College students' sexual health information needs and source preferences in relation to worry about sexual health outcomes

Introduction

The sexual health of young people has become a particularly significant public health issue worldwide. Data from studies and international statistics (Center for Disease Control and Prevention, 2017; Da Ros and da Silva Schmitt, 2008; Public Health England, 2019) show that sexually active young people aged 15 to 24 years are at a higher risk of acquiring sexually transmitted infections than any other age group. Risky sexual behaviour and sexually transmitted infections in youth can have long-term consequences such as infertility (Tsevat et al., 2017) or cancer (Palmer et al., 2019). Increased rates of human papillomavirus infections are directly related to cervical cancer, which is the fourth most common cancer in women worldwide (International Agency for Research on Cancer, 2018). Furthermore, adolescents account for about 16 % of new Human Immunodeficiency Virus (HIV) infections in adults worldwide (UNICEF, 2018).

Croatia, where this study was conducted, is one of the European Union countries with a low level risk of contracting HIV or sexually transmitted infections, however an upward trend in the incidence of these diseases has been noted in recent years (European Centre for Disease Prevention and Control, 2019). In addition, studies on the risks of sexually transmitted infections carried out in Croatia confirm the particular vulnerability of young people. For example, the highest prevalence of human papillomavirus in Croatia is found among girls younger than 21 (Marijan et al., 2007) or 24 years (Milutin-Gašperov et al., 2007). A national study of the sexual behaviour of young people aged 18 to 24 in 2006 revealed that most sexually active young people in Croatia did not use condoms or used them inconsistently (Štulhofer et al., 2006). A study of sexual risk behaviour and attitudes toward condom use in the Croatian college student population found that only 10% of sexually active students always use condoms, 14% never use condoms, and the others only occasionally use condoms. Almost half of the students (49%) had experience engaging in sex under the influence of alcohol and 11% under the influence of drugs (Nekic and Tucak Junakovic, 2011). A national study conducted among Croatian young adults aged 18-25 years found that more than a half of the respondents reported at least one condom use error or problem in the preceding year, leading authors to conclude that correct condom use appears to be an important public health issue in Croatia (Bacak and Štulhofer, 2012). Furthermore, there is an upward trend in the early initiation of sexual activity. In 2014, a significantly higher number of first-year students, compared to last-year students, started sexual intercourse at younger age, with an average age of sexual initiation being 17.28±1.29 years (Dijanic et al., 2014).

College students were the target population of this study because they represent the peak ages for acquiring sexually transmitted infections (20 to 24) (Cassidy et al., 2018). Besides being a high-risk group in general, there are additional difficulties related to the prevention of sexually transmitted infections in the college population in Croatia. According to a study about college students' perceptions of individual and institutional responsibility for sexual health (Lechner et al., 2013), students believe that it is the college's responsibility to provide sexual health information resources and it is the students' responsibility to access resources. However, the majority of Croatian universities do not provide information sources or services for sexually transmitted infections prevention. For example, Croatian universities do not have health centres and services or organized collections of sexual health information resources, meaning that college students are left to their own devices in learning about sexual health topics at a time when two thirds of the student population are already sexually active and one third will become sexually active (Landripet et al., 2010; Dijanic et al., 2014; Willoughby and Muldrow, 2017).

Therefore, this study aims to investigate college students' information needs and demands regarding sexually transmitted infections during the last six months. It also aims to determine information seeking practices and information sources used for seeking information about sexually transmitted infections. A particular interest of this research is to better understand the relation between worry about sexual health outcomes and information behaviour with regard to sexually transmitted infections.

Human information behaviour literature emphasises the role of the knowledge gap as a motivator of information seeking. Significantly less attention has been given to the role of perceived risk as a motivating factor for information seeking (Shakeri, Evangelopoulos and Zavalina, 2018). However, worry, as a mental reaction to perceived risk, and its related concepts (fear and anxiety) have been recognized as relevant concepts in the human information behaviour literature. Although individuals differ in their response to perceived threat, as indicated by theories such as avoidance and vigilance (Krohne, 1993; 2002), monitoring and blunting (Miller, 1987; Rood et al., 2015) and sensitisation and repression (Kim et al., 2014; Krohne, 2002), information seeking as a reaction to potential threat has been widely documented, especially in the health context, (Kahlor, 2010; Lagoe and Atkin, 2015; Rains and Tukachinsky, 2015; Yang and Kahlor, 2013) and several empirically tested models have been in use that theoretically support association between worry and information seeking (Lee and Hawkins, 2016).

Since worry about sexual health outcomes is related to a perceived threat of adverse sexual health outcomes, discovering possible relationships between worry about sexual health outcomes and seeking information about sexually transmitted infections in college students could explain what role information seeking has in facing adverse sexual health outcomes, which can be valuable information for sexual health educators.

College students' sexual health information needs and source preferences

Sexual health has been identified as one of the key health concerns of college students (Dearmond et al., 1991; Escoffery et al., 2005; American College Health Association, 2013; Britt et al., 2017) and one of their most popular health topics for information seeking (Britt et al., 2017; Rideout, 2001). For example, a study by Buhi et al. (2009) found that sexual health was the most common health topic which college students reported seeking online, and information about sexually transmitted infections or HIV was the most common sexual health topic which students reported seeking online. Research conducted by Rivera, Cooper and Rodríguez-Díaz (2013) about safer sex information seeking of college students also found that the most common type of safer sex information students purposively sought was sexually transmitted infections: their symptoms, risks and treatment. Sexually transmitted infections and/or pregnancy prevention was the second most common type of information students sought for.

As for sexual health, college students are often considered as a high-risk population (Habel et al., 2018). Although research on sexual health behaviour and outcomes in the college population is extensive, a general picture of sexual health knowledge among college students is not clear (Cassidy et al., 2015). Studies show that college students knowledge regarding sexually transmitted infections has increased over the past decade (Thompson et al., 2018). However, although they generally perceive themselves as knowledgeable regarding sexually transmitted infections (Rouner and Lindsey, 2006; Yazici, et al., 2012), studies show gaps in their knowledge, such as lack of knowledge about the symptoms associated with sexually transmitted infections, their transmission and diagnosis (Baer et al., 2000; Rouner and Lindsey, 2006; Sandfort and Pleasant, 2009; Albright and Allen, 2018).

Studies about information sources that college students use for sexual health information show that they rely on multiple sources of information, such as healthcare providers (Garcia et al., 2014), friends (Ege et al., 2011; Rittenour and Booth-Butterfield, 2006), college health services (Eisenberg et al., 2012; Lechner et al., 2013), media, and the Internet. Peers/friends have been recognized as a common source of sexual information for college students in several studies (Ege et al., 2011; Rittenour and Booth-Butterfield, 2006), while the Internet is increasingly becoming the leading source for health information, including sexual health topics (Basch et al., 2018; Britt et al., 2017; Buhi et al., 2009).

There have been only a few studies that deal specifically with information sources that college students use about sexually transmitted infections. Furthermore, the main focus of existing studies is to identify sources of learning about sexually transmitted infections, and not sources used for purposive information seeking about sexually transmitted infections (D'Urso et al., 2007; Katz et al., 2011; Lewis et al., 1999; Kamzol et al., 2013). These studies show that college students rely on media such as television, magazines and the Internet and their friends, healthcare providers and health education programmes as sources of information about sexually transmitted infections (Table 1).

There are several more recent studies that deal with HPV vaccine knowledge, attitudes, and information source preferences of college students. One of those studies found that the Internet was the most common source of information for male students and healthcare providers for female students. Both male and female students reported school as their second most common source of information about human papillomavirus and the associated vaccine (Barnard et al., 2017). Another study found that TV advertisements, school/college/university and word of mouth were the most prominent sources of information about the vaccine for college students (McCusker et al., 2013).

Regarding purposive information seeking about sexually transmitted infections, Rivera, Cooper and Rodríguez-Díaz (2013) conducted a study about safer sex information seeking of college students. Their study found that most students reported searching for this information on the Internet or through interpersonal sources. Two main motivations for seeking safer sex information were personal and external reasons. External reasons urge students to search safer sex information for non-personal motives (like having a course assignment), while personal reasons include wanting additional knowledge, diagnosis of a friend or partner, being sexually active, and a future medical appointment. When they sought information for personal reasons, students mainly went to the Internet and their friends. However, none of the students spoke about searching information about sexually transmitted infections for their own symptoms or diagnosis (Rivera et al., 2013).

Studies show that sexual health is an important topic to college students, and sexually transmitted infections and HIV are one of the most salient topics which college students seek information about. Although college students perceive themselves as knowledgeable about sexually transmitted infections, several studies have identified gaps in their knowledge. As shown in Table 1, college students rely on media (such as television, magazines and internet) and their friends, healthcare providers and health education programmes as sources of information regarding sexually transmitted infections. However, few studies have focused specifically on purposive information seeking about sexually transmitted infections, rather than on sources for learning about sexually transmitted infections. There is a lack of knowledge about the role of information seeking when college students address their sexual health worries. Thus this study seeks to fill in this gap.

Worry about sexual health outcomes and information seeking

Sexual health information seeking by youth can be motivated by 'need to know information for the future' or ' presence of symptoms' related to adverse outcomes (Magee et al., 2012, p. 4). In the second scenario, symptoms present a perceived threat. Worry, as a mental reaction to a perceived threat, is positively related to different problem-focused coping activities, and has been recognized as a relevant concept in the human information behaviour literature.

Borkovec, Robinson, Pruzinsky and DePree (1983) define worry as a cognitive thinking process that is closely correlated with unpleasant emotions of fear and anxiety. Kahlor (2010) defines worry as an affective response to perceived risk. Lee and Hawkins (2016, p. 2) define worry as an uncertainty-associated emotion, while Chae (2015a) in her conceptualization of worry makes a distinction between risk perception, fear and worry. She defines risk perception as a cognitive process involving the intellectual judgment of susceptibility or severity of the perceived risk. Fear is defined as an affective state experienced as physiological arousal, while worry is a mental reaction that is highly correlated with emotions of fear and anxiety, and therefore it is an affective-cognitive condition (Chae, 2015a). Although various definitions of worry exist, they reveal its closely related concepts: uncertainty, risk perception and perceived risk, and fear or anxiety. There have been efforts to build theories and models to generalise or describe patterns of information behaviour in the contexts and situations related to these concepts.

For example, uncertainty has been widely recognized as a motivation for information seeking (Rains and Tukachinsky, 2015). Uncertainty management theory (Hogan and Brashers, 2015) recognises information seeking as an uncertainty management strategy. Theories such as avoidance and vigilance (Krohne, 1993, 2002), monitoring and blunting (Miller, 1987; Rood et al., 2015) and sensitisation and repression (Kim et al., 2014; Krohne, 2002) describe different cognitive styles in the response to perceived threat, indicating that sensitisers/monitors/vigilant individuals are more likely to be seeking out information relating to potential threat.

In the health context where information seeking as a reaction to a potential threat has been widely documented (Kahlor, 2010; Lagoe and Atkin, 2015; Rains and Tukachinsky, 2015; Yang and Kahlor, 2013), several empirically tested models have been in use that theoretically support association between worry, fear, anxiety and information seeking (Chae, 2015b; Lee and Hawkins, 2016). For example, the comprehensive model of information seeking has been widely used and empirically validated in the health information seeking context (Johnson and Meischke, 1993; Hartoonian et al., 2014; Ruppel, 2016; Van Stee and Yang, 2018). The comprehensive model explains that health-related factors determine information carrier factors which, in turn, determine information-seeking actions. Salience, which is one of the health-related factors, refers to the personal significance of health information to an individual and is related to the degree of perceived health threat an individual feels (Johnson and Meischke, 1993). In other words, salience is measured by risk perception and fear. Another model that takes affect into account (Dunwoody and Griffin, 2015) is a model of risk information seeking and processing by Griffin, Dunwoody and Neuwirth (1999). This model explains that seven factors, including affective response to the risk, influence the extent to which an individual will seek out and analyse risk information. Empirical testing of the model confirmed that worry, as an affective response to the risk, was positively related to information insufficiency that prompts information seeking (Griffin, et al., 2004; Noh et al., 2016). The planned risk information seeking model (Kahlor, 2010) is an augmented version of the risk model. Study based on the planned risk model (Kahlor, 2010) demonstrated that the extent to which individuals worried about their health was related to the perceived knowledge insufficiency, which corresponds to information sufficiency in the risk model. Worry about health was also related to the intention to seek health information. The planned risk model has been tested in a variety of health contexts (Hovick, Kahlor and Liang, 2014; Hovick et al., 2014; Yang and Kahlor, 2013).

In the sexual health context, worry is operationalized through the degree of worry an individual associates with either self or partner-specific outcomes, such as sexually transmitted infections, HIV or unintended pregnancy (Sales et al., 2009). Worry is a relatively new concept used in the studies on sexually transmitted infections, HIV or unintended pregnancy risk. However, empirical literature suggests that worry about an unintended pregnancy or contracting sexually transmitted infections or HIV is connected to a number of high risk sexual practices, such as not using condoms (Crosby et al., 2001a), the number of lifetime partners (Ellen et al., 1996), the risk of unwanted sex (Sionéan et al., 2002) and lack of sexual communication self-efficacy (Crosby et al., 2001b; Sales et al., 2009). Thus, it is useful to identify individuals engaging in risky sexual behaviour and facing adverse sexual health outcomes.

Since previous studies show that worry in general is related to health information seeking, we hypothesise that college students who express more worry regarding their sexual health outcomes are more likely to seek information about sexually transmitted infections. Therefore, in this study, we seek to find out whether worry regarding sexual health outcomes is related to specific information needs and demands and types of information sources used for seeking information about sexually transmitted infections. Information sources whose usage is related to increased worry about sexual health outcomes need to be examined in more depth for their possible role in the decision-making process regarding adverse sexual health outcomes.

Research aims and objectives

The aim of this research is to broaden the current understanding of the relation between information needs and source preferences regarding sexually transmitted infections and worry about sexual health outcomes in college students.

Specific objectives of this paper are:

• to study elements of sexual health information behaviour of college students, namely information needs and demands regarding sexually transmitted infections, and information seeking and information sources used for seeking information about sexually transmitted infections
• to analyse aspects of the worry about sexual health outcomes relating to sexually transmitted infections in college students
• to identify if there is a correlation between analysed elements of sexual health information behaviour and the worry about sexual health outcomes relating to sexually transmitted infections in college students.

The findings of this study can help to provide safe sex promotion strategies that can be useful for the health educators of college students.

Research methods

Respondents and the procedure

Since data on the age distribution relating to sexually transmitted infections in Croatia are not available, we chose our sample based on the available data from other studies and international statistics which show that the peak ages for acquiring sexually transmitted infections are 20 to 24 (Cassidy et al., 2018). Therefore, college students were our target population as they fit in this age group.

Due to the sensitive nature of the research topic and our intention to receive the highest extent of honest answers, we used a questionnaire in an online format to ensure that respondents felt comfortable and that their privacy was not invaded. Respondents were recruited from Josip Juraj Strossmayer University in Osijek, Croatia from November 2017 to February 2018. After obtaining permission from faculty administration to conduct the survey, researchers attended classes to explain the purpose of the research and to encourage students to answer the survey through their mobile device.

Among 523 potential participants in total, 431 students submitted complete questionnaires. Two hundred and seventy-six respondents stated they had sexual experience and their answers were included in the further analysis for the purpose of this study. There were 170 (62.7%) female and 101 (37.3%) male respondents. Five students did not provide their sex information. The number of sexual partners is shown in Table 2.

Of the 276 respondents, 223 students (80.8%) have been sexually active in the last six months, while 41 students (14.9%) have not. There were 12 missing answers (4.3%).

The greatest number of respondents were 19 years old (32.7%, n=88), followed by 20 years old (23%, n=62), then 21 years old (19.3%, n=52). The age distribution of the respondents is shown in Table 3.

Questionnaire design

The questionnaire used in this study had twenty-five multiple choice questions. Only part of the results will be presented in this paper. Questions were grouped into four parts. Content of the first, second and the fourth part of the questionnaire was designed by authors based on current literature about sexual health information needs and information seeking. For the third part of the questionnaire, we have used four items from psychometrically tested and validated scale Worry about sexual health outcomes scale (Sales et al., 2009). Prior to its launch, the survey was tested with the target group of respondents (college students) to ensure general readability and interpretability of the items.

Part 1: Sexual health information needs and demands

Part 1 consisted of two questions. The first question asked about health topics relating to sexually transmitted infections respondents would like to know more about. The second question asked which health topics relating to sexually transmitted infections respondents have searched for in the last six months. In order to differentiate between a current need to know more about sexually transmitted infections and recent information searches about it, we have used the term 'information needs' for the former, and 'information demands' for the latter meaning (Case and Given, 2016). Ten topics were offered with a multiple-choice option.

Part 2: Information seeking and sources used for sexual health information

Part 2 consisted of two questions:

1. How often have you searched for information about sexually transmitted infections in the last six months? (1 = Never- 5 = Very often)
2. How often have you used the following information sources to seek information about sexually transmitted infections in the last six months? (1 = Never - 5 = Very often)

The following information sources were included: books and brochures, boyfriend or girlfriend, Internet forums, doctor, video, father, friends, mother, magazines and Websites.

Part 3: Worry about sexual health questions

Worry about sexual health outcomes scale was developed by Sales et al. (2009) as a brief self-administered instrument containing ten questions regarding worry about sexual health outcomes (sexually transmitted infections, HIV and unintended pregnancy) in the past six months. We have decided to use it because it is psychometrically tested and validated scale, and because there are no other scales aimed at measuring worry related to sexual health (Halkitis et al., 2018). Four items relating to worry about sexually transmitted infections in the past six months from Worry about sexual health outcomes scale were used to measure worry about sexual health. Worry about sexual health outcomes scale consists of two types of items. One measures the affective aspect of risk perception (worry regarding one's susceptibility to sexually transmitted infections) and the other, worry regarding already present adverse outcomes. Taking into consideration the distinction between these two types of constructs is theoretically supported by the literature (Chae, 2015a).

Part 4: General demographic questions and sexual activity questions

There were two questions regarding demographic characteristics of the respondents: How old are you? and What is your gender? The last two questions dealt with sexual activity of the respondents and they asked: How many sexual partners have you had so far in your life? and Have you been sexually active in the past six months?

Data analysis

Quantitative analyses were conducted using the IBM SPSS statistical package. Besides descriptive statistics, the Pearson chi-squared test and non-parametric Kruskal Wallis and Mann-Whitney tests were used to test possible differences between the groups in the sample. Spearman's rank correlation was used for testing statistical dependence between variables. We have used non-parametric tests because they do not rest upon an assumption of normality. Statistical difference was tested at the level of 95%.

Three hypotheses were tested in this study:

• H1: Worry about sexual health outcomes is related to the range and type of information needs and demands regarding sexually transmitted infections.
• H2: Worry about sexual health outcomes is related to the frequency of information seeking about sexually transmitted infections.
• H3: Worry about sexual health outcomes is related to using specific information sources for seeking information about sexually transmitted infections.

Results

Worry about sexual health outcomes

In order to analyse worry about sexual health outcomes using the four items from the Worry about sexual health outcomes scale, respondents who stated that they had not been sexually active in the last six months were omitted from further analysis. Of the 276 respondents, 223 students stated that they had been sexually active in the last six months and their answers were included in our further analysis. The frequencies and percentages of participants' responses are presented in Table 4.

A great majority of the respondents were never worried regarding all four worry items. The distribution of answers regarding the second item (worry that they might already have a sexually transmitted infection), the third item (worry that their partner may be infected with a sexually transmitted infection) and the fourth item (worry that their partner may become infected with a sexually transmitted infection) is almost identical. Close to three quarters of respondents were never worried, close to one fifth of respondents were rarely worried, and around 5% of respondents were sometimes worried about their sexual health outcomes relating to sexually transmitted infections.

Although the greatest share of respondents was also never worried regarding the first item (worry that they might get a sexually transmitted infection), the distribution of answers is slightly different, and it indicates that the first item was the greatest cause of worry (Table 4).

The Kruskal-Wallis Test identified that there was a statistically significant difference in the frequency of worry about all four sexual health outcomes between female and male respondents, with male respondents being more frequently worried. Mean ranks and statistical differences are presented in Table 5.

The Kruskal-Wallis Test identified that there was a statistically significant difference in the frequency of worry about getting a sexually transmitted infection (first item) and already being infected by it (second item) between respondents with different number of sexual partners. Respondents who have had more sexual partners were more often worried. Mean ranks and statistical differences are presented in Table 6.

Range and type of information needs and demands regarding sexually transmitted infections in the last six months

To assess range and type of information needs and demands regarding sexually transmitted infections in the last six months, two questions were used Which of these topics would you like to know more about? and Which of these topics have you searched information about in the last six months? Ten topics were provided with a multiple-choice answer option. The frequencies and percentages of participants' responses are presented in Table 7.

Almost half of the respondents stated that they would like to know more about Recognizing the symptoms of sexually transmitted infections in partner (46.2%, n=126) and Recognizing the symptoms of sexually transmitted infections in oneself (44.3%, n=121). Topics that respondents were least interested in were those related to Negotiating safer sex (14,3%, n=39), Premarital purity (11.4%, n=31), Abstinence and its benefits (10.6%, n=29) and How to refuse sexual intercourse (10,3%, n=28) (Table 7).

In the case of information demands in the last six months, the three most popular topics were Methods of protection against sexually transmitted infections (9.9%, n=27), Recognizing the Symptoms of sexually transmitted infections in oneself (8.8%, n=24) and Negotiating safer sex (7.7%, n=21). Topics of least interest to respondents were Treatment of sexually transmitted infections (4.8%, n=13), Testing for sexually transmitted infections (4.4%, n=12) and Complications of sexually transmitted infections (1.5%, n=4) (Table 7).

The Pearson chi-squared test identified that there was a statistically significant difference between female and male respondents regarding three information needs. More female respondents were interested in Recognizing the symptoms of sexually transmitted infections in partner, Recognizing the Symptoms of sexually transmitted infections in oneself and Complications of sexually transmitted infections.The proportion of respondents and statistical differences are presented in the Table 8.

On the other hand, more male respondents sought information about sexually transmitted infections than female respondents in seven out of ten offered topics in the last six months, as shown in Table 9.

In order to analyse correlations between the worry about sexual health outcomes and the range of information needs and demands regarding sexually transmitted infections, the following null hypothesis was formulated:

• NO: there is no statistically significant correlation between the frequency of worry about sexual health outcomes and the range of information needs and demands regarding sexually transmitted infections in the last six months.

Spearman's rank correlation test identified that there was a statistically significant positive correlation between the range of information needs and worry about sexual health outcomes for three sexual health worry items (second, third and fourth), meaning that those respondents who have been more frequently worried about sexually transmitted infections in the last six months, have more information needs regarding sexually transmitted infections. From the sense that a large correlation is 0.5, medium is 0.3 and small is 0.1 in social sciences (Cohen, 1988), correlations were weak, as shown in Table 10.

When it comes to information demands in the last six months, Spearman's rank correlation test identified that there were medium statistically significant positive correlations between the range of information demands in the last six months and worry about sexual health outcomes for all four worry items, indicating that respondents who were more often worried about their sexual health outcomes searched more topics regarding sexually transmitted infections in the last six months. Correlation coefficients and statistical differences are presented in Table 11.

We were also interested in differences regarding specific information needs and demands between respondents who were more and less often worried about their sexual health outcomes. For that purpose, we have created composite variables by computing sum of answers regarding all four worry items, and performed T-test.

Statistically significant differences were discovered for four information demands between more and less frequently worried respondents. Respondents who were more often worried tended to report seeking information about Recognizing the symptoms of sexually transmitted infections in partner (t(219)=2.98, p=0.003), Recognizing the symptoms of sexually transmitted infections in oneself (t(219)=2.57, p=0.011), Testing for sexually transmitted infections (t(9,19)=2.55, p=0.031) and Sexual abstinence and its benefits (t(219)=1.99, p=0.049). The last topic was marginally significant.

Seeking sexual health information

Cumulatively, the greatest number of respondents who answered the question How often have you searched for information related to sexually transmitted infections in the last six months? have never and rarely searched for information about sexually transmitted infections in the last six months (n=211, 78.4%), while only 4.5% (n=12) of respondents have searched for this information often and very often (Table 12).

In order to analyse correlations between the worry about sexual health outcomes and the frequency of seeking information about sexually transmitted infections, the following null hypothesis was formulated:

• NO: there is no statistically significant correlation between the frequency of worry about sexual health outcomes and the frequency of seeking information about sexually transmitted infections in the last six months.

Spearman's rank correlation test identified that there was a moderate statistically significant positive correlation between the frequency of worry about sexual health outcomes for all four worry items and the frequency of seeking information about sexually transmitted infections in the last six months. The relationship was strongest for the second (already have a sexually transmitted infection) item. Correlation coefficients and statistical differences are presented in Table 13.

Information sources used for seeking information about sexually transmitted infections in the last six months

The frequencies and percentages of participants' responses to the question How often have you used following information sources to seek information about sexually transmitted infections in the last six months? are presented in Table 14.

The information source which was used often or very often cumulatively by the greatest portion of respondents were Websites (n=33, 12.3%). Internet forums with 8.9% of respondents (n=24) and friends with 7.8% (n=21) of respondents followed. All other information sources were used often or very often cumulatively by 3.7% (n=10) of respondents or less.

In order to analyse correlations between worry about sexual health outcomes and the frequency of using different sources of information for seeking information about sexually transmitted infections, the following null hypothesis was formulated:

• NO: there is no statistically significant correlation between the frequency of worry about sexual health outcomes and using different information sources for seeking information about sexually transmitted infections in the last six months.

Spearman's rank correlation test identified that worry about sexual health outcomes was related to using every information source. For a majority of information sources, correlations were low, except for girlfriend or boyfriend, Internet forums, friends and Websites, whose use was moderately related to worry about sexual health outcomes. Using girlfriend or boyfriend, Internet forums and Websites for information about sexually transmitted infections was most strongly correlated to already being infected with a sexually transmitted infection (second item), while using friends for information about sexually transmitted infections was most strongly correlated to worry that a partner may be infected with an sexually transmitted infection (third item). In both cases, worry about already present symptoms was related to more frequent use of aforementioned sources. Correlation coefficients and statistical differences are presented in the Appendix.

Discussion

Although human information behaviour literature emphasises the role of the knowledge gap as a motivator of information seeking, perceived risk and affective responses to it (worry, fear and anxiety) have been recognized as relevant concepts in the human information behaviour literature (Shakeri et al., 2018). Information seeking has been identified as a coping mechanism that people turn to in order to manage uncertainty (Hogan and Brashers, 2015) and empirical testing of health information seeking models confirmed that worry is related to the problem-focused activity of information seeking (Chae, 2015b; Lee and Hawkins, 2016).

Worry in the sexual health context is related to perceived threat of adverse sexual health outcomes such as HIV, sexually transmitted infections and unintended pregnancy (Crosby et al., 2001a; 2001b; Sales et al., 2009; Sionéan et al., 2002). However, in spite of its possible implications to sexual health decision-making regarding worrisome sexual health situations, the relationship between sexual health information seeking and sexual health worry has not been adequately studied. Therefore, in this study, we intended to broaden understanding of this topic. We have developed three hypotheses for testing:

• H1: Worry about sexual health outcomes is related to the range and type of information needs/demands regarding sexually transmitted infections.
• H2: Worry about sexual health outcomes is related to the frequency of information seeking about sexually transmitted infections.
• H3: Worry about sexual health outcomes is related to using specific information sources for seeking information about sexually transmitted infections.

College students were our target group because data show that they are a high-risk population (Habel et al., 2018). Sexually transmitted infections were chosen as a main topic of interest since they represent the most salient sexual health topic for college students (Buhi et al., 2009; Rivera et al., 2013).

When information needs regarding sexually transmitted infections of college students are concerned, two topics that stand out with close to half of respondents stating that they would like to know more about them are Recognizing the symptoms of sexually transmitted infections in partner (n= 123, 46,2%) and Recognizing the symptoms of sexually transmitted infections in oneself (n=121, 44,3%). Even the least chosen topic (Complications of sexually transmitted infections) was marked by 19% of respondents. These results support previous findings which suggest that college students lack knowledge about sexually transmitted infections (Baer et al., 2000; Rouner and Lindsey, 2006, Sandfort and Pleasant, 2009), and, therefore, express the need for additional information. The Pearson chi-squared test identified that female respondents were, to a greater extent than male respondents, interested inRecognizing the symptoms of sexually transmitted infections in partner, Recognizing the Symptoms of sexually transmitted infections in oneself and Complications of sexually transmitted infections. At the same time, more male respondents sought out information in about 7 out of the 10 offered sexual health topics in the last six months than female respondents. The Kruskal-Wallis Test identified that male respondents were more frequently worried about their sexual health outcomes regarding all four worry items. Previous studies reported that college age males may be unaware of their risk for acquiring sexually transmitted infections (Gillison et al., 2008; Nielson et al., 2007; Palefsky, 2010), leading to a suggestion that the male college population may need more specific approaches to successful sexual health education.

Regarding our first hypothesis (worry about sexual health outcomes is related to the range and type of information needs/demands regarding sexually transmitted infections), there was a statistically significant positive correlation between the worry about sexual health outcomes and the range of both information needs (low correlation) and demands (medium correlation). For both information needs and demands, the relationship was strongest for second item (already have a sexually transmitted infection), meaning that the worry about already present adverse sexual health outcome results in the greatest range of information needs and demands. Furthermore, statistically significant differences were discovered for four information demands between respondents who were more or less often worried regarding all four sexual health outcomes. More respondents who were more often worried reported seeking information about Recognizing the symptoms of sexually transmitted infections in partner (p=0.003), Recognizing the symptoms of sexually transmitted infections in oneself (p=0.011), Testing for sexually transmitted infections (p=0.031) and Sexual abstinence and its benefits (p=0.049). This finding suggests that individuals experiencing more frequent worry about sexual health outcomes primarily search for information directed at coping with already suspected negative sexual health outcomes, but not on their future prevention as well. Sexual abstinence and its benefits (p=0.049) was the only topic of preventive nature more often searched by those who were more often worried, however, it was marginally significant.

Our second hypothesis stated: worry about sexual health outcomes is related to the frequency of information seeking about sexually transmitted infections. Although a great majority of respondents in our study reported never or seldom searching for information about sexually transmitted infections in the last six months, college students who were more often worried about their sexual health outcomes in the last six months, were more often seeking information about sexually transmitted infections. This finding is in line with health information seeking models that conceptualise worry as an antecedent to seeking information (Griffin et al., 1999; Johnson and Meischke, 1993; Kahlor, 2010). Correlation between the frequency of worry about sexual health outcomes and the frequency of seeking information about sexually transmitted infections in the last six months was a moderately positive statistically significant for all four worry items, meaning that those respondents who were more often worried about their sexual health outcomes were more often seeking information about sexually transmitted infections in the last six months. The relationship was strongest for already have a sexually transmitted infection item, indicating that the worry about already present adverse outcome is the strongest incentive to search for information, and, as explained earlier, results in the greatest range of information needs and demands. This finding supports the need to distinguish between the affective aspect of risk perception (worry regarding one's susceptibility to the risk), and worry regarding already present adverse outcomes (Chae, 2015a).

The third hypothesis said that worry about sexual health outcomes is related to using specific information sources for seeking information about sexually transmitted infections. In our study, Websites were the most utilised information source when it comes to seeking information about sexually transmitted infections. Internet forums and friends followed. All other sources were used to an inconsiderable extent. A great majority of previous studies have focused on sources of learning about sexually transmitted infections, and not on purposive information seeking about sexually transmitted infections (D'Urso et al., 2007; Katz et al., 2011; Lewis et al., 1999). However, a study by Rivera et al. (2013) found that college students mostly used internet or interpersonal sources when seeking information about safer sex. Results from our study confirm these findings. When seeking information about sexually transmitted infections, college students in our study predominantly chose information sources that are readily available, easily accessible, contain personal experiences and provide privacy. Regarding relation between the worry about sexual health outcomes and the use of information sources for information about sexually transmitted infections, worry was positively related to the use of every information source, but to a different extent. For a majority of information sources, correlations were low (>r=0.3), while the use of friends, girlfriend or boyfriend, internet forums and Websites were moderately related to the worry about sexual outcomes (=r=0.3). Except for friends, the use of aforementioned information sources were in strongest relation to the second worry item (already have a sexually transmitted infection). Using friends for information about sexually transmitted infections was most strongly correlated to third worry item (partner may be infected with a sexually transmitted infection). In both cases, the worry about already present symptoms was related to more frequent use of friends, girlfriend or boyfriend, internet forums and Websites.

Conclusion

In the broadest sense, results of this study confirm that worry is related to the problem-focused activity of information seeking, as several health information seeking models (Chae, 2015b; Lee and Hawkins, 2016) and theories of risk related information behaviour (Lagoe and Atkin, 2015) have postulated. Moreover, findings of this study confirm that affective aspect of risk perception (worry regarding one's susceptibility to the risk), and worry regarding already present adverse outcomes are differently related to information seeking (Chae, 2015a). Worry about already present (in contrast to the potentially present) adverse sexual health outcome was most strongly related to information seeking and resulted in the greatest range of information needs and demands, as well.

This study shows that college students information needs regarding sexually transmitted infections (what they would like to know) significantly exceed their information demands (what they sought for in the last six months). What this means is that although they wanted to know more about sexually transmitted infections, they were not looking for this information on purpose. This knowledge should serve as an incentive to ensure easy availability of sexually transmitted infection information for college student population. Knowing the fact that humans are open to serendipitous discoveries of information they are interested in, students need to be provided with situations for opportunistic information discoveries such as brochures, leaflets, posters, commercials or email-based sexually transmitted infections prevention interventions (Okwumabua et al., 2018).

Moreover, only one topic of preventive nature (Sexual abstinence and its benefits) was more often searched by respondents who were more often worried about their sexual health, and it was marginally significant. This finding suggests that individuals experiencing more frequent worry about sexual health outcomes primarily search for information directed at coping with already suspected negative sexual health outcomes, but not on their future prevention as well. Information encountering is offered as a possible solution in this context as well. Information resources dealing with negative sexual health outcomes should incorporate information about protective behaviour as well, to ensure serendipitous discovery of this information even when it is not specifically searched for.

Our study adds to previous knowledge by showing that forums, friends, girlfriend or boyfriend and sexual health Websites are consulted by college students not only for the purpose of obtaining new information and learning, but for the purpose of clarifying worrisome sexual health issues as well. Although our study is correlational, meaning not justifying us in making any conclusions on causality, what we suspect is that worry predicts using information sources which are readily available, easily accessible, private and contain personal experiences. These sources provide possibility for interaction, personal input, and learning from experiences of others. Previous studies have shown that sexual health information sharing and using friends as information sources affects sexual health decision making of young adults (Chang, 2014; Waterman eta l., 2018). Therefore, we need to be aware of the information sources young people use when they are worried about their sexual health outcomes because these sources might influence their decision making, such as to get a sexually transmitted infection test or not, to seek medical counsel or not or to practice safe sex in the future or not.

We hope that findings from this study contribute to a better understanding of sexual health information seeking of college students when their seeking is related to worry about sexual health adverse outcomes. Knowledge about this topic could be valuable because of its possible implications to sexual health decision-making regarding worrisome sexual health situations.

Limitations

There are a few limitations to this study. First, this study is local and, therefore, the results are not completely generalisable. Second, according to the international statistics, Croatia is a low-level risk country where sexually transmitted infections are concerned. Respondents in this study were college students who represent the age group most subject to adverse sexual health outcomes, however, their sexual behaviour was not predominantly risky, according to the number of sexual partners and the expressed worry about sexual outcomes. Third, we have used a convenience sample that cannot be considered representative. Fourth, the correlational nature of the study and the reliability of self-reported measures also represent methodological concerns. Since the levels of correlation between the constructs of interest were either low or medium, they should be taken as preliminary. Our findings justify the need for further research into this topic.

Future studies

It would be beneficial to confirm results of this study on a wider sample of young adults aiming at those groups who are more susceptible to risky sexual practices. Also, due to the correlational nature of this study, it could be useful to investigate furthermore the role of information sources whose use was most strongly related to worry about sexual health outcomes using qualitative methodology. Since male respondents were less interested in several of the most prominent topics regarding sexually transmitted infections in this study, but at the same time were more worried and had more information demands in the last six months; and previous studies reported that college age males may be unaware of their risk for acquiring sexually transmitted infections (Gillison et al., 2008; Nielson et al., 2007; Palefsky, 2010), college age male students' sexual health information seeking practices should be studied more thoroughly. In a more general sense, this research confirms that it is necessary to deepen the understanding of the relationship between information behaviour and related, but at the same time, different concepts of risk perception, worry and fear.

Acknowledgements

This study was funded by the University of Josip Juraj Strossmayer in Osijek in Croatia. The authors thank the participants of the study.

About the authors

Snježana Stanarević Katavić is an Assistant Professor in the Department of Information Sciences, Faculty of Humanities and Social Sciences, University of Osijek, Croatia. She holds a PhD in the information science from the University of Zadar, Croatia. Her areas of interest include human information behaviour, health information, information literacy and reading for pleasure. She can be contacted at sstanare@ffos.hr
Ivana Martinović is an Assistant Professor at the Department of Information Sciences, Faculty of Humanities and Social Sciences, University of Josip Juraj Strossmayer, Osijek. She holds a Master's degree in Croatian Language and Literature and Librarianship and a PhD in Linguistics from the University of Josip Juray Strossmayer, Osijek. Her research interests are early literacy, library services for children and young people, information-seeking behaviour of children and young people, information literacy, reading. She can be contacted at imartinovic@ffos.hr
Sung Un Kim is an Associate Professor in the Department of Library and Information Science at the Catholic University of America, located in Washington, D.C. in the United States. She holds a PhD from the School of Communication and Information at Rutgers, The State University of New Jersey. She earned a BA and an MA from Yonsei University, South Korea. Her research interests include youth information behaviour, information literacy, learning process, and instructional technology. She can be contacted at kimi@cua.edu

How to cite this paper

Appendix: Correlation between use of information sources for information about sexually transmitted infections and worry about sexual health outcome