Youth Sexual Health: Sexual Knowledge, Attitudes, and Behavior Among Students at a University in Turkey

Abstract

Introduction

To determine sexual attitudes, behavior, and knowledge of Namik Kemal University (NKU) students about sexual health and sexually transmitted infections (STIs).

Method

A sample representing 10% of the undergraduate population of NKU in 2009–2010, was studied. Of 1,500 questionnaires distributed, 1,314 (87.6%) were filled out.

Results

The mean age of the respondents (52.9% male) was 20.07±1.75 years. The rate of students who had received sexual health education was 32.0%, and 15.3% had previously used a sexual health service. Eleven percent of the female students and 50.3% of the male students had had sexual intercourse. The average age of initial sexual intercourse was 16.83±2.07 years. Of the students who had had sexual intercourse, 46.6% reported that they did not use any contraception method. The most preferred method was condoms (37.6%). The rate of contraceptive use was 58.7% in sexually educated students and 43.9% in those not educated (p=.004). The most well-known STI was AIDS (96.5%), with sexually educated students giving higher rates of correct answers about STIs (p<.05)

Conclusion

The students who had received sexual health education were more knowledgeable about vital consequences of STI’s, even though it is not sufficient, than sexually active students. Awareness of safe sexual practices and changes in behavior, in particular, promoting condom use should be established in higher risk youths. Deficiencies in knowledge could be addressed by adding a sexual healthtraining component to the university curriculum, and unmet requirements could be met by reorganizing medico-social centers in universities.

Introduction

Adolescents, defined by the World Health Organization (WHO) as persons between the ages of 10 and 19 make up about 20% of the world’s population, of whom 85% live in developing countries (1). The United Nations (UN) use the term “adolescent” for people aged 10–19 years and “young people” for those aged 15–24 years (1,2). The major causes of morbidity and mortality among youth include suicide, road accidents, drug use (including tobacco use), and sexual and reproductive health problems (1). Sexually transmitted infections (STIs) among youths continue to be an important public health problem for many industrialized and developing countries (3,4,5). According to the WHO, 333 million new cases of curable STIs occur annually, with the highest rates among 20-to 24-yearolds, followed by 15- to 19-year-olds (6).

According to the UN Population Fund report, people aged 15–24 years are at the highest risk for STI, and STI prevalence is highest among them (7,8). One of the reasons why young people are particularly vulnerable to STIs is lack of sex education, including education on STI prevention (2).

Turkey is a developing country. Despite its bridge position between East and West, sexuality is still predominantly taboo in Turkish society, and, generally, Turkish people do not adequately taking preventive measures for STIs. At the same time, in adolescents and youth, which constitute 20% of the Turkish population (9), the rate of sexual experience is increasing (9,10,11). Lack of sexual education combined with rapid sociocultural changes has made adolescents and youths more prone to STIs, unwanted pregnancies, and consequent psychological problems. Research on the sexual behavior of youth is thus of great importance for understanding educational requirements and determining risk groups that require preventive health care.

Tekirdağ, constitutes the western border of İstanbul and northern border of the Marmara Sea. Tekirdağ is 100 km from the border with Greece Although agriculture is the main source of income, Tekirdağ is also known as a city of tourism, university education and scholarship. According to the census, the total population in Turkey reached 783.310 in 2009 (12). The Namık Kemal University (NKU), with 11.726 students, is in Tekirdağ Although studies on sexual attitudes and behaviors of young people in Turkey has been increased recently (9,11,13,14,15,16) there remains a need for comprehensive information on sexual behavior of youths in Turkey and for putting these findings into practice.

The aim of this study was to investigate sexual attitudes, behavior, and knowledge about sexual health and STIs among students of NKU in one region of Turkey.

Method

Sampling

This cross-sectional study examined survey responses from 1.314 undergraduate students of NKU (Population: 11.726) in the 2009–2010 school year. The sample size represented 10% of the student population (n=1.173), with 20% estimated dropouts (234), to yield a total sample size of 1.407. Out of 1.500 questionnaires handed out, 1.314 (87.6%) were filled out.

Multistage sampling methods were used. The students selected systematically from class lists, after stratifying all underground students for sex and grade. Students were given 30 minutes to complete the survey.

Approval from the NKU Senate was obtained to use the questionnaire and collect data. Study participation was voluntary, participants were not rewarded, and the questionnaires were completed under conditions of confidentiality and anonymity.

Measurements

Structured Developmental History Questionnaire (SDHQ)

We developed a 39-item questionnaire. The first seven items evaluate the socio-demographic variables such as age, gender, grade, family type, income level, birthplace, and place of residence. The others examine current medical history, along with tobacco, alcohol, and substance use behavior, and sexual attitudes and behavior, and STIs.

Sexuality Questionnaires for Adolescents: Knowledge Test (SQAKT)

The SQAKT is a 34-item multiple-choice test. It includes questions on physical development, relationships, sexual activity, pregnancy and marriage of adolescents, the probability of pregnancy, birth control, and STI. It has been used successfully in high school students. The test-retest reliability coefficient was 0.89. Content validity was determined by an expert who selected both the domains and the items for the domains (17).

The original English version was translated into Turkish by the authors and independently re-translated back into the original language by native Turkish speakers who also have a thorough knowledge of English. The differences between the original and the back-translated versions were discussed and resolved, and three questions that were not adaptable to Turkish culture were eliminated. Thus, the Turkish version included 31 questions.

Scoring was done according to the percentage of correct answers, obtained by the number of correct answers, divided by 31, and multiplied by 100. The highest score was 100% and the lowest score was 0%. The deduced level of knowledge increases as the percentage score rises. Cronbach’s alpha coefficient was found to be .95 for internal consistency. Test-retest reliability coefficient was .82 in this study.

Statistical Analysis

All statistical evaluations were performed using the Statistical Package for the Social Sciences (SPSS) for Windows (version 18.0; SPSS Inc., Chicago, IL, USA). Descriptive statistics were computed for all data. Student t and chi-squared tests were used for comparisons. Cronbach’s alpha coefficients were computed for reliability. A 95% confidence interval was used for statistical significance.

Results

Socio-Demographic Characteristics

The mean age of the 1.314 participants (52.9% male) was 20.07±1.75 years (range: 16–28 years). Most of them were single (97.9%). Most participants were Muslims (95.9%). Forty percent of the students were living in the dormitory; the rest was living either with their friends (32.4%) or with their family (27.3%). Almost half of them (51.5%) were born in one of the big cities. The rate of tobacco use, alcohol use and substance use were 36.1%, 47.5% and 7.6%, respectively (Table 1).

Table 1.

Characteristics of students according to gender, NKU Turkey, 2010

Characteristics	Sex		p
Demographic	Female	Male
Gender, n (%)	619 (47.1)	695 (52.9)
Mean age (±SD)	20.06±2.51	20.28±2.24	.35**
Born in metropolis, n (%)	332 (53.6)	316 (45.5)	.08*
Live in the dormitory, n (%)	295 (47.7)	236 (34.0)	.07*
Marital status-Single, n (%)	604 (97.6)	661 (95.1)	.73*
Religion (Islam), n (%)	599 (96.8)	661 (95.1)	.94*
Substance use
Use of cigarettes (every day at least one), n (%)	161 (26.0)	282 (40.6)	<.001*
Use of alcohol (social drinkers), n (%)	212 (34.2)	323 (46.5)
Use of another substance (abuse), n (%)	12 (1.9)	77 (11.1)	<.001*
Sexual behavior
Had a girlfriend/boyfriend, n (%)	532 (85.9)	561 (80.7)	.97*
Had had sexual intercourse, n (%)	71 (16.9)	350 (83.1)	<.001*
Mean age at first intercourse, (±SD)	17.80±2.58	16.75±2.01	.21**
Sexual activity in the previous six months, n (%)	21 (8.9)	213 (65.7)	<.001
Condom use during last intercourse, n (%)	6 (25.6)	81 (34.6)	.06*

^*χ² test

^**Student t test

Sexual Education and Sexual Health Service Usage

The percentage of subjects who have received sexual health education (SHE) was 32.0% (n=421). The rate of students who have previously used a sexual health service (SHS) was 15.3% (n=201) and among them, 61.3% had “consulted/received information”. Of the participants who had not used a SHS, most of them (73.5%) stated that they did not need it. Of the sample, 62.2% (n=816) emphasized that they talked about sexuality often with their friends. The most discussed subjects were ‘hymen’ and ‘wedding night’, with a rate of 20.5%. Of the students, 53.7% (n=706) stated that they wanted to receive SHE. Of the 438 students who did not want to receive SHE, 90.9% (n=398) emphasized that though they did not need, it should nevertheless be given. Of the students, 84.0% emphasized that SHE should be given and 73.2% (n=962) stated that the place for the education should be “a medico-social center”, 54.7% (n=719) “school” as a part of formal education, and 33.9% (n=446) “special centers”.

Sexual Attitudes and Behavior

Most of the students (83.2%, n=1.093) had had at least one girlfriend/boyfriend. The number of students who had had sexual intercourse at least once was 421 (32.0%); 16.9% female and 83.1% male (p<.001). The mean age at first sexual intercourse was 16.83±2.07 years, with no difference between genders (p=.21) (Table 1).

There was a difference between genders for the type of sexual partner in the initial sexual intercourse (p=.02). The first sexual experience was most frequently with a girlfriend/boyfriend (65.7%, for females; 51.1%, for males).

Considering sexual experiences in the previous six months, 73.7% (n=767) responded, “I did not have any sexual intercourse”, 12.9% (n=134) responded “I had sexual intercourse but not regularly”, and 9.6% (n=100) responded “I had sexual intercourse regularly”. The difference between genders was significant (p<.001), with the number of irregular sexual intercourse less in female sexually active students.

The rate of sexually active students was significantly higher among students who used alcohol compared with those who did not (p<.001).

Use of Contraceptives

Of the students who had had sexual intercourse, 46.6% (n=196) responded that they did not use any method of contraception. Of those using contraceptives, 11.6% (n=49) were female and 41.8% (n=176) were male (p=.004). The most preferred method was condoms, which was used by 37.6% (n=87) of the sexually active students. Contraceptives were purchased most frequently in pharmacies (45.9%). Only 84.4% of the students were able to write the names of three contraceptive methods (n=1,109). Among them, 40.6% had learned them from newspapers and magazines.

The rate of contraceptive use was 58.7% in students who had received training in sexual health, vs. 43.9% in those who had not (p=.004). The rate of contraceptive use was 49.8% among students who used alcohol and 64.2% in those who did not (p=.02).

Knowledge About Sexually Transmitted Infections

Three questions were asked to assess students’ knowledge of STIs. The first question was “Is there any STI for which an infected person seems healthy?” Of the students, 84.4% answered “Yes”. The second question asked if “AIDS”, “hepatitis B”, “hepatitis C”, “syphilis”, “gonorrhea”, “candidiasis”, “chlamydia”, “herpes genitalis”, and “urinary tract infection” were STIs. Of the participants, 1.3% (n=17) answered correctly for all conditions. The most known STI was “AIDS” (96.5%). The third question included seven suggestions about STIs, to be marked true or false. None of the students correctly identified all three false suggestions. Having received sexual health education did not change the results (p>.05). The propositions are listed in Table 2.

Table 2.

Propositions about sexually transmitted disease

Propositions
A person who have sexually transmitted disease is immune to the disease (F)
Sexually transmitted diseases may be fatal (T)
A person may have more than one sexually transmitted disease (T)
Sexually transmitted diseases can be transmitted from mother to child (T)
Sexually transmitted diseases do not cause infertility (F)
Sexually transmitted diseases can be transmitted through ways other than sexual intercourse (T)
Human immunodeficiency virus (HIV) is not transmitted through sexual intercourse with a person who has a negative HIV blood test (F)

Sexuality Questionnaires for Adolescents: Knowledge Test

The average SQAKT score was 35.40±18.76 (0–83.87). In males who had had sexual intercourse, had been sexually active during the previous six months, and had not received any education about sexual health, the SQAKT score was significantly lower (p<.05; Table 3).

Table 3.

The scores of the Sexuality Questionnaires for Adolescents: Knowledge Test (SQAKT) according to patients’ characteristics

Characteristics	Total SQAKT Score Mean±SD	p*
Gender
Female (n=619)	38.8±17.4	<.001
Male (n=695)	32.4±19.4
Had Sexual Intercourse
Yes (n=369)	34.0±18.2	<.001
No (n=833)	38.3±17.4
Sexually active
Yes (n=234)	34.05±18.22	<.001
No (n=737)	39.56±17.19
Had Sexual Health Education
Yes (n=421)	39.2±19.0	<.001
No (n=847)	34.0±18.2

SD: standard deviation

^*Student t test

Discussion

The descriptions of the interventions to be covered in this review also attest to the variety of approaches to sexual health education. The variety of approaches its content and range of nomenclature used to describe sexual education. Health education interventions most frequently used strategy for sexual health promotion among young people, particularly considering many studies show that young people have low levels of information about sexuality, reproduction, contraception, and sexually transmitted diseases and as in many studies, age at first intercourse is showing a steady decline with cohort age and high level of knowledge (18).

In this study, about one third of the participants had received sexual education similar to the study of Chen et al. on 5,243 Shanghai University students (38.4%)(19). However, the rate was 65.3%, in a study of senior university students in the Faculty of Education in Turkey (20). This difference may be attributed to the inclusion of only senior class students in Eskiocak’s study. Comprehensive sex education programs that help participants navigate young adulthood with accurate information, increased self-knowledge, enhanced safety and strengthened interpersonal skills (21).

Slightly over half of the students wanted to receive SHE (53.7%), compared with 86.1% of the students in Cumhuriyet University (22). However, most of the students (90.9%) who did not want to receive SHE emphasized that it was necessary even though they did not need it. There are two conclusions: the first is that students thought they received enough sexual health information and were unwilling to undergo further sexual education (contrary to the results). The second is that the students were ashamed of seeming to be willing to receive sexual education. In this study, 73.2% emphasized that SHE should be given in medico-social centers, which was the second most common response in Akın’s study (16).

In Akın’s study, 9.5% and 18.1% of first-year students at Dicle University and Hacettepe University, respectively, had previously used a SHS. The rate of 15.3% found in this study was similar to the rate at Hacettepe University, which includes a more cosmopolitan student population (16).

It is well known that young people have particular difficulties with accessing healthcare. These include issues of confidentiality, of competence, and restrictions associated with school commitments. A search of the medical literature reveals that most studies involve people already using services; these will obviously fail to sample those with greatest difficulty in accessing services, including those who do not attend for reasons of ignorance, fear, or a perception that they do not need such services. Little exists with respect to the establishment “from scratch” of a service for young people with input from teenagers before it is set up (23).

Similar to the studies in Hacettepe University and Dicle University, most of the students who had used a SHS stated that they consulted/took information, and the most common reply for not using a SHS was “did not need it” (73.5%). According to the students, the most appropriate place to obtain sexual information was a special physician/special hospital, in both this study and Akın’s study (16). The cost of the health service can present a serious obstacle in accessing information.

Over half of the students had talked about sexual topics with their friends, and the most discussed subjects were “hymen” and “wedding night”, in the present study. However, in Akın’s study, students preferred to talk with their parents before friends, and the most discussed subjects were “problems of menstruation and adolescence” (16). The reason for this difference may be the inclusion of only first-year students in Akın’s study. Subjects of interest may change with age and advancing to a higher class.

Most students in this study had had at least one girlfriend/boyfriend (83.2%). In Akın’s study, the rates were 76.3% and 66.0%, in Hacettepe and Dicle Universities, respectively (16). The results of this study may represent more universal values. Moreover, NKU is located in Western Turkey, where having a girlfriend/boyfriend is considered more normal than in many other regions of Turkey.

In this study, one third of the students indicated that they had had sexual intercourse at least once, and the majority of these were male. The rate of sexual intercourse was five-fold higher for males compared with females. Almost one quarter of the students assessed themselves as sexually active in the previous six months. In Ireland, the rate of sexual intercourse was 50% for males and 44% for females in 1988 (24). A study from Thailand found that 43% of female students and 48% of males had sexual intercourse (25). In Hong Kong University students, the rate of sexual intercourse was 56.7% for males and 43.3% for females (26). In Beijing, the rate of sexual intercourse was 5.3% and 3.9% in university students in 1992 and 1996, respectively, and the rate increased to 12% in 2002 (27,28). In Ukraine 59% of female and 83% of male first-year medical students stated that they had had sexual intercourse (29). Only 6.5% of female and 9% of male students from Hacettepe and Dicle Universities had had sexual intercourse (16). However, a study including senior students in the Education Faculty of Trakya University found that 46.4% of unmarried students were sexually active (19). This research’s finding of lower rates in female students compared with male students is consistent with the literature. The studies included only senior class or first-year students (11,16,20,30), and different student characteristics may result in different outcomes. However, the lower rates of sexual intercourse for female students found in the current study, compared with the rates in other countries, may stem from sociocultural and religious beliefs in Turkey, which exert pressure on the sexuality of single females.

The average age at first sexual intercourse was approximately 16, with no significant difference between genders. In a study from England, 26% of females and 30% of males stated that they had their first heterosexual intercourse before 16 years of age (31). In Ukraine, the average age at first sexual intercourse was 15.7±1.4, with no significant difference between genders, in agreement with presenting study (29). The average age at initial intercourse was 16.4 for females and 16.2 for males, in a study of 304 patients admitted to clinics for STIs in Tanzania, with no difference between genders (32). A study from Thailand, on the other hand, reported a lower average age of initial sexual intercourse in males (25). In addition, a study of intern students in the Faculty of Medicine in Izmir (Turkey), reported a lower average age for males compared to females (17.9±2.0) (9). Finally, a study performed in Dokuz Eylul University students, Turkey, reported an average age of 17.58±2.90 (30). The age and gender distribution of initial sexual intercourse reported in Turkish studies are frequently similar to those found in foreign studies. The similarities observed in this study may result from the relative modernity of the university, which may serve to attract students from this region, which is known for relatively positive opinions regarding the sociocultural structure with respect to sexuality.

Alcohol use was correlated with an increased rate of sexual intercourse, similar to the finding of a study conducted in Hong Kong University (26).

Almost half of the sexually active students did not use any method of contraception (46.6%). Over one third of the students using contraceptives used condoms. In Chen’s study, 79.7% of the students claimed to use condoms each time they had sexual intercourse (19). This might have been resulted from the schoolbased sexual health education offered in Shanghai. Condoms were also the most preferred contraceptive method among university students in Ireland (41%), Ukraine (69%), and Beijing (69%) (24,28,29). In addition, most of the patients admitted to clinics in Tanzania preferred condoms (32). Eskiocak et al. also reported that 45.5% of sexually active students used a contraceptive method, and the most preferred method was condoms (32%) (20). This research’s findings were consistent with the general literature.

Similar to the findings of Eskiocak et al., in the current study, 60.9% of students reported that they learned methods of contraception from newspapers and magazines, (20). The frequency of contraceptive use was lower in participants who used alcohol (p=.02). A study of post-college students from Sweden reported that using alcohol had an adverse effect on using contraception during sexual intercourse (33).

Students did not know the names of several common STIs, with AIDS being a widely recognized (96.5%) exception. In a study of university students from Italy, AIDS, as in this study, was well known (94.4%) but other STIs were not sufficiently apprehended (5). In a study performed in Ukraine, all students marked AIDS as an STI (26). HIV/AIDS is a well-known topic worldwide; this can explain the greater knowledge about AIDS. However, poor rates of using condoms demonstrate that knowledge is not always translated into appropriate actions.

In addition, approximately 15% of the students did not have information on signs, symptoms and ways of transmission of STIs they were under the potential risk of.

Although the highest score for the SQAKT questionnaire was 100, the mean score in this study was about 35 which was under the expectations. SQAKT scores were lower in males who had not received SHE, had had at least one experience of sexual intercourse, and were sexually active in the previous six months.

The lower, rather than higher scores observed in this group demonstrated that they were at great risk. Sexual health training correlated with higher SQAKT scores, but this correlation was not sufficient, indicating that well-qualified sexual health training may be more beneficial for students.

Similar to that in this study, the level of knowledge concerning STIs was significantly lower in males compared with females in a study of university students from Beijing (28). In a study of highschool students from Trabzon, Turkey, knowledge among males regarding birth control and STIs was significantly lower than knowledge among females, although the mean values were low in both genders (34). Although the level of knowledge was similar in male and female students in Hacettepe University, it was higher in female students in Dicle University (16).

The questionnaires were distributed only to students present in the school. Since cigarette use, alcohol use, and sexuality may correlate with irregular attendance at school, lack of data from absent students may result in a lower representation of these groups.

The questionnaires were administered in the classrooms which may not provide optimum conditions for answering a questionnaire on such a sensitive topic in Turkish society. It is possible that students may have replied falsely to some questions; accurate replies might have been embarrassing due to taboos concerning sexuality among students.

The NKU is a medium-sized city located in Western Turkey and includes mostly students from nearby regions. Results of this study should therefore not be generalized until corroborated with results from different regions.

Young people’s lifestyles include sexuality, in spite of social taboos. Since the vast majority learns about sexuality from their friends, incomplete and defective information has become prevalent, leading to unsafe sexual practices. Of the students who had received SHE, whereas the expected knowledge about sexuality to be high, unfortunately we found that it was disappointingly low. Most of the students indicated that they would like to receive SHE.

The students had some knowledge of contraception methods, but this has not resulted in sufficient use of such methods, especially considering their vital importance for preventing unwanted pregnancies, unsafe abortions, and STI in sexually active students. Since students had no access to SHS, they could not ask for advice. The most preferred option for obtaining sexual advice was “special physician/hospital”. This can represent a significant obstacle to SHS access due to economic reasons. Medico-social centers in universities can be restructured within the context of adolescent health to include SHS.

It is important to create social awareness of safe sexual behavior. STI prevention is possible through changes in attitudes, and specifically, through promoting condom use in high-risk students. Governments should provide sexual health education, including adequate information on preventing unsafe sexual behaviors, in formal training programs. In the short term, it is possible to create sensitivity concerning safe sexual life by adding sexual health training to the curriculum required for graduation. Whatever the implementation strategy, it is necessary to address the current deficiency in knowledge of sexual health in university students.

This study and similar studies provide information highlighting the need for adding obligatory sexual health training to the required curriculum for graduation in Turkey, a developing country where sexuality is taboo.