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The effects of an education/behavioral intervention on knowledge, perceived risk and self-efficacy in women

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Title:
The effects of an education/behavioral intervention on knowledge, perceived risk and self-efficacy in women
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English
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Johnson-Mallard, Versie
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University of South Florida
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Tampa, Fla.
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Subjects / Keywords:
Women's health
Childbearing
Intervention study
Reliability testing
Condom use
Dissertations, Academic -- Nursing -- Doctoral -- USF   ( lcsh )
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government publication (state, provincial, terriorial, dependent)   ( marcgt )
bibliography   ( marcgt )
theses   ( marcgt )
non-fiction   ( marcgt )

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Summary:
ABSTRACT: The purpose of this research study was to test the effects of an education/behavioral intervention on knowledge, perceived risk, and self-efficacy for sexually transmitted infections (STIs) prevention in women. Additionally, the instruments that measured knowledge of sexually transmitted infections and perceived risk were tested for reliability. Instruments used to test the effects of the intervention at pretest and following the intervention included the Sexually Transmitted Infection Knowledge Survey (Johnson-Mallard, 2002); the Perceived Risk for Sexually Transmitted Infection Survey (Johnson-Mallard, 2002); and the Sexual Self-Efficacy Survey (Heather and Pinkerton, 1998). Participants included 89-women seeking family planning services, sexually transmitted infection services or prenatal care at three county health units. Participants were randomly assigned to a treatment (n = 47) or control (n = 42) group.The treatment group received the theory based STI education/behavioral intervention. A logic model and Banduras Social Cognitive Theory were used to test the effects of an education/behavioral intervention on decreasing individual exposure to sexually transmitted infections by increasing individual knowledge, perceived risk, and self-efficacy. Data were analyzed using Analysis of Variance. Significantly differences from pretest to posttest was obtained between the experimental and control group on knowledge of STIs F (1, 87) = 73.66, p less than .001.Test results for the effect of the education/behavioral intervention on sexual self-efficacy resulted in significance difference between groups at posttest on refusing sexual intercourse F (1, 87) = 50.18, p less than .001; questioning potential sex partners F (1, 87) = 15.48, p less than .001; and condom use F (1, 87) = 19.60 p less than .001; indicating the brief (30-minute) education/behavioral intervention had an effect on the experimental group. However, posttest on STI perceived risk for women receiving the education/behavioral intervention did not approach significance F (1, 87) = .02 p less than .901 indicating the education/behavioral intervention did not have a statistically significant effect on the experimental group. The findings of the study indicate the importance of healthcare providers reinforcing STI information during clinical encounters with women.
Thesis:
Thesis (Ph.D.)--University of South Florida, 2005.
Bibliography:
Includes bibliographical references.
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Mode of access: World Wide Web.
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by Versie Johnson-Mallard.
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Title from PDF of title page.
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Document formatted into pages; contains 188 pages.
General Note:
Includes vita.

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aleph - 001670335
oclc - 62278650
usfldc doi - E14-SFE0001196
usfldc handle - e14.1196
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ABSTRACT: The purpose of this research study was to test the effects of an education/behavioral intervention on knowledge, perceived risk, and self-efficacy for sexually transmitted infections (STIs) prevention in women. Additionally, the instruments that measured knowledge of sexually transmitted infections and perceived risk were tested for reliability. Instruments used to test the effects of the intervention at pretest and following the intervention included the Sexually Transmitted Infection Knowledge Survey (Johnson-Mallard, 2002); the Perceived Risk for Sexually Transmitted Infection Survey (Johnson-Mallard, 2002); and the Sexual Self-Efficacy Survey (Heather and Pinkerton, 1998). Participants included 89-women seeking family planning services, sexually transmitted infection services or prenatal care at three county health units. Participants were randomly assigned to a treatment (n = 47) or control (n = 42) group.The treatment group received the theory based STI education/behavioral intervention. A logic model and Banduras Social Cognitive Theory were used to test the effects of an education/behavioral intervention on decreasing individual exposure to sexually transmitted infections by increasing individual knowledge, perceived risk, and self-efficacy. Data were analyzed using Analysis of Variance. Significantly differences from pretest to posttest was obtained between the experimental and control group on knowledge of STIs F (1, 87) = 73.66, p [less than] .001.Test results for the effect of the education/behavioral intervention on sexual self-efficacy resulted in significance difference between groups at posttest on refusing sexual intercourse F (1, 87) = 50.18, p [less than] .001; questioning potential sex partners F (1, 87) = 15.48, p [less than] .001; and condom use F (1, 87) = 19.60 p [less than] .001; indicating the brief (30-minute) education/behavioral intervention had an effect on the experimental group. However, posttest on STI perceived risk for women receiving the education/behavioral intervention did not approach significance F (1, 87) = .02 p [less than] .901 indicating the education/behavioral intervention did not have a statistically significant effect on the experimental group. The findings of the study indicate the importance of healthcare providers reinforcing STI information during clinical encounters with women.
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The Effects of an Education/Behavioral In tervention on Knowledge, Perceived Risk and Self-Efficacy for Sexually Transmitted Infections in Women. by Versie Johnson-Mallard A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy College of Nursing University of South Florida Major Professor: Cecile A. Lengacher, R.N., Ph.D. Jeffrey Kromrey, Ph.D. Doris Campbell, ARNP, Ph.D., FAAN Cecilia Jevitt, CNM, Ph.D. Ellen M. Daley, Ph.D. Date of Approval: July 5, 2005 Keywords: women’s health, childbearing, inte rvention study, reliability testing, condom use Copyright 2005, Versie Johnson-Mallard

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Acknowledgements The writing of this dissertation has be en demanding, all encompassing, and very exciting. I thank my advisor, Dr. Cecile Lengacher, for her valued confidence and treasured encouragement. She posed questions that constantly chal lenged me to express my thoughts and ideas clearly. Patiently, she guided me through the dissertation process while always demanding my best effort. Als o, I am very grateful to everyone who has read any part of the manuscript. I especi ally thank Dr. Doris Campbell, the editing authority. Special thanks to Dr Jeffrey Kr omrey for his sharp statistical guidance and gentle demeanor. I also offer great thanks to Drs. Cecilia Jevitt and Ellen Daley who filled me with insightful commentary and often reminded me that my research is useful and purposeful for the health of women. I am very grateful to Dr. Karla Schmitt for her acceptance and support of this idea from its inception. In addition to my committee members, I offer much thanks to Dr. Kim Vaz, Tricia Holtje, and Vince Cesario for their continued support and precious time expenditures on behalf. I am truly fortunate to have had the opportunity to work with such dynamic people. A heartfelt thank you goes to my husband (Leonard) and son (Corey). Without the support of the two most important men in my life the writing of this dissertation would not have been possible.

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i Table of Contents List of Tables................................................................................................................. iii List of Figures................................................................................................................ .v Abstract....................................................................................................................... ..vii Chapter One Introduction...............................................................................................1 Statement of the Problem..........................................................................................10 Purpose of the Study.................................................................................................11 Research Hypotheses................................................................................................11 Definition of Terms...................................................................................................12 Delimitations.............................................................................................................13 Limitations................................................................................................................13 Significance of the Study..........................................................................................14 Chapter Two Literature Review....................................................................................16 Introduction...............................................................................................................16 Theoretical Framework.............................................................................................16 Hypothesized Logic Model.......................................................................................17 Review of Empirical Literature................................................................................24 Knowledge and Sexually Transmitted Infections.................................................24 Perceived Risk and Sexually Transmitted Infections...........................................35 Self-Efficacy and Sexually Transmitted Infections..............................................42 Sexually Transmitted Infection and Intervention Studies.....................................49 Preliminary Study.................................................................................................54 Chapter Three Methods.................................................................................................57 Introduction...............................................................................................................57 Design.......................................................................................................................57 Setting and Subjects..................................................................................................57 Inclusion Criteria......................................................................................................58 Exclusion Criteria.....................................................................................................60 Gender, Minority, Children Inclusion.......................................................................60 Instrumentations........................................................................................................61 Sexually Transmitted Infection Knowledge Survey.............................................61 Perceived Risk of Sexually Transmitted Infection Survey...................................62 Self-Efficacy Survey of Protective Sexual Behaviors..........................................63 Demographic Data Form.......................................................................................65 Procedures.................................................................................................................66 Approvals..............................................................................................................66 Data Collection Procedures...................................................................................67 Subject Retention and Follow-up Procedures.......................................................68

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ii The Education/Behavior al Intervention................................................................69 Data Analysis........................................................................................................73 Data Management.................................................................................................74 Chapter Four Results.....................................................................................................76 Sample.......................................................................................................................76 Research Hypothesis Number One...........................................................................92 Research Hypothesis Number Two..........................................................................94 Research Hypothesis Number Three........................................................................97 Chapter Five Discussion, Conclusion, and Recommendations..................................110 Introduction.............................................................................................................110 Summary of Study..................................................................................................110 Discussion and Conclusions...................................................................................112 Implications for Nursing.........................................................................................119 Recommendations for Further Study......................................................................121 References...................................................................................................................12 3 Appendices..................................................................................................................138 Appendix A: Demographic Data Form..................................................................139 Appendix B: Sexually Transmitted Infection Knowledge Survey........................141 Appendix C: Perceived Risk of Se xually Transmitted Infection Survey..............144 Appendix D: Self-Efficacy Survey of Protective Sexual Behavior.......................145 Appendix E: Consent to Use Instrument...............................................................146 Appendix F: Research Site Consents.....................................................................147 Appendix G: Institutional Review Board Approval..............................................151 Appendix H: Informed Consent/Assent Form.......................................................153 Appendix I: An STI Knowledge/Beh avioral Intervention for Women ................164 Appendix J: Information Brochure........................................................................176 About the Author...............................................................................................End Page

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iii List of Tables Table 1 U.S. Census Percent by Race/ Ethnicity in Targ eted Counties of Study................................................................................................................59 Table 2 Health Department Censuses by Race/Ethnicity.............................................59 Table 3 Instruments/Reliability Used To Measure Knowledge, Self-Efficacy, and Perceived Risk Of STIs.............................................................................65 Table 4 Demographic Characteristics (F requency and Percentage) by Age and Ethnicity Per Intervention and Control Group..........................................78 Table 5 Frequency and Percentage of Women by Level of Education per Group Status.....................................................................................................79 Table 6 Frequency and Percentage of Women by Level of Household Income per Group Status..............................................................................................80 Table 7 Frequency and Percentage of Number of Children per Intervention and Control Group...........................................................................................81 Table 8 Frequency and Percentage of Work Status and Medical Insurance.................82 Table 9 Frequency and Percentage Data of Marital Status...........................................83 Table 10 Frequency and Percent of Times Pregnant per Intervention and Control Group..................................................................................................84 Table 11 Frequency and Percentage Data of Sexually Activity during Pregnancy.........................................................................................................84 Table 12 Age of First Sexual Encounter (Frequency and Percentage) by Group...........85 Table 13 Frequency and Percentage of Sex Partners Within the Last Year...................86 Table 14 Frequency and Percentage of Sexual Partner Behaviors.................................87 Table 15 Frequency and Percentage of Women with an STI While Pregnant...............88 Table 16 Self-Reported Sexual Inte rcourse and STIs Frequency and Percentage per Group.......................................................................................89

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iv Table 17 Frequency and Percentage of Women by Birth Control per Group.................90 Table 18 Frequency and Percentage of Women by Birth Control per Group.................91 Table 19 Means and Standard Deviations for Knowledge of STI at Preand Posttest.............................................................................................................92 Table 20 Test of Betweenand Within-S ubject Effect for Dependent Variable, Knowledge of STIs..........................................................................................94 Table 21 Means and Standard Deviations for Perceived Risk of STI at Preand Posttest......................................................................................................94 Table 22 Post test of Intervention E ffect on Perceived Risk for Between and Within Subjects................................................................................................95 Table 23 Means and Standard Deviat ions for the Subscale Refusing Sexual Intercourse at Pretest and Posttest....................................................................97 Table 24 Means and Standard Deviat ions for Questioning Potential Sex Partners at Preand Posttest.............................................................................98 Table 25 Means and Standard Deviations for Condom Use at Preand Posttest...........99 Table 26 Betweenand Within-Subject Effect on Refusing Sexual Intercourse..........100 Table 27 Betweenand Within-Subject Effect on Questioning Potential Sex Partner............................................................................................................101 Table 28 Betweenand Within-Subject Effect on Condom Use During Sexual Intercourse......................................................................................................102 Table 29 Ranking of Items for the Self-Efficacy Subscale “Ability to Refuse Sexual Intercourse” Experime ntal Group Pretest Score................................103 Table 30 Ranking of Items for the Self-Efficacy Subscale “Ability to Refuse Sexual Intercourse” Experime ntal Group Posttest Score..................................104 Table 31 Ranking of Items for the Self-Efficacy Subscale “Ability to Question Potential Sex Partners” E xperimental Group Pretest.....................................105 Table 32 Ranking of Items for the Self-Efficacy Subscale “Ability to Question Potential Sex Partners” E xperimental Group Posttest...................................106

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v Table 33 Ranking of Items for the Self-Efficacy Subscale “Ability to Question Condom Use” Experimental Group Pretest...................................................107 Table 34 Ranking of Items for the Self-Efficacy Subscale “Ability to Question Condom Use” Experimental Group Posttest..................................................108

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vi List of Figures Figure 1. Logic Model: Hypothesized Logic Model: Sexually Transmitted Infection Education/Behavior al Intervention for Women...............................18

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vii The Effects of an Education/Behavioral In tervention on Knowledge, Perceived Risk and Self-efficacy for Sexually Tr ansmitted Infections in Women Versie Johnson-Mallard ABSTRACT The purpose of this research study was to test the effects of an education/behavioral intervention on knowle dge, perceived risk, and self-efficacy for sexually transmitted infections (STIs) prevention in women. Additionally, the instruments that measured knowledge of se xually transmitted infections and perceived risk were tested for reliabilit y. Instruments used to test th e effects of the intervention at pretest and following the intervention included the Sexually Transmitted Infection Knowledge Survey (Johnson-Mallard, 2002) ; the Perceived Risk for Sexually Transmitted Infection Survey (Johnson-Ma llard, 2002); and the Sexual Self-Efficacy Survey (Heather & Pinkerton, 1998). Particip ants included 89-women seeking family planning services, sexually transmitted infecti on services or prenatal care at three county health units. Participants were randomly assi gned to a treatment (n = 47) or control (n = 42) group. The treatment group received the theory based STI education/behavioral intervention. A logic model and Bandura’s Soci al Cognitive Theory were used to test the effects of an education/behavioral interv ention on decreasing i ndividual exposure to sexually transmitted infections by increasing individual knowledge, perceived risk, and self-efficacy. Data were analyzed using Anal ysis of Variance. Si gnificantly differences from pretest to posttest was obtained betw een the experimental and control group on knowledge of STIs F (1, 87) = 73.66, p < .001. Test results fo r the effect of the

PAGE 10

viii education/behavioral intervention on sexua l self-efficacy resulted in significance difference between groups at postt est on refusing sexual intercourse F (1, 87) = 50.18, p < .001; questioning pote ntial sex partners F (1, 87) = 15.48, p < .001; and condom use F (1, 87) = 19.60 p < .001; indicating the brief (30minute) education/behavioral intervention had an effect on the experi mental group. However, posttest on STI perceived risk for women receiving th e education/behavioral intervention did not approach significance F (1, 87) = .02 p < .901 indicating the education/behavioral intervention did not have a st atistically significant effect on the experimental group. The findings of the study indicate th e importance of healthcare providers reinforcing STI information during clinical encounters wi th women. Women need to understand that STIs contribute greatly to mo rbidity associated with reproductive health.

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1 Chapter One Introduction Sexually transmitted infections represent a serious public health problem that needs to be, and can be, brought under cont rol. The incidence rates for sexually transmitted infections (STIs) such as syph ilis, herpes simplex virus, gonorrhea, and chlamydia have increased dramatically (H utchinson, 1999; Sexton, Garnett, & Rottingen, 2005). Paz-Bailey et al. (2005) reported an estimated 18.9 million new cases of STIs occur annually. More specifically, Van Devanter et al. (2002) reported that two-thirds of the estimated 12 million cases of STIs in the United States occur in women, and in fact, after only a single exposure, wo men are twice as likely as men to become infected with the pathogens causing gonorrhea, chancroid, he patitis B, and chlamydia infection (King et al., 2001; Lambert, 2001; Robinson, 2002; Sh ain, 1999). In particular, chlamydia is reported as a leading cause of reproductiv e morbidity in women (Asbill et al., 2000; Duncan et al., 2001; Gray et al., 2001), and the prevalence of chlamydia trachomatis is highest among female adoles cents, women under 24 years, and African-American and Hispanic women (Asbill et al., 2000; Jemmott et al., 2005; King et al., 2000; Mahon et al., 2002; Ramus, 2001). As many as 54% of girls younger than 15 years develop a second infection with chlamydia trachomatis one to six years af ter initial chlamydia infection (Lauby et al., 2000; Orr, 2001; Shrier, et al., 2001; Tobin, 2002). Women (and children) have the most severe symptoms and sequelae to sexually transmitted infections

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2 (Shain, 1999). Sexually transmitted infections cause considerable morbidity and mortality among nonpregnant and pregnant women (D’Souza, 1999; Wilson, Minkoff, McCalla, Petterkin, & Jaccard, 1996). Indeed, most of the women accounting for 46% of the five million incidences of sexually tran smitted infections in adults during 1999 were women of childbearing age (Niccolai, Et hier, Kershaw, Lewis, & Ickovics 2003). Premature delivery is the chief problem in obstetrics today, accoun ting for 70 percent of perinatal mortality and nearly half of long-term neurologic al morbidity (Andrews Health & Goldenberg, 2000), but many premature deliver ies might be avoided by prevention and treatment of STIs. Chlamydia trachomatis, and Neisseria gonorrhea are the leadi ng etiology of pelvic inflammatory disease and may lead to ectopic pregnancy, in fertility, and chronic pelvic pain. First, it is estimated that more than 200,000 new hepatitis B surface antigen (HBsAg) infections occur annually in the United States (Corrarino, Walsh, & Anselmo, 1999; Gilbert et al., 2005), and each year an estimated 20,000 infants are born to women who test positive for HBsAg. Without vaccin ation against HBsAg, a woman can transmit the disease to the fetus during the perinata l period (Corrarino, Walsh, & Anselmo, 1999; Gilbert et al., 2005). Even more important, Chlamydia trachomatis and Neisseria gonorrhoeae are highly prevalent in young adults (Asbill et al., 2000; King et al., 2001; Weitz, 2001). Chlamydia is also a leading cause of re productive morbidity in women (Duncan, Hart, Scoular, & Brigrigg, 2001; Wong et al., 2005), and gonorrhea has been shown to ascend in the female genital tract attached to mo tile spermatozoa. Weitz (2001) reported that chlamydia and gonorrhea are associated with premature rupture of fetal amniotic

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3 membranes. In addition, fetal death sec ondary to premature delivery, pneumonia, and sepsis can occur. Next, conflicting informati on exists as to whether Bacterial vaginosis (BV) should be classified as an STI. Bacterial vaginosis is most frequently described as a change in vaginal PH leading to altered vagina l fluid. However, little conflict exists over the possible serious obstetrical complic ations that can occur with BV. Bacterial vaginosis has been linked to high risk of spontan eous abortions, pr eterm birth, preterm premature rupture of membranes, postpar tum endometritis, and post-cesarean wound infections (Carey et al., 2001) Most significantly, Stevens at al. (2004) reported that women with bacterial vaginosis have a doubled risk of spontaneous preterm delivery— again, the chief problem in obstetrics today. Likewise, syphilis is an important caus e of morbidity particularly among women and their newborn infants and if untreated has many serious sequela e (Todd et al., 2001). Untreated syphilis during pregnancy can lead to infant disorders such as deafness, neurologic impairment, and bone deformities, or worse, stillbirth or neonatal death (Mehment, Ledger, & William, 2000; MMWR, 2001; Osman, et al., 2001; Salkind, 2001; Temmerman, et al., 2000). Herpes simplex virus (HSV) neonatal infections most often occur because of firstepisode maternal infections during late pr egnancy when delivery occurs before the development of protective maternal antibodies (Corey & Flynn, 2000; Mullick, Beksinksa & Msomi, 2005; Rouse & Stringer, 2000). Human papillomavirus (HPV) is the most common sexually transmitted infecti on in American, and women can be infected at any time, certainly including pregna ncy (Ebrahim, McKenna, & Marks, 2005;

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4 Lambert, 2001). Sexually transmitted infecti ons also increase the likelihood of HIV transmission. An estimated 2.4 million HIVinfected women give birth annually, and 1600 infants acquire HIV infection ever y day (Timmermens et al., 2005). In summary, exposure to sexually transmitted infections during pregnancy (other than human immunodeficiency virus ) such as Chlamydia trachomatis and/or Neisseria gonorrhoeae, syphilis, herpes simplex virus (HSV) and bacterial vaginosis (BV) has been associated with adverse pregnancy outcomes (Asbill et al., 2000; Weitz, 2001; King et al., 2001; Weisbord, 2000). Another aspect of the problem is th at pregnant women go unnoticed in STI preventive education because most prenatal care providers do not embrace this time to educate concerning sexually tr ansmitted infections (Wilson et al., 1996; Weisbord et al., 2001). Traditionally women’s health care provi ders counsel women about sexual activity during pregnancy in reference to preterm la bor, premature rupture of membranes, or strategies to increase comfort as the abdomen protrudes. Howe ver, since prenatal care is likely to be pregnant women’s only contact w ith the health system (Wilson et al., 1996), prenatal care should include information a bout STIs. In these times of significantly higher prevalence of sexually transmitted in fections among women of childbearing age, the focus for pregnant women should include behavior intervention that empowers them with increased knowledge and increased perception of risk. After all, a woman’s sexual self-concep t or need for intimacy and sexual expression is a basic drive that does not di sappear when she becomes pregnant and in actuality may increase because she does not fear becoming pregnant. Of the millions of women giving birth each year in the United States, virtuall y all engage in unprotected

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5 intercourse (Wilson et al., 1996). Pregnant adolescents may be at high risk for STIs because of their sexual risk history, likely reductions in us e of condoms no longer needed for birth control, and the fact that pr egnancy results in additional physiologic vulnerabilities to STIs (Wilson et al., 1996). Niccolai et al. (2003) found that pregnant adolescents have high levels of STIs duri ng pregnancy, but most interestingly Niccolai reported that if adolescents were routinely sc reened and treated in the first trimester of pregnancy, and those infections detected during the third trimester were acquired recently, then the women’s perceptions about being in monogamous partnerships are likely to be incorrect. In addition, women lack adequate knowle dge concerning risk factors associated with sexually transmitted inf ections during pregnancy and may not know the associated risk for their unborn fetus (Asbill et al., 2000; Shrier et al., 2001; Weitz, 2001) The Dixon-Wood et al. (2001) study results suggest ed that women’s lack of knowledge about STIs played a significant pa rt in seeking sexual health services. For example, many women who test positive for hepatitis B surface antigen during the perinatal period lack basic knowledge regarding the hepatitis B virus; this makes it essential that nurses teach important information to this population (Corrarino, Walsh, & Anselmo, 1999). Risk association such as premature rupture of membranes in the presence of chlamydia and gonorrhea infections may go unide ntified without in tervention that focuses on client education among sexually active women (Weitz, 2001) Thus, adequate knowledge about sexually transmitted infections is necessary to reduce behavior that may place women at risk of transmission (Swanson, Dibble, & Chapman, 1999).

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6 This problem is not limited to the Unite d States alone. Although several studies provide evidence that African-American wo men do not receive timely, routine, and adequate preventive health care services, th e literature also shows that the United Kingdom has the highest rate of STIs in We stern Europe and knowledge about STIs is generally poor (Jolley, 2001). In fact, Jolley (2001) reported that even many health care workers do not have adequate knowledge of STIs and therefore cannot advise clients properly. Further, Colvin’s study (2000) demonstrated a high prevalence of STIs and HIV infections in the Lesotho highlands ch aracterized by low levels of knowledge about STIs and HIV. With the increase in HIV infectio n among women of childbearing age in Hong Kong, a study was aimed at explor ing pregnant women’s knowledge about HIV/AIDS. Women’s percepti on of risk, risk behavior and management, and their attitudes toward HIV screeni ng were explored (Ho & Loke, 2003). The participants in the study were 17 to 40 years old, with a mean age of 29.6. More than half (62.8%) were primiparas. The vast majority were ma rried (97.4%) and had received secondary education or above (96.9%). The majority knew that AIDS is an infectious disease (91.6%), recognized that “the appearance of HIV carries no difference from that of the normal population” (84.4%). The women disagreed with the statement that “women with only one sexual partner will not get AIDS ” (79.1%), knew that “using condoms can reduce the chance of getting AIDS” (89.0%), and realized that “there is no medication to cure AIDS” (78.5%). However, nearly half (43.5%) of the women thought that mosquitoes are carriers of HIV. Clearly, pr enatal care worldwide must educate women to modify their behaviors in order to pr event the infections discussed above.

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7 Preventive education duri ng prenatal care can identif y behaviors and knowledge gaps that increase the likelihood of adverse he alth outcomes and provide information that could lead to health promoting behavior (Peterson, Connelly, Martin, & Kupper, 2001; Wilson et al., 1996; Weisbord et al., 2001). Lambert’s (2001) study found significant improvement in knowledge after a brief information-only intervention about STIs specifically HPV. Positive behavior change s can occur with creative nursing practice, such as interventions to enhance self-e fficacy and perceived risk and to increase knowledge of sexually active pregnant women. Another essential component to prevention of acquiring a sexually transmitted infection (STIs) is to gain an understandi ng as to why women at risk for STIs and pregnant do not use condoms for disease preven tion. Knowledge of partners’ past sexual history, the importance of limiting number of sex partners, and knowledge of how to avoid the exchange of body fluids during se xual intercourse must be emphasized and disseminated in order to eff ectively develop the disease prevention message. However, this study’s literature review found little research that de alt with women’s knowledge of symptoms, prevention, treatment, and transmi ssion of sexually transmitted infections during the course of pregnanc y. Many of the infectious di seases contracted sexually during pregnancy can be easily diagnosed and treated (Weisbord et al., 2001 ) but even better, the message that condoms are effective, when used consistently and correctly, against HIV and other STIs must c ontinue throughout prenatal care. Pregnancy should be a time of sexual ha rmony, a time to enjoy sexual intercourse. The only concerns the mother should have are whether th e baby is a girl or boy, how much the baby weighs, and who the baby will look like. This is not a time to wonder

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8 whether the baby will be HIV positive or born with syphilis. No woman should have such worry, but if she does, how can health car e professionals relieve her of some of the concern relating to potentia l infections? If sexual m onogamy is at question during pregnancy, then safe sex should be practi ced and continued throughout pregnancy. But how can prenatal health care professi onals help to relieve the concerns of sexually active pregnant women? One model used often to predict protective behaviors, including self-perceptio n of risk for STIs, is the perceived risk model or threat recognition, perceived susceptibility m odel (Hutchinson, 1999). A woman must recognize that she is at risk for sexually tran smitted infections before she will take action to prevent them. Weisbord, Koumans, Toomey, Grayson, and Markowitz (2001) reported women’s perceived risk necessitate s assessment by the health care provider to establish its impact on intention to engage in health-related preventive behaviors. Data from Lauby, Smith, Stark, Person, and Adams ( 2000) indicated that many women at risk for sexually transmitted infections such as HI V did not perceive their risk, particularly with their main partners. This situation confirms the necessity for relevant, effective prevention behavior-modification intervention that targets women. The issue of main partner is important because pe rceived risk is a complex variable that may incorporate each subject’s perceived risk, and the subject’s perceptions about the risk exposure as a result of the sexual perceived risk of their spouses or other partne rs (Todd et al., 2001). Hutchinson (1999) reported the effectivene ss of programs that assisted women to examine their perceptions of their partner’s risk. Further, Weisbord, Koumans, Toomey, Grayson, and Markowitz (2001) conducted a provider-of-prenatal-care survey acknowledging that the rate of screening for STIs depends on the woman’s perception of

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9 her risk. If she has poor perception of persona l risk, she may go untreated or uninformed. Women not perceiving sexually transmitted inf ections as personally relevant may be functioning according to stereotypical belief s about who is “at risk” of sexually transmitted infections (Duncan, Hart, Scoular & Bigrigg [check spelling], 2001). Numerous other research studies have b een conducted to review self-efficacy. Siegel, Aten, and Enaharo (2001) evaluate d self-efficacy and knowledge following an educational-behavioral intervention. The in tervention was succe ssful in increasing knowledge and self-efficacy to behave in sexua lly safer ways. Berarducci and Lengacher (1998) expressed that an individual’s conf idence in the ability to perform a certain behavior is a necessary bri dge between knowing what to do and actually performing the behavior. In addition to knowing what to do, a person must know how to perform the behavior and must possess a need or want to do so. Key strategies, addressed in this study, advocated for lowering personal risk of sexual exposure to STI/HIV include having fewer partners, avoiding risky partners, and education against such behaviors. In summary, this study included inform ation to increase knowledge of and responsiveness to the consequences of unsafe sexual beha vior. The intervention sought to increase self-regulatory skill development toward behavioral change directly relating to translating knowledge into preventive acti on. The education/be havioral intervention offered an opportunity for guided practice by women’s health care providers and sought to introduce corrective feedback by introducing ways to apply the new skills directed at increasing knowledge, perceived risk, and self-efficacy relating to sexually transmitted infections.

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10 Statement of the Problem Research has identified sexually transm ittable infections as a public health concern in women (Dilorio, Dudley, Soet Watkins, & Maibach, 2000). However, limited research addresses pregnant wo men’s knowledge of sexually transmitted infections during the course of their pregnancy (Weisbor d et al., 2001; Wilson et al., 1996). A small number of facts have been established in assessment of consistent condom use while pregnant. Cases of STIs have b een reported in the pr egnant population, and pregnant women may be at greater than th e predicted risk of contracting sexually transmitted infections to the extent that they engage in risk-taking behaviors (Wilson et al., 1996). Based on the review of available research regarding the most prevalent age groups for contracting STIs, the traditional child bearing years are in the midst of the age group at high risk for contracting and transmitting sexually transmitted infections such as HIV (Morrison-Beedy et al., 2002). Literature that exists on knowledge about STIs, perceived risk, and STI prevention among pr egnant and nonpregnant women is quite limited. Little evidence exists regarding the ex tent to which pregnant women perceive a risk. Research is needed to assess the degree of knowledge and perceived risk that women have about STIs and pr egnancy. After identifying data needs, the next logical step is to select a method to measure chosen variables, in this specific case knowledge and perceived risk of sexually active women, an d develop strategies to modify behavior. Purpose of Study The purpose of this study was to test the effects of an educational intervention on knowledge, self-efficacy, and perceived risk of sexually transmitted infections in women. This study also tested the va lidity and feasibility of th e instruments with women of

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11 childbearing age and tested knowledge reten tion. Additionally, the instruments that measure knowledge of sexually transmitted infec tions and perceived risk were tested for reliability. Research Hypotheses The effects of the intervention were a ssessed by testing the following aims and hypotheses: Aim 1: Differentiate the effectiveness of an educational intervention from the control group by assessing changes in knowledge of sexually transmitted infections. Hypothesis 1: There will be significa nt increases in knowledge of sexually transmitted infections in the educatio nal intervention group compared to the control group. Aim 2: Differentiate the effectiveness of an educational intervention from the control group by assessing changes in perceived ri sk of sexually transmitted infections. Hypothesis 2: There will be significant increases in pe rceived risk of sexually transmitted infections in the educatio nal intervention group compared to the control group. Aim 3: Differentiate the effectiveness of an educational intervention from the control group by assessing changes in self-efficacy of protective sexual behavior from sexually transmitted infections. Hypothesis 3: There will be significant increases in self-efficacy of protective sexual behavior from sexually transmitted infections in the educational intervention group compared to the control group.

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12 Aim 4: Test the reliability of the inst ruments developed to measure knowledge and perceived risk of sexually transmitted infections in women. Definition of Terms For the purpose of this study, the following definitions were used. 1. Knowledge: Awareness of sexually transmitted infections during pregnancy as a serious health problem for self, fetus, a nd newborn; an understanding of how symptoms present and available measures to preven t, treat, and avoid in fection transmission (Johnson-Mallard, 2002). 2. Beliefs: Opinions that pregnant woman embrace as factual about STIs, risk factors, and prenatal screening for these infections (Asbill et al., 2000). 3. Reproductive sexual risk behavior: Operationally defined as women’s plans and efforts to seek necessary information about STIs throughout their childbearing years and to practice preventive behavior during sexual intercourse (Wilson et al., 1996). 4. Safer sex: Sexual intercourse with condom use as a normal pract ice (Hatcher, 2004). 5. Sexually transmitted diseases/infections: Contagious maladies contracted through unprotected sexual interc ourse (Hatcher, 2004). 6. Self-efficacy: Individual’s belief that she has the competence to perform a necessary behavior to attain a particul ar goal or desired outcome in order to promote physical, psychological, or social well-being; a mediator be tween knowledge and action (Berarducci & Lengacher, 1998, p. 58). 7. STI perceived risk: The belief that one has about contracti ng a sexually transmitted infection while pregnant and the belief that certain behavior change will eliminate or

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13 reduce the susceptibility to contracting a sexually transmitted infection (Perceived Risk Scale, 2002). Delimitations The sample included women of childb earing age and included the following parameters, that participants were 1. Between 15 and 45 years of age; 2. Currently seeking prenatal care, family care, or primary-care services within the rural areas of Northwest Florida; and 3. Able to read, write, and speak English Limitations The study provided the primary steps toward the expansion of a sexually transmitted infection preventive education/beha vioral intervention and the identification of predictors of STI preventive behavioral intentions of childbearing age women. Limitations of the study include those genera lly experienced with intervention research and are as follows: 1. This study used a homogenous group of women; generalizations to other age groups, socioeconomic groups, and men are limited. 2. The study participants were concentrated inside several rural geographic areas that may have unique influential characteristics, thereby limiting generalization of findings to other geographic locations. 3. The use of (paper-and-pencil) questionnaires may enhance measurement error. 4. The surveys may bring into play anxi ety that may influence participants’ answers.

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14 5. Study participants may reply in a socially desirable manner. 6. The surveys are written for low literacy; the reading level of participants were not controlled. 7. Dissemination of treatment may occur between experimental and control group participants seeking care at the same county health unit. 8. Subjects in the intervention group are expos ed to the intervention; those in the control group may attempt to compensa te by looking for information in an attempt to outperform the intervention group. Significance of the Study Women’s health care providers and wome n are challenged to recognize critical points in at-risk situations, such as expos ure to sexually transmitted infections, which precipitate preterm labor, and if not successfu lly treated, lead to pr eterm delivery. This study tested a nursing intervention with a theore tical base that has the intent of disease prevention, specifically STI prevention among wo men of childbearing age. This study potentially impacts women’s health by elim inating knowledge gaps and contributing to the development of evidence-ba sed practice. Generally, foll owing exposure to sexually transmitted infection, women are not aware of ri sks to themselves or their unborn fetuses. Teaching safer-sex messages alone does not change risky sexual behaviors. In conjunction with safer-sex messages, women’ s health care providers specializing in obstetrics and gynecology can stimulate invest igation, which affects prevalence rates and encourages behavior change with simple yet effective behavior modification interventions.

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15 Individual knowledge of STI-related i ssues does not necessarily reduce risktaking behaviors. Women must perceive pe rsonal risks and have the knowledge to implement behavior modifications. Nurse di rected creative interventions could empower women with knowledge to perceive risks and to take personal action and circumvent high-risk behaviors.

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16 Chapter Two Literature Review Introduction This chapter presents the theoretical framework and logic model that provide direction for review of empiri cal literature. The l iterature review rela tes to knowledge of sexually transmitted infections, perceived risk, and self-efficacy of sexually transmitted infections as well as interventions related to sexually transmitted infections. Finally a summary of preliminary research and a summar y of the literature revi ew are presented. Theoretical Framework This study is guided by a logic model in tegrating constructs of the Social Cognitive Theory. The logic model and Social Cognitive Theory were used to test the effects of an education/behavioral interv ention on decreasing i ndividual exposure to sexually transmitted infections by increasing individual knowledge, perceived risk, and self-efficacy. The following exploratory a nd theoretical logic model postulates the effects of an education/behavioral interv ention on decreasing i ndividual exposure to sexually transmitted infections by increasing individual self-efficacy and knowledge.

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17 Hypothesized Logic Model Although the effects of the proposed edu cation/behavioral intervention were unknown, Figure 1 below depicts a logic mode l identifying variable s related to the proposed tested intervention and tested outco mes. This logic model, developed by Evans (1992), is based upon the Psychosocial Nursing Research Model as a heuristic device for research. It should be empha sized that although this model is exploratory in nature, additional outcomes not depicted in the mode l may be plausible. These logic models along with constructs from the Social C ognitive Theory were used to guide this intervention designed to impact the preven tion of sexually transmitted infections. Based upon the literature a nd prior research, it was hypot hesized that knowledge, perceived risk, and self-efficacy of sexually tr ansmitted infections would increase with an educational intervention. Limited eviden ce was available to support these hypotheses, and the development and testing of the eff ects of preventive educational intervention were further evaluated through this study. Data collection provided for these effects to be tested. The distal outcomes depicted in the model were not measured through this research but were hypothesized to occur if the specific pa th leading to the proximal outcomes was indeed accurate It was hypothesized that the education/behavioral intervention would increase women’s knowledge and self-efficacy related to safer sex decision making and would have a positive impact on outcomes related to change behaviors and retained knowledge, thus leading to decrea sed rates of diagnosed sexually transmitted infection. The education/beha vioral intervention was delivered through (“modeling” or observational learni ng) by the primary investigator.

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18Inputs Intervention Intervention Proximal Distal Activities Activities Outcomes Outcome Figure 1. Logic Model: Hypothesized Logic Model: Sexually Transmitted Infection Education/Behavioral Intervention for Women The logic model extended from the theoretical constructs in Social Cognitive Theory (Bandura 1997; Dilorio et al., 2000; Whitehead, 2001). Bandura (1995) suggests that whether individuals adopt valued health behaviors or renounce detrimental behaviors may depend on three expectations of consciousness: 1) the expect ancy that one is at risk; 2) the expectancy that behavioral changes will reduce the threat; a nd 3) the expectancy that one is sufficiently cable of exercisi ng control over risky be haviors. It is hypothesized that behavior is dependent on one’s efficacy beliefs, which determine the behaviors one chooses to perform, the degr ee of perseverance, and the quality of the performance (Bandura, 1986, 1997). Intentions to change risky be haviors, amount of effort expended to attain these goals, and pers istence to continue in spite of barriers and Selfefficacy Perceived risk Demographics Pregnant and Non-pregnant Women Knowledge Prevention Screening Treatment Symptoms Disease consequences Scope of problem Risk factors Methods to incorporate preventive measures into usual routine Information Brochure Group discussion Lecture and discussion Increased knowledge concerning STI prevention Increased Self–efficacy Increased perceived risk Adoption of preventive behavior Knowledge and behavior retention

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19 setbacks that may undermine motivation are conclusions that Bandura (1995) believes vitally affects self-efficacy (confidence in ones ability to perform a desired behavior). Bandura (2001) reports perceived self-efficacy occupies a pivotal role in the causal structure of Social Cognitive Theory becau se efficacy beliefs affect adaptation and change not only in their own right, but also through their impact on other determinants. According to Shrier et al. (2001), Social C ognitive Theory postulates that a person’s behavior is uniquely determined by reci procal interaction among environmentally influenced behavior and personal factors, including self-efficacy. Therefore related to STIs, the influence of the construct of self-efficacy has been established to explain condom use behaviors (DiClemente et al., 2001; Dilior et al., 2000; Stewart et al., 1999; Von Sadovsky, 2002). These studies also demonstrated support for a condom-use model based on Social Cognitive Th eory and provided implications for STI interventions. DiClemente et al. (2001) examined perceived self-efficacy to negotiate safer sex as an association between pare nt-adolescent communicati ons. The findings of Von Sadovszky (2002) indicated a misunderstand ing of perceived risky behaviors and the primary motive behind adolescents’ and young adu lts’ perceived safer behavior appeared to be prevention of unwanted pregnancy. Stewart et al. (1999 ) reported that many interventions, especially school-based a nd community-based interventions, have incorporated the primary components of th e Social Cognitive Theory into programs, suggesting the relative strength of this model for preventive interventions. The Social Cognitive Theory was also used as an approach to educate nurses in an adolescent HIV intervention conducted by Stewar t et al. (1999). The continue d development of a social cognitive model for nursing will prove necessary for facilitating a move away from the

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20 situation of health education being conducted on the basis of chance, to tailored health education being conducted on preven tive needs (Whitehead, 2001). Social learning theory according to (B andura, 1997) emphasized the importance of observing and modeling the behaviors, att itudes, and emotional reactions of others. Bandura (1997, p. 22) explains, "Learning w ould be exceedingly laborious, not to mention hazardous, if people had to rely solely on the effects of their own actions to inform them of what to do. Fortunately, most human behavior is le arned observationally through modeling: from observing others one forms an idea of how new behaviors are performed, and on later occasions this coded information serves as a guide for action." In addition to self-efficacy, behavior is also influenced by another important Social Cognitive Theory construct, outcome expectations. Outcome expectations are defined as the expected results that will occur with performance of the behavior. Outcome-expectancy theories (i.e., expectan cy-valence theories) further consider the impact of the value of the expected outcom e on an individual's be havior. Bandura (1986) defined outcome expectancy as the individual's belief that performing a behavior will yield specific consequence. Self-efficacy expe ctation beliefs are fo rmed from cognitive processing of sources of efficacy informati on conveyed enactively, vicariously, socially, and physiologically (Bandura, 1986). Enactive mastery experiences are an individuals’ most significant source of information with regard to their capabilities and limits. Although successes contribute to build firm be liefs in one's personal efficacy, failures will sap it, especially if they occur before one has established a strong sense of efficacy (Bandura 1997). Vicarious experiences offer the individual a reference point to judge their capacities to master a given situation. Bandura (1997, p. 79) explains, “Such

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21 experiences allow transmission of competenci es and comparison with the attainments of others by observation and modeling.” Self -efficacy beliefs can be reinforced through verbal persuasion. Bandura (1997) comments that maintaini ng self-efficacy beliefs is easier for individuals when they receive rein forced verbal persuasion. When one is not able to apply self-efficacy to a physiological state of well be ing such as protecting self from a STI, this behavior can be interpreted as a sign of inefficacy. In Social Cognitive Theory one's belief in a behavior's positive consequence is more important than whether the behavior ha s caused a positive cons equence in the past (Bandura, 1986). This study investigated sexu al self-efficacy and outcome expectations for individuals’ confidence in their ability to refuse sexual intercourse, confidence in questioning potential sex partne rs about previous sexual and drug history, and the ability to obtain and use condoms in various situ ations after exposure to an education intervention. The constructs of self-efficacy explai n why people with the same skill set may perform the same task poorly, well, or extr aordinarily well. Knowledge and self-efficacy are enhanced by specific learning strategi es, especially obser vational learning and modeling (Ngo & Murphy, 2005). This educatio n/behavioral intervention used visual presentation in addition to verbal instructions such as demonstration of the techniques of donning a male or female condom and how to shie ld the vulva with plas tic wrap or dental dam. The ultimate choices that individuals ma ke about performance of specific behaviors are strongly influenced by beliefs about th eir ability to perform the behavior (selfefficacy) and by beliefs about the likely c onsequences of performing the behavior (outcome expectation) (Bandura, 1986). The proximal outcome expectancy for this study

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22 is retention of knowledge a nd increased self-efficacy towa rd positive protective sexual behaviors. Social Cognitive Theory also emphasized one’s perceived difficulty of performing a behavior (Bandura, 1997, 1995). Perceived barriers may be one component of the interpreted environment that influen ces decisions about beha vior. If a woman with moderate self-efficacy expectations to use a condom during sexual intercourse perceives a situation filled with barriers, she may deci de not to attempt to use the condom. For example, if it is perceived that she was expec ting to have sex or prepared to have sex, she may not be comfortable with in itiating the use of a condom. Self-efficacy is the mediator between know ledge and action, and it influences the selection of behavior, the e nvironment in which the behavi or occurs, and the amount of effort performance of a specific behavior (Berarducci & Lengacher, 1998). Social Cognitive Theory postulates that a person’s behavior is uniquely determined by reciprocal interaction among environmental influence behavior, and personal factors, including self-efficacy (Shrier et al., 2001). For example, women who believe they have control over sexual decision making would tend to be more motivated in playing a role in informed decision making and performing behavi ors reflective of increased self-efficacy. Women who have a high sense of self-efficacy would persist in behaving and believing that they posses the knowledge and capability to make and perform safer-sex decisions. Intervention studies based on self-efficacy have been found to decrease HIV risk behavior in Latina women. Peragallo et al. (2005) conducted a study to evaluate a randomized culturally tailored intervention to prevent high-HIV-risk sexual behaviors for Latina women residing in urban areas. The sample consisted of Mexican and Puerto

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23 Rican women (18-44 years of age; N = 657) who were sexually active during the previous three months. These women were re cruited and randomized into an intervention and control group. The intervention consis ted of culturally tailored sessions on understanding HIV/AIDS, STIs, condoms (m yths and use), negotiating safer-sex practices, violence prevention, and partne r communication. The content of the intervention drew from the Social Cognitive Theory of behavior change. Peragallo’s study used the Social Cognitive Theory to provide an opportunity to develop social and self-regulatory skills and the self-beliefs th at are needed to practice safer behaviors Furthermore, DiClemente et al. (2004) us ed the social cognitive model to evaluate the efficacy of an HIV prevention interven tion in reducing risky sexual behaviors and sexually transmitted infections and enhanci ng skills and mediators of HIV-preventive behaviors among sexually experi enced African-American adolescent girls residing in the southern United States. Pa rticipants were randomly a ssigned to either the HIV intervention or a general health promotion control group. DiClemente et al. concluded that interventions for African-American adol escent girls that ar e gender-tailored and culturally congruent can enhance HIV preven tive behaviors, skills, and mediators and may reduce pregnancy and chlamydia infection. D’Souza (1999) suggested that when usi ng a behavior change theory to explain relationships between an indivi dual’s belief and willingness to change, the benefits must outweigh the risks. To perform a behavior, the adolescent must possess the skills and intention to perform the behavior and be lieve the behavior will produce a positive emotional response. That positive emotiona l response may not be projected when a sex

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24 partner is asked to wear a c ondom. However, if the woman is instructed on how to make this task an exciting part of fore play it may be better received. In summary, strong perceptions of one’s ability to prevent the transmission of STIs and increased expectations of use of condoms with positive ou tcomes can contribute to their use. Self-efficacy has been found to be associated with re search investigating health behavior such as sexual risk taking behavior. Therefore, the continued study of Bandura’s Social Cognitive Theory is impor tant to further explain women’s health concerns that are linked to decreasing e xposure to sexually transmitted infections and increasing knowledge and self-efficacy. Review of Empirical Literature The succeeding section is a review of empirical literature on knowledge, selfefficacy, and perceived risk in STI preventive behaviors. In the conclusion of this section, a summary of a preliminary study results and a summary of the empirical literature cited are discussed. Knowledge and sexually transmitted infections. Women’s knowledge of symptoms, prevention, treatment, and transmi ssion of sexually transmitted infections (STIs) has not been widely investigated in relationship to the course of pregnancy. Wilson, Minkoff, McCalla, Petterkin, and Jacca rd (1996) studied the differences in risk of acquiring sexually transmitted infections between pregnant and nonpregnant women. A convenience sample of 1465 (332 pregna nt and 1069 nonpregnant ) sexually active women between 15 and 45 years of age receivin g reproductive health care were included in the study. All patients had cervica l and vaginal cultures obtained for Chlamydia trachomatis and Trichomonas vaginalis which served as biologic markers of risk. A

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25 self-report questionnaire format was used to measure several variables. Respondents were asked to report the consistency of condo m use during the previous 30 days. This measure involved a five-point scale assessment. An independent t test was conducted comparing pregnant and nonpre gnant women. The difference between these means was statistically significant, t (501.88, corrected ) = 11.43, p< 0.01, indicating that pregnant respondents reported they used condoms less consistently than those who were not pregnant. A second index of sexual behavior involved the self-reported frequency of sexual intercourse. On average, those who reported that they were not pregnant reported a higher frequency of sexual activity than pregnant women. This difference was statistically significant, t ( 1362) = 2.56, p<0.05. A third behavioral measure involved a self-report of the number of men with whom they had engaged in sexual intercourse within the past 30 days. A significant mean difference was found in the total number of sexual partners reported, t (885.26, corrected ) = 7.99 p 0.01, such that those who were pregnant at the baseline in terview reported fewer sexual partners. In the pregnant sample, 17.2% had a positive result for chlamydia. In the nonpregnant sample, 10.9% had a positive result. A chi square analysis was applied to the relationship between the presence of chlamydia and pregnancy status which was statistically significant, chi square (degree of freedom = 1, n = 1315) 746.83, p 0.01 ) A chi square analysis also revealed that the difference between tr ichomonas and pregnancy was statistically significant, chi square (degree of fr eedom = 1, n = 1390) 529.61, p 0.01. This study suggested that women are not drastically changing their behaviors during pregnancy, except for decreasing the consis tency with which they use c ondoms and increasing risk of STI.

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26 Niccolai et al. (2005) conducted a study investigating the knowledge of sex partner treatment for past bacterial STI and risk of current STIs. The study included women aged 14-19 years, multiracial. A total of 411 adolescent females were enrolled in the study; half of the participants were pregnant. On e hundred and four reported a past diagnosis of chlamydia or gonorrhea. More than half (66%) reported knowing their partner was treated for a past STI. Those who knew their partner was treated were less likely to have a current infection, compar ed to those who did not know (11%). Asbill et al. (2000) conducted a study to determine whether a gram stain of cervical mucus can accurately rule out colonization of gonorrhea and chlamydia on the gravid cervix. The sample consisted of 519 pregnant women. The lack of consistent barrier contraceptive use and a previous hi story of a sexually transmitted disease were both commonly reported. Analysis of patients with a C trachomatis infection identified by DNA probe revealed that age greater than 20 years (p = .0001) a nd unmarried status (p = .005) were both predictors of the presence of disease. For N gonorrhoeae infection, age <20 years (p = .031) and African-American race (p = .048) were both significant predictors of the presence of disease. Narouz, Wade, and Wagstaff (2003) conducted a study for the purpose of assessing patients’ knowledge and attitude towards genital herpes infection and its serotesting, before and after counseling. Tw o hundred and twenty three (107 males and 116 females) completed a self administered que stionnaire after verbal consent. Patients were counseled (pretest counsel ing) for five to ten minutes about genital herpes and its serotesting and were asked to complete anot her copy of the same questionnaire. When the results were given a week later, patients were counseled again (posttest counseling).

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27 Posttest counseling (three to five minutes) discussed the results of serotesting and any other points brought up by the patients and an swered their questions. Overall, 85% of participants showed improvement scores in knowledge and attit ude towards genital herpes after counseling compared with scores before counseling. Counseling appears to be necessary to provide patients with knowledge about infections, to combat misconception, to assess need for testing, and, above all, to help in preventing transmission. The greatest risk to the neonate of cont racting herpes occurs when the mother acquires genital herpes during pregnancy, particul arly if this occurs toward or at the end of the third trimester (Minde l et al., 2000). Mindel conduc ted a study to establish HSV seroprevalence and the rate of HSV. Wome n were asked to complete a questionnaire covering risk factors for the acquisition of genital herpes. Serum samples were also obtained for syphilis and rubella. Partic ipants numbered 3706. A total of 326 (12.5%) were HSV-2 seropositive. Of the women w ho were negative, thr ee seroconverted during pregnancy. The risk of HSV-2 acquisiti on during pregnancy may be dependent on several factors including sexual behavior during pregnancy. A study by Williams, Norris, and Bedor ( 2003) investigated sexual relationship, condom use, and concerns about pregnancy, HIV/AIDS, and other sexually transmitted diseases. Study participants were psychology students (n= 31), predominately Caucasian (88%) and female (73%). The mean age was 21.76 years (range 18-43) years. A questionnaire containing bot h closed-ended and open-ended questions was used. Less than half of the participants (47%) reported using a condom during their last episode of vaginal intercourse. Most par ticipants had engaged in vagina l intercourse with a primary

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28 partner (77%), compared w ith a causal (22%) or unknown (2 %) partner. Concern about pregnancy, HIV/AIDS, and STIs other than HIV/AIDS were reported to be low. Concern about pregnancy was slightly greater than concern about HIV/AIDS or STI other than HV/AIDS (p<.02). Findings such as these cha llenge providers of women’s health care to generate innovative strategies to promote condom use in all types of relationships. A study by Temmerman (2000) assessed the im pact of a syphilis control program on pregnancy outcome in Kenya. The objectives of the assessment were to measure risk factors for syphilis at delivery, assess the e ffects of syphilis on pregnancy outcomes. A structured questionnaire incl uding socio-demographic, medi cal, and obstetric data was administered, and pre-HIV test counseling and medical examination were performed. Blood samples for syphilis and HIV were taken. Serology testing was done in 12,414 women at delivery. Syphilis-seropositive women suffered significantly more adverse obstetric outcome than did syphilis-serone gative women (22.5% vs. 6.6%; odds ratio (OR 4.1). Women who were syphilis-seropositive a nd untreated were four times more likely to have adverse pregnancy outcomes. The impact of maternal syphilis infection was slightly higher on the inciden ce of low birth weight (OR 4.0) than of the incidence of stillbirths (OR 3.3). Women who received treatment during pregnancy and were found syphilis-negative at delivery had similar pregnancy outcomes to syphilis-seronegative women (8.0% vs. 6.2%). Multivariate analysis of risk factors for maternal syphilis infection at delivery confirmed the predicta ble fact that syphilis-positive women more often showed risky sexual behavior. Th ese women could benefit from a behavior modification intervention that increases know ledge and perception of syphilis infections.

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29 Lambert (2001) conducted a study to evaluate the effectiveness of a brief Human Papillomavirus (HPV) focused education inte rvention on college students’ knowledge of HPV. Sixty students were surveyed initi ally, 33 psychology students and 27 physician’s assistant students. Students attended a private college in upstate New York. Questionnaires were distributed to students in their classroom and immediately returned. The knowledge of HPV was evaluated using an information-only education intervention between two groups of college students. The cohorts’ knowledge about HPV was reevaluated three months afte r the intervention. The goal wa s to determine how well this high-risk population retained HPV knowledge. At pre-intervention phy sician’s assistant students had significantly better knowledge sc ores than the psychology students for the HPV and non-HPV items. There was no signifi cant difference in scores for HPV items between the men and the women. The women, however, performed significantly better than the men on the non-HPV items. Three mo nths after the educat ional intervention, both cohorts showed a statis tically significant improvement in knowledge scores for HPV-specific questions. Kellock and Rogstad (1999) studied Ge nitourinary Medicine (GUM) clinic attendees to determine their knowledge level of sexually acq uired infections (gonorrhea, syphilis, chlamydia, trichomonas, thrush, b acterial vaginosis, HIV/ AIDS, warts, herpes, hepatitis B and C. Four hundred and eight y two questionnaires were analyzed (57% female). The most common infections previ ously experienced by females (n = 259) were thrush (72.2%), genital warts (30.1%), and chlamydi a (22.4%). The three least heard of infections were trichomonas (13.7%), bacterial vaginosis (20.1) and chlamydia (60.0%). Of the 460 respondents who answered the chlamydia knowledge questions, 54 (26.3%)

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30 males and 130 (51.05) females achieved a mean knowledge score of over 0.5; none attained a perfect score. The overall mean knowledge score was 0.38 (SD 0.28, range 0.0-0.91) with significantly higher sc ores achieved by females 0.45 (SD 0.27) vs. males 0.29 (SD 0.26). Devonshire, Hillman, Capewell, and Clar k (1999) conducted a study in the United Kingdom to evaluate knowledge of Chlamydia trachomatis infections, with a comparison of knowledge of Neisseria gonorrhea infections. The sample consisted of 200 subjects, of which 163 (82%) completed a short anonym ous questionnaire; 90 participants were male (55%), and 73 were female (45%). Sixty-nine of 90 (77%) males had heard of gonorrhea and only 44 of 73 (60%) of the female s had heard of gonorrhea. The majority (68-82%) did not know that untreated gonorrh ea caused complications. A misconception existed that gonorrhea did not cause eye in fections. No significant difference was reported between the sexes in their knowledge of gonorrhea. Forty-six of 90 (51%) males and 44 of 73 (60%) females had heard of chlamydia (p = 0.24). For all questions related to chlamydia knowledge, most subjec ts (65-82%) did not know that chlamydia caused complications, such as eye infections or chest infections in babies. There was no significant difference between the sexes in overall chlamydia knowledge score. However, females were more aware that chlamydia caused infer tility (p=0.04), lower abdominal pains (p = 0.01), and genital disc harge (p = 0.01). Overall, males showed a significantly higher level of knowledge about gonorrhea than about chlamydia (p = 0.008); females did not (p = 0.53). Equal numbe rs of participants reported reading leaflets always/often as their source of patie nt information. Signifi cantly (p = 0.03) more females read leaflets always/often (femal es 42/72, males 35/86) whereas males tended to

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31 read them rarely/never (fem ales 30/77, males 51/86). The me dian total knowledge score of those 77 participants who read le aflets always/often was 50 (IQR 2.0-7.0), significantly higher than th e median of 3.0 (IQR 1.55.5) for the 81 subjects who rarely/never read leaflets (p= 0.04). The most commonly reported source of information was health information leaflets, followed by friends, women’s magazi ne, and television. Still, the medical profession was by far the preferred source for health information. Weisbord et al. (2001) conduc ted a prenatal-care-provider survey to determine sexually transmitted infection screening, diagnosis, and treatment practices. Questionnaires (n = 3,082) were mailed to li censed Georgia obstetrician/gynecologists, family practitioners, and nurse-midwives. Of the 565 responding prenatal-care providers 75% were European-American, 12% were Afri can-American, 6% were Asian-American, 4% were Hispanic-American, and 18% identif ied their race as “Other.” The most common setting among the respondents was priv ate practice 256 (45%). Only 55 (10%) of the clinicians reported testing asymptom atic pregnant women for herpes. Five hundred and four (89%) routinely tested wo men symptomatic for trichomonas, and 477 (84%) routinely tested women symptomatic for bacterial vaginosis. A small percentage reported treating gonorrhea, 4% (23), chlamydi a 1% (5), and syphilis 4% (23) with regimens that are inappropria te or contraindicated for us e during pregnancy. Providers whose office had a written policy on screening were significantly more likely to screen women at high risk for bacterial vaginosis (6 4% vs. 8%; adjusted = unadjusted OR 20; 95 % CI, 12-32), women symptomatic for trichom onas (96% vs. 8%; adjusted OR = 4.2; 95% CI, 6-7.5), and all women for HIV infectio n (88% vs. 64 %; adjusted OR = 4.2; 95% CI, 3-7) than those providers whose practice setting did not have such a policy. Practice

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32 settings that had no Medicaid pa tients were less likely to have a written office policy for trichomonas screening (adjusted OR = 0.6; 95% CI, 0.4-0.9) and HIV infection (adjusted OR = 0.5; 95% CI, 0.2-0.8). The most commonly cited barrier to screening for sexually transmitted infections during pregnancy was th e inability to bill or lack of insurance coverage for the diagnostic test. As reported in Chapter One, the United Kingdom has the highest rate of teenage pregnancies and STIs in Western Europe (J olley, 2001). In order to investigate this problem, Jolley designed a study to investig ate the teenage sexua l health services provided by gynecology nurses. A cross secti onal questionnaire surv ey of nursing staff on the gynecology wards and in the gynecol ogy clinic was conducted. In addition, a small random sample of nursing staff who re sponded to the questionnaire survey was selected for semi-structured interviews. There was a 100% response rate (n = 46) for both parts of the study with all 46 nurses filli ng in the questionnaire and 10 agreeing to be interviewed. The majority of staff (65%, n = 30) had worked on the unit for more than five years. No relationship was found be tween length of service and stated STI knowledge (P = 03, Fisher’s Exact Test). A th ird of the nurses (33%, n = 15) claimed to take a thorough sexual history. Factors a ffecting how well nurses take sexual history include time, privacy, embarrassment, and avai lable documentation. Nurses felt strongly that they should all be taking a sexual histor y in the same way and that some guidelines or a protocol, proper training, and specific doc umentation would help. The main health promotion method mentioned was a leaflet (41%, n = 19), and this education leaflet was not generally backed up by any verbal explan ation. When asked to identify training needs, nearly half (48%, n = 22) indicated that they needed more information on STIs.

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33 Hellerstedt, Smith, Shew, and Resnic k (2000) reported a similar study on adolescent health. A self-reported, discip line-specific survey was mailed to assess perceived knowledge and intere st in training about adolesce nt pregnancy prevention for each of four disciplines (800 psychologists, 800 social workers, 1000 nurses, and 400 pediatricians). The overall response rate wa s 51%. Respondents were asked to indicate their level of knowledge (i.e., lo w, moderate, or high) and thei r interest in training (i.e., low, moderate, or high). With the exception of the pediatricians, le ss than half of the respondents from each discipline reported high knowledge in areas related to adolescent pregnancy prevention. Res pondents from psychology reported the lowest percentage, followed by social work. More than half of the respondents from nursing, pediatrics, and social work reported moderate to high interest in training in the c ontent areas. Perceived knowledge was not associated with interest in training for nursing or pediatrics. There were modest positive correlations between pe rceived knowledge and interest in training for social work (r = 0.18, p = .004) and for psychology (r = 0.29, p = .001). Knowledge about the morbidity caused by chlamydia trachomatis in Eastern Europe is insufficient according Domeika et al. (2001). The Goberis et al. study aimed to investigate the prevalence of C trachomatis infection in Lithuanian women. Enrolled were women (n = 1008) attending four gynecolo gical outpatient clin ics and two antenatal clinics between November 1999 and December 2000. The study participants were given a standardized questionnaire concerning social status, sexua l behavior, and contraceptive habits, medical and sexual history, and presen ce of genitourinary symptoms. The median age of the population tested was 25 (mean age 26.1) years. The highest prevalence of C trachomatis was observed in women under 19 years of age (17.4%). The prevalence for

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34 women 20-40 years was (6.1-7.9%). Approximately one-fourth of the women could not answer a question about their se xual partners’ genita l symptoms: if they were tested for any sexually transmitted infections or if they had ever had any sexually transmitted infections. Chlamydia trachomatispositive women had significantly more concomitant infections with T vaginalis (7.1% vs. 2.5%, OR 2.9, 95% CI 1.1-7.1, p = 0.02) and N gonorrhea (2.4% vs. 0.3%, OR 7.3, 95% CI 1.045.1, p = 0.02), as well as bacterial vaginosis (21.2% vs. 13.5%, OR 1.7, 95% CI 1.0-2.9, p = 0.05) and ce rvicitis (52.9% vs. 10.5 %, R 9.6, 95 % CI 6.0-15.5, p = 0.00). A study by Tideman et al. (2001) examined risk factors for the presence of HSV-1 and HSV-2 infections in pregnant wome n. A prospective sample of 306 women completed a self-administered questionnaire to establish risk factor s for the presence of HSV-1 and HSV-2. The study concluded that the presence of antibodies to HSV-1 and HSV-2 was related to a number of sexual and demographic factors. Lower education level, partner with genital herpes, early ag e of first sexual intercourse, more than one lifetime sexual partner, and previous chlamydi a infection were independently associated with HSV-2 seropositivity. A study in Uganda was conducted with the purpose of assessing presumptive STIs on pregnancy outcomes and HIV transmission (G ray et al., 2001). A randomized trial of 2070 pregnant women who received presum ptive STI treatment one time during pregnancy at varying gestations, and 1963 control mothers received iron/folate and referral for syphilis. STIs were reduced: Trichomonas vaginalis (rate ratio, 0.28; 95% CI, 0.18%-0.49%), BV (rate ratio, 0.78; 95% CI, 0.69-0.87 ), Neisseria gonorrhea Chlamydia trachomatis (rate ratio, 0.43; 95% CI, 0.27-0.68 and infant opthalmia (rate ratio, 0.37;

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35 95% CI, 0.20-0.70). There were reduced rates of neonatal death (rat e ratio, 0.83; 95% CI, 0.71-0.97), low birth weight (rate ratio, 0.68; 95% CI, 0.53-0.86), and preterm delivery (rate ratio, 0.77; 86% CI, 0.561.05); but there was no effect on maternal HIV acquisition or perinatal HIV transmission. This study concluded that reduction of maternal STI improved pregnancy outcomes. In summary, the knowledge about sexually transmitted infections and the effects on reproductive health is limited among wome n and health care providers. Women are not able to identify the relationship between untreated, undiagnosed sexually transmitted infections and future fertility and reproductive healt h. It also appears that when patient information is presented w ithout verbal explanation, i ndividual knowledge is not increased. Perceived Risk and sexually transmitted infections. One frequently used model for predicting sexual risk taking and protective behaviors includes self-perception of risk for sexually transmitted infections. This conceptualization has also been referred to as threat recognition, perceived risk and perceived susceptibility Perceived risk is a multifaceted variable that may incorporate both the subjec ts’ own risk behavior and their perceptions about the risk they are exposed to as a result of the sexual behavior of their spouses or other partners. Duncan, Hart, Scoular, and Bigrigg (2001) explored the psychosocial impact for women with a diagnosis of Chlamydia trachomatis Chlamydia trachomatis is a leading cause of reproductive morbidity in women, including pelvic inflammatory disease and infertility. Duncan et al. (2001) recruited women with a current or recent diagnosis of chlamydia who were attending either a gen itourinary-medicine clinic or a family-

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36 planning clinic for the study. The sample was comprised of 17 women: 10 from the genitourinary-medicine clinic and seven from the family-planning clinic (response rate 62%). Semi-structured interviews were conduc ted in a clinic setting or in the women’s homes. Most participants re portedly perceived themselves as relatively invulnerable to infections. Participants supposedly distan ced themselves from the “type” of persons likely to contract a sexually transmitted infection. This thinking led them to believe that chlamydia and other sexually transmitted inf ections were not pers onally relevant. Six women reported some knowledge of chlamydia before diagnosis; only two acknowledged any sense of personal vulnerabil ity to infection. All attendees of genitourinary-medicine clinics reported receiving information and a dvice from health a dvisors, a service not available to women attending the family -planning clinic. Participants’ sexual relationships were mainly serially monoga mous, with some women having sex with casual partners between relationships. Ther efore, diagnosis of a sexually transmitted infection introduced the possibility of a current partner’s infidelity. Rosengard, Millstein, Gurvey and Ellen (2004) investigated the psychosocial factor (or, perceived risk). They examined the amount of time adolescents waited to have intercourse. Adolescents waited le ss time to have intercourse with most recent casual than with most recent main partners ( 2 = 31.97, p<0.0001). The amount of time waited with past partners was shorter than intended time to wait in future relationships: medians of 1 month vs. 2 months (main) ( t = 3.47, p<0.0010; medians of 2 weeks vs. 1 month (casual) ( t = 6.14, p<0.0001). Factors influencing intentions to delay intercourse with future main partners differed by sex; males were negatively influenced by importance of

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37 sex in relationships, whil e females were positively influenced by importance of intimacy in relationships, perceived risk of STDs, and health values. Kershaw et al. (2004) recognized that adolescent female s are at significant risk for sexually transmitted infections (STIs) a nd may not accurately incorporate indicators of risk into their perceptions of susceptibility. The investigators examined the relation between perceived susceptibility and indicators of risk, and they al so investigated the relationship between perceived susceptibility and actual STI di agnosis. Most participants perceived little or no chance that they would be diagnosed with an STI in the following year. There was no relationship between almost all STI indicators and perceptions of susceptibility. Among those rece iving a positive chlamydia or gonorrhea test (n = 49) at baseline or in the year following, 81.3% had perceived themse lves to be at little or no risk. Todd et al. (2002) formulated a study to investigate the effectiveness of an intervention for prevention and treatment of syphilis in an African population. A structured questionnaire was administered to ascertain social demographic characteristics and detailed information on sexual behavior and perception of risk. Sexual partners were classified as spouses (marital partners), regular partners, or casual partners. A total of 857 men (14%) and 1070 women (16%) were syphilis positive. Of these, 456 men (7.7%) and 605 women (9.1%) had active s yphilis, while 344 men (5.8%) and 427 women (6.4%) had high titers for active syphilis Of those initially syphilis-negative, 148 men (4.1%) and 118 women (3.1%) seroconverted during two years of follow-up, equivalent to an annual incident of 1.8%. Results showed that the perceived risk of acquiring an STI was not associated with the prevalence of active syphilis but was

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38 strongly associated with incidental syph ilis. The reported age of sexual debut and perceived risk of an STI were significantly associated with the prevalence of active syphilis in women. The prevalence of active syphilis was considerably higher among young women, and this fact is of special c oncern as a high proportion of women become pregnant and commences childbearing before reaching 20 years of age. To assess the level of HIV-related risk behavior among the general U.S. adult population, Holtzman, Bland, Lansky, and Mack (2001) analyzed data from a sexual behavior questionnaire availa ble for states to use with the Behavioral Risk Factor Surveillance System. The correlation be tween actual and perceived HIV risk was determined. The Behavior Risk Factor Surveillance System was a state based surveillance system initiated in 1984 and used in all 50 states. The system gathered information on health behaviors related to the leading causes of death from chronic diseases. HIV-related sexual behavior questions were added to the systems survey. Also included in the analysis were measures for pe rceived risk of HIV in fection; these ranged from high risk to no risk, whether the responde nt had been tested voluntarily for HIV, and sociodemographic characteristics. A total of 35,484 respondents provided usable data across participating st ates. The median response rate was 61.7 % (range = 44.2 %88.9 %). Seventy-seven of the respondents re ported one partner, and 13.7% reported no partners. Only 2.1% reported four or more se xual partners. Of thos e who reported one or more sexual partners, 26% reporte d that they used a condom at last intercourse. Of these adults, 54.9 indicated that the condom was used to prevent both pregnancy and disease; however only 8.7% reported that they used a condom solely to prevent disease. To determine whether those who reported that they were at high risk for HIV as a result of

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39 engaging in certain behaviors ( actual risk for HIV) were si milar to those who perceived themselves to be at risk for HIV, the au thors examined a correlation between the two measures (actual vs perceived) and found a statistically significant positive correlation. Among those who reported that they were at increased risk for HIV because of their behavior, the proportion that perceived themselves to be at risk for HIV increased steadily from none (3.1%) to high (11.9%). In a study by et al. (2000), the eff ects of multisite community-level HIV prevention intervention on women’s condom-u se behaviors was examined. Sexually active women of childbearing age were targ eted for this study. The intervention consisted of role model stories, brochures, posters, and newspapers. Interviewed in each intervention and comparison community were 225 to 240 women, aged 15 through 34 years, who had been sexually active in the past 30 days. A standardized interview instrument was used at all study sites. Th e mean age of the women was 25 years. Most were African-American (73%). Of the part icipants, 68% did not intend to use a condom pre-baseline, 13% had consistently used condom s with their main partners for one month or more. Women used condoms more fre quently with other pa rtners: 33% had no intention of using condoms, but 30% had used condoms consistently. Attempting to get a partner to use a condom increased 11% more for women in the intervention group than for those in the comparison communities (P = .01). Never talking with main partner about condoms decreased 13 percentage point s more (p = .03) and never using condoms decreased 9 percentage points more (p = .054) for women in intervention communities than for those in comparison communities.

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40 Hutchinson (1999) examined sexual ri sk communication between young women and their main sexual partners. This research was based on the premise that in order to take action to reduce risk for in fection, a person must first rec ognize that she is at risk for acquiring the infection. The study sample included 93 unmarried, sexually active heterosexual women, ages 17 to 26 years. S ubjects were asked a bout their number of past sexual partners and their estimates of th e partners’ number of past partners. They were asked to rate their own risk for havi ng or becoming infected with an STI and to estimate their partners’ risks. Nearly all of the women in th e study rated themselves to be at no risk or low risk for STIs. No ri sk was reported by 32.3% of the women, and low risk by 62.6%. Only 5.1% reported they were at moderate risk. Estim ates of their sexual partners’ risks were nearly identical: no risk, 28%; low risk, 65.6%; and moderate risk, 6%. Furthermore, perceptions of self-risk were highly correlated with estimates of the partner’s risk (r = .63, df = 90, p <.0001). Men’s perception of self ri sks and estimates of their partners’ risks were nearly identical to those of the wo men. Men reported a somewhat greater number of sexual partners than did women, with means of 7.4 and 3.5, respectively. The differences were statis tically significant according to a test for dependent sample means (t = 2.32, df = 173, p < .05). Women’s estimates of their male partners’ number of past part ners were significantly lower than reports from the males partners themselves (t = 4.77, df = 160, p .001). The role of perceived risk, anticipated negative consequence, and relationship quality in patient-initiated sex partner notification following treatment for STIs was investigated by Fortenberry ( 2002). The sample consisted of 241 thirteento twentyyear-old subjects (83% women; 83% Af rican-American) diagnosed with gonorrhea,

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41 Chlamydia trichomonas or nongonococcal urethritis. Partner notification was increased among persons with higher levels of self-e fficacy and in relationships with stronger affinitive and emotional ties. A study conducted by Hutchinson (1999) id entified the individual, dyad, and family variables that influence young wome n’s perceptions of risk for sexually transmitted infection. A convenience sample of 66 women, ages 20-26 years, was recruited from a statewide sa mple of young adults participat ing in a longitudinal study comparing young adults’ relationships with thei r married or divorced parents. A second group of 27 women, ages 17-22 years, was recr uited from a mid-Atla ntic university and the surrounding community. A total of 93 sexually active heterosexual women completed telephone interviews. Respondents answered forced-choice questions in the areas of frequency of condom use, having been tested for HIV, perception of the partner’s sexual risk disclosure, and perception of partner’s sexual risk. Two dyad variables perceiving the partner as “no risk” and relationship satisfaction were significant predictors of women’s perception of “no risk ” at the p < .05 level. Women who reported consistent condom use were more than eight time s more likely to report that they were at no risk for HIV/AIDS. Women who were less satisfied with their relationships were 50% less likely to report th ey were at no risk. Bettinger (2004) investigated whether ri sk perceptions, condom use, and STD prevalence differs within sexual networks. Perceived Risk Scales measured the perception of STD risk in the previous six m onths with a main partner, who was defined as “someone that you have sex with and you consider to be the person that you are serious about.” Casual partners were all othe r types of sexual partners. Risk perceptions

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42 for HIV/AIDS and two discharge-associated STDs (gonorrhea and chlamydia) in two separate scales cons isting of five questions each we re measured. The participant’s perception of her risk for each disease if she had unprotected sex with her main sex partner was assessed. The respondents were 303 females participating in the study of adolescent STD risk percepti ons and condom use. Those pa rticipants with high-risk perceptions were more likely to use condoms at last sex than were t hose participants with low-risk perceptions: odds ratio [OR], 3.93; 95% confidence interval [CI], 2.21–6.98; high HIV risk perceptions: OR, 2.03; 95% CI, 1.19–3.46). In summary, women’s actual and per ceived risk for sexually transmitted infections differs. Women are engaging in unprotected sexual intercourse with their casual partners. Education is needed to en lighten women that their estimation of their male partners’ sexual history is lower than repo rted numbers of past partners reported by the male partners themselves. Self-Efficacy and sexually transmitted infections. Wilson et al. (2004) investigated potential predictors of consistent condom us e (CCU). This study reinforced the need for CCU for all sexually active individuals who are not sure of being in a mutually monogamous relationship with a partner who has been tested and is fr ee of HIV or other STIs. Factors considered in this study included perceived HIV risk and sense of selfefficacy regarding condom use. The sample (n = 214) had a mean age of 27.9 years and 14.1 years of education. The majority of par ticipants were African-American. More than three-fourths were single, divorced, or wi dowed and not cohabiting with their current sexual partner. The mean number of lifetime STIs was 2.5. The sample averaged 1.4 sexual partners in the preceding three mont hs and 11.9 lifetime partners. Consistent

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43 condom use was significantly associated with younger age, African-American ethnicity, having casual partners, recent HIV testing, co ndom use, and self-efficacy about partner relationship. Siegel, Aten, and Enaharo (2001) ev aluated self-efficacy and knowledge following an education/behavior interventi on. The subjects (n = 4001) were recruited from ten urban schools in a medium-sized nor theastern U.S. city with a population of approximately 250,000. The ethnicity of the sample was diverse: 50% were AfricanAmerican; 16%, Hispanic-American; 20%, Eu ropean-American, non-Hispanic; and 14%, “Other” (Native American, Asian-American, bi racial). Seventy percent of the families had incomes less than the federa l poverty level. Students co mpleted a confidential survey at pre-intervention, immediat ely post-intervention, and at long-term follow-up. The study instruments measured constructs such as self-efficacy and knowledge regarding sexual matters and behavior intentions. The means for self-efficacy at post test were higher for the intervention groups compar ed as with the control groups. Ethnic differences were noted in th at Hispanic-American youth ge nerally reported less selfefficacy than did other groups. There were no differences for self-efficacy in relationship to whether there was a history of sexual intercourse. The long-term knowledge means were consistently greater for the interven tion groups compared with the controls. European-American non-Hispanics generally had higher knowledge scores, followed by African Americans and Hispanic Americans. Long-term [eta] values ranged from 0.11 to 0.15 for self-efficacy and 0.17 to 0.29 for knowledge. The proportion of variance explained by the models (R2) ranged from 0.12 to 0.35 for self-efficacy and 0.11 to 0.27 for knowledge.

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44 The relationship between self-efficacy and condom use was investigated by Dilorio, Dudley, Soet, Watkins, and Maibach (2000). The intent of the study was to examine the role of self-efficacy, outcome e xpectancy, anxiety, and substance use in explaining condom use for a sample of college students. The cons tructs were tested through the use of structural equation modeling techniques. Analysis was limited to participants who were 18 to 25 years of age, single, and w ho reported initiation of sexual intercourse. The mean age for the sample of 1,380 participants was 20.6 years (SD = 1.76). Of the participants, 63% were fe male, 42.5% were Black, 50.0% were White, 3.9% were Asian-Americans, 2.9% were Hispanic, and 0.7% selected “other.” Most participants, 95.8%, reported having had va ginal intercourse, 86.5% oral sex, and 16.0 anal sex. The mean age at first intercourse was 16.6 years for vaginal sex, 17.2 years for oral sex, and 18.4 years for anal sex. The me dian number for lifetime sexual partners was three, and the median number for the previous month was two. Only 27.5% of participants noted that they used a condom every time they had sexual intercourse. Selfefficacy for condom use was assessed using a four-item scale that measured confidence in one’s ability to use a condom in a variety of situations. These four items are part of a 21-item scale measuring self-efficacy for safer-s ex practices. The longe r scale consists of four subscales (1) self-efficacy for refusal to have sex, (2) self-efficacy for condom use, (3) self–efficacy to say no to sex when under th e influence of drug/alcohol, and (4) selfefficacy for discussion with pa rtners about sex. Total possible scores for the condom self-efficacy subscale range from 4 to 40, w ith higher scores indicating higher selfefficacy for condom use. Cronbach’s alpha for the four-item condom-use subscale was

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45 .89. Condom-use behaviors were measured by four items for the Safer Sex Behavior Questionnaire. The four items were rated on a four-point scale from “never” to “always,” with higher scores correspondi ng to more frequent condom use. Cronbach’s alpha was 0.79. The model was based on a polyserial corre lation matrix. Items on a ten-point scale were treated as continuous, and polyseria l correlations were computed using PRELIS 2.12. Findings indicated that self-efficacy was related directly to condom-use behaviors and indirectly through its effect on outcome expectancies. As predicted, self-efficacy was related to anxiety, but anxiety was not re lated to condom use. Substance use during sexual encounters was related to outcome e xpectancies but not to condom use, as predicted by the authors. Ludwig and Pittman (1999) conducted a study examining the relationships of selfefficacy and prosocial values to three types of adolescent problem behaviors, delinquency, risky sex, and drug use. The study explored moderating effects of age, gender, and race on the relationship between self-efficacy, values, and the three problem behaviors. A total of 2,146 adolescents attending nine secondary schools in rural communities of a southeastern state were surveyed. Of the sample 60% were AfricanAmerican and 40% were Caucasian. The sample was 49% male and 51% female. Surveys were completed in a given hi gh school in one class period on one day. Homeroom teachers distributed questionnaires and instructions were self-contained. Two questions evaluated involvement in risky sexual behavior. A score of 0 indicated no sexual involvement, a score of 1 indicated co nsistent use of condoms by the male and some form of birth control either by the male or the female, but not both; a score of 3 indicated inconsistent use of birth c ontrol (mean = 1.44, SD = 1.35). Higher scores

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46 corresponded with greater risk of pregnanc y and sexually transmitted infections. Three measures of self-efficacy were used. Self -mastery was operationalized using the SelfEfficacy/Self-Mastery Scale, a seven-item self -report measure answered with a four-point Likert type scale. Higher scores indicated a higher level of self-mastery. Two additional self-efficacy measures were based on a factor analysis of the Self-Esteem /Self-Efficacy Scale—a twelve-item semantic differential, where each adjective pair was scored on a five-point scale. Higher scor es indicated self-esteem/efficac y. The results showed that all seven of the predictor variables are relate d to risky sexual behavi or and drug use. Race was significant in the prediction of both risky sex and drug use. African Americans were more likely than Caucasians to report involvement in risky sexual behavior. More prosocial values, greater self-mastery, and f eelings of trustworthiness were associated with lower levels of delinquent behavior, ris ky sex, and drug use. Of the measures of values and efficacy, self-perception of trustwor thiness had the strongest unique effect in the prediction of delinquency and risky sex. Having more prosocial values was a preventive mechanism to engaging in risky sex for adolescents. Race moderated the relation between the self-per ception of trustworthiness and risky sexual behavior. Feeling trustworthy was negatively related to risky sex for African Americans. Gender was a significant moderator of the effects of both prosocial values a nd self-mastery. For females, having stronger prosocial values was associated with less risky sexual behavior. Tests for moderating effects of prosocial valu es on the relation between the three efficacy measures and risky sexual behavior revealed one significant result. Given weak prosocial values, the relationship between self-mastery and risky sex was significant and negative.

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47 With strong prosocial values, there was no re lationship between self-efficacy and risky sex. Numerous research studies have shown the importance of self-efficacy and its influence on potential be haviors (Cecil & Pinkerton, 1998; Crosby et al., 2002; Von Sadovsky, 2002). Within the realm of sexual be havior, self-efficacy has been found to be a predictor of intentions to use condoms (Crosby et al., 2002; Von Sadovsky, 2002). As an example, the woman may have enough self-efficacy to buy a condom; however, she may not have a higher magnitude of self-efficacy to perform the more difficult task of using the condom with a new sexual partner. Van Devant er (2002) examined women’s use of the female condom to protect them fr om acquiring STIs. Self-efficacy for refusing unsafe sexual intercourse was f ound not significant between users and nonusers of female condoms. However, the women who receiv ed an education in tervention did report significantly more positive attitude s toward the female condom. Social Cognitive Theory provided the conceptual framework for a randomized controlled trial of a safer-sex intervention fo r female adolescents who have had an STI (DiClemente et al., 2001; Shrier et al., 2001). DiClemente et al. (2001) examined adolescents’ perceived self-efficacy to negotia te safer sex. These studies concluded that adolescents who communicated le ss frequently about sex-relate d issues with their parents were more likely to have lower self-efficacy to negotiate condom use or otherwise refuse sex. An international study assessing percei ved self-efficacy for Hong Kong Chinese reported low self-efficacy as a reason for not using condoms (Abdullah, 2002). Studies have also evaluated the feasibility and im pact of health educ ation interventions

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48 promoting self-efficacy as a predictor of th e ability to notify a partner of possible sexually transmitted infections (Dilorio et al., 2000; Hilton, 2001; Mathews, 2002). The intervention studies reported improvemen ts on the measure of self-efficacy about notifying casual sex partners of the importance of seeking STI treatment. Intervention studies have applied the Social Cognitive Theory to provide information to increase awareness and knowledge of the consequences of behavior, to increase social and self-regulative skill de velopment, and to translate knowledge into preventive action (Berarducci & Lengacher 1998; Mathews, 2002; Siegel, Aten, & Enaharo, 2001). These studies evaluated the effects of self-efficacy and knowledge on individuals’ confidence in th eir ability to perform a certa in behavior and reported a positive correlation. Intervention studies have proven successful at increasing knowledge and self-efficacy to behave in sexually safer ways for college students, adolescents, and sex workers (Abdullah, 2002; Diclemente et al., 2001; Dilorio et al. 2000; Mathews, 2002; Shrier et al., 2001; Siegel, Aten, & Enaharo 2001). Although studies have examined self -efficacy with STIs, no st udy has been found that examined knowledge, self-efficacy and perceived risk in Af rican-American women. Given the strong theoretical and empirical suppor t for the relationship between self-efficacy and behavior, this study hypothesized a significant increase in self-efficacy of sexually transmitted infections in the women receiving the educat ional/behavior intervention compared to the control group. Wong (2005) used self-efficacy, risk asse ssment, modes of STI transmission and prevention, and HIV/AIDS as key issues th at counselors emphasi zed during one-on-one counseling provided to each study participant. Wong’s study evaluated patterns of long-

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49 term use of male condoms among partners of Cameroonian women who received intensive monthly counseling sessions about condoms and sexually transmitted infection testing and treatment. Consistent condo m use decreased while women were still receiving monthly counseling, with every month in the trial associated with an odds ratio of 0.96 (95% confidence interval [CI], 0.94–0.99) of consistent condom use, and use dropped substantively after the trial w ith a 0.39 (95% CI, 0.26–0.59) odds ratio in a logistic regression analysis. The inciden ce of unprotected coital acts as each month passed increased by 3% (95% CI, 1–4%) with no statistically signi ficant change during the condom-use follow-up survey as indicat ed in a zero-inflated Poisson regression model for unprotected coital acts. Condom us e in a coital act was 0.84 (95% CI, 0.78– 0.92) less likely during the follow-up survey than during the trial. In summary, it is important to recogni ze individual factors that promote or obstruct a woman’s perception of personal risk for acquiring a sexually transmitted infection. It is also import ant to increase women’s sexual risk perception to raise the likelihood that she will take acti on to prevent sexually transm itted infections. From the review of relevant studies, wome n do not perceive themselves or their sex partners as the “type” to contract sexually transmitted infections. Discrepancies seem to exist between perceived and actual risk, with actual risk being higher. Empi rical data from a variety of researchers supports the premise that increase d individual perceived ri sk is necessary to narrow the gap between actual and perceived risk for contracting sexually transmitted infections among women. Sexually transmitted infections and intervention studies. The ability of women to negotiate the use of condoms to prevent preg nancy and STIs has been studied many times

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50 (Crosby et al., 2003; Durant & Carey, 2000; D ilorio et al., 2000; Fi shbein & Pequegnat, 1999; Weir, et al., 1998). Wilson et al. (1996) attempted to determine whether risks of acquiring sexually transmitted infections differ between pregnant and nonpregnant women. A convenience sample of women r eceiving reproductive health care were interviewed and tested for STIs. All m easures of behavior relied on self-report questionnaire format. A chi2 analysis revealed that the difference between the rates of the disease and pregnancy status was statistically significant, chi2 (df = 1, n = 1390) = 529.61, p< 0.01. The Wilson study also reported th at pregnant women used condoms less consistently than those who were not pregnant. Questionnaires were developed by Weisbor d et al. (2001) and mailed to family practitioners, obstetricians/ gynecologists, and nurse mi dwives asking about their screening, diagnosis, and treatment practices for syphilis, gonorrhea, chlamydia, BV, trichomonas, HIV, hepatitis B, GBS, and rubella. A small percentage of the providers reported treating gonorrhea (4%), chlamydia (1 %), and syphilis (4%) with regimens inappropriate or contraindicated for use dur ing pregnancy. The majority of providers surveyed reported using appropriate treatm ent regimens for STI among their pregnant patients. Dilorios et al. (2000) inves tigated the use of a social cognitive-based model for condom use among college students and reporte d that interventions focused on selfefficacy are more likely to reduce anxiet y and increase positive perception about condoms as well as increase the likelihood of adopting condom use as normal behavior. The Dilorios et al. interventi on study used the following tool s to elucidate aspects (selfefficacy, outcome expectancy, anxiety, and subs tance abuse) for consistent condom use:

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51 1. Self-efficacy for condom use was assessed using a four-item scale (Cronbach’s alpha .89) that measured confidence in one’s ability to use condoms in a variety of situations, 2. Outcome expectancy was measured using a twelve-item Likert scale (Cronbach’s alpha .86) to measure belie fs about physical outcomes associated with using condoms. 3. Anxiety about condom use was measured by use of four items from the condom interaction subscale of the AIDS Social Assertivene ss Scale, a thirtythree-item Likert scale developed by Ross, Caudle, and Taylor (1998). 4. Condom-use behaviors were measured by four items from the Safer Sex Behavior Questionnaire (Cronbach’s al pha .94) developed by Dilorio et al. (2000) to measure frequency of use of safer-sex behaviors. Shrier et al. (2001) conducted a randomized controlled trial u tilizing a self-report questionnaire, an education video, and individu alized intervention sessions. This study reported increased sexual risk knowledge and a more positive att itude toward condom usage among the intervention group. Duran and Carey (2000) compared self-a dministered questionnaires to face-toface interviews as methods of assessing sexual behaviors in young women. They concluded that both modes of assessment were reliable. That is, consistency did not differ as a function of face-to-face interviewing vs questionnaires use as a mode of assessment. Swanson (1999) assessed effects of ps ycho-educational interventions on sexual health risk and psychosocial adaptation in young adults with genital herpes. Psychoeducational intervention is a psychological and educatio nal intervention used for

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52 increasing coping skills, acceptance of the illn ess, and cooperation with treatment and rehabilitation (Swanson, 1999). Instrumenta tion included a demographic questionnaire, the Herpes Knowledge Scale ( HKS), a true/false self report test; Sexual Health Risk (SHR), a self administered questionnaire; the Protection from Sexually Transmitted Disease (PSTD), a questionnaire to measure se lf-efficacy regarding prevention of STIs; the profile of Mood States (POMS), an adjec tive checklist measuring feelings or moods; and the Beck Depression Inventory (BDI), a Likert scale to measure distress. The study results implied that psycho-educational in terventions can be used by nurses in the community with population at risk for highl y stigmatized, chronic sexually transmitted diseases. D’Souza (1999) suggested interventi on programs based on behavior-change theories that emphasized self-efficacy and motivational enhancement to change riskbehavior patterns among adolescents. Si egel, Aten, & Enharo (2001) conducted intervention studies examining effects of school-based HIV and STI interventions on knowledge, self-efficacy, and behavior inten tion to address student knowledge on risk behavior. Stewart (1999) designed a study to increa se nurses’ awareness of HIV risk to adolescents and to increase nur ses’ comfort with and intent to implement risk assessment and preventive education with adolescents. Pretest, posttest and follow-up tests were to measure knowledge of HIV/AIDS; attitudes to wards HIV; comfort with preventive behaviors such as sexual hi story taking, HIV risk couns eling and recommendation of HIV testing; and intent to utilize these be haviors in a time-limited office visit. The

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53 researchers found improved knowledge and attitude about HIV and increased comfort with an intent to implement risk assessments and HIV risk counseling. This author believes that the counseli ng of pregnant women about safer-sex practices must be personalized and indi vidualized. HIV/STI counselors generally provide the public with tests and a simple pr evention message; then they move on to the next individual. To address self-report condom use and new diagnosis of STIs, Kamb (1998) compared the effects of interactive HI V/STI counseling interventions tailored to each individual’s risk, with the typical or current prevention message. Kamb concluded that short counseling intervention using pe rsonalized risk reduction plans increase condom use and prevent new STIs. Rouse and Stringer (2000) appraised th e screening methods for maternal typespecific herpes simplex virus antibodies and suggested counseling such as abstinence, regular condom use, avoidance of oral geni tal contact, and limitation of the number of sexual partners as a means of lowering the ri sk of maternal HSV acquisition. Yet, Rouse and Stringer did not directly evaluate the eff ectiveness of counseling on their study group. Indirectly, they reviewed randomized tr ails of behavior intervention to estimate how counseling might have been effective. Their review concluded that counseling could be effective in decreasing the spread of STIs, but the couns elor must be effective in determining the effect of an individualized safer-sex intervention on condom use among female adolescents (excluding pregnant adolescents) diagnos ed with a sexually transmitted disease. A research synthesis was conducted on in terventions to reduce sexual risk for HIV in adolescents (Johnson, Carey, Mars h, Levin & Scott-Sheldon, 2003). Reports

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54 were gathered by accessing computerized databa ses, by contacting individual researchers, by searching conference proceedings and rele vant journals, and by reviewing reference sections of articles. The sample consisted of adolescents 11-18 years of age. Data from 44 studies and 56 interventions (N = 35282 participants) were included. Findings were that intensive behavioral interventions redu ced sexual HIV risk, especially because they increased skill acquisition, sexual communications, and condom use: they decreased the onset of sexual intercourse or the number of sexual partners. Wang et al. (2000), in a study of sc hool based programs used to reduce unprotected sexual intercourse found reduced HIV infection and other STIs, and unintended pregnancy among US adolescents. Evaluations of these school-based programs have shown that such programs i ndeed reduce incidence of unprotected sexual intercourse and substantially increase use of condoms and other forms of contraception among sexually active students. The Wang st udy also evaluated the cost effectiveness and cost benefit of school-based education programs designed to prevent HIV and other STIs. Results suggest these interventions can be justified from an economic perspective because they are cost effective and cost saving. In summary, many studies have shown th at health educati on interventions do promote behavior that lowers the chances of contracting sexu ally transmitted infections. Intervention studies have proven successful at increasing knowle dge and self-efficacy behavior towards safer ways for women to engage consistently in safer sexual intercourse.

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55 Preliminary Study For the current study, a pilot was conducted using a pretest/posttest experimental design to examine whether participation in a sexually transmitt ed infection (STI) educational/behavioral intervention has a posi tive effect on knowledge and perceived risk of STIs in female college students (JohnsonMallard et al.2003). Study participants were 112 women of childbearing age (18-48) attending two state universities in Florida. Those who agreed to participate were required to sign an informed consent document. Participants were randomized to either a cont rol or an experimental group. At pretest both groups completed a demographic data form, the Sexually Transmitted Infection Knowledge Survey (STIKS), and the Perceived Risk for Sexually Transmitted Infection Survey. Participants randomized to th e experimental group participated in an educational/STI knowledge/behavior interven tion. Four weeks follo wing the intervention, subjects from both the contro l and experimental group agai n completed the demographic data form, the STIKS, and the Perceived Risk for Sexually Transmitted Infection Survey. Results of the pilot study s howed the mean age of the participants was 21 years; 51% were African American, 31 % were Ca ucasian-American, 14% were HispanicAmerican, and 4% marked “Other.” Tw o-way ANOVA results showed increased knowledge and perceived risk in the experi mental group. Significant differences were found between the experimental and control group in knowledge of STIs (F = 109, p = .0001) and perceived risk (F = 117, and p = .0001). Results indicate that the educational/behavioral intervention made a difference between the experimental and control group. The alpha coefficient for th e STIKS was .76, and for the perceived risk survey .71.

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56 In summary, it is significant to recogn ize individual factors that promote or obstruct a woman’s perception of personal risk for acquiring a sexually transmitted infection. It is also importan t to increase women’s sexual ri sk perceptions to increase the likelihood that they will act to prevent sexually transmitted infections. According to the relevant studies, women do not perceive themse lves or their sex partners as the “type” to contract sexually transmitted infections. A discrepancy exists between perceived and actual risk, with actual risk being higher. Em pirical data from a va riety of researchers supports the premise that increased individual pe rceived risk is necessary to close the gap between women’s actual and perceived risk for contacting sexually transmitted infections.

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57 Chapter Three Methods Introduction Chapter three outlines the re search methods and procedures for this study. The research design is discussed first. This is followed by the methods, setting and sample, inclusion/exclusion, instrume ntation, recruitment and da ta analysis procedures. Design An experimental, explorat ory, two group randomized cont rol pretest; post test research design was used to test the hypothese s of this study. This study was designed to determine if participation in an educationa l program has a positive effect on knowledge and perceived risk of sexually transmitted infections. Subjects were randomly assigned to either an experimental or control group. The experimental group participated in an educational program. Setting and Subjects Pregnant and nonpregnant women were recruited from three Florida Departments of Health clinic s in northwest Florida (Leon, Gadsden, and Wakulla counties). The first eight w eeks of the study occurred in Leon County, followed by eight weeks in Gadsden County, and lastly by eight weeks in Wakulla County. These counties were selected because of the high incidence of reported STIs (Tallahassee Bureau of STI). A sample of 107 participants were recruited during a prenatal care visit, a primary care visit or during a family planni ng clinic visit. The

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58 participants were randomized to either the experimental group or the control group. The experimental group received the educational/b ehavioral intervention. The control group was offered the intervention after they complete the post tests. The number of subjects was determined by statistical power analysis. Preliminary conservative pilot estimates were based on an alysis of variance (ANOVA) procedures using tables for the F test on means in the ANOVA (Cohen, 1988). Based upon power analysis using means from the pilot data, a sample size of 30 per group was needed to achieve a power of .80 at the .05 level of significance when exp ecting a .50 effect. However, 40 per group were recruited to cove r possible attrition and to add robustness to the study. Inclusion/Exclusion criteria. According to the 2000 fede ral census, the northwest Florida (Leon, Wakulla and Gadsden) coun ties involved in the study have a high percentage of African Americans varying fr om 11.5% to 57.1% with half being women (Table 1). It was expected that the number of subjects would reflect the racial/ethnic diversity of the area and the population served by the clinics (Table 2).

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59 Table 1 U.S. Census Percent by Race/Ethnicity in Targeted Counties of Study Source Total County population African American/Non Hispanic Hispanic Female persons Leon 239,376 29.1% 3.5% 52.3% Gadsden 45,321 57.1% 6.2% 52.4% Wakulla 24,761 11.5% 1.9% 48.2% Table 2 Health Department Censuses by Race/Ethnicity Source Total Health Department White Hispanic African American Non Hispanic Leon 14,884 6,050 723 8,111 Gadsden 5,887 2,203 127 3,557 Wakulla 2,362 1,966 66 330 Inclusion criteria included : (1) women aged 15-48 year s; (2) pregnant and nonpregnant women; and (3) ability to give in formed consent or assent if a minor. The National Institutes of Health (NIH) guideline s to include women and minorities were met by this study. Persons of all culturally divers e groups were offere d the opportunity to participate in the study (e.g., English speaking Hispanic women). According to Manover (2002) the traditional age of childbearing in the United Stat es is 15-48 years of age.

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60 Inclusion of women younger than 15 years of age may skew data analysis due to emotional and developmental issues. Exclusion criteria included : (1) women who are not of traditional childbearing age (under 15 or over 48); (2) men (the th ree surveys have not yet been tested for reliability and validity in males); and (3) non-English speaking persons were excluded because survey instruments are in English only and the student investigator does not speak or read Spanish. Data from the health departments indicate that less than 2% of the populations seen were non-English speaking. Therefore, few subjects were lost as a result of inability to communicate in English. Gender, Minority, Children Inclusion Caucasian, African American and Hispan ic women of childbearing age (15-48) were the participants included in this study. Research has i ndicated that women have one of the highest rates of STIs (Jemmott, Je mmott, Braverman & Fong, 2005). Children age 15 and above were included in this study, si nce this is an age group reported to have higher incidences of STIs (Biddlecom, 2004). If children were living at home, consent was obtained from the parent and assent was obt ained from the child prior to enrollment. Federal guidelines indicate whenever possible, studies s hould include children. Men and children below 15 years were excluded becau se the investigation focuses on women, a population currently at greatest risk for contract ing STIs. At a future date, it is the goal of the researcher to test the reliability a nd validity of a revised version of the three surveys in males and among Spanish speaking men and women.

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61 Instrumentation The following instruments were used: Demographic Data Form (Appendix A), Sexually Transmitted Infections Knowledge Survey (STIKS) (Appendix B), the Perceived Risk of Sexually Transmitted Infection Survey (Appendix C) and a SelfEfficacy of Protective Sexual Behavior Survey (Appendix D). Sexually Transmitted Infection Knowledge Survey (STIKS). The knowledge survey is a researcher-developed questionna ire. A 29-item multiple-choice survey was developed and used to investigate wo men’s knowledge of contracting sexually transmitted infections. Multiple-choice items were used because of their ability to measure knowledge, understanding, and app lication (Gronlund, 1990; Norwood, 2000). Each item was scored “1” for correct responses and “0” for incorrect responses. Scores range from zero (0) to twenty-n ine (29) with highest scores indicative of greater sexually transmitted infection knowledge. Content Validity of STIKS. A panel of experts with theoreti cal grounding in the areas of women’s health, pregnancy, and ST Is used content interrater agreement to quantify the extent of relevance of ea ch content area (prevention, symptoms, transmission, treatment) to the behaviors of contracting or preventi ng the contractions of sexually transmitted infections. Content areas were determined from review of the literature on sexually transmitted infections. The panel of experts’ consisted of five doctoral prepared nurses. Two of the five ar e experts in the areas of women’s health and midwifery, one is an expert in child and adolescent health an d the other is an expert in public health nursing with a concentration in sexually transmitted infection. Content agreement was established by using the following quantitative procedure. Each member

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62 of the expert panel was asked to assess the relevancy of each item for the construct of knowledge as related to STI by i ndicating (1) if not relevant, (2 ) if somewhat relevant, (3) quite relevant (4) very relevant. Dividing th e number of items rated one or two plus the number of items rated three or four and divi ding by the total number of items calculated interrater agreement (Munro, 2001). Interrater agreement for item relevancy was found to be .93. The investigator-developed STIKS survey (Appendix B) is a representative sample of subject-matter cont ent areas with eight (28%) que stions addressing prevention of sexually transmitted infections, (consis tency, and timing of condom use, partner choice, safe sex practice, knowledge of suscep tibility, therapeutic measures, and value of prenatal care). Four (14%) questions addressed symptoms, (female and newborn presentation, and effects on pregnancy). Ten (34%) questions addressed transmission, (mother to baby, unprotected sexual intercou rse, and possible sequelae). Seven (24%) questions addressed treatment (partner notification, medi cation, and medical compliance). These questions were forwarded to the panel of experts who were asked to comment on the representativeness and releva nce of each question in the survey. Reliability of STIKS Cronbach’s Alpha reliability was used to estimate internal consistency reliability of the STIKS. Cronbach ’s alpha reliability estimates for the entire survey was 0.76. Cronbach’s alpha is one co mmon way of computing correlation values among survey questions (Polit, & Hungler, 1999) Perceived Risk of Sexually Transmitted Infection Survey. Questions regarding perceived risk were developed by modifying a previously validated approach to studying perceived risk about breast cancer. The formats for these items are based on McCaul,

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63 Schroeder, and Reid’s (1996) study of the re lationship of breast cancer worry and selfprotective behaviors. Perceived risk was ev aluated by asking five questions. The first question asked, “How often do you worry about getting a sexually transmitted infection?” The response was rated using the following Like rt scale (Never to always)”. The second question asked, “How would you rate how worried you are about getting a sexually transmitted infection?” The response was rated using the following Li kert scale (not at all to extremely). The third question as ked, “Thinking about getting a sexually transmitted infection makes me feel upset and frightened.” The response was rated (strongly disagree to strongl y agree). The fourth questi on asked, “What do you think are the chances of a woman getting a sexually transmitted infection? ” The response were rated using the following Likert scale (very likely to very unlikely). The fifth question asked, “What do you think your chances are of getting a sexually transmitted infection?” The response was ranked (very unlikely to very likely). Higher range on the Likert scale indicates a lower perceived ri sk for contracting a STI. Reliability of Perceived Risk Sexuall y for Transmitted Infection Survey was determined by Pearson Product Moment Correla tion. Reliability estimates for the entire survey was 0.71. SelfEfficacy Survey of Protective Sexual Behaviors. Heather and Pinkerton (1998) developed the Self-efficacy Survey fo r Protective Sexual Behavior. The selfefficacy survey covering three domains of protective sexual behavior were used to measure the self-efficacy construct. Nine items were used to assess the individual’s confidence in her ability to refuse sexual intercourse. Five items assessed the individual’s confidence in ques tioning potential sex partners about their previous sexual

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64 and drug histories. Eight items measured the individual’s ability to obtain and use condoms in various situations. For each item, respondents in dicated how sure they were of their ability to perform (or refuse to perform) the specifie d activity on a 5 point Likert scale ranging from 1 (not at all sure) to 5 (very sure). Increasi ng total scores indicate increasing levels of self-efficacy. Reliability of Self-Efficacy Surv ey of Protective Sexual Behavior. Previous Cronbach’s alpha reliability estima tes for the entire survey was 0.80. Subscale scores using Cronbach’s alpha reliability estimate s based on previous studies were 0.85 for refusing sexual intercourse; 0.80 for questio ning potential sexual partners; and 0.81 for condom use. Higher range on the Likert scale indicated intention to engage in protective sexual behaviors. See Table 3 for pretest and post test reliability study results. The post test results indicated stability of the STIKS and Self-efficacy surveys

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65 Table 3 Instruments/Reliability Used To Measure K nowledge, Self-Efficacy, And Perceived Risk Of STIs VARIABLES INSTRUMENTS PRE POST Knowledge of STIs Sexually Transmitted Infection Knowledge Survey (STIKS) 0.695 0.860 Perceived Risk of STIs Perceived Risk of Sexually Transmitted Infection Behavior Survey 0.780 0.605 Self-Efficacy The Self-Effi cacy of Protective Sexual Behaviors 0.883 0.919 Subscales Refusing Sexual Intercourse Questioning Potential Partners Condom Use 0.898 0.913 0.843 0.957 0.896 0.905 Demographic Data Form A 25-item researcher developed demogra phic form was used to investigate personal variables of the target study group. The data was used to describe demographic attributes such as-age, work status, ma rital status, ethnicity, medical coverage, educational level, annual household income number of children, number of times pregnant, and birth control methods. In a ddition, participants were asked questions relating to condom use and frequency, number of sex partners, history of STI and

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66 abnormal Pap test, gestation of pregnancy if applicable. The recruitment process consisted of the primary investigator expl aining the study purpose and intent to present an education program on STI prevention st rategies for women of childbearing age. Potential participants were informed that pa rticipation was voluntar y. It was explained that participation in this st udy was voluntary and they could withdraw from the study at any time. It was also explaine d that all data coll ected would be kept confidential. The process of randomization was explained to potenti al participants. All subjects that agreed to participate in the study we re asked to provide informed consent and given a copy of the signed consent for their own record. These data were statistically analyzed to examine associations between subject charact eristics and other vari ables of significance in the study. Procedures Approvals Approvals for this study by the Institu tional Review Boards of the Florida Department of Health and the University of South Florida were granted (Appendix G). Potential participants were appr oached by the principa l investigator and as ked to take part in the study. Only those i ndividuals who met the inclusi on criteria were invited to participate in the study. Those who agreed to participate were asked to sign an informed consent/assent form (Appendix H = Adult Informed Consent H1, Child Assent H2, Parent Consent H3).

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67 Data Collection Procedures The primary investigator approached wo men and minors who sought STI, family planning, or prenatal care services at three county health departments. After explaining the details of the study, potential participants were asked to take part in this research study. Only women with the ability to obtain or give consent/asse nt were allowed to participate in this study. If minors 15-17 were living at home prior to enrollment, they were strongly encouraged to obtained consen t from a parent/guardian. The investigator informed the minor of the importance of ha ving a parent/guardia n involved in advising them about the participati on in the study. Florida Statutes, chapters 384.30, 743.01, and 743.065, permit minor persons under the age of 18 years to independent ly seek prenatal care, family planning, and STI services without parental permission. If the minors were concerned about their confidentiality about STI, family planning, or prenatal care services and did not wish to involve a parent/guardian but de sired to participate in the research study, enrollment was allowed. Th erefore, a Waiver of Informed Consent Federal Statutes 45 CFR.46.408 (c) was requested based on the 1) research involving no more than minimal risk to the participants 2) rights and welfare of the participants not being adversely affected and 3) research not feasibly possible without the waiver. Permission to recruit subjects was obtained from each research site by the principal investigator. Potential participants were approached in the waiting area of the health units by the principal investigator. If potential subjects met inclusion criteria they were asked to take part in the study. Only those individuals w ho meet the inclusion criteria were invited to part icipate in the study. Those who agreed to participate were asked to sign an informed consent/assent form. Subjects were recruited from three

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68 county health departments. First in Leon County followed by Gadsden County, and lastly in Wakulla County (Appendix F). All da ta were reported as aggregated data. No county health department is uniquely iden tifiable. Particip ants were given a predetermined date (approximately one week following pre-testing) to meet for the education intervention. All pa rticipants completed a Demographic Data Form (Appendix A), the Sexually Transmitted Infection Knowledge Survey (Appendix B), the Perceived Risk of Sexually Transmitted Infection Surv ey (Appendix C), and the Self-Efficacy for Sexually Transmitted Infection Survey (Appendix D). The demographic form and surveys required approximately 30 minutes to complete. Each participant in the intervention group was asked to complete th e measurement surveys two times; once at pre-intervention and once at pos t-intervention. Each particip ant in the control group was asked to complete the surveys two times; once at baseline and once after a three week period. Measurements from the control group were used to compare outcomes of the educational intervention as well as to re -evaluate the reliability of the Sexually Transmitted Infection Knowledge Survey and the Perceived Risk for Sexually Transmitted Infection Survey. Participants who were randomized to the intervention group participated in an educational program facilitated by the prim ary investigator. Subject Retention and Follow-Up Procedures Follow-up visits are common for women expe riencing prenatal care visits, family planning services, and test of cure after dia gnosis of STIs. If th e participant was not scheduled for a follow-up visit, she was given written and verbal instructions to complete the surveys two weeks after the intervention a nd to mail or deliver su rveys to the county health department. Postage paid, preaddressed envelope was provided. Written

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69 permission to mail a reminder postcard was obt ained from assenting minor participants. If the minor refused parental involvement, th en the minor was asked to provide the PI with a confidential, safe and comf ortable manner of contacting her. The control group was pre-tested at their initial county h ealth department visit and instructed to mail or deliver the completed surveys to the co unty health department three weeks after pre-testing. The envelopes we re pre-addressed to the county health department to the joint attention to both the Nursing Director and the principal investigator. So that comparisons could be made, study pa rticipants were instructed to use the same code (mothers’ birth month and day) fo r pretest and post test surveys. At pretesting, persons randomized to the control group were informed of the opportunity to receive the educational interv ention after the comp letion of the study (at no cost to the participant). Persons returning the surveys received a ten-dollar gift certificate to Wal-Mart. Study participants were given the option to pick up their gift cer tificates from the principal investigator from the county h ealth department at a designated time. Alternatively, they could contact the investigat or to provide an address where they would like the gift certificate mailed. If mailed, confidentiality was not a concern because of prior parental consent and minor assent. The STI Education/Behavioral Intervention The intervention group participated in an STI educational program facilitated by the investigator (Appendix I). The intervention group received an educational intervention designed from em pirical standards and information from the Centers for

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70 Disease Control. This program was designed at increasing women’s knowledge regarding sexually transmitted infections, and increasing women’s perceptions of their risk for contracting STI. Specifically, the intervention was targeted at increasing the awareness of the consequences of STI and encour aging the incorporati on of healthy behaviors into the life of women during their childbe aring years. The interventi on took approximately one hour to complete and included lecture, Power Point slides, and an information brochure discussing how the health of women can be affected by sexually transmitted infections. The educational intervention in cluded content on the magnitude of sexually transmitted infections in women; susceptibility to a nd risk for contracting sexually transmitted infections, preventive behaviors, identif ying barriers to preventive behaviors and techniques to incorporate preventive beha viors in their life. Teaching techniques included didactic instruction with group di scussion. In addition, subjects in the intervention group were encouraged to read the STI Information Brochure about sexually transmitted infection prevention at least th ree times weekly following the educational intervention to encour age knowledge retention. This intervention was delivered to women only. However, EL-Bassel (2003) examined whether it is more effective to deliver a STI prevention program to heterosexual couples or to women alone. No significant differences in effects were observed between couples receiving the inte rvention together and those in which the women received it alone. As many as 44 million adults in the United States have impaired ability to read basic written materials and lo w literacy has been demonstrat ed in several populations at

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71 risk for STIs. Educational material tailored at the 8th grade reading level has been shown to produce improvement in knowledge, att itude and self-efficacy. The information brochure was prepared using short words, avoiding obscure medical terminology or abstract thoughts. Encouragi ng repetition (three times a week reading) along with visual and verbal communication (the in tervention) may have assisted the reader to more easily understand and follow the information, thus improving comprehension. The information brochure and intervention was intended to link changes in knowledge and behavior. Fortenberry (2001) conducted a study to discuss low literacy as a risk factor for STIs. Data were obtained using face to face intervie w. Health literacy was measured by Rapid Estimate of Adult Literacy in Medicine (REALM), REALM is a 66 item literacy screening instrument based on word pronuncia tion. REALM is record ed to represent 8th grade or lower reading or 9th grade and higher reading level. Fortenberry concluded that low literacy appears to pose a barrier to care for STIs. The intervention’s proximal outcome was to increase sexually transmitted infection knowledge, adopti on of preventive behaviors and to increase women’s perceptions of their risk to STI and the need for incorporation of healthy sexual behavior. The nursing intervention was aimed at in creasing sexually transmitted infection knowledge and changing behaviors toward an increased perception toward sexually transmitted infection prevention. Specifically, aims 1 and 2 were intended to increase knowledge. Aim 3 and 4 were intended to increase perceived risk. 1. (Aimed at increasing STI knowledge) To increase knowledge re garding STI, the primary investigator presented an info rmation brochure. Explanations were provided as to potential sequelae of undiagnosed and untreated STI.

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72 2. (Aimed at increasing STI knowledge) A structured discussion and answers session about sexually transmitted infections was conducted in an open forum. This was used as a step beyond the standard of care (literature w ith instructions to review). 3. (Aim at changing behaviors by increasing perception) This brochure described ways of lowering individual risk of contra cting an STI. The information brochure also addressed potential effects of STI on pregnant women and their fetuses. The importance of protective sex even during pregnancy was addressed. 4. (Aimed at increasing perceived risk) Structured lecture and discussion supplemented with overheads depicting condoms, dental dams, and spermicidal agents to decrease potential risk of STI transmission fr om mother to fetus were presented.

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73 Data Analysis The effects of the intervention were a ssessed by testing three hypotheses. The following describes the data analyses methods using ANOVA that were used to test the following hypotheses. Hypothesis 1: There will be significant in creases in knowledge of sexually transmitted infection in the educationa l intervention group when compared to the control group. Hypothesis 2: There will be significant increases in pe rceived risk of sexually transmitted infections in the educational intervention group compared to the control group. Hypothesis 3: There will be significant increases in self -efficacy of protective sexual behavior from sexually transmitted infections in the educational intervention group compared to the control group. To determine the intervention’s effect on knowledge, self-efficacy and perceived risk, statistical analysis focused on the e ffect of the educati onal intervention on the critical variables of knowledge, self-efficacy an d perceived risk measured at two times: (1) pre-intervention and (2) two weeks followi ng the intervention. Two-way Analysis of Variance was performed to dete rmine within group and between group differences and to test the interaction of time and treatment group. Analysis of Variance is a prevailing, robust test that allows the researcher to test for relationships between categorical independent variables. By us ing ANOVA, testing of the interaction provided information about whether or not the interv ention effects were changed by other factors. This method allowed the researcher to investigate di fferences between groups (control versus

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74 experimental) of subjects in relation to ch ange in knowledge, self -efficacy and perceived risk. For this research study, the independe nt variables (control versus experimental) group had two levels. The between-subject fa ctor was group, with two levels, one that received the intervention (experimental group) and one that did not receive the intervention (control group). To determine whether the between group difference was great enough to accept hypotheses one through thr ee, it was statistically compared to the within group variance using F valu es at a probability level of 0.05. Reliability for the Sexually Transmitted Infection Knowledge Survey and the Perceived Risk for Sexually Transmitted Infection Survey was evaluated by using Cronbach’s alpha to determine the internal c onsistency of the instruments over time. Descriptive statistics were used to ex amine data for missing values and outliers. Inconsistency of data was checked and descrip tion of data was verifi ed by the principal investigator and a statistician. Demogr aphic data was reported using descriptive statistics. To determine the intervention effect on each variable, the statistical analysis focused on the effect of the intervention on the critical variables of knowledge, selfefficacy, and perceived risk. Data Management A S tatistical A nalysis S ystem (SAS) Version 9 data system with a password to secure confidentiality was used for data entry, management, and analysis. Each participant was given instructions to ma rk the pretest and post test surveys with a code known only to them (mother’s birth month and date). The coding allowed the primary investigator to match pretest and pos t test data forms and simultaneous blinding

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75 the identity of the participants. Results of the study were reported as group data and no identifying information related to each person was presented.

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76 Chapter Four Results This chapter first presents the results of this study related to the sample of childbearing-age women. These results are followed by a presentation of the results according to each of the th ree research hypotheses. Sample Using means and standard deviations from the pilot study, a sample size was determined to be 60 (30 per group). Of th e potential participants approached, 107 women from the three research sites expressed an interest in par ticipating in the study. Eighteen were lost to attrition. Of those, five were intervention group participants, and thirteen were control group participants. Randomizati on was conducted to divide the participants into two homogeneous groups w ith respect to intervention ve rsus control group. Eighty nine (N = 89) pregnant and nonpregnant women completed all pretests and posttests. The 89 participants included 76 (85%) nonpre gnant and 13 (15%) pregnant women. The participants were recr uited from three Florida County Health Departments (Leon, Gadsden, and Wakulla Counties). Partic ipants were recruite d during a prenatal care, family planning, or an STI visit. The participants were rando mized to either the experimental group or the cont rol group. All participants completed a demographic data form at baseline and completed Sexually Transmitted Infection Knowledge Survey,

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77 Perceived Risk for Sexually Transmitted Infection, Self-Efficacy Survey of Protective Sexual Behaviors at baseline and at the tw o-week post-intervention interval. The racial/ethnic mix of the participants wa s as follows: 67 (75%) African American/NonHispanic; 13 (14.6%) Caucas ian-American/Non-Hispanic; 1 (1.1%) Native American; 4 (4.4%) Hispanic-American; and 3 (3.3%) defi ned as “Other.” Collected demographic data included the following characteristics: age, work status, marital status, ethnicity, type of medical coverage, education le vel, annual household income, number of pregnancies, number of livi ng children, gestational age of pregnancy, type of birth control, sexual activity during pregnancy, condom use, condom use during pregnancy, age of first sexual intercourse; number of se x partners in the la st year, having an abnormal pap, douching habits, having an abnormal vaginal discharge, STI while pregnant, having a sexually transmitted infecti on, sex partner with an STI, believing sex partner is having sex with someone else, di fficulty asking sex partner to use a condom, pregnant women having sexual relation with so meone other than the baby’s father, being treated for an STI while pre gnant, and number of months pregnant. The tables on the following pages display the results of the demographic data collection. Table 4 displays frequency and percent for the demographic factors (age and ethnicity). The control group and experimental group were approximately equivalent. The mean age of the sample was 29 years with a range from 15 to 48 years.

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78 Table 4 Demographic Characteristics (Frequency and Percentage) by Age and Ethnicity Per Intervention and Control Group Source Intervention Group n = 47 Control Group n = 42 Age 15-25 29 (61.7%) 23 (54.8%) 26-48 18 (38.3%) 19 (45.2%) Ethnicity Caucasian-American 6 (12.8%) 7 (16.7%) African-American 35 (74.5%) 33 (78.6%) Hispanic-American 4 (8.5%) 0 Native American 1 (2.1%) 0 Defined as “Other” 1 (2.1%) 2 (4.8%) Note. N = 89 Table 5 displays the level of education atta ined by each participant. The majority 41 (46%) had some college education. Ho wever, only 13 (14.6%) had completed their college degrees. The study sample was recrui ted from an area that has two universities and several colleges.

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79 Table 5 Frequency and Percentage of Women by Level of Education per Group Status Education Intervention Group N = 47 Control Group N = 42 Less than High School Diploma 4 (8.5%) 6 (14.3%) High School Diploma 10 (21.3%) 10 (23.8%) Technical School 3 (6.4%) 2 (4.8%) Some College 20 (42.6%) 21 (50%) College Degree 10 (21.3%) 3 (7.1%) Note. N = 89 The annual household income ranged from none being reported to $30.000. Table 6 displays the frequency a nd percentage by household income of the two groups. The average household income fo r the study group was $10,000, with 37% of the participants reporting no income.

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80 Table 6 Frequency and Percentage of Women by L evel of Household Income per Group Status Household Income Intervention Group N= 47 Control Group N= 42 No Income Reported 14 (29.8%) 19 (45.2%) Less than $5,000 10 (21.3) 10 (23.8) $5,000 to $10, 000 10 (21.3%) 6 (14.2%) $11,000 to $15, 000 6 (12.7) 3 (7.8%) $16,000 to $30, 000 7 (14.8) 4 (9.5%) Note. N = 89 Table 7 displays the numbe r of children reported by th e intervention and control groups. Fifty-four (49%) of the sample had no children, twenty-four (27%) had one child, sixteen (18%) had two children, thr ee (3.4%) had three ch ildren and two (2.2%) had four children.

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81 Table 7 Frequency and Percentage of Number of Children per Intervention and Control Group Number of Children Intervention Group n = 47 Control Group n = 42 None 24 (51.1%) 20 (47.6%) One 12 (23.5%) 12 (28.6%) Two 8 (17.2%) 8 (19.1%) Three 2 (4.3%) 1 (2.4%) Four 1 (2.1%) 1 (2.4) Note N = 89 Table 8 depicts the frequency of work status and type of medical insurance reported by the participants. A third, 29 (33 %), of the study participants were employed full time. One reported being disabled. Tw enty-nine were employed part time. Some reported being in school and employed. Me dical coverage was reported as Medicaid, 30%; private insurance 12%; no insurance 34 %; and group insurance through work, 12%.

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82 Table 8 Frequency and Percentage of Wo rk Status and Medical Insurance Source Intervention Group N= 47 Control Group N= 42 Work Status Unemployed 12 (25.5%) 9 (21.4%) Unemployed—Laid off 1 (2.1%) 0 Employed Part Time 13 (27.7%) 16 (38.1%) Employed Full Time 19 (40.4%) 10 (23.8%) In School 12 (25.5%) 19 (45.24%) Disabled 0 1 (2.4%) Type of Medical Insurance Medicaid 15 (31.9%) 12 (28.6%) Private Insurance 7 (14.9%) 4 (9.5%) No Insurance 14 (29.8%) 16 (38.1%) Group Insurance 5 (10.6%) 6 (14.3%) Other 6 (12.9%) 4 (9.5%) Note: N = 89 Table 9 depicts the demographic characteris tics related to marital status of the two groups. The majority of the subjects had never been married (66.3 %), and a small percentage were divorced (4.5%). Ten percent reported their ma rital status as “Other.”

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83 Table 9 Frequency and Percentage Data of Marital Status Marital Status Intervention Group n = 47 Control Group n = 42 Married 8 (17%) 4 (9.5%) Separated 2 (4.3%) 1 (2.4%) Never Married 30 (63.8%) 29 (69%) Divorced 1 (2.1%) 3 (7.1%) Widowed 2 (4.3%) 0 Other 4 (8.5%) 5 (11.9%) Note. N = 89 Table 10 depicts frequency and percent of tim es pregnant. Thirty-eight (43%) of the sample had never been pregnant, twenty-six (29%) had been pregnant one time, fourteen (16%) had been pregnant two times, seven (8 %) had been pregnant three times, two (2.2%) had been pregnant four times, and two (2.2%) had been pregnant five times.

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84 Table 10 Frequency and Percent of Times Preg nant per Intervention and Control Group Number of Pregnancie s Intervention Group n = 47 Control Group n = 42 Never 18 (38.3%) 20 (47.6%) One 14 (29.8%) 12 (28.6%) Two 6 (12.8%) 8 (19%) Three 6 (12.8%) 1 (2.4%) Four 1 (2.3%) 1 (2.4%) Five 2 (4.3%) Note. N = 89 Table 11 displays the results of study part icipants being asked if they were sexually active during pregnancy. More than half (53%) reported being sexually active during pregnancy. Table 11 Frequency and Percentage Data of Sexually Activity during Pregnancy Sexually Active During Pregnancy Intervention Group n = 47 Control Group n = 42 Yes 26 (55.3%) 21 (50.0%) No 4 (8.5%) 8 (19.1%) Never Pregnant 17 (36.2) 13 (30.9) Note. N = 89

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85 Table 12 displays information on age of sexual initiation. The mean age for initiating sexual intercourse was reported as 18 years. Most of the sample (52%) were 15 to 17 years before their first sexual encounter Only six percent of the sample reported being 21 years or older before experienci ng sexual intercourse for the first time. Table 12 Age of First Sexual Encounter (Frequency and Percentage) by Group Age at First Sexual Encount er Intervention Group n = 47 Control Group n = 42 12-14 11 (23.4%) 5 (12%) 15-17 22 (46.8%) 24 (57%) 18-20 11 (23.4%) 10 (23.8%) 21 and above 3 (3.4%) 0 Note. N = 89 Table 13 displays the frequency and per centage of self-reported sexual partners within the last year. In response to a question on sexual partner behavior, 55 (62%) women self-reported one sex partner, 17 (19.1%) reported two sex partners, and 10 (11.2%) reported 3 or more sex part ners within the last year.

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86 Table 13 Frequency and Percentage of Sex Partners Within The Last Year Number of Sex Partners Within the Last Year Intervention Group n = 47 Control Group n = 42 None 2 (4.3%) 5 (11.9%) One 28 (59.6%) 27 (64.3%) Two 12 (2.5%) 5 (11.9%) Three 4 (8.5%) 3 (7.1%) Four or More 1 (2.1%) 2 (4.8%) Note. N = 89 Table 14 depicts self-reported sexual-par tner behavior in relationship to two questions. Women were specifically asked if they “had difficulty asking their sex partner to use a condom” and if they “believed their sex partner was sexually active with someone else.” Only 10 (11.2%) reported difficulty aski ng their sex partners to use a condom, and 85% of the sample reported that th ey were in monogamous relationships. In a previous study, 91% of wome n reported difficulty asking their sex partners to use a condom (Johnson-Mallard, 2003).

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87 Table 14 Frequency and Percentage of Sexual Partner Behaviors Source Intervention Group n = 47 Control Group n = 42 Difficulty asking sex partner to use a condom? YES NO 6 (12.8%) 41 (87.2%) 4 (9.5%) 38 (90.5%) Sex partner having sex with someone else? YES NO 8 (17.0%) 39 (82.9%) 5 (11.9%) 37 (88.1%) Note. N = 89 Table 15 displays the frequency and per centage of pregnant women in the study and the number reporting having an STI while pregnant. Twen ty percent (n = 9) of the women in the intervention group and ten per cent (4) of the women in the control group were pregnant. Women were asked to self-re port past incidence of diagnosed sexually transmitted infections while pregnant; 7 (7.8 %) reported previous episodes of sexually transmitted infections while pregnant.

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88 Table 15 Frequency and Percentage of Wo men With an STI While Pregnant Source Intervention Group n = 47 Control Group n = 42 Treated for an STI while pregnant? YES 4 (8.5%) 3 (7.1%) NO 27 (57.4%) 22 (52.4%) Never Pregnant 16 (34.0%) 17 (40.5) Number of Months Pregnant? One-Three 7 (14.9%) 2 (2.2%) Four-Seven 2 (4.3%) 2 (2.2%) Not pregnant 38 (80.9%) 38 (90.5%) Note. N = 89 Table 16 is a depiction of the women se xually active with someone other than their baby’s father and women ever having a sex partner with an STI. Participants selfreporting being sexually active with someone other than their baby’s father were 4 (4.5%). Having a sex partner with an STI was reported to be 18 (20%) of the total sample.

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89 Table 16 Self-Reported Sexual Intercourse and STIs Frequency and Percentage Per Group Source Intervention Group n = 47 Control Group n = 42 Sex with someone other than baby’s father? Yes 3 (6.4%) 1 (2.4%) No 27 (57.5%) 25 (59.5%) Never pregnant 17 (36.2%) 16 (38.1%) Sex partner with an STI? Yes 10 (21.3%) 8 (19.1%) No 37 (78.7%) 34 (80.9%) Note. N = 89 Women were asked to self-report past in cidence of diagnosed sexually transmitted infections. Eighteen (20%) reported previous episodes of sexually transmitted infections. Table 17 displays the history of type of birth control. The leading method of family planning was oral contraceptives, 42 (47%). Condom use was reported by 32 (36%) of the women. However, it was unclear if condom s were used in conj unction with another form of birth control or as the primary method of birth control. The Depo Provera injection was used by 25 (28%), diaphragm 3 (3.4%), and IUD 2 (2.1 %). None reported using the vaginal Estrogen ring, a newer form of birth control. A patch was used by 3

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90 (7.1%) of the study participants. A small numb er of participants 12 (13.1%) reported not using any type of birth control. Table 17 Frequency and Percentage of Women by Birth Control per Group Type of Birth Control Intervention Group N = 47 Control Group N = 42 The Pill 20 (42.6%) 22 (52.4%) Depo Provera or Lunelle 13 (27.7%) 12 (28.6%) Norplant 0 0 Diaphragm 0 3 (7.1%) Condoms 16 (34%) 16 (38.1%) Patch 0 3 (7.1%) IUD 1 (2.1%) 1 (2.4%) Estrogen Ring 0 0 None 6 (12.7%) 6 (14.3%) Note N = 89 Table 18 displays frequency and percen tage of women reporting douching and vaginal discharge. Douching was reported by 32 (36%) of the partic ipants. Researchers have linked vaginal douching not only to pe lvic inflammatory disease but also to bacterial vaginosis (Martino & Vermont, 2002). Forty-three ( 48%) participants reported having a vaginal discharge.

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91 Table 18 Frequency and Percentage of Women by Birth Control per Group Source Intervention Group N = 47 Control Group N = 42 Do you douche? Yes 20 (42.6%) 12 (28.57%) No 27 (57.4%) 30 (71.4%) Do you have a vaginal discharge? Yes 26 (55.3%) 17 (40.5%) No 21 (44.7%) 25 (59.5%) Note. N = 89 In summary, the demographic data reveal ed that the majority 67 (75%) of the women that participated in this research study were African-American. The mean age was 29 years, and most 59 (66%) had never been married. Clos e to half of the participants had some college educati on, 41 (46.1%). Although 33 (37%) reported having no annual income, most of the part icipants were employed. Half 45 (51%) indicated that they had dependent children. The most frequent choice for birth control was the pill 42 (47%), and 48 (54%) of the study participants reported using condoms during sex. More than half 55 (62%) reported having only one sex partner within the last year.

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92 Research Hypothesis Number One To test the first hypothesis, “There will be significant increases in knowledge of sexually transmitted infections in the edu cational intervention group compared to the control group,” analysis of variance (ANOVA) was used. Means and standard deviations for th e dependent variables of STI-related knowledge are presented in Table 19. In te sting the first hypoth esis, a significant difference in means resulted after exposure to the education/be havioral intervention. Overall, the group mean ( M = 25.61 SD .990) for the intervention group was higher, indicating greater knowledge about sexually transmitted infections at posttest as compared to the control-gr oup mean at posttest of ( M = 20.09 SD 3.90). Table 19 Means and Standard Deviations for Knowle dge of STI at Preand Posttest STI Knowledge Pretest Posttest N Mean SD Mean SD Intervention Group 47 21.31 4.20 25.61 .990 Control Group 42 22.30 4.02 20.09 3.90 Note. Two weeks between pretest and posttest for both groups

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93 Based on the results of ANOVA, knowledge test results for the effect of the educational/behavioral intervention resulted in statistically significant mean differences between groups at posttest on STI knowledge for women receiving the educational/behavioral intervention F (1,87) = 73.66, p < .001. This indicates that the brief (30-minute) education/behavioral inte rvention had an effect on the experimental group. Table 20 illustrates test of betweena nd within-subject effect s of the STI related knowledge intervention. Table 20 Test of Betweenand Within-Subject Effect fo r Dependent Variable, Knowledge of STIs STIKS df F MS p Between Subjects Intervention Group 1 12.44 227.7 .001* Error 87 (18.30) Within Subjects Time of Assessment 1 7.54 48.14 .001* Time by Group 1 73.66 470.3 .001* Error (Time) 87 (6.38) Note. Values enclosed in parenthese s represent mean square errors. *p< .05

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94 In summary, the experimental gr oup of women had greater STI-related knowledge as compared to women in the control group. Therefore, women who participated in the STI prevention inte rvention had higher levels of STI-related knowledge as compared to those that did not pa rticipate in the interv ention. These data support hypothesis one. Research Hypothesis Number Two In testing the second hypothesis, “ There will be significant increases in perceived risk of sexually transmitted infections in the educational intervention group compared to the control group,” analysis of variance (ANOVA) was used. Means and standard deviations for the de pendent variable of perceived risk are presented in Table 21. The means for the se parate groups did not differ. The results revealed no significant main di fference in the group mean ( M = 14.89 SD .2.6) at posttest for perceived risk of sexually tran smitted infections between women exposed to the intervention as compared to th e control-group mean at posttest ( M = 14.90 SD .4.3). Table 21 Means and Standard Deviations for Perceived Risk of STI at Preand Posttest STI Perceived Risk Pretest Posttest N MeanSD Mean SD Intervention Group 47 15.2 3.92 14.89 2.65 Control Group 42 15.3 5.09 14.90 4.30 Note. Two weeks between pretest and posttest for both groups

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95 Group by time within-subjects test did not approach significance F (1, 87) = .02, p = .901. Test results for the effect of the e ducational/behavioral inte rvention did not result in statistical significance betw een group differences at postte st on STI perceived risk for women receiving the educational/behavioral intervention F (1,87) = .01, p = .929, indicating the brief (30-minute) ed ucational/behavioral intervention had no effect on perceived risk in the experimental group. Table 22 illustrates test of betweenand within-subject effects for the dependent variable, perceived risk. Th ere was no between-group varia tion. The lack of interaction effect suggests no differential changes between the two groups. The interaction effect of the mean for perceived risk reveals that the treatment group did not change between pretest and posttest. Table 22 Post test of Intervention Effect on Perceived Risk fo r Between and Within Subjects Perceived Risk df F MS p Between Subjects Intervention Group 1 0.01 0.19 .929 Error 87 (24.36) Within Subjects Time of Assessment 1 0.730 6.20 0.395 Time by Group 1 0.02 0.132 0.901 Error (Time) 87 (8.49) Note. Values enclosed in parentheses represent mean square errors. *p< .05

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96 In summary, the changes for perceived risk scores at two weeks posttest interval did not approach significance between groups (p = .929), with experimental participants scoring lower than control group participants at posttest. Hypothesis number two was not supported.

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97 Research Hypothesis Number Three In testing the third hypothesis, “There will be significant increases in self-efficacy of protective sexual behavior from sexually transmitted infections in the educational intervention group compared to the control gr oup,” analysis of va riance (ANOVA) was used. The information for the three self-e fficacy subscales relating to Refusing Sexual Intercourse, Questioning Potential Sex Part ners, and Condom Use is presented in the following summary of ANOVA tables. Table 23 depicts means and standard deviat ions for the dependent variable selfefficacy subscale of “refusing sexual intercourse .” The results revealed that women in the intervention group were sign ificantly more likely to re fuse sexual intercourse at posttest than at pretest. The mean was 42.53 at posttest for the experimental group and 29.76 at posttest for those not exposed to the educati on intervention. Table 23 Means and Standard Deviations for the Subscale Refusing Sexual Intercourse at Pretest and Posttest Refuse Sexual Intercourse Pretest Posttest N Mean SD Mean SD Intervention Group 47 30.53 9.11 42.53 3.04 Control Group 42 28.47 9.78 29.76 10.9 Note Two weeks between pretest and posttest for both groups

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98 As shown in Table 24, confidence in questio ning potential sex partners resulted in a higher mean at posttest for the experime ntal group. Overall, subjects in the experimental group were more confident a bout questioning potential sex partners at posttest (mean = 24.27) than at pretest (mean = 20.97). Table 24 Means and Standard Deviations for Questioni ng Potential Sex Partners at Preand Posttest Question Potential Sex Partners Pretest Posttest N Mean SD Mean SD Intervention Group 47 20.97 4.62 24.27 1.58 Control Group 42 20.23 4.98 20.59 4.75 Note. Two weeks between pretest and posttest for both groups Table 25 depicts means and standard deviations for condom use for the two groups. Exposure to the educat ion intervention resulted in an increased plan to use condoms during sexual intercourse.

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99 Table 25 Means and Standard Deviations for Condom Use at Preand Posttest Condom Use Pretest Posttest N Mean SD Mean SD Intervention Group 47 19.89 4.13 23.93 1.53 Control Group 42 18.90 4.39 19.52 4.28 Note Two weeks between pretest and posttest for both groups As shown in Tables 23 through 25, the inte raction effect of the means for the three subscales of Sexual Self-Efficacy Survey revealed that the treatment group changed rather substantially between pr etest and posttest. The STI education intervention had an effect on the intervention group at posttest, indicating higher self-efficacy for protective sexual intercourse. Tables 26 through 28 illustrate test of be tween-subjects and with in-subjects effect for the dependent variable sexual self-efficacy. Table 26 displays the ANOVA test results for the effect of the education/beha vioral intervention on the ability to refuse sexual intercourse. ANOVA results showed a statistical significance between group differences at posttest F (1, 87) = 50.18, p < .001, indicating the brief (30-minute) education/behavioral intervention had an e ffect on the experimental group in refusing sexual intercourse.

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100 Table 26 Betweenand Within-Subject Effect on Refusing Sexual Intercourse Refusing Sexual Intercourse df F MS p Between Subjects Intervention Group 1 19.54 2437 .001* Error 87 (124) Within Subjects Time of Assessment 1 77.15 1957 .001* Time by Group 1 50.18 1273 .001* Error (Time) 87 (25.37) Note. Values enclosed in parenthese s represent mean square errors. *p< .05 Table 27 displays results of between-subjec ts and within-subject effects involving questioning potential sex pa rtners. ANOVA summary for questioning potential sex partners was significant F (1, 87) = 15.48, p < .001, indicating the brief (30-minute) education/behavioral intervention had an effect on the experimental group.

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101 Table 27 Betweenand Within-Subject Effect on Questioning Potential Sex Partners Questioning Potential Sex Partners df F MS p Between Subjects Intervention Group 1 7.54 216.8 .007* Error 87 (28.77) Within Subjects Time of Assessment 1 23.92 148 .001* Time by Group 1 15.48 95.9 .001* Error (Time) 87 (6.19) Note. Values enclosed in parenthese s represent mean square errors. *p< .05 Table 28 displays betweenand within-s ubject effect for condom use. The ANOVA results were significant for condom use F (1, 87) = 19.60 p < .001. The results indicate that scores for condom use across the two time periods differed significantly. The women were significantly more confiden t in their ability to use condoms during sexual activity.

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102 Table 28 Betweenand Within-Subject Effect on Condom Use duri ng Sexual Intercourse Refusing Sexual Intercourse df F MS p Between Subjects Intervention Group 1 15.11 323.5 .002* Error 87 (21.4) Within subjects Time of Assessment 1 36.43 240 .001* Time by Group 1 19.60 130 .001* Error (Time) 87 (6.63) Note Values enclosed in parenthese s represent mean square errors. In summary, the interaction between th e time of assessment (pretest versus posttest) and group was statistically significan t for the subscales for self-efficacy of protective sexual behavior from sexually transmitted infect ions. Therefore, hypothesis number three was supported. Table 29 depicts the ranking of items on the self-efficacy subscale for the “ability to refuse sexual intercourse” for the experi mental group at pretest. For each item, participants indicated how sure they were of their ability to perform or refuse to perform the specified activity of refusing sex based on a 5-point Likert scale ranging from 1, “not at all sure” to 5, “very sure.” Study participan ts were not “very sure” if they could refuse

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103 sex with partners they have da ted a long time; with someone th ey want to date again; and with someone with whom they ha ve already had sexual intercourse. Table 29 Ranking of Items for the Self-Efficacy Subsca le “Ability to Refuse Sexual Intercourse” Experimental Group Pretest Score Ability to Refuse Sexual Intercourse Pretest Most common ranking Second most common ranking Third most common ranking Fourth most common ranking Fifth most common ranking 1. With someone you have known for a few days or less 5 (62%) 1 (13%) 3 (11%) 2 (9%) 4 (6%) 2. With someone whose sex and drug history is not known to you 5 (38%) 4 (23%) 3 (17%) 1 (15%) 2 (6%) 3. With someone you have dated a long time 4 (28%) 3 (26%) 2 (23%) 5 (13%) 1 (11%) 4. With someone you want to date again 3 (36%) 4 (23%) 2 (20%) 5 (15%) 1 (6%) 5. With someone with whom you have already had sexual intercourse 4 (30%) 2 (26%) 3 (24%) 5 (13%) 1 (9%) 6. With someone whom you want to fall in love with you 5 (28%) 4 (26%) 3 (26%) 1 (13%) 2 (9%) 7. With someone who is pushing you to have sexual intercourse 5 (38%) 4 (19%) 1 (195) 3 (13%) 1 (11%) 8. With someone, after you have been smoking marijuana 5 (32%) 1 (24%) 4 (21%) 3 (13%) 2 (11%) 9. With someone, after you have been drinking alcohol 5 (32%) 3 (24%) 2 (17%) 1 (15%) 4 (13%) Note. 1 = not at all; 2 = a little sure; 3 = somewhat sure; 4 = pretty sure; 5 = very sure Table 30 displays the posttest ranking of items for the self-efficacy subscale for “refusing sexual intercourse.” After bei ng exposed to the education/behavioral

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104 intervention women were very likely to be “pretty sure” on all but one item relating to their ability to “refuse sexual intercourse.” Table 30 Ranking of Items for the Self-Efficacy Subscale “Ab ility to Refuse Sexual Intercourse” Experimental Group Posttest Score Ability to Refuse Sexual Intercourse Posttest Most common ranking Second most common ranking Third most common ranking Fourth most common ranking Fifth most common ranking 1. With someone you have known for a few days or less 5 (89%) 4 (9%) 1 (2%) 2 (0) 3 (0) 2. With someone whose sex and drug history is not known to you 5 (66%) 4 (30%) 3 (4%) 2 (0) 1 (0) 3. With someone you have dated a long time 5 (68%) 4 (32%) 3 (0) 2 (0) 1 (0) 4. With someone you want to date again 5 (62%) 4 (38%) 3 (0) 2 (0) 1 (0) 5. With someone with whom you have already had sexual intercourse 5 (66%) 4 (43%) 3 (0) 2 (2%) 1(0) 6. With someone whom you want to fall in love with you 5 (76%) 4 (23%) 3 (0) 2 (0) 1 (0) 7. With someone who is pushing you to have sexual intercourse 5 (83%) 4 (17%) 3 (0) 2 (0) 1 (0) 8. With someone, after you have been smoking marijuana 5 (77%) 4 (23%) 3 (0) 2 (0) 1 (0) 9. With someone, after you have been drinking alcohol 5 (77%) 4 (23%) 3 (0) 2 (0) 1 (0) Note. 1 = not at all; 2 = a little sure; 3 = somewhat sure; 4 = pretty sure; 5 = very sure

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105 Table 31 displays the pretest ranking of items for the self-efficacy subscale “ability to question potential sex partners.” The most common ranking by participants on items relating to their ability to question poten tial sex partner was “very sure” at pretest. Table 31 Ranking of Items for the Self-Efficacy Subs cale “Ability to Qu estion Potential Sex Partners” Experimental Group Pretest Score Ability to Question Potential Sex Partners Pretest Most common ranking Second most common ranking Third most common ranking Fourth most common ranking Fifth most common ranking 1. Ask your boyfriend if he has ever injected drugs such as heroin or cocaine into his veins 5 (60%) 4 (15%) 3 (15%) 2 (9%) 1 (2%) 2. Discuss preventing AIDS or STIs or pregnancy with your boyfriend 5 (60%) 4 (19%) 3 (17%) 2 (2%) 1 (2%) 3. Ask your boyfriend about sexual relationships that he has had in the past 5 (51%) 4 (26%) 3 (15%) 1 (7%) 2 (6%) 4. Ask your boyfriend if he has ever had anal intercourse 5 (43%) 4 (34%) 2 (13%) 3 (11%) 0 (0) 5. Ask your boyfriend if he has ever had an STI 5 (51%) 4 (26%) 3 (20%) 1 (2%) 2 (2%) Note. 1 = not at all; 2 = a little sure; 3 = somewhat sure; 4 = pretty sure; 5 = very sure

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106 Table 32 displays posttest ranking of ite ms for women’s reported “ability to question potential sex partners.” Women were “very sure” in their confidence in questioning sex partners about se xual matters at pretest and po sttest for the experimental group. Table 32 Ranking of Items for the Self-Efficacy Subs cale “Ability to Qu estion Potential Sex Partners” Experimental Group Posttest Score Ability to Question Potential Sex Partners Posttest Most common ranking Second most common ranking Third most common ranking Fourth most common ranking Fifth most common ranking 1. Ask your boyfriend if he has ever injected drugs such as heroin or cocaine into his veins 5 (91%) 4 (6%) 2 (2%) 1 (0) 3 (0) 2. Discuss preventing AIDS or STIs or pregnancy with your boyfriend 5 (87%) 4 (13%) 3 (0) 2 (0) 1 (0) 3. Ask your boyfriend about sexual relationships that he has had in the past 5 (89%) 4 (11%) 3 (0) 2 (0) 1 (0) 4. Ask your boyfriend if he has ever had anal intercourse 5 (81%) 4 (17%) 3 (2%) 2 (0) 1 (0) 5. Ask your boyfriend if he has ever had an STI 5 (85%) 4 (15%) 3 (0) 2 (0) 1 (0) Note 1=not at all, 2= a little sure, 3= some what sure, 4= pretty sure 5= very sure

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107 Table 33 depicts the pretes t ranking of items from the self-efficacy subscale, “ability to question condom use. ” Ranking of items relating to the ability to question sex partners about drug use, past relationships, engaging in anal sex, or past STI exposure does not appear to be an issue for women. Women reported being “very sure” (5) about such behaviors as getting the money to buy condoms and going into the store and purchasing the condoms. Furthermore, wome n were “very sure” (5 ) they possessed the ability to use the condom correctly. Table 33 Ranking of Items for the Self-Efficacy Subs cale “Ability to Question Condom Use” Experimental Group Pretest Score Ability to Question Condom Use Pretest Most common ranking Second most common ranking Third most common ranking Fourth most common ranking Fifth most common ranking 1. Use a condom correctly 5 (62%) 4 (30%) 3 (6%) 2 (2%) 0 (0) 2. Use a condom every time you had sexual intercourse 4 (45%) 5 (23%) 2 (17%) 3 (13%) 1 (2%) 3. Use a condom during sex after you have been drinking 5 (47%) 5 (23%) 2 (17%) 3 (13%) 1 (2%) 4. Use a condom during sex after you have been using marijuana 5 (51%) 4 (23%) 2 (11%) 1 (9%) 3 (6%) 5. Insist on using a condom during sex even if your boyfriend does not want to use a condom 5 (34%) 4 (32%) 3 (15%) 2 (11%) 1 (9%) 6. Refuse to have sex if your boyfriend will not use a condom 5 (28%) 4 (26%) 3 (26%) 2 (15%) 1 (6%) 7. Get the money needed to buy condoms 5 (60%) 4 (24%) 3 (11%) 1 (6%) 2 (2%) 8. Walk into a store and buy condoms 5 (64%) 4 (17%) 1 (6%) 2 (2%) 3 (0) Note. 1 = not at all; 2 = a little sure; 3 = somewhat sure; 4 = pretty sure; 5 = very sure

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108 Table 34 displays posttest ranking of wo men’s “ability to question condom use.” Women were confident in thei r ability practice prevention be haviors every time they have sexual intercourse. Table 34 Ranking of Items for the Self-Efficacy Subs cale “Ability to Question Condom Use” Experimental Group Posttest Score Ability to Question Condom Use Posttest Most common ranking Second most common ranking Third most common ranking Fourth most common ranking Fifth most common ranking 1. Use a condom correctly 5 (89%) 4 (11%) 3 (0) 2 (0) 1 (0) 2. Use a condom every time you had sexual intercourse 5 (72%) 4 (23%) 2 (4%) 3 (0) 1 (0) 3. Use a condom during sex after you have been drinking 5 (81%) 4 (19%) 3 (0) 2 (0) 1 (0) 4. Use a condom during sex after you have been using marijuana 5 (83%) 4 (17%) 3 (0) 2 (0) 1 (0) 5. Insist on using a condom during sex even if your boyfriend does not want to use a condom 5 (77%) 4 (23%) 3 (0) 2 (0) 1 (0) 6. Refuse to have sex if your boyfriend will not use a condom 5 (77%) 4 (23%) 3 (0) 2 (0) 1 (0) 7. Get the money needed to buy condoms 5 (94%) 4 (6%) 3 (0) 2 (0) 1 (0) 8. Walk into a store and by condoms 5 (87%) 4 (11%) 1 (2%) 2 (0) 1 (0) Note. 1 = not at all; 2 = a little sure; 3 = somewhat sure; 4 = pretty sure; 5 = very sure

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109 In summary, Tables 29 through 34 summari zed the rankings of how women in the education intervention projected confidences in specific items relating to sexual selfefficacy. For example, women were “ver y sure” that they could use a condom consistently with their sex partners. Th e posttest ANOVA results showed that women were educated on the importance of consis t condom use and likely to use condoms consistently during sexual encounters. Cons istent condom use is a key factor in the prevention of contracting and spreading sexually transmitted infections.

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110 Chapter Five Discussion, Conclusions, and Recommendations Introduction This final chapter presents a synthesis of the research results, with a discussion of the findings, conclusions, implications and recommendations for future investigation. This study endeavored to demonstrate that br ief yet comprehensive sexually transmitted infection prevention education presentations can augment knowledge, perceived risk, and self-efficacy for STI prevention. This study also sought to explore whether a diverse sample of pregnant and n onpregnant women of childbear ing age increased their STIrelated knowledge, perceived risk, and self-e fficacy behavior toward the prevention of STIs, as a result of participat ing in this education/behavior al intervention. The research also investigated the reliability of the STIKS and Perceived Risk Survey. Summary of the Study This study used an experimental design to determine whether pa rticipating in an educational program has a positive effect on knowledge, perceived risk, and self-efficacy for sexually transmitted infection prevention. An experimental two-group randomized control pretest/posttest research design was used to test the hypotheses. The sample included 89 pregnant and nonpre gnant women meeting the crite ria of 15 to 48 years of age, ability to read, write, and speak the E nglish language at the seventh-grade level, and the ability to provide informed consent or as sent as a minor. All participants completed

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111 the Demographic Data Form, Sexually Transm itted Infection Survey (STIKS), Perceived Risk of Sexually Transmitted Infection Behavior Survey and the Sexual Self-Efficacy for Sexually Transmitted Infection Survey. The pretest surveys were completed in a comfortable room in the three county health de partments while the participants waited to be seen by healthcare providers. Posttest, i. e., completion of the same surveys a second time, occurred during the client’s next schedu led clinic visit or at a time agreed upon by the primary investigator and the client. The participants in the control group were also asked to complete the surveys two times: (1) at baseline and (2) af ter a four-week period. Measurements from the control group were us ed to compare outcomes of the educational intervention between the two groups. The control group participants were also offered the education intervention after completion of the posttest at a time agreed upon by the investigator and the client. Very few (5) took advantage of this opportunity. Descriptive data were obtained for th e demographic data reflecting means, percentages, ranges, frequencie s, and standard deviations. The sample included 13 (14%) pregnant and 76 (85%) nonpregna nt women. The mean age of the study participants was 29 years. This was a diverse population with most of the study participants being African-American, never married, and employed full time. A large number had an annual income of less than $5,000. More than ha lf of the sample (60%) had some college or were working toward a college degree. To determine whether the STI preventiv e education/behavi oral intervention increased STI knowledge, perceived risk of se xually transmitted infection behavior, and STI preventive behavior, three hypotheses were proposed. Analysis of variance was used

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112 to determine within-group and between-group di fferences and to test for interaction of time and treatment group. The reliability and validity of the Sexually Transmitted Infection Survey (STIKS) and the Perceived Risk of Sexually Transmitted Infection Behavior Survey were also investigated. Discussion and Conclusion The following is a discussion of the fi ndings according to the hypotheses in the study, with the conclusions that may be drawn from this research study then presented. This research is imperative because it demonstrated the efficacy of an education/behavioral intervention for a nationa l health problem in a diverse population of women. Sexually transmitted infection knowle dge, perceived risk, and sexual selfefficacy are imperative constructs to be inves tigated in women of childbearing age. This research study sought to examine whethe r participating in an STI preventive education/behavioral intervention had a posit ive effect on knowledge, perceived risk and sexual self-efficacy, as predictors to engage in preventive behaviors. The sample selection for this study was purposeful, as it in cluded women of childbearing age, a group currently at greatest risk for sexually transmitted infections (Shrier et al., 2001; Page-Shafer et al., 2002; Von Sadovszky, 2002). All participants in this research study were women of child bearing age (15-48 y ears). The majority of the study participants were African-American, fulltime or part-time students seeking familyplanning, prenatal or primary-care services at a Florida health unit. The response rate was good; only 18 women were lo st to attrition. This st udy is unique in that few investigations have tested an interven tion on a diverse population of women seeking reproductive health care service.

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113 The first hypothesis was tested usin g ANOVA to determine changes in STIrelated knowledge as a consequence of pa rticipating in an education/behavioral intervention. Pre-interv ention knowledge (prevention, screening, treatment, and symptoms) of STIs indicated that the majority of the participants in this research study were unacquainted with the risk factors and behaviors for acquiring sexually transmitted infections. These findings are consistent with previous research relating to women’s lack of STI knowledge, particularly during pregnancy (Gray et al ., 2001; Mahon et al., 2002; Ramus, 2001). The results of testing this hypothesis es tablished an increase in STI knowledge. Subjects who participated in the STI-preventiv e intervention had a significant increase in STI knowledge, and its associated pregnancy risks and sequelae for female reproductive health. The findings support previous investig ations that brief educational interventions can influence knowledge of STIs (Johnson et al., 2003; Jolley, 2001; Va n Devanter et al., 2002). The noted increase in STI knowledge sc ores indicated that women of childbearing age gained knowledge of risk factors relating to the asym ptomatic nature of STIs, possible danger to the unborn fetus, and preven tive behaviors. Thes e results, relating to the first hypothesis, confirmed that introduction of brief educ ational interventions related to sexually transmitted infections targeted at increasing knowledge and sexual selfefficacy could be effective in areas heavily populated with African-American women of childbearing age. The results were significan t in that the theory based logic model and constructs related to the ach ievement of self-efficacy, provi ded effective strategies for STI prevention among African-American women. Data showed that women needed and were able to obtain knowledge on decreasing personal risk for STI. Even though there

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114 appears to be a plethora of information avai lable on STI prevention, a gap remains in that persons most burdened with STIs do not a ppear to be receiving the information. The theory based intervention and culturally sens itive approach for this intervention could serve as a model for other researchers and health care providers to teach safer-sex strategies acceptable among African-Ame rican women of childbearing age. The second hypothesis was tested usi ng ANOVA to determine changes in perceived risk as a result of participating in the education/behavi oral intervention. No significant treatment effect on perceived risk resulted from the education/behavioral intervention. The interaction effect of the mean for perceived risk revealed that the treatment group changed rather modestly between pretest and posttest. A possible explanation for this modest change between groups could be that as a group, they exhibited confidence in identifying perceive d risk among their potential and actual sex partners. Another possible cont ributing factor may be the lo w reliability of the survey instrument to measuring perceived risk of STIs. The low alpha score (.605) of the Perceived Risk for Sexually Transmitted In fection Survey further supports this possibility. A possible solution would be to include additional items to assess more clearly the constructs of perceived risk, thus increasing reliability. The Perceived Risk for Sexually Transmitted Infection Survey instrument should be revised and retested in future studies. The modest enhancement of perceive d risk by this education/behavior intervention was supported by other research studies (Ducan, Hart, Scoular, & Brigrigg, 2001). In the current study, participants exhi bited relatively low perceived risk at both preand posttest. This finding may reflect that women do not recognize risk for STIs,

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115 especially with their main sex partner. Th e issue of main partner is important because perceived risk is a complex variable that may incorporate both subjects’ perceived risk and their perception about the ri sk they are exposed to as a result of the sexual risk of their spouses or other partners. Inclusion of the male sex partner in the intervention may play a significant part in increased perceived ri sk in the couple. However, the goal at this time was to increase a woman’s perceived ri sk by increasing knowledge and self-efficacy to encourage protective behavior s for herself to prevent transm ission of STIs to herself or an unborn fetus. Taking this data into consid eration when revising the intervention could be crucial. Placing an empha sis on perceived risk may chan ge behavior by increasing mastery of information and boosting the possibi lity of adopting new behaviors, and in so doing, translating information into increased perceived risk of sexually transmitted infections. Lacking personal experience w ith and worrying less about health threats especially among adolescent may be significant pr edictors of more sanguinely biased risk perception. Also, as evidenced by the relative insignificant in crease in perceived risk of sexually transmitted infections in the mean s of the educational intervention group as compared to the control group, statistical trea tment of the data suggests that Hypothesis 2 was unsupported. However after a logical examin ation of the analysis, it may be feasible to establish support for insignificant changes in perceived risk between the intervention and control groups. That is, if one’s know ledge is enhanced and their overall selfefficacy is improved, then it may prove likely th at the perception of risk remains constant (perceived as no more risky) because of improved individual understanding of sexually transmitted infections and better preparation in prevention of contraction of sexually transmitted infections. These circumstances may explain the relatively unchanged means

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116 between the education interv ention group and the control group. Also, there may be other explanations such as cu ltural or subcultural factors that contribute to notions of vulnerability as related to ri sks of contracting sexually transmitted infections. For example, acceptance of practices of polygamy and tolerance of unfaithful partners may lead to perceived risks remaining elevated with diminished regard to knowledge or efficaciousness. The third hypothesis was tested using ANOVA to determine changes in sexual self-efficacy as a result of participating in th e STI education/behavior intervention. Selfefficacy is an important construct influenci ng a wide range of potential behaviors. Overall, the subscales measuring self-efficacy were found to increase significantly in the intervention group as compared to the control group. The constructs of self-efficacy and knowledge, regarding sexual matters, and beha vior intentions were measured by the Sexual Self-Efficacy Survey. Study participants were asked to rate how confident they were that they could perform 22 behavior s comprising 3 domains: (a) refusing sexual intercourse, (b) questioning potential sexual partners, and (c) using condoms. Through ANOVA, the effectiveness of the interven tion on self-efficacy was determined by assessing changes in self-efficacy behavior in the three domains. This was accomplished by exploring women’s perceptions of how hard it is to carry out various tasks associated with safer sex such as refusing sexual inte rcourse; using condoms; refusing intercourse with persons not well known; discussing AIDS pregnancy, and injection drug use with a partner; and being able to purchase condoms. The changi ng of increased sexual selfefficacy scores were higher during posttest in the intervention group shows that the intervention was effective.

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117 The education/behavioral intervention, ba sed on a logic model and constructs from Social Cognitive Theory, made a difference in sexual self-efficacy. This finding is similar to previous research supporting the use of the social cognitive model and the construct of self-efficacy in the usefulness of education and behavioral change targeted at safer sexual activities (Cecil & Pinke rton, 1998; Crosby, 2002; Von Sadovsky, 2002). The current intervention study provided informa tion that apparently increased awareness of the consequences of behavior and incr eased self-regulative skills development that translated the knowledge in to preventive action. The data from the intervention showed in creased sexual self-efficacy in a diverse group of women. The intervention can therefor e be used to guide the development of culturally sensitive sexual behavior messages for women who need assistance in developing sexual communication and self-asse rtiveness skills. Although STIs pose a significant health threat to all women, African-American women are disproportionately affected, and therefore, enhanced prevention efforts specially tailor ed for this population are particularly important. Health care providers could eval uate women’s selfassessment skills as a means of helping them to determine their levels of self-efficacy for engaging in sexual self-p rotective behaviors and then base education opport unities on this assessment. Studies have not consistently found the psychological assessments such as knowledge, attitudes toward condom use, a nd self-efficacy statistically significant (Crosby et al., 2003) whereas this study f ound that self-efficacy for condom use was statistically significant. Other studies have linked knowledge with preventive behaviors. Siegel, Aten, and Enaharo (2001) reported an interventi on study that translated knowledge into

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118 preventive action, resulting in increased knowledge and self-efficacy to behave in sexually safer ways. It could be deduced that the education/behavior intervention introduced new and “easier said than done” sa fe sexual behavior, at the same time increasing sexual self-efficacy. Significant treatment effect was observed for subjects exposed to the education intervention as indicated by increased mean score for selfefficacy at posttest. The association between participation educa tion interventions and significant changes in self-efficacy is a finding shared by other researchers (Diloris et al., 2000; Siegel, Aten & Enaharo 2001). This is an important finding since it has been established in previous research and suppor ted in this research study that significant treatment effects occur in relati onship to increased knowledge. Since this education intervention was deliv ered in a relaxed, brief format, it may have been non-threatening a nd supportive of the individual learning styles. Encouraging study participants to read the information br ochure may have been helpful in increasing the intervention outcome of increased sexua l self-efficacy. The improvement of sexual self-efficacy mean scores by this education/beha vioral intervention is an important result, validating the education/be havioral intervention. In summary, this study employed an expe rimental, pretest/posttest, control-group design. Descriptive data for the sample were obtained with frequencies, percentages, means, standard deviations, and ranges. To determine whether the STI preventive behavioral/educational intervention increased knowledge, perceived risk and self-efficacy through participation in an education/be havior intervention, three hypotheses were proposed. ANOVA was utilized to dete rmine within-group and between-group differences and to test for th e interaction of time and treatm ent group. The reliability of

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119 two investigator-developed survey instrume nts (Perceived Risk of Sexually Transmitted Infection Behavior Survey, and the Sexually Transmitted Infection Knowledge Survey) was also investigated. Implications for Nursing The findings of this study indicate d that nurse-directed, theory-based education/behavioral interventi ons can effect change in ST Is for a diverse population of women. Since African-American women were in attendance in large numbers during the educational/behavioral intervention, the findi ngs may indicate that the intervention was also culturally appropriate for African-American women. Replicating this study in settings highly populated with African-American women seek ing health care may prove beneficial in lower STIs. There is also need for development of re liable, valid, and cult urally sensitive and appropriate instruments that assess or measur e constructs and beha viors related to STI prevention. The findings of this study may a ssist providers of women’s health care in anticipating questions where answers may not a ppear evident in current practice settings. Educating women about STIs could include brief interventions such as explaining literature in a simple and dire ct manner as well as fost ering trusting patient/provider communication throughout the health-seeking encounter. These findings add to the growing body of literature that reports pa tient/provider encounters are brief and communication of health promoting concepts mu st be conveyed clearl y and with brevity. It cannot be assumed that women previously seen by health care providers received informative instructions targeted at increasi ng knowledge of and prev entive behavior for

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120 sexually transmitted infections. Patients require information, along with appropriate treatment. Helping the patient to understand an STI diagnosis is important in allaying possible fears. The findings also indicate the importan ce of women’s health care providers in reinforcing sexually transmitted infection in formation during clinical encounters with clients. Health care providers and women are challenged to recogni ze critical points in at-risk situations such as exposure to ST Is. Women need to understand that STIs contribute greatly to morbidity associated with reproductive hea lth, including pelvic inflammatory disease, infertility, ectopic pregnancy, chronic pelvic pain, compromised birth outcomes, and cervical cancer. Health ca re providers in a vari ety of settings play major roles in the management of STIs. Th ese care providers should attempt to ensure that their clients have a good understanding of treatment opt ions and relevant health education information about the prevention of STIs. Testing a nursing intervention has a po tential influence on women’s health by eliminating knowledge gaps and adding to evidence-based practi ce. Creative nursedirected interventions could give power to women with knowledge to perceive STI risks and to take personal action at circumventing high-risk behaviors. This study’s results confirmed that introduction of brief educat ional interventions related to sexually transmitted infections targeted at increasing knowledge could be effective. The findings of this study corroborate previ ous investigations that brief educational interventions can influence knowledge of STIs a nd increase sexual self-efficacy.

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121 Recommendations for Future Study Based upon the review of relevant studies and this study, the following recommendations are made for future research. 1. Replicate this research study with a larg er sample, following subjects for a longer time period and providing exposure to intervention several times. 2. Since the study represents only wome n accessing north Florida county health departments, research whether the results may be generalized to women in other geographic locations. 3. Investigate STI knowledge among men a nd heterosexual couples of diverse cultural/ethnic backgrounds with a goal of generating new findings and prolonged behavior changes. 4. Investigate variables such as work experience, age, and maturity level that could contribute to individual di fferences in response to th e STIKS and Perceived Risk surveys. 5. Replace or revise the Percei ved Risk of Sexually Transmitted Infections Behavior Survey to include more questions (lengt hen the survey) that may strengthen the reliability and add to construct validity of the survey. 6. Refine the intervention to make it more accessible, cost effective, and easily implemented, while incorporating and testing theoretical concepts relating to increasing perceived risk. Seek funding to deliver the interv ention through video technology and research the eff ectiveness of such delivery.

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122 7. Recruit a more diverse population of women (e.g., Spanish-speaking) to investigate STI knowledge and preventive behaviors. Furthermore, obtaining a larger sample would refine testing of the STIKS survey. 8. Initiate a longitudinal study that would a llow measurement of the critical distal outcomes identified in the study to determ ine if knowledge was retained long term and resulted in sustained be havioral change related to increased perceived risk and increased sexual self-efficacy. 9. Qualitative research may be useful in identifying additional individual perceptions and behaviors associated with STI pe rceptions and preventive behaviors. 10. Develop an STI awareness program for nurses and health care providers about STIs and preventive behaviors to estab lish lifelong healthy STI practices among women.

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126 Devonshire, P., Hillman, R., Capewell, S., Cl ark, B., & Brian J., ( 1999). Knowledge of chlamydia trachomatis genital infection and its consequences in people attending a genitourinary medicine clinic. Sexually Transmitted Infections. 75 (6):409-411 DiClemente, R., Wingood, G., Crosby, R., Cobb, B ., Harrington, K., & Davis, S. (2001). Parent-adolescent communication and se xual risk behavior among African American adolescent females. The Journal of Pediatrics, 139 (3), 407-412. DiClemente, R., Wingood, G., Harrington, K ., Lang, D., Davies, S., Hook, Edward W., Oh, M., Crosby, R., Hertzberg, V., Gordon, A., Hardin, J., & Parker, S. (2004). Efficacy of an HIV prevention intervention for African American adolescent girl. JAMA, 292 (2). 171-179. Dilorio, C., William, D., Lehr, S., Soet, J., & Johanna, E. (2000). Correlates of safer sex communication among college students. Journal of Advanced Nursing, 32 (3), 658-665. Dilorio, C., Dudley, W., Soet, J., Watkins, J., & Maibach, E. ( 2000). A social cognitivebased model for condom use among college students. Nursing Research, 49(4), 208-214. Dixon-Woods, M., Stokes, T., Young, B., Ph elps, K., Windridge, K., & Shukla, R., (2001). Choosing and using services for sexual health: a qua litative study of women’s views. Sexually Transmitted Infections, 77 (5), 335-339. Domeika, M., Butylkina, R., Hallen, A., S pukaite, T., Juceviciute, V., Morkunaite, D.; Jakutiene, R., Paliuniene, V., Barakauskien e, J., Goberis, M., (2001). Prevalence of Chlamydia trachomatis infections in women attending six women's healthcare units in Kaunas, Lithuania. Sexually Transmitted Infections. 77 (6):459-460

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134 Rosengard, C., Adler, N., Millstein, S., Gurve y, J., Ellen, J., (2004). Perceived STD risk, relationship, and health va lues in adolescents' delayi ng sexual intercourse with new partners. Sexually Transmitted Infections. 80 (2),130-137 Sexton, J., Garnett, G., & Rottingen, J., (2005) Meta analysis and meta regression in interpreting study vari ability in the impact of sexua lly transmitted diseases on susceptibility to HIV Infection. Sexually Transmitted Diseases. 32 (6):351-357. Shain, R., Piper, J., Newton, E., Perdue, S., Ramos, R., Champion, J., & Guerra, F. (1999). A randomized controlled trial of a behavioral intervention to prevent sexually transmitted diseases among minority women New England Journal of Medicine, 340 (2) 93-100. Shrier, L., Ancheta, R., Goodman, E., Chi ou, V., Lyden, M., & Emans, S. (2001). Randomized controlled trail of a safer sex intervention for high risk adolescent girls. Pediatric & Adolescent Medicine. 155 (1), 73-79. Siegel, D., Aten, M., & Enaharo, M., (2001). Long term effects of a middle school and high school based human immunodeficien cy virus sexual risk prevention intervention. Pediatrics & Adol escent Medicine, 155 (10), 1117-1126. Stevens, A., Chauhan, Suneet P., Magann, E., Martin, R., Bofill, J., Cushman, J., & Morrison, J., (2004). Fetal fibronectin and bacterial vaginosis are associated with preterm birth in women who are symptomatic for preterm labor. American Journal of Obstetri cs & Gynecology. 190 (6),1582-1589. Stewart, K., DiClemente, R., Ross, D., ( 1999). Adolescents and HIV: Theory-based approaches to education of nurses. Journal of Advanced Nursing. 30 (3), 132-138. Stoner, B., Whittington, W., Aral, S., Hughes, J., Handsfield, H., & Holmes, K. (2003).

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136 Wang, Y., Davis, M., Robin, L., Collins, J., Coyle, K., & Baumler, E. (2000). Economic evaluation of safer choices: a school based human immunodeficiency virus, other sexually transmitted diseases, and pregnancy prevention program. Arch Pediatric Adolescent Medicine, 154 (10), 1017-1024. Weisbord, S. J., Koumans, E. H., Toomey, E. T., Camilla, G., & Markowitz, L. E. (2001). Sexually transmitted diseases during pr egnancy: Screening, diagnostic, and treatment practices among prenatal care providers in Georgia. Southern Medical Journal, 94 (1), 47-53. Weitz, B., (2001). Premature rupture of the fetal membranes: An update for advanced practice nurses MCN, Ameri c an Journal of Maternal Child Nursing. 26(2) ,8692. Whitehead, D. (2001). A social cognitive mode l for health education/health promotion practice. Journal of Advanced Nursing, 36 (3), 417-425. Whitehead, D. (2001). Health education, beha vior change and social psychology: nursing contribution to health promotion. Journal of Advanced Nursing, 34 (6), 822-832 Whitehead, D. (2001). A stage planning pr ogram model for health education/heath promotion practice. Journal of Advanced Nursing, 36 (2), 311-320. Williams, S., Norris, E., & Bedor, M. (2003) Sexual relationships, condom use, and concerns about pregnancy, HIV/AIDS, a nd other sexually transmitted diseases. Clinical Nurse Specialist. 17 (2), 89-94. Wilson, S., Brown, N., Chin, V., Levin, D., Y., Hu, P., & Lavori, P. (2004). Condom use by women recently diagnosed with a sexually transmitted infection: effects of

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137 study methodology on the apparent influen ce of hormonal/surgical contraception. Sexually Transmitted Diseases, 31 (12). 740-747. Wilson, E., Minkoff, H., McCalla, S., Pette rkin, C., & Jaccard, J. (1996). The relationship between pregna ncy and sexual risk taking. American Journal of Obstetrics and Gynecology, 174 (3), 1033-1036. Wong, E., Roddy, R., Tucker, H., Tamoufe, Ub ald M., Ryan, K., Ngampoua, F. (2005). Use of male condoms during and after random ized, controlled trial participation in Cameroon. Sexually Transmitted Diseases. 32 (5).300-307.

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138 Appendices

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139APPENDIX A: DEMOGRAPHIC DATA FORM

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140 Appendix A: (Continued)

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141 Appendix B: Sexually Transmitted Infection Knowledge Survey

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142 Appendix B: (Continued)

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144 Appendix C: Perceived Risk for Sexually Transmitted Infection Survey

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145 Appendix D: Sexually Self-Efficacy Survey

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146 Appendix D: (Continued)

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147 Appendix E: Consent to Use Instrument

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148 Appendix F: Research Site Consents

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149 Appendix F: (Continued)

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150 Appendix F (Continued)

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151 Appendix G: Institutional Review Board Approval

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152 Appendix G: (Continued)

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153 Appendix H: Informed Consent/Assent

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154 Appendix H (Continued)

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155 Appendix H (Continued)

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156 Appendix H: (Continued)

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162 Appendix H: (Continued)

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163 Appendix H: (Continued)

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164 Appendix I: An STI Knowledge/B ehavior Intervention for Women A Sexually Transmitted Infection Knowledge/ Behavior Intervention for Women Overall Goal: The overall goal is to educate women on sexua lly transmitted infecti ons and to offer ways to strengthen perceived risk and self-efficacy for the prevention of sexually transmitted infections. Specific Objectives: 1 To educate women on the importance of knowing and understanding the transmission, symptoms and prevention of sexually transmitted infections. 2 To empower women by making them an ac tive participant in the prevention of sexually transmitted infections. 3 To provide tailored communications and e ducational material that may improve women’s knowledge and understanding of sexually transmitted infections. 4 To increase self-efficacy by enc ouraging women to focus on individual convections so that they can exercise c ontrol over their motivation, behaviors and sexual environment (i.e. condom use). 5 To assist women to recognize that she is at risk for STIs and assist her to learn ways to take action to prevent the expos ure to sexually transmitted infections. 6 To strengthen knowledge, perceived ri sk and self-effica cy through vicarious modeling from each other during the open discussion.

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165 Appendix I (Continued) Script for Intervention A Sexually Transmitted Infection Knowledge / Behavior Intervention for Women Background Information This intervention is targeted for women of childbearing age. This intervention is intended to assist with the effort on preventi ng sexually transmitted infections (STIs). An educational intervention, based on up to date research-based STI knowledge and guidelines from the Centers for Disease Control (CDC) will be offered. The STI knowledge/behavior intervention is based on th e following major concepts: a) What are sexually transmitted infections; b) How are people affected by sexually transmitted infections; c) How can sexually transmitted inf ections be prevented; d) What can be done to treat sexually transmitted infections? This intervention is targeted at changing attitudes and increasing knowledge regarding sexually transmitted infection preventive behaviors. Specifically, the intervention is designed to increase women’s awareness and knowledge about their susceptibility to sexually transmitted infections, the severity of sexually transmitted infections, and the bene fits of gaining knowledge about preventive behaviors. The intervention will utilize a lecture and power point presenta tion addressing the above-mentioned concepts. An information brochure based on information from empirical data and CDC’s guidelines will be presented following the lecture/ power point presentation. The brochure provides inform ation about how women can be affected by sexually transmitted infections and informati on about what can be done to treat and prevent sexually transmitted infections. Educational materials tailored for participants

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166 Appendix I (Continued) with low literacy skills (defined as 8th grade reading level) facil itate greater improvement in knowledge, attitudes and self -efficacy (Frontenberry et al 2001) Open discussion will be encouraged with time allowed for a question and answer period following the introduction of the brochure. The lecturer will summarize the content matter delivered during the seminar following the question and answer period to reinforce teaching and learning objectives. The proposed intervention has been de signed to provide information about sexually transmitted infections as well as suggest behavior changes that can reduce a woman’s risk of contracting th ese infections. It has been suggested that educational interventions often produce changes in know ledge but do not produce changes in health behavior unless additional steps are taken to link changes in attitudes and beliefs to behavior. To facilitate behavior change, partic ipants will be provided with written guidelines in the form of an information br ochure to assist them in evaluating their knowledge of sexually transmitted infection an d to reinforce the information presented during the knowledge/behavior intervention. Th e information brochure can read at their leisure at least three times weekly. The br ochure was developed from content within the intervention. The following script summari zes the content matter of the lecture and power point portion of the intervention. Comm ents in italic font summarize the aim of the interventions.

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167 Appendix I (Continued) Introductory Comments Advancements are being made daily by researchers that will help women live longer, healthier more productive lives. Re grettably, for women a ffected by sexually transmitted infections, quality of life can be decreased. Taking care of your health is imperative. Women need to take steps to in crease their awareness of sexually transmitted infections (perceived risk of STI: aimed at impr oving self-efficacy and beliefs regarding STI). There are steps that women can take to prevent and treat sexually transmitted infections. This discussion will help you decide if you are at risk for contracting sexually transmitted infections and will provide useful information on prevention, diagnosis, and treatment of sexually transmitted infection (aimed at changing beli efs and attitude about STIs; increasing perceived risk of STIs). Defining the disease. Sexually transmitted infections are contagious infections contracted by unprotected sexual intercourse Women can become infected with gonorrhea, syphilis, herpes simplex virus (HPV ) and chlamydia after a single exposure. Women are also twice as likely as men to become infected with these pathogens (aimed at changing beliefs and perceived risk regarding the susceptibil ity to and severity of STI by increasing knowledge, power point depi cting these pathogens will be shown and described to provide a vivid representation). Affects of STIs. Sexually transmitted in fections are silent diseases that can progress in women without wa rning or symptoms for many years. You may not know you have a STI until you attempt to have children and find that you cannot due to

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168 Appendix I (Continued) reproductive scaring. Once reproductive orga n scaring has occurred, your fertility (ability to have a baby) is lowered or maybe non e existent. That is way it is so important for you know about sexually transmitted infections (aimed at changing behaviors and increasing knowledge by using fear applic ation to change sexual behaviors and increasing perceived risk regarding susceptibility to STIs). Magnitude of the problem Previous research has provided use with a lot of information about sexually transmitted inf ections and we learn more everyday. For example, we know that 46% of the 5 million in cidences of sexually transmitted infections diagnosed are diagnosed in women of childbe aring age. We know that chlamydia is a leading cause of reproductive morbidity in women. We also know that gonorrhea has been shown to ascend into the female genita l tract attached to motile sperm. We know that bacterial vaginosis has been linked to high risk of spontaneous abortions, preterm birth, preterm premature rupture of membranes and postpartum endometritis (information brochure will be given to all intervention participants. In half of the brochures, neon orange color dot will be included. Those participants whose brochures contain this orange dot will be asked to hold up their brochure. The purpose of this exercise is to provide a representation of the 50% of wome n who will be affected by a sexually transmitted infection during th eir childbearing years. Anothe r 4% of the initial 50% of participants will have a green dot indicating the percentage of women who will not know they have a sexually transmitted infection. Women with green dots will be asked to hold up their brochures. Another four percent of participants will have an orange, green, and red dot These persons with three colored dots will be asked to hold up their brochure.

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169 Appendix I (Continued) This last group is a symbolic representa tion of the percentage of women who will be pregnant and have an undiagnosed, untreated ST I that could affect their pregnancy ). Educational materials such as information brochures tailored for participants with low literacy skills (defined as 8th grade reading level) facilitate greater improvement in knowledge, attitudes an d self-efficacy (Front enberry et al 2001) Presentation of Risk Factors Protecting yourself from sexually tran smitted infections requires a lifelong approach. Sexually transmitted infections can occur at any time. Certain risk factors increase your likelihood of being affected by sexually transmitt ed infections. That is why it is imperative for women to know their risk a nd how the risk applies to her lifestyle on a normal basis. Accordingly self-appraisal can lead to improved self-effica cy. As report by Bandura self-efficacy behavior can be c hanged with the presentation of efficacy information. There are risk factors that you can cha nge. Today, we will discuss some of them. (Vicarious learning from discuss is the goal) The most reliable way to avoid being affected by a sexually transmitted infection is to abstain from sexual intercourse or to be in a long term, mutual monogamous relationship with an uninfected partner. Ho wever, if you become infected with a STI both partners should be tested for the STI and treated. If you choose to have sex with a partner whose infection statue s are unknown or infected with an STI, a condom should be used for each act of intercourse. The literature supports the utili ty of self-efficacy as a

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170 Appendix I (Continued) predictor of intending to use condoms (Cecil & Pinkerton, 1998). (Aimed at changing attitudes and beliefs regarding sexually transmitted infections and to increase knowledge of susceptibility to STIs). Sexually intercourse during pregnancy is also a time of potential exposure to sexually transmitted infections. STIs can ha ve debilitating effects on pregnant women, their partners, and their fetuses. All pre gnant women and their se x partners should be asked about STIs, counseled about the possibi lity of perinatal infections and ensured access to treatment, if needed. All pregnant women should be tested for syphilis. Penicillin G is the preferred drug treatment during pregnancy and for all stages of syphilis. Pregnant women with reported pe nicillin allergy should be desensitized and treated with penicillin ( aim at changing attitudes and perc eived risk regarding sexually transmitted infections and to increase knowledge of suscep tibility to STIs). Role of condoms Condoms work as a form of barrier to STI exposure Condoms are regulated by the FDA and are tested electronically for holes before packaging. Condom failure usually results from inconsistent or incorrect use rather than condom break age. Male condoms made of material other than latex are availa ble. However, they have had higher breakage and slippage rates when co mpared to latex condom. (Aim is to change attitudes and selfefficacy regarding STIs and to increase knowledge of susceptibly to STIs).

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171 Appendix I (Continued) Role of Female condom Female condom consists of a lubricated polyurethane sheath with a ring on each end that is inserted into the vagina and act as a barrier to STI exposure. Data regarding the use and efficacy of female condoms are in complete. However, if used consistently and correctly, the female condom may substantially reduce the risk for STIs. (Aim is to change self-efficacy and beliefs regarding STIs and to increa se knowledge of susceptibly to STIs). Role of pre-exposure Vaccination is one of the most effec tive method for preventing transmission of hepatitis B. Hepatitis B vaccination is r ecommended for all unvaccinated persons being evaluated for an STI ( Aim is to increase knowledge and decrease risk by changing perceived risk regarding STIs ). Role of dental dams, saran wrap, and latex gloves Persons wishing to reduce their risk for exposure during oral-a nal and oral-genial contact might consider using dental dams or similar barriers methods (saran wrap) for protection. Wearing latex gl oves during digital anal cont act along with washing hands and genital with warm soapy water during an d after activities that bring body parts in contact with feces might further reduce risk for STIs and illness (strategy to change behavior and decrease susceptibility and increase knowledge).

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172 Appendix I (Continued) Role of life style behaviors Use of illicit drugs, smoking, and drinking alcohol can increase your risk of contracting sexually transmitted infections by limiting inhibition. Being self-motivated and skillful in talking about STIs with your sex partners can decrease your exposure to STIs. Having a mutually monogamous rela tionship and agreement between the two partners in the relationship to tell each othe r if either one has sexual relations with someone else has positive affects on d ecreasing your personal risk to STIs (aimed at changing perceived self-efficacy and perceive d risk regarding STI and to increase knowledge and decrease susceptibility to STIs). Preventive Measures Now that you know what the risk factor s for STIs are, you can take steps to protect yourself against the infections. Taking steps to prevent being affected by STIs are critical (preventive measures discussion is aimed at increasing perceived risk and by increasing knowledge of preven tive behaviors and methods to adopt these behaviors into normal lifestyle). Condoms When used consistently and correctly, male and female latex condoms lines the vagina, traps semen and is then discarded. A few recommendations to ensure proper use of a male condom include: using a new condom with each act of sexual intercourse, (e.g., oral, vaginal, and/or anal) handling the condom carefully as to avoid damaging it with fingernails, teeth, or other sharp objects; pu tting the condom on after the penis is erect

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173 Appendix I (Continued) and before any genital contact; using water base lubricant like ky jelly not oil base lubricants like petroleum jelly or massage o ils that can weaken latex; and withdrawing while the penis is still er ect to prevent slippage. Here is an illustration of a female and male condom. Hepatitis B vaccination The hepatitis B vaccination is given in a series of three doses over a 6-month period. Vaccination during pregnancy is not thought to pose risk to the fetus. To decrease transmission of the virus, women with hepatitis B or who test positive for the virus should maintain high levels of persona l hygiene (e.g., wash hands after using the toilet, carefully dispose of tampons, pads, ba ndages in plastic bags ; do not share razor blades, toothbrushes, needles, or manicure sets; have male partners use a condom; avoid sharing saliva through kissing). Behavior Modification The following behavior modifications can assist in decreasing your exposure to sexually transmitted infections. This information is based on Bandura’s definition of the four sources for efficacy information (mas tery, vicarious learning, verbal persuasion, and autonomic arousal). 1). Not using illicit drugs, smoki ng, and drinking alcohol before engaging in sexual intercourse. 2). Being self-motivated and skillful in talking about STIs prevention with your sex partners. 3). Having a mutually monogamous sexually relationship can also decrease your exposure to STIs.

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174 Appendix I (Continued) Dental Dams Dental dams can reduce your risk for e xposure during oral-genial contact by preventing saliva to mucous membrane contact. Wearing latex gloves during digital anal and good hand washing might further reduce risk for STIs. An illustration of a dental will be presented. Diagnosis and Treatment Bacterial STIs are easily dia gnosed from genital tract, ur ine, and blood studied. Viral agents can also be cultured, but less successfu lly. Because women often are infected with more than one STI and many are asymptomatic, additional laboratory test may be done. Effective treatment includes taking all the medication and not stoppi ng even if symptoms diminish or disappear in a few days. Y ou should refrain from intercourse until all medication is finished and you have been back to your health care provider. You should also continue using condoms to prevent re peated infections. You should avoid having sex with a partner who has ma ny other sexual partners. In many instances your sexual partner should be treated and sometimes it is difficult to tell him. I suggest you say to him “I care about you and I’m concerned about you. That’s why I’m calling to tell you that I have a sexually transmitted disease. My clinician is and he/she will be happy to talk with you if you would like.” Treatment of specific STIs maybe different for the pregnant women and may even be different at different st ages of pregnancy. Let’s take some time to reflect silently about a

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175 Appendix I (Continued) time you may have been exposed to an ST I and how you now have the knowledge to minimize your risk if you encount er such a situation again. I thank you for your time and interest in this discussion.

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176 Appendix J

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177 Appendix J: (Continued)

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178 About the Author Versie Johnson-Mallard is a native of Fl orida. Versie received her BSN from Florida A&M University. She received her MS N from the University of Florida. Her area of concentration was women’s health. Her research interest is in the area of behavior change in response to educatio n/behavioral intervention specifically “Knowledge Perceived Risk and self-efficacy of contracting Sexually Transmitted Infections”. Versie Johnson-Mallard received a pr estigious Kirschstein National Research Service Award, a fellowship from the National Institute of Nursing Research. Versie is a member of an international honor society, Sigma Theta Tau, and Florida A&M University Honor Society. She is also a me mber of the American Nurses Association, Southern Nursing Research Society, Associ ation of Women’s Health, Obstetric and Neonatal Nurses’, the Council of Advanced Practice Nurses. Versie is a board member of National Association of Nurs e Practitioners Women’s Health.