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. 2021 Mar 3;9(2):100323. doi: 10.1016/j.esxm.2021.100323

Danish Health Professional Students' Attitudes Toward Addressing Sexual Health: A Cross-Sectional Survey

Helle Gerbild 1,2,∗, Camilla Marie Larsen 1,3, Tina Junge 1,3, Birgitte Schantz Laursen 2,4, Kristina Areskoug-Josefsson 5,6,7
PMCID: PMC8072180  PMID: 33676228

Abstract

Introduction

Danish health professional (HP) students' attitudes toward addressing sexual health are unknown.

Aim

To investigate Danish HP students' attitudes toward addressing sexual health in their future professions, and to assess differences in perceived competences and preparedness between professional programs.

Methods

A Danish national survey of nursing, occupational therapy, and physiotherapy students was conducted. Totally, 1,212 students were invited to respond to an online questionnaire “The Students' Attitudes toward Addressing Sexual Health.”

Main Outcome Measure

The main outcome measures investigated were Danish HP students' attitudes toward addressing sexual health in their future professions, and differences in perceived competences and preparedness depending on the professional program.

Results

A total of 584 students (48%; nursing 44%, occupational therapy 70%, physiotherapy 43%) responded. Mean total score ranged between 63.7 and 66.3 (±8.3–8.8) classifying students in the low-end of the class: “comfortable and prepared in some situations.” No clinically relevant differences were determined between the professional programs with respect to perceived competences and preparedness to address sexual health.

Conclusion

In the field of addressing sexual health, most Danish HP students reported positive attitudes and a need for basic knowledge, competences, communication training, and education.

H Gerbild, C M Larsen, T. Junge, B. S. Laursen, K. Areskoug-Josefsson. Danish Health Professional Students' Attitudes Toward Addressing Sexual Health: A Cross-Sectional Survey. Sex Med 2021;9:100323.

Key Words: Attitudes, Health Professional, Sexual Health, Students, Survey

Introduction

For decades, sexual health training has been defined as a necessity for health professionals (HP).1 Sexuality is an important part of health and quality of life.2,3 Diseases, lifestyle, and vascular risk factors can affect sexual health2 defined as “a state of physical, emotional, mental and social well-being in relation to sexuality.”4 Nurses (RN), occupational therapists (OT), and physiotherapists (PT) have important roles in promoting sexual health;2,5, 6, 7 consequently, HPs should be comfortable and competent when addressing sexual health.8 HPs are rarely prepared to address sexual issues and often report providing insufficient care and rehabilitation regarding sexual health.8,9 Common barriers are lack of education,8,10, 11, 12, 13 knowledge,8, 9, 10, 11,14 training,11,12,14 communication skills,10,12 as well as professionals' embarrassment,8,10 and the view that sexual health is not part of their professional responsibility.8,11 Additional barriers are sociocultural norms,12,14 lack of routine,10,12 priority,8,12 time,8,12 and organizational support.8,9 Negative experiences of professional inadequacy and lack of institutional policy hinder professionals from integrating sexual health issues into their professional capacity.8,10,11 The mentioned barriers present challenges for the HPs in developing attitudes promoting sexual health for people in rehabilitation.12,15 HPs' competences to promote sexual health are influenced by their attitudes to addressing sexual health in their professional interventions.8,13,15, 16, 17, 18 Danish HPs are expected to adhere to their professional and clinical guidelines recommending communication with patients about sexuality.18,19 To be able to meet the patients' needs, HP students must be prepared to address sexual health in their future care and rehabilitation interventions.17,18,20,21 Danish HP students' attitudes toward addressing sexual health have been investigated in a small study indicating that the students have low competence and educational level in the field of sexual health.18 Other studies found that RN, OT, and PT students report having had insufficient sexual health education.16,20,22, 23, 24 HP students' attitudes may affect how they succeed in addressing the needs of their future patients.20,24,25 Their attitudes toward sexual health are influenced by society, culture, and education.26 Professional programs differ between countries in terms of the curriculum implying the need to assess HP students' perceived competence and preparedness to address sexual health in national contexts. There is a need for knowledge regarding the Danish HP students' attitudes toward addressing sexual health. The hypothesis is that students would not be sufficiently competent and prepared to address sexual health and there would be differences in students' perceived competence and preparedness depending on the students' educational program. To understand how to educate Danish RN, OT, and PT students regarding addressing and communicating sexual health in their future professional care and rehabilitation interventions, it is essential to assess their current attitudes, perceived competences, and educational needs. The aim of this study was to investigate Danish HP students' attitudes toward addressing sexual health in their future professional practice and to assess differences in students' perceived competence and preparedness depending on the students' educational program.

Materials and methods

Design

This study was a cross-sectional survey to determine HP students' attitudes toward addressing sexual health in their future professional work. The study has been performed following the Strengthening the Reporting of Observational Studies in Epidemiology guidelines.27 The quality of reporting was further appraised with relevant parts of the Checklist for Reporting Results of Internet E-Surveys.28

Population

The participants were bachelor students enrolled in their final semester in HP programs in all Danish University Colleges (UCs). In Denmark, each of the 6 UCs provides education at more than 1 location. In this study, only the 6 central locations offering all 3 education programs—RN, OT, and PT—were invited.

Procedure

At each UC, the educational manager appointed a project ambassador for each educational program, who also gave brief information about sexual health education within the program. The ambassadors were assistant professors who were interested and willing to assist with the data collection and no reward was given. The ambassadors received written information on how to assist with the data collection and ensure quality of the project. Data collection was performed by using the Danish version of The Students' Attitudes towards Addressing Sexual Health (SA-SH-D).17,18 The SA-SH-D was distributed via a web-based application SurveyXact. Prior to the distribution of the SA-SH-D, the ambassadors pilot tested the usability and technical functionality of the online version, which led to minor changes of the layout. Several steps were taken to promote the survey response rate:

  • •

    the day of data collection was optimized for each educational program with each project ambassador selecting appropriate dates for the data collection;

  • •

    reminder emails were sent to the ambassadors the day before the initiation of data collection;

  • •

    each ambassador presented written information about the survey (purpose, time required, and anonymity), a short video introduction of the survey, and an open link to the SA-SH-D at the students' respective learning platform;

  • •

    13 (of 16) ambassadors introduced the study and the SA-SH-D to the students in a face-to-face session where the students were given time to answer the SA-SH-D;

  • •

    during the data collection period (26th August–24th October 2019), ambassadors were asked twice by email to remind the students about answering the SA-SH-D; and

  • •

    to motivate the ambassadors they received feedback on the current response rate at their specific educational program together with the reminders.

The SA-SH-D Questionnaire

The original questionnaire, SA-SH, has shown good psychometric qualities when tested on RN, OT, and PT students according to the classical test theory and Rasch analysis.21,29 The SA-SH has a possible total score value between 22 and 110, and 3 response patterns: uncomfortable and unprepared (score 22–56), comfortable and prepared in some situations (score 57–79), and comfortable and well prepared to work with sexual health in their future profession (score 80–110).30 Psychometric testing shows that the SA-SH-D is reliable (Cronbach alpha 0.67), has high relevance (item content validity index 0.82–1.0), and is useful in measuring HP students' attitudes toward working with sexual health in their future profession.17 The SA-SH-D consists of 22 items distributed across 4 domains: feelings of comfortableness (questions 1–9), fear of negative influence on future patient relations (questions 10–15), future working environment (questions 16–18), and educational needs (questions 19–22).17,18 Items are answered on a Likert scale with 5 options: disagree, partly disagree, partly agree, agree, and strongly agree. Items 9–14 and 16–18 were reversed for analysis as these items were phrased in a negative way compared to all the other items.20 Descriptive questions related to educational programs, institutions, gender, and age were included in the questionnaire. The online version of SA-SH-D was distributed over 8 pages, had 3–9 items per page, and the respondents were able to review and change their answers.

Data Processing

The responses “strongly agree and agree” were collapsed, and they were reported as a positive response for positively loaded items. For negatively loaded items, the responses “disagree and partly disagree” were collapsed and they were also reported as showing a positive attitude. The response option “partly agree” was not considered as a positive or a negative attitude since the response categories of the SA-SH clearly show response discrimination in a Rasch analysis.29

Single responders total score of the SA-SH-D was calculated with points from 1 to 5, where 5 was the most positive value and 1 the most negative value. For items 1–8, 15, and 19–22 the responses were coded as follows: 1 = disagree, 2 = partly disagree, 3 = partly agree, 4 = agree, and 5 = strongly agree. Items 9–14 and 16–18 had reverse coding (5 = disagree, 4 = partly disagree, 3 = partly agree, 2 = agree, and 1 = strongly agree).30

Statistical Analyses

Characteristics of the sample are presented by gender, age, and educational program. Descriptive statistics are presented in numbers and percentages for gender and educational programs, and for age in mean and SD. Each item of the SA-SH-D is presented with descriptive statistics, including both responders with a complete data set and responders answering at least 10 questions. The response rates in the categories “disagree” to “strongly agree” of each of the 22 items are illustrated by horizontal bar charts in percentage. A one-way ANOVA was conducted to determine if there were any statistically significant differences between the mean of the total score of SA-SH-D between the RN, OT, and PT programs (between program variation), taking into account the random variation between individuals within each program (within-program variation). Assumptions for one-way ANOVA were fulfilled. A post hoc multiple comparisons Tukey's test was applied in an attempt to reveal how the groups differed from each other and to control for type 1 error. Outcome variables were the ordinal variables of the total score for the single responder. Exposure variables were the nominal categorical variables: educational program defined as RN, OT, or PT therapy program. Only responders with a complete data set were included in the ANOVA analyses. Significance level was set at P < .05.

STATA 16.0 (StataCorp, College Station, TX) was used for the analyses.

Ethics

Ethical consideration followed the directions of the Helsinki Declaration and ethical approval was applied in line with the recommendations of The General Data Protection Regulation and the Danish Data Protection Agency.31 The review board at UCL University College, approved of the study since no personal identification data would be collected. Prior to responding to the SA-SH-D, the students received information about the project and gave their informed consent to participate. Upon answering the SA-SH-D, the students were informed that their answers were voluntary and anonymous. In order to assure anonymity, no personal identifying information was collected.

Results

Of the 18 invited educational programs, 16 programs participated in the survey. A total of 1,212 enrolled students from the HP programs were invited (733 RN students, 201 OT students, and 278 PT students) (Figure 1). The individual program response rates were 44% (322) for RN students, 70% (143) for OT students, and 43% (119) for PT students. The overall response rate was 48%.

Figure 1.

Figure 1

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Flowchart of survey responses. RN = nurses; OR = occupational therapists; PT = physiotherapists.

The mean age of the responders was 26.8 years (SD 5.8, range 21–57) (Table 1). Among the responders, most were RN, followed by OT and PT.

Table 1.

Demographic characteristics of Danish HP students (n = 584)

Demographical variable Total number of respondents (584) Educational programs
RN (n = 322, 55%) OT (n = 143, 25%) PT (n = 119, 20%)
Male, n (%) 65 (11) 16 (5) 11 (8) 38 (32)
Female, n (%) 519 (89) 306 (95) 132 (92) 81 (68)
Age, mean ± SD, min, max 26.8, SD: 5.8, min: 21, max: 57 26.9, SD: 6.1, min: 21, max: 57 27/2, SD: 6.2, min: 22, max: 53 26.3, SD: 4.7, min: 21, max: 47
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HP = health professional; OT = occupational therapists; PT = physiotherapists; RN = nurses.

Approximately a quarter of the students felt comfortable about informing future patients about sexual health, about initiating a conversation about sexual health, and about discussing sexual health with future patients regardless of their sex, age, cultural background, or sexual orientation (Figure 2). A smaller proportion of the students felt comfortable about discussing specific sexual activities with future patients. A quarter of the students disagreed that they felt unprepared to talk about sexual health with future patients.

Figure 2.

Figure 2

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Danish HP students reporting feelings of comfortableness addressing sexual health in their future professional work (n = 584). HP = health professional.

Approximately one-third of the students disagreed that they would feel embarrassed if future patients talk about sexual issues (Figure 3). A smaller proportion of the students disagreed that future patients might feel embarrassed if they, as professionals, raise the subject. A smaller proportion of the students were not afraid that future patients might feel uneasy if they, as professionals, talk about sexual issues; however, half of the students were not afraid that conversations regarding sexual health might create a distance in the relation between the patients and them as professionals. Approximately a quarter of the students did not believe that they would have too much to do in their future professions to have time to handle sexual issues; approximately one-third of the students believed that they would take time to include sexual issues in their future profession.

Figure 3.

Figure 3

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Danish HP students' fear of negative influence on future patient relations due to addressing sexual health (n = 582). HP = health professional.

More than half of the students were not afraid that their future colleagues would feel uneasy if they bring up sexual issues with patients, and nearly one-third of the students were not afraid that their future colleagues would feel uncomfortable in dealing with questions regarding patients' sexual health (Figure 4). Nearly half of the students did not believe that their future colleagues would be reluctant to talk about sexual issues.

Figure 4.

Figure 4

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Danish HP students' future working environment regarding sexual health (n = 577). HP = health professional.

A very small proportion of the students had been educated in sexual health, and a very small proportion had sufficient competences to talk about sexual health issues with future patients (Figure 5). A majority of the students thought that basic knowledge about sexual health should be included in their education, and that they needed to be trained to talk about sexual health as part of their education.

Figure 5.

Figure 5

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Danish HP students' educational needs regarding sexual health (n = 576). HP = health professional.

For the total score, responders were categorized into 3 groups of RN, OT, and PT students (Table 2); there was a significant difference between groups as determined by one-way ANOVA (P = .004). A Tukey post hoc test revealed that the total score was significantly higher (2.7 ± 1.1, P = .034) in the PT program group (66.3) compared to the OT program group (63.7). There were no significant differences between the RN program group and the OT program group, or between the RN program group and the PT program group. All 3 programs had a total mean score between 63.7 and 66.3 in the SA-SH-D, placing the students in the low-end of the response class: “comfortable and prepared in some situations (score between 57 and 79).”

Table 2.

Difference in HP students' attitudes toward addressing sexual health (n = 576)

Program Mean total score (SD) Program Mean differences SE Tukey
T P > I t I 95% CI
RN students (n = 316) 64.5 (8.8) PT students −1.8 0.9 −1.99 0.116 −4.3 0.33
OT students (n = 141) 63.7 (8.6) RN students −0.8 0.9 0.96 0.6 −1.21 2.9
PT students (n = 119) 66.3 (8.3) OT students 2.7 1.1 2.5 0.034 0.16 5.21
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HP = health professional; OT = occupational therapists; PT = physiotherapists; RN = nurses.

Discussion

This study is the first to examine Danish RN, OT, and PT students' attitudes toward addressing sexual health in their future profession. The findings show that HPs students across programs share the same difficulties relating to addressing sexual health. Less than a quarter of the HP students felt comfortable in dealing with sexual health issues with future patients. Many of the students thought future patients might feel embarrassed and uneasy if they as professionals raise the subject and talk about sexual issues. Half of the students would not feel embarrassed and were not afraid that conversations regarding sexual health might create a distance in the patient-professional relationship or that future colleagues would find it unacceptable. However, less than one-third of the students believed that they would take time to include sexual issues in their future profession. A majority of the students reported lack of education and competences in the field of sexual health, and that their education should include knowledge and communication training in the field of sexual health.

All the HP program groups had a total mean score between 63.7 and 66.3, which placed all the HP program groups in the low-end of the response class: “comfortable and prepared in some situations (score 57–79).”30 There was a statistically significant difference in the total score between the PT program group and the OT program group. However, the difference in the total score was minor and all the HP program groups were placed in the same response pattern. Therefore, the minor difference was interpreted as having no clinical relevance considering students' perceived competences and preparedness depending on the students' educational program. In comparison, a Swedish survey found a more positive attitude among RN and OT students compared to PT students.20

The barriers of discussing sexuality might be influenced by the culture in which the HPs are shaped and educated. Denmark and other Nordic countries differ from other countries due to their more liberal views on sexuality.32,33 Our results show that Danish HP students lack competences, preparedness, and education in the field of sexual health, which is comparable with previous international research.13,16,20,23,24,34 Most of the Danish HP students did not feel comfortable about discussing sexual health issues with future patients regardless of their age. This result is in line with previous findings that show that HP students and HPs often consider older people's sexuality as beyond their scope of practice and lack knowledge and confidence in this area.14,15,20,35 The majority of the Danish HP students did not feel comfortable about discussing sexual health issues with future patients regardless of their sexual orientation. This result has also been reported in systematic reviews showing that most HPs lack knowledge and education in providing sexual health services for non-heterosexuals.15,35,36 Most of the students did not feel comfortable discussing specific sexual activities with future patients, which is largely in line with a Swedish survey.20 HP students did not consider their own embarrassment as a major issue if future patients were willing to discuss about sexual issues. However, most of them acknowledge that future patients might feel embarrassed if the students, as professionals, bring up sexual issues. This result confirms the sexual “two-way taboo” in health care, which has been found earlier.15,35,37 A few of the students felt that they have been educated about sexual health in their educational program and that they have sufficient competences to talk about sexual health with their future patients, which is comparable to previous studies.8,11, 12, 13,20 As the hesitation of HPs to discuss sexual concerns may be due to feelings of inadequacy in responding to patients' questions in this field,38 competences in how to communicate about sensitive issues are important in HP students' education.10,12 Sexual health education increases the comfortableness of HPs and makes it more likely that they take the initiative to address sexual health with their patients.38 Educational contents of sexual health influence the development of professional competences in the field13,25,39; however, Danish RN, OT, and PT education curricula do not formally address sexual health.40, 41, 42

Methodological Considerations

All 6 UCs in Denmark and nearly all HP education programs participated in the study, which indicates a positive interest in the topic from the institutions. The response rate of 48% is comparable to a Swedish study with a response rate at 44%.20 The response rate presents a risk for non-response bias. There is a possibility that the students with the most positive attitudes responded; however, the inclusion of all UCs in Denmark lessens the risk of non-respondent bias. The ambassadors' face-to-face introduction, the video, the 2 reminders, as well as the feedback they received have probably affected the data collection positively. The SA-SH-D was distributed via an open link on the HP students' learning platform; therefore, there is a risk that a student could have answered the questionnaire more than once. However, an online open link questionnaire is simple to distribute nationwide via email, it is anonymous, the data collection can be followed, and after the data collection, data are immediately available online and ready for analysis. The SA-SH-D is valid and reliable.17 In earlier SA-SH studies the response option “partly agree” was considered as a positive attitude; however, in our study the response option “partly agree” was not considered or reported to be a positive or a negative attitude, since the response categories of the SA-SH clearly show response discrimination in Rasch analysis.29 By comparing our results with earlier SA-SH studies, this difference in the reporting of “partly agree” has been recognized. The items give a quick overview of students' attitudes and competences regarding addressing sexual health in their future profession. The closed-ended items are a potential limitation of the SA-SH-D as they do not allow students to present their own reflections about specific situations in which they can or cannot address sexual health, and the SA-SH-D does not include items regarding how educational interventions have been tailored. The sexual health themes, level, and type of education received regarding sexual health differ at different UCs, and it would be of interest to explore this by applying appropriate methods. The results from the survey present a baseline for the Danish HP students' current capacity, which can be used to plan and evaluate future interventions. The rigor of the study was strengthened by use of the Strengthening the Reporting of Observational Studies in Epidemiology checklist27 and Checklist for Reporting Results of Internet E-Surveys.28

Conclusion

In this Danish national survey, a substantial proportion of the HP students reported positive attitudes as well as a lack of basic knowledge, competences, communication training, and education in the field of addressing sexual health. The response pattern of the SA-SD total score places the students in the low-end of the class: “comfortable and prepared in some situations,” and there were no clinically relevant differences between the RN, OT, and PT students' perceived competences and preparedness in relation to the students' educational program. Sexual health is an important aspect of inter-professional rehabilitation and Danish HP programs should acknowledge the importance of sexual health and include sexual health education to enable HPs to meet the needs of patients.

Statement of authorship

Helle Gerbild: Conceptualization, Methodology, Formal Analysis, Investigation, Writing - Original Draft, Writing - Review & Editing, Project Administration; Camilla Marie Larsen: Conceptualization, Methodology, Writing - Original Draft, Writing - Review & Editing, Supervision; Tina Junge: Conceptualization, Methodology, Formal Analysis, Writing - Original Draft, Writing - Review & Editing; Birgitte Schantz Laursen: Conceptualization, Methodology, Writing - Original Draft, Writing - Review & Editing, Supervision; Kristina Areskoug-Josefsson: Conceptualization, Methodology, Writing - Original Draft, Writing - Review & Editing, Supervision.

Footnotes

Conflicts ofInterest: The authors report no conflicts of interest.

Funding: This work was supported by the UCL, University College, Denmark.

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