondary measures of prevention have failed to decrease

reported cases of chlamydia infection in this population.

Incidence rates of chlamydia infection for all students who access services at UF

SHCC are higher than nationally reported rates. Self-efficacy is a significant predictor of

health behaviors but may be impacted so strongly by the transition to a campus culture it

scarcely affects condom use.

The scores from CUSES had no apparent relationship with high-risk drinking or

sexual risk taking. Despite a reasonable degree of self-efficacy using condoms, female









students continue, even at junior class standing, to participate in high-risk drinking and

sexual risk taking. The number of sexual partners was the only significant predictor of

whether a female student had a gynecologic complaint. Female students reported on

average 1.64 partners in the past year. The picture of what is occurring in the health of

these young women is unclear, and chlamydia infection is increasing.

Fortunately policy changes are already being discussed at UF SHCC to change

clinical practice and screening policies as a result of this research. This research has

made an impact directly on the lives of students. But, further research is needed to

determine other population specific risk factors that influence the prevalence of

chlamydia infection in female university students and their male classmates. Research to

promote changes in health policy and nursing practice could make the difference in the

lives of all students. This research was just a beginning.















APPENDIX A
CHLAMYDIA QUESTIONNAIRE

Please complete the following information. Where a blank is present put the number that
corresponds or list your race as you report it for the University of Florida Registrar's
Office. Circle the answer that best describes you and your experiences.

1. Age


2. Ethnicity circle one: White


Hispanic


Black


Asian


Other


3. Class Standing-circle one:
Freshman Sophomore Junior Senior


Grad Student


4. Residence-circle one:
On-campus dormitory On-Campus sorority house Off Campus-Apartment
Off campus-living at home

5. The number of sexual partners I have had in the last 12 months

6. I have engaged in the following sexual behaviors in the past 12 months, please circle:
Petting (touching of the genitals or breasts with clothing off or on)
Masturbating Oral Sex Sexual Intercourse Anal Sex


7. My partners are strictly: Male


Female


Both


8. In the past 12 months I have used condoms:
Never 20%of the time 50 % of the time


70% of the time Always


9. In the past 12 months, the numbers of occasions I consumed alcohol and engaged in
sexual activity at the same time or during the same occasion were


10. In the past 12 months, I have had 5 drinks (one beer = 1 drink, one shot = 1 drink, one
glass of wine = 1 drink) or more the following number of times

11. The number of occasions in the past two weeks I chose to drink

12. The number of drinks (one beer = 1 drink, one shot = 1 drink, one glass of wine = 1
drink) I had on each occasion









13. My comfort with asking my partner about seeking treatment if they were diagnosed
with a sexually transmitted infection:
Uncomfortable Somewhat Comfortable Moderately Comfortable
Very Comfortable

14. My comfort with discussing a diagnosis of a sexually transmitted infection in myself
with my current partner is:
Uncomfortable Somewhat Comfortable Moderately Comfortable
Very Comfortable

15. I have been diagnosed in the past or I am currently being treated for:
Chlamydia Gonorrhea Herpes HPV Yeast Infection Bacterial Vaginitis
None

16. I have been treated more than once for the following :
Chlamydia Gonorrhea Herpes HPV Yeast Infection Bacterial Vaginitis
None

Condom Use Self-efficacy Scale
(Brafford & Beck, 1991)

These questions ask about your own feelings about using condoms in specific situations.
Please respond even if you are not sexually active or have never used (or had a partner
who used) condoms. In such cases indicate how you think you would feel in such a
situation.

1. I feel confident in my ability to put a condom on myself or my partner
Strongly Disagree Undecided Agree Strongly
Disagree Agree

2. I feel confident I could purchase condoms without feeling embarrassed.
Strongly Disagree Undecided Agree Strongly
Disagree Agree

3. I feel confident I could remember to carry a condom with me should I need one.
Strongly Disagree Undecided Agree Strongly
Disagree Agree

4. I feel confident in my ability to discuss condom usage with any partner I might
have.
Strongly Disagree Undecided Agree Strongly
Disagree Agree

5. I feel confident in my ability to suggest using condoms with a new partner.
Strongly Disagree Undecided Agree Strongly
Disagree Agree









6. I feel confident I could suggest using a condom without my partner feeling
"diseased."
Strongly Disagree Undecided Agree Strongly
Disagree Agree

7. I feel confident in my own or my partner's ability to maintain an erection while
using a condom.
Strongly Disagree Undecided Agree Strongly
Disagree Agree

8.* I would feel embarrassed to put a condom on myself or my partner.
Strongly Disagree Undecided Agree Strongly
Disagree Agree

9.* If I were to suggest using a condom to a partner, I would feel afraid that he or she
would reject me.
Strongly Disagree Undecided Agree Strongly
Disagree Agree

10.* If I were unsure of my partner's feelings about using condoms, I would not suggest
using one.
Strongly Disagree Undecided Agree Strongly
Disagree Agree

11. I feel confident in my ability to use a condom correctly.
Strongly Disagree Undecided Agree Strongly
Disagree Agree

12. I would feel comfortable discussing condom use with a potential sexual partner
before we ever had any sexual contact
(e.g., hugging, kissing, caressing, etc.)
Strongly Disagree Undecided Agree Strongly
Disagree Agree

13. I feel confident in my ability to persuade a partner to accept using a condom when
we have intercourse.
Strongly Disagree Undecided Agree Strongly
Disagree Agree

14. I feel confident I could gracefully remove and dispose of a condom after sexual
intercourse.
Strongly Disagree Undecided Agree Strongly
Disagree Agree









15.* If my partner and I were to try to use a condom and did not succeed, I would feel
embarrassed to try to use one again (e.g., not being able to unroll condom, putting it
on backwards or awkwardness).
Strongly Disagree Undecided Agree Strongly
Disagree Agree

16. *I would not feel confident suggesting using condoms with a new partner because I
would be afraid he or she would think I've
had a past homosexual experience.
Strongly Disagree Undecided Agree Strongly
Disagree Agree

17. *I would not feel confident suggesting using condoms with a new partner because I
would be afraid he or she would think I have a sexually transmitted disease.
Strongly Disagree Undecided Agree Strongly
Disagree Agree

18. *I would not feel confident suggesting using condoms with a new partner because I
would be afraid he or she would think I thought they had a sexually transmitted
disease.
Strongly Disagree Undecided Agree Strongly
Disagree Agree

19. I would feel comfortable discussing condom use with a potential sexual partner
before we ever engaged in intercourse.
Strongly Disagree Undecided Agree Strongly
Disagree Agree

20. I feel confident in my ability to incorporate putting a condom on myself or my
partner into foreplay.
Strongly Disagree Undecided Agree Strongly
Disagree Agree

21. I feel confident that I could use a condom with a partner without "breaking the
mood."
Strongly Disagree Undecided Agree Strongly
Disagree Agree

22. I feel confident in my ability to put a condom on myself or my partner quickly.
Strongly Disagree Undecided Agree Strongly
Disagree Agree

23. I feel confident I could use a condom during intercourse without reducing any
sexual sensations.
Strongly Disagree Undecided Agree Strongly
Disagree Agree









24. I feel confident that I would remember to use a condom even after I have been
drinking.
Strongly Disagree Undecided Agree Strongly
Disagree Agree

25. I feel confident that I would remember to use a condom even if I were high.
Strongly Disagree Undecided Agree Strongly
Disagree Agree

26. If my partner didn't want to use a condom during intercourse I could easily
convince him or her that it was necessary to do so.
Strongly Disagree Undecided Agree Strongly
Disagree Agree

27. I feel confident that I could use a condom successfully.
Strongly Disagree Undecided Agree Strongly
Disagree Agree

28. I feel confident I could stop to put a condom on myself or my partner even in the
heat of passion.
Strongly Disagree Undecided Agree Strongly
Disagree Agree


* item reverse scored


















APPENDIX B
POSITIVE CHLAMYDIA RESULTS BY MONTH

Data gathering instrument used to record reported cases of chlamydia in students who
access services from the University of Florida Student Health Care Center via laboratory
records.

Month/Year Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec
reported 99 99 99 99 99 99 99 99 99 99 99 99
Females
Males
Total
3871 3874 3877 3880 3883 3886 3889 3892 Sept Oct Nov Dec
7 8 6 7 7 8 8 9 00 00 00 00
Females
Males
Total
3871 3874 3877 3880 3883 3886 3889 3892 Sept Oct Nov Dec
7 8 6 7 7 8 8 9 01 01 01 01
Females
Males
Total
3871 Feb 3877 3880 3883 3886 3889 3893 Sept 3899 Nov 3905
8 02 7 8 8 9 9 0 02 1 02 2
Females
Males
Total
3871 3875 3877 3880 3883 3887 3890 3893 Sept 3899 Nov 3905
9 0 8 9 9 0 0 1 03 2 03 3
Females
Males
Total















APPENDIX C
DEMOGRAPHIC CHARACTERISTICS FOR POSITIVE CHLAMYDIA RESULTS

Data collection log for review of chlamydia cases reported by laboratory results form the
laboratory at the University of Florida Student Health Care Center.

Case number Age Sex Ethnicity Repeat infection Residence
Jan 99 # 1
Jan 99 # 2
Jan 99 # 3
Jan 99 # 4
Jan 99 # 5
Jan 99 # 6
Continue
asneeded

Information on this data sheet will be recorded as follows. A number will signify age, sex
will be noted as 0 for male and 1 for female and ethnicity will be reported as 0 for
Caucasian, 1 for African American, 3 for Hispanic, 4 for Asian, 5 for Native American,
6 for nonwhite other. Repeat infection will be indicated as 0 for no and 1 for yes and
residence will be recorded as 1 for on-campus dormitory, 2 for on-campus sorority or
fraternity house, 3 for off-campus apartment/house and 4 for off-campus home.















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BIOGRAPHICAL SKETCH

Ms. Thomas graduated from Saint Petersburg Junior College in 1979 with an

associate degree in nursing science and an associate's degree in social arts. She received

a bachelor's degree in nursing science from the University of Florida in 1996 and a

master's degree in nursing science from the University of Florida in 1998. Ms. Thomas'

expertise includes 18 years of clinical nursing experience in maternal newborn nursing,

neonatal intensive care, adult critical care, and advanced practice nursing. Advanced

practice areas include general pediatrics, pediatric forensics, adolescent gynecology,

college health, primary care, and women's reproductive health. She has also enriched her

career with 8 years of progressive management experience, including clinical

supervision, charge nurse roles, and director levels. She has garnered 6 years of research

during her career including coordination of an NIH funded study, clinical trials, and

epidemiologic research. Epidemiology is Ms. Thomas's minor course of study.

Presently, Ms. Thomas serves as a research associate and site coordinator for the

Addictive and Health Behaviors Research Institute and as an advanced registered nurse

practitioner at the University of Florida Student Health Care Center.