College students’ preferences for information on self-initiated sexually transmitted infection testing

Abstract

Objective:

The purpose of this study was to identify preferences for content, method of delivery and frequency of information to encourage self-initiated sexually transmitted infection (STI) testing.

Design:

Qualitative study involving individual in-depth interviews with 35 college students aged 18–24 years.

Setting:

A university in Central Pennsylvania, USA.

Method:

Data were collected using a demographic and sexual history questionnaire, Sexually Transmitted Disease Knowledge Questionnaire and a semi-structured interview guide. Transcribed interviews were analysed using qualitative content analysis.

Results:

Findings from the study document STI testing information preferences as they relate to self-initiated testing. The majority of participants preferred receiving STI testing information through email. Themes within their accounts included Actionable Information Content, Frequently Accessed Delivery Method, and Routine STI Testing Information.

Conclusion:

The high incidence of STIs among US college students is an indication of the need to increase diagnosis and treatment to reduce transmission. Study findings have implications for the development and evaluation of low-cost interventions to improve the uptake of STI testing and reduce STI burden among college students.

Keywords

College students self-initiated STI testing STI testing STI testing information USA

Introduction

Sexually transmitted infections (STIs) are rapidly rising in the USA, with 2.5 million new infections (Centers for Disease Control and Prevention [CDC], 2019). Young people aged 15–24 years are disproportionately burdened, accounting for 50% of reported STIs in the USA (CDC, 2018). College students are particularly susceptible to STIs due to high rates of sexual risk behaviour, including inconsistent condom use, multiple sexual partners and low perceived risk of STIs (Collado et al., 2017; Hickey and Cleland, 2013; James and Ryan, 2018). There continues to be a need for intervention efforts to reduce the incidence of STIs among US college students.

STI testing is a crucial tool that allows for the identification of infected individuals. Testing individuals for STIs reduces transmission of new infections, leads to treatment when possible and prevents poorer sexual health outcomes (CDC, 2018; Wombacher et al., 2018). American College Health Association Healthy Campus 2020 goals include increasing STI-related information provided by campuses, increasing access to STI testing and decreasing STIs (American College Health Association [ACHA], 2012). Despite these benefits, young people have very low rates of STI testing; only 11.5% of sexually active youth have ever tested for STIs (Cuffe et al., 2016). Delayed STI testing leads to the transmission of infection by individuals who are unaware of their diagnoses and are not linked to care (Cuffe et al., 2016; Maraynes et al., 2017). STI testing among young people often occurs because of recommendations from clinicians in clinical settings (Adebayo and Gonzalez-Guarda, 2017; Cuffe et al., 2016). However, limited access (e.g. delays in scheduling), cost of clinician visit and fear of judgement and stigma have impeded this approach to STI testing (Avuvika et al., 2017; Cuffe et al., 2016; Gilbert et al., 2019).

The national Get Yourself Tested (GYT) campaign has been instrumental in reducing STI stigma and promoting self-initiated STI testing among young people (Friedman et al., 2014; Eastman-Mueller et al., 2019; Habel et al., 2015). However, it has not led to sustained increases in STI testing rates for young people. Some drawbacks of the GYT campaign are transient campaign periods, cost, non-inclusive messaging on promotion materials, provision of incentives for participation that impede sustainability, and limited adoption by universities and colleges (Eastman-Mueller et al., 2019; Garbers et al., 2016; Habel et al., 2015; McFarlane et al., 2015; Roston et al., 2015). Routine targeted dissemination of STI testing information is a potential low-cost sustainable way to encourage self-initiated STI testing (Friedman et al., 2014).

Self-initiated STI testing describes any form of testing requested, sought or performed by an individual in an offering site without immediate assessment and recommendation from a healthcare professional (Adebayo and Salerno, 2019; Joore et al., 2017; Jürgensen et al., 2012). In self-initiated STI testing, the individual has to be empowered with information, skills and direction to seek testing on their own. Self-initiating STI testing can improve access and uptake of testing among college students by reducing cost (e.g. eliminating cost of clinician visit) or reducing contact with unnecessary individuals, subsequently limiting anticipated or experienced stigma (Fielder et al., 2013; Habel et al., 2018; Salako et al., 2012).

College health services have begun to include options for students to self-initiate STI testing and self-collect test specimens to achieve these goals (Fielder et al., 2013; Habel et al., 2018). Studies undertaken with college students have found high acceptability and willingness to self-initiate STI testing (Fielder et al., 2013; Habel et al., 2018). A recent study evaluating the effectiveness of self-initiated STI testing among college students found increases in testing rates by 28.5% in men and 13.7% in women (Habel et al., 2018).

The ACHA (2012) notes that 57% of students reported receiving STI-related information from their college and 52% reported wanting STI-related information. However, there is no information available related to the content, quality or quantity of the information students received or would like to receive (ACHA, 2012). We explored the perspectives of college students on preferences for content, method of delivery and frequency of STI testing information that could prompt self-initiated STI testing.

Method

Penn State University (PSU) Institutional Review Board (IRB; Protocol No. STUDY00009990) approved the study. We utilised a qualitative descriptive design (Colorafi and Evans, 2016; Sandelowski, 2000), which uses a naturalistic inquiry process in which sampling, data collection and data analysis were performed with minimal theoretical manipulation, allowing findings to more accurately represent data (Colorafi and Evans, 2016; Sandelowski, 2000). Since self-initiation of STI testing is an understudied testing behaviour, a qualitative descriptive approach was more appropriate than other research methods/designs.

Setting

PSU is located in a rural part of Pennsylvania with a student population of ~46,000 (46.5% women, 53.5% men). The racial distribution of the student body is mostly White (65.6%). Hispanic/Latino comprise 7.31%; Asians, 6.12%; Black/African Americans, 5.65%; and other/unknown races, 15.32% of the student population. STI tests occur on-campus either following a clinician recommendation (i.e. clinician-initiation) or are self-initiated (explicitly sought and requested without an immediate clinician recommendation) by students with options for testing samples to be self-collected or collected by the healthcare staff.

Procedure and sample

We recruited participants through criterion-based purposive sampling (Polit and Beck, 2017) from the following sites: (1) student-centred settings (e.g. dorms) distributed across the college campus and city; (2) a Health Promotion and Wellness (HPW) centre and the University Health Services (UHS) – both college health settings. Study flyers were placed on front desks and bulletin boards and distributed by research assistants. Potential participants contacted the study team via the electronic information posted on STUDYfinder – a university-hosted online resource that facilitates study-related student recruitment. Eligible participants were (1) sexually active (oral, vaginal or anal intercourse) in the past 6 months, (2) aged 18–24 years and (3) able to provide informed consent. Participants were grouped into three categories of STI testing based on their testing history or how their last STI test was initiated (self-initiated, clinician-initiated, never tested). Recruitment and data collection occurred between September 2018 and February 2019.

Data collection

College students were screened for eligibility by the first author and a trained research assistant, in-person or via telephone using a screening questionnaire. A one-time data collection process occurred using a demographic and sexual history questionnaire, Sexually Transmitted Disease Knowledge Questionnaire (STD-KQ; Jaworski and Carey, 2007) and a semi-structured interview guide (see Table 1). The individual audio-recorded interviews were conducted by the first author. The first author is a doctoral-prepared registered nurse, trained and experienced in conducting qualitative research interviews and had no prior relationship with the study participants. Data collection occurred in a private room at the college of nursing. The total time for data collection lasted an average of 65 minutes, with audio-recorded interviews lasting an average of 37 minutes. Data collection and analysis occurred concurrently and continued until thematic saturation (Polit and Beck, 2017; Saunders et al., 2017) after the 30th interview. An additional five interviews were conducted to confirm thematic saturation. Study participants were compensated for their time with a US$30 visa gift card.

Table 1.

Examples of semi-structured interview questions.

• Tell me about the resources that you would need to self-initiate STI testing?
• Have you received any information on STI testing from the University?
• How would you like to access information on STI testing? Or how would you like to receive information on STI testing?
• How often would you like to receive information related to STI testing?
• What content in the information on STI testing would appeal to you? Or what would you like to see in the information on STI testing?

STI: sexually transmitted infection.

Data analysis

Data from the demographic and sexual history questionnaire and STD-KQ were analysed using SPSS statistical software (IBM Corp, 2017). Previous studies using the STD-KQ have reported score means or used inconsistent cut-offs to describe high or low scores (Fenkl et al., 2016; Goldsberry et al., 2016). However, this was not suitable to highlight the differences in participant scores of this sample. Instead, we divided the STD-KQ total score into three groups and recoded these into categorical variables representing Low Knowledge (0–9), Medium Knowledge (10–18) and High Knowledge (19–27). Audio-recordings of interviews were transcribed professionally and reviewed for accuracy. Qualitative data were analysed using conventional content analysis (Hsieh and Shannon, 2005) in which codes and categories were not predetermined but were developed from the data (Hsieh and Shannon, 2005). In line with this approach, the first author began the analysis process by reading the transcripts multiple times to obtain an overall sense of the data (Hsieh and Shannon, 2005). The first author derived codes used for data analysis from participant keywords and notes taken during interviews. These codes were then grouped into categories based on the participant descriptions and how they related to each other. Congruent with our research aim, we organised categories into themes describing participant preferences for content, method of delivery and frequency of STI testing.

Rigour

A rigorous qualitative study was ensured by maintaining data credibility, data confirmation and dependability (Cypress, 2017; Polit and Beck, 2017). We ensured credibility by using open-ended semi-structured interview questions that allowed for participant-led responses. The first author ensured data confirmation by keeping field notes that documented reflections from each interview (Cypress, 2017; Polit and Beck, 2017). This process of reflection helped the first author guard against biases that might have influenced data collection and analysis and ensured a continuous re-orientation to each participant (Cypress, 2017; Polit and Beck, 2017). To ensure dependability, members of the research team reviewed the derived categories and themes and crosschecked with participant quotes to achieve triangulation and to ensure interpretations were congruent with the data (Cypress, 2017; Polit and Beck, 2017).

Results

Participants

Thirty-five college students met study criteria and completed data collection. The majority of participants identified as women (n = 25, 71.4%), White (n = 22, 62.9%) and straight/heterosexual (n = 32, 91.4%); perceived themselves as having no risk of STIs (n = 23, 65.7%); and did not use a condom during last oral, vaginal or anal sexual intercourse (n = 20, 57.1%). More than half (n = 18, 51.4%) of the participants had a moderate level of STI knowledge. A complete description of the participants’ demographic characteristics and sexual history is presented in Tables 2 and 3.

Table 2.

Demographic characteristics of study participants.

Characteristics	n (%)
Age
18–19	11 (31.4)
20–21	16 (45.7)
22–24	8 (22.9)
Gender
Female	25 (71.4)
Male	10 (28.6)
Ethnicity
Non-Hispanic	33 (94.3)
Hispanic	2 (5.7)
Race
White	22 (62.9)
Black/African American	6 (17.1)
Asian	6 (17.1)
Other	1 (2.9)
Sexual orientation
Straight/Heterosexual Gay/Homosexual	32 (91.4) 2 (5.7)
Other (bi-curious)	1 (2.9)
Insurance
Public	9 (25.7)
Private	25 (71.4)
Prefer not to answer	1 (2.9)

Table 3.

Sexual history characteristics of study participants.

Variables	n (%)
Types of STI testing^a
Self-initiated	13 (37.1)
Never tested	10 (28.6)
Clinician-initiated	12 (34.3)
STD questionnaire
Low knowledge (0–9)	6 (17.1)
Medium knowledge (10–18)	18 (51.4)
High knowledge (19–27)	11 (31.4)
STI risk perception
No	23 (65.7)
Yes	10 (28.6)
Don’t know	2 (5.7)
Condom use during last sexual encounter
No	20 (57.1)
Yes	14 (40.0)
Prefer not to answer	1 (2.9)

STI: sexually transmitted infection; STD: sexually transmitted disease.

Types of STI testing: self-initiated – individually sought and requested STI testing; never tested – never tested for STIs in lifetime; clinician-initiated – tested due to recommendation of a clinician.

Study themes

Three predominant themes were developed through the analysis: Actionable Information Content, Frequently Accessed Delivery Method and Routine STI Testing Information. Together, these three themes summarised participants’ perspectives on the lack of STI knowledge among students, and the expressions of desire for information and proactive efforts by the university to fill knowledge gaps that would bring awareness of STIs and provide direction on ways to independently seek testing.

Actionable information content

Students described their preference for STI testing information that encouraged actions to self-initiate. Such information would contain words and phrases that are attention-grabbing and prompt immediate reflection on STI risk, the need to seek testing and the specific steps to do so:

Something that catches your eye, like, ‘Are you infected?’, Or something, and then something like that. I would read it and then be like, all right, let’s do it. Let’s get tested. I think something like, ‘Would you like to . . .’ Something basic that would probably cause people to be like . . . erase. (Male, 21 years)

Students also explained that STI information that contained statistics that described the incidence of STIs or a striking knowledge on the risk and consequences of STIs would lead to STI testing. This kind of information would stress students’ susceptibility and instil an urgency to seek testing:

. . . a fact, a statistic to freak me out. ‘Did you know that one in two people have STIs and don’t know?’ Something to kind of, ‘Oh, crap. I should go get tested’. Freak me out a little bit because then I’d be more inclined to get tested. Or, ‘do you know people can have an STD for three months and not know it?’ Something like that. Something to freak me out to be like, ‘Okay, I should definitely go’. (Female, 21 years)

Actionable information content also included STI information that addressed stigma. Students acknowledged that the fear of being judged and the stigma of sexual risk behaviours were experienced barriers to testing and they would be more likely to act on STI information if the content addressed those barriers:

I feel like they should just be more . . . The information should be more encouraging, and you definitely shouldn’t feel judged for your behaviour. It should be like non-judgment like if you need this, you can get it here. No questions asked. We want to help you. (Male, 21 years)

Another critical aspect of actionable information content was the inclusion of resources, directions and contact information that linked students directly to STI testing services. Students wanted more detailed information about the services offered and steps to take when accessing testing sites:

Just the variety of resources that I could go to and a little description of each. Like if there was one where I mentioned that you would go to see a doctor, the doctor would perform it, and just a little blurb on how you would go to see a doctor, the doctor could perform it. You could have that conversation. Or, if there was another service where you would go into the bathroom, perform it by yourself, and the receptionist would ask you, then just like a self-performance kit where you could go, perform it by yourself, walk out, it would be totally enclosed, no one would see you, and then you could talk to someone if you wanted to. Just like little snippets of information . . . (Female, 20 years)

Frequently accessed delivery method

Participants preferred the receipt of STI testing information through delivery methods that are used daily and are part of the college lifestyle. Participants listed multiple modes of information delivery (see Figure 1); however, the majority of participants mentioned email (n = 31, 88.6%) and described it as the preferred method of delivery. Participants considered email effective because most university-related information is sent through emails. With emails coming directly to mobile devices, students can easily access and act on STI testing information:

It might sound really clichéd, but emails do really work. They are really helpful because that is something which at this time you do look at regularly. That is the most comfortable way to leisurely look up that information, and at your own ease, I guess. That information’s always there on your hand, fingertips. (Female, 23 years)

Figure 1.

Students’ preferences for STI testing information delivery method.

Participants described the preference of privacy in accessing STI testing information. Privacy was a quality that made emails preferable to other delivery methods such as text messages. One student noted that unlike emails, text messages could be read by friends, which would bring discomfort in acting on STI testing information:

I check it (email) frequently, and it’s a little more private than a text message. You get a text alert on your phone, if you’re with somebody, they could read it. (Female, 18 years)

In addition, STI information posted at campus locations and frequently accessed by students was said to improve normalisation and decrease the stigma associated with testing. The student below described how posting STI testing information in the student union building would normalise the information provided as opposed to making it available in private locations such as toilets, which may suggest an attempt to ‘hide’ the information:

. . . the unsubtle approach and put posters around the [student union building], make it more blatant, because then that would normalise it a bit more, not hide it in the bathroom, kind of like how some women hide their periods and they just don’t talk about it. Doing that, I feel like it would help erase the stigma against it. (Female, 20 years)

Participants also described that while they might not always read STI testing information, frequently seeing STI testing information could ensure that the information will eventually lead to testing:

I think that they could include that on the flyer that they offer STI testing and they just stick it in your mailbox, and you just go get it, even if you don’t really read it they are still doing it. Someone’s going to see it, and someone might go get tested. (Female, 21 years)

Routine STI testing information

STI testing information that is sent out routinely by the university was described as encouraging action towards self-initiating testing. Students explained that STI testing information could systematically target periods of higher sexual risk behaviour that will make them more apt to seek testing. Routine STI testing information could function as reminders when there were delays in seeking testing due to the absence of symptoms:

It can’t hurt to send out and say, ‘Hey. It’s around the holidays’. Or, ‘It’s around Valentine’s Day’. Or whatever those main target areas are that people are more sexually active, I guess. It can’t hurt to send something out and be like, ‘These are your resources where you can go. Don’t be afraid to get tested’. Stuff like that. Or like, ‘Here’s some warning signs’. Just an email that everyone gets sent to their . . . blasted to their email. (Female, 22 years)

While there was no consensus on the best frequency for the receipt of STI testing information, participants expressed that they did not want to be bombarded with the information, which might lead to adverse reactions such as deleting or ignoring the message:

Probably like once a month, because that’s not like super excessive like it wouldn’t make people want to delete it cos it wouldn’t be like every week, and then it’s just once a month you can kind of see every so often. (Female, 19 years)

Discussion

Preferences for STI testing information can influence how people access and act on the basis of the information received. However, few studies have evaluated information needs specific to STI testing or explored their specific influence on self-initiation of testing (Fernandez et al., 2018; Meyer et al., 2011). Our study contributes to this knowledge gap by describing college students’ preferences for STI testing information, to provide recommendations on how to structure and disseminate STI testing information that encourages self-initiated STI testing.

The Health Belief Model (HBM), which has been used to understand preventive behaviours, can further situate our findings (Rosenstock, 1974; Rosenstock et al., 1988). The HBM suggests that an interaction between constructs including perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action and self-efficacy influences health behaviours (Janz et al., 2002; Rosenstock, 1974; Rosenstock et al., 1988).

Stigma has frequently been identified as a barrier to testing that could be influenced by STI testing information (Cunningham et al., 2009; James and Ryan, 2018; Morris et al., 2014). Normalising STI testing information by providing it in open spaces on campus and through routine email distribution to all students could reduce the stigma around STI testing. Innovative approaches like the use of graphics, story-telling and games may also be useful in creating appealing and engaging STI testing information that targets stigma and misconceptions that may delay testing (Gilliam et al., 2012; Grieb et al., 2016).

Consistent with other work, our findings highlight the susceptibility of college students to STIs (Delauer et al., 2020; Hickey and Cleland, 2013). Low perceived STI susceptibility is a barrier to seeking out sexual health information (Myrick et al., 2015). Consistent with previous studies, college students indicated that self-initiation of STI testing could be influenced by information with content that increases perceptions of susceptibility and severity of STIs (Iwata and Katsuda, 2016; Leonard et al., 2014). Such STI information immediately captures attention, especially if it contains compelling statistics about the risk and consequences of STIs and incites fear of possible infection. This finding is congruent with those studies that have found that health information that incorporates fear tactics can be effective in facilitating behaviour change (Cummings, 2012; Simpson, 2017). There are, however, mixed findings on the influence of fear on STI testing. Fears of positive test results, reactions from others, stigma, testing procedures and breach of confidentiality are notable barriers to STI testing (Cuffe et al., 2016; Cunningham et al., 2009; Wirtz et al., 2014).

Similar to previous work, we found that self-efficacy may moderate the impact of fear messaging (Tannenbaum et al., 2015). More importantly, self-efficacy aligns with students’ desire for actionable information to be part of messaging (e.g. including a link with testing sites or countering any fear-inducing statistics with positive messages on the proportion of STIs that are curable). Further research is needed to untangle the kinds of fear experienced by students and the mechanisms through which fear might influence STI testing.

Students’ preference for email over text message is important and contradictory to work suggesting students’ preference for text messages regarding health information (Miners et al., 2018; Whiteley et al., 2018). It indicates that health education interventions cannot be one-size-fits-all. Incorporating these unique preferences could facilitate the delivery, acceptance and effectiveness of interventions.

Our study results have also highlighted cues that could guide the dissemination of STI testing information. College students noted the potential benefit from STI testing information that was planned around periods of higher sexual risk behaviour like Valentine’s Day, Spring Break and large-scale social events. This finding has promising sexual health promotion benefits, as these periods of time may be associated with heightened perceived susceptibility. Targeted dissemination of STI testing information could cue college students to self-initiate STI testing in addition to the creation of comprehensive services on campus and in adjacent towns, which may consequently increase the uptake of STI risk reduction services.

Limitations

Our sample was mostly women, White and heterosexual, which limits findings to the context and experiences of the study participants. Sexual and gender minority (lesbian, gay, bisexual or transgender) and racial minority students may have different needs and preferences for STI testing information that we did not identify. Nevertheless, findings from this research can inform future investigations on STI testing communication among college students with different demographics. In addition, the primary recruitment site of one university in Central Pennsylvania may have influenced participants to answer study questions within the context of specific experiences related to the university location – there being no comprehensive sexual and reproductive health service provider within 80 miles of the campus location.

Collecting data on participants’ perceived risk and condom use allowed us to understand two essential aspects of STI risk, but certainly not all potential factors. Physiological factors such as genital inflammation, relationship factors such as number of partners and community factors such as access to testing and preventives (e.g. condoms and pre-exposure prophylaxis for HIV) were not explored (Hess et al., 2012; Orchowski et al., 2018; Passmore et al., 2016; Schofer, 2014; Traeger et al., 2019). Future related studies should therefore explore the STI testing communication preferences of college students alongside other unexplored STI risk factors.

Conclusion

Much previous research and interventions have focused on reducing sexual risk behaviours among young people. However, this is only one aspect of primary prevention and cannot adequately address the need for multilevel preventive efforts. STI testing leads to diagnoses and treatment that can prevent new infections, prevent adverse sexual health outcomes and improve long-term sexual health outcomes (Cuffe et al., 2016; Maraynes et al., 2017; Wombacher et al., 2018). Findings from this study show that to self-initiate STI testing, college students prefer testing information that has actionable content delivered broadly and effectively targeting periods of heightened STI susceptibility. Proactive strategies like self-initiated STI testing facilitated by the ease of a self-collecting STI testing specimen could increase the uptake of testing and reduce STI disparities.

Footnotes

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by Penn State College of Nursing Affiliated with the KL2 Program of the Clinical and Translational Science Institute.

ORCID iD

Oluwamuyiwa Winifred Adebayo

References

Adebayo

Gonzalez-Guarda

(2017) Factors associated with HIV testing in youth in the United States: An integrative review. Journal of the Association of Nurses in AIDS Care 28(3): 342–362.

Adebayo

Salerno

(2019) Facilitators, barriers, and outcomes of self-initiated HIV testing: An integrative literature review. Research and Theory for Nursing Practice: An International Journal 33(3): 275–291.

American College Health Association (ACHA) (2012) Healthy Campus 2020. Available at: https://www.acha.org/HealthyCampus/Objectives/Student_Objectives/HealthyCampus/Student_Objectives.aspx?hkey=a9f191de-243b-41c6-b913-c012961ecab9 (accessed 30 March 2020).

Avuvika

Masese

Wanje

, et al. (2017) Barriers and facilitators of screening for sexually transmitted infections in adolescent girls and young women in Mombasa, Kenya: A qualitative study. PLoS ONE 12(1): e0169388.

Centers for Disease Control and Prevention (CDC) (2019) STDs increased for the fifth consecutive year, reaching all-time high. Available at: https://www.cdc.gov/nchhstp/newsroom/2019/2018-STD-surveillance-report.html (accessed 30 March 2020).

Centers for Disease Control and Prevention (2018) STDs in Adolescents and Young Adults. Atlanta, GA: Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/std/stats17/adolescents.htm (accessed 30 March 2020).

Collado

Johnson

Loya

, et al. (2017) Discounting of condom-protected sex as a measure of high risk for sexually transmitted infection among college students. Archives of Sexual Behavior 46(7): 2187–2195.

Colorafi

Evans

(2016) Qualitative descriptive methods in health science research. Health Environments Research & Design 9(4): 16–25.

Cuffe

Newton-Levinson

Gift

, et al. (2016) Sexually transmitted infection testing among adolescents and young adults in the United States. Journal of Adolescent Health 58(5): 512–519.

10.

Cummings

(2012) Scaring the public: Fear appeal arguments in public health reasoning. Informal Logic 32(1): 25–50.

11.

Cunningham

Kerrigan

Jennings

, et al. (2009) Relationships between perceived STD-related stigma, STD-related shame, and STD screening among a household sample of adolescents. Perspectives on Sexual and Reproductive Health 41(4): 225–230.

12.

Cypress

(2017) Rigor or reliability and validity in qualitative research: Perspectives, strategies, reconceptualization, and recommendations. Dimensions of Critical Care Nursing 36(4): 253–263.

13.

Delauer

Mcgill-O’Rourke

Gordon

, et al. (2020) Human papillomavirus and health decision-making: Perceptions and accountability in college. Health Education Journal 79: 46–57.

14.

Eastman-Mueller

Habel

Oswalt

, et al. (2019) Get Yourself Tested (GYT) campaign: Investigating campaign awareness and behaviors among high school and college students. Health Education & Behavior 46(1): 63–71.

15.

Fenkl

Jones

Orta

(2016) Young Hispanic men’s HIV and STI knowledge, attitudes, beliefs, and behaviors. Hispanic Health Care International 14(3): 109–115.

16.

Fernandez

Howard

Hospital

, et al. (2018) Hispanic students’ perceptions about HIV/STI testing and prevention: A mixed-methods study in a Hispanic-serving university. Health Promotion Practice 20(5): 742–750.

17.

Fielder

Carey

(2013) Acceptability of sexually transmitted infection testing using self-collected vaginal swabs among college women. Journal of American College Health 61(1): 46–53.

18.

Friedman

Brookmeyer

Kachur

, et al. (2014) An assessment of the GYT: Get Yourself Tested campaign: An integrated approach to sexually transmitted disease prevention communication. Sexually Transmitted Disease 41(3): 151–157.

19.

Garbers

Friedman

Martinez

, et al. (2016) Adapting the Get Yourself Tested campaign to reach Black and Latino sexual-minority youth. Health Promotion Practice 17(5): 739–750.

20.

Gilbert

Thomson

Salway

, et al. (2019) Differences in experiences of barriers to STI testing between clients of the internet-based diagnostic testing service GetCheckedOnline.com and an STI clinic in Vancouver, Canada. Sexually Transmitted Infections 95(2): 151–156.

21.

Gilliam

Orzalli

Heathcock

, et al. (2012) From intervention to invitation: Reshaping adolescent sexual health through storytelling and games. African Journal of Reproductive Health 16(2): 189–196.

22.

Goldsberry

Moore

Macmillan

, et al. (2016) Assessing the effects of a sexually transmitted disease educational intervention on fraternity and sorority members’ knowledge and attitudes toward safe sex behaviors. Journal of the American Association of Nurse Practitioners 28(4): 188–195.

23.

Grieb

Flores-Miller

Gulledge

, et al. (2016) Vive!: Designing an intervention to improve timely HIV diagnosis among Latino immigrant men. Progress in Community Health Partnerships 10(3): 365–372.

24.

Habel

Brookmeyer

Oliver-Veronesi

, et al. (2018) Creating innovative sexually transmitted infection testing options for university students: The impact of an STI self-testing program. Sexually Transmitted Disease 45(4): 272–277.

25.

Habel

Haderxhanaj

Hogben

, et al. (2015) Does your college campus GYT? Evaluating the effect of a social marketing campaign designed to raise STI awareness and encourage testing. Cases in Public Health Communication & Marketing 8: 51–70.

26.

Hess

Javanbakht

Brown

, et al. (2012) Intimate partner violence and sexually transmitted infections among young adult women. Sexually Transmitted Diseases 39(5): 366–371.

27.

Hickey

Cleland

(2013) Sexually transmitted infection risk perception among female college students. Journal of the American Association of Nurse Practitioners 25(7): 377–384.

28.

Hsieh

Shannon

(2005) Three approaches to qualitative content analysis. Qualitative Health Research 15(9): 1277–1288.

29.

IBM Corp (2017) IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp.

30.

Iwata

Katsuda

(2016) Somatic symptoms after sexual behavior with fear of four sexually transmitted diseases: A proposal of novel disorder. Journal of Family Medicine and Primary Care 5(3): 706–708.

31.

James

Ryan

(2018) HIV knowledge mediates the relationship between HIV testing history and stigma in college students. Journal of American College Health 66(7): 561–569.

32.

Janz

Champion

Strecher

(2002) The health belief model. In: Glanz

Rimer

Lewis

(eds) Health Behavior and Health Education: Theory, Research, and Practice. 3rd ed. San Francisco, CA: Jossey-Bass, pp. 45–66.

33.

Jaworski

Carey

(2007) Development and psychometric evaluation of a self-administered questionnaire to measure knowledge of sexually transmitted diseases. AIDS Behavior 11(4): 557–574.

34.

Joore

Geerlings

Brinkman

, et al. (2017) The importance of registration of sexual orientation and recognition of indicator conditions for an adequate HIV risk-assessment. BMC Infectious Disease 17(1): 178.

35.

Jürgensen

Tuba

Fylkesnes

, et al. (2012) The burden of knowing: Balancing benefits and barriers in HIV testing decisions. A qualitative study from Zambia. BMC Health Service Research 12: 2.

36.

Leonard

Rajan

Gwadz

, et al. (2014) HIV testing patterns among urban YMSM of color. Health Education Behavior 41(6): 673–681.

37.

McFarlane

Brookmeyer

Friedman

, et al. (2015) GYT: Get Yourself Tested Campaign Awareness Associations with sexually transmitted disease/HIV testing and communication behaviors among youth. Sexually Transmitted Diseases 42(11): 619–624.

38.

Maraynes

Chao

Agoritsas

, et al. (2017) Screening for asymptomatic chlamydia and gonorrhea in adolescent males in an urban pediatric emergency department. World Journal of Clinical Pediatrics 6(3): 154–160.

39.

Meyer

Ahlers-Schmidt

Harris

, et al. (2011) STI testing information available to teens on the internet: What’s missing? Journal of Pediatric Adolescent Gynecology 24(2): e17–e19.

40.

Miners

Llewellyn

King

, et al. (2018) Designing a brief behaviour change intervention to reduce sexually transmitted infections: A discrete choice experiment. International Journal of STD & AIDS 29(9): 851–860.

41.

Morris

Lippman

Philip

, et al. (2014) Sexually transmitted infection related stigma and shame among African American male youth: Implications for testing practices, partner notification, and treatment. AIDS Patient Care STDS 28(9): 499–506.

42.

Myrick

Willoughby

Verghese

(2015) How and why young adults do and do not search for health information: Cognitive and affective factors. Health Education Journal 75(2): 208–219.

43.

Orchowski

Gobin

Zlotnick

(2018) Correlates of condom use among community college women: The role of victimization, substance use, and mental health symptoms. American Journal of Sexuality Education 13(2): 170–189.

44.

Passmore

JAS

Jaspan

Masson

(2016) Genital inflammation, immune activation and risk of sexual HIV acquisition. Current Opinion in HIV and AIDS 11(2): 156–162.

45.

Polit

Beck

(2017) Nursing Research: Generating and Assessing Evidence for Nursing Practice. Philadelphia, PA: Wolters Kluwer.

46.

Rosenstock

(1974) Historical origins of the health belief model. Health Education & Behavior 2: 328–335.

47.

Rosenstock

Strecher

Becker

(1988) Social learning theory and the health belief model. Health Education Quarterly 15(2): 175–183.

48.

Roston

Suleta

Stempinski

, et al. (2015) Get Yourself Tested 2011–2012: Findings and prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae at an urban public health system. International Journal of STD & AIDS 26(5): 322–328.

49.

Salako

Jeminusi

Osinupebi

, et al. (2012) Characteristics of clients accessing HIV counseling and testing services in a tertiary hospital in Sagamu, Southwestern Nigeria. Nigerian Journal of Clinical Practice 15(4): 391–396.

50.

Sandelowski

(2000) Whatever happened to qualitative description? Research in Nursing & Health 23: 334–340.

51.

Saunders

Sim

Kingstone

, et al. (2017) Saturation in qualitative research: Exploring its conceptualization and operationalization. Quality & Quantity 52(4): 1893–1907.

52.

Schofer

(2014) Circumcision of the man from an infectiological point of view. The Dermatologist 66(1): 30–37.

53.

Simpson

(2017) Appeal to fear in health care: Appropriate or inappropriate? Chiropractic & Manual Therapies 25: 27–27.

54.

Tannenbaum

Hepler

Zimmerman

, et al. (2015) Appealing to fear: A meta-analysis of fear appeal effectiveness and theories. Psychological Bulletin 141(6): 1178–1204.

55.

Traeger

Cornelisse

Asselin

, et al. (2019) Association of HIV preexposure prophylaxis with incidence of sexually transmitted infections among individuals at high risk of HIV infection. Journal of the American Medical Association 321(14): 1380–1390.

56.

Whiteley

Brown

Curtis

, et al. (2018) Publicly available internet content as a HIV/STI prevention intervention for urban youth. Journal Primary Prevention 39(4): 361–370.

57.

Wirtz

Kamba

Jumbe

, et al. (2014) A qualitative assessment of health-seeking practices among and provision practices for men who have sex with men in Malawi. BMC International Health and Human Rights 14: 20.

58.

Wombacher

Dai

Matig

, et al. (2018) Using the integrative model of behavioral prediction to understand college students’ STI testing beliefs, intentions, and behaviors. Journal of American College Health 66(7): 674–682.