Using Qualitative Methods to Understand Perceptions of Risk and Condom Use in African American College Women: Implications for Sexual Health Promotion

Abstract

Background. Young African American women are disproportionately affected with sexually transmitted infections (STIs) and unintentional pregnancies. Despite adequate knowledge, assertiveness, and negotiation skills, consistent condom use remains low. Aims. We sought to assess the role of pregnancy and STI risk perception in condom decision making among African American women. Method. We conducted a phenomenological qualitative study. Utilizing a purposive sampling strategy, 100 African American women (18-24 years) were recruited from a historically Black college and university for an open discussion of condom use. Thirteen focus groups were conducted via a semistructured interview guide and analyzed with an inductive thematic approach. Results. Uniformly women perceived pregnancy as a greater threat than STIs which appears to be maintained by (a) their sense of fertility, (b) self-care concept, and (c) experiences with condom failure. Thus, women were skeptical about using condoms as a form of contraception. Women perceived casual sex as having the greatest HIV/STI risk and emphasized the importance of assertiveness and self-respect to negotiate condom use. However, condom use in monogamous relationships is less likely due to (a) testing/knowing partner’s status, (b) relationship trust, and (c) the use of hormonal contraception for pregnancy prevention. Perceived threat of infidelity increases condom use. Conclusion. The implications of these findings suggest sexual health promotion programs may focus on improving women’s estimate of the effectiveness of condoms to prevent pregnancy and addressing women’s reliance on testing for STI prevention.

Keywords

African American college women condoms qualitative research risk perception sexual health

Sexually transmitted infections (STIs) and unplanned pregnancy remain a major public health concern, particularly among adolescents and young adults. Among the 20 million new cases of STIs each year, individuals aged 15 to 24 years account for 50% of infections (Centers for Disease Control and Prevention [CDC], 2016). STIs are disproportionately affected by gender and ethnicity, with young African American women being most vulnerable. Prevalence rates of chlamydia and gonorrhea among African American women aged 15 to 19 years are 4.7 times and 11.3 times greater than rates among European American women in the same age group (CDC, 2016). Among African American women aged 20 to 24 years, the chlamydia rate is 3.9 times greater and gonorrhea rate is 9 times greater than the rate among European American women in the same age group (CDC, 2016). Similarly, the rate of HIV infection is 3.5 times higher in young African American women than young European American women (CDC, 2015a). Furthermore, approximately 37% of all births in the United States are unintended, with the highest rates among unmarried, noncohabitating women aged 15 to 24 years (79%) and African Americans (45%; Finer & Zolna, 2011; Mosher, Jones, & Abma, 2012). Correct and consistent condom use is highly effective against both STIs and unintended pregnancy (CDC, 2013; Trussell, 2011). However, only about 21% of sexually active, unmarried women aged 15 to 24 years use condoms consistently and rates are lower among African American women (16%) in this age group (Daniels, Daughtery, Jones, & Mosher, 2015). As in the general population, sexual health disparities are evident on college campus, but African American students are largely underrepresented (Buhi, Marhefka, & Hoban, 2010). Historically Black colleges and universities (HBCUs) are important educational and cultural context in which to further study sexual health (Chandler, Anstey, Ross, & Morrison-Beedy, 2016; Younge, Corneille, Lyde, & Cannady, 2013).

The existing literature about African American college women has focused on knowledge, intrapersonal factors, and behaviors that affect condom use. Notably, African American college women demonstrate adequate knowledge of STI/HIV transmission and prevention (Annang, Johnson, & Pepper-Washington, 2009; Braithwaite & Thomas, 2001; Brown, Shepperson, Gopalan, & El-Amin, 2012; Mancoske, Rountree, Donovan, & Neighbors, 2006; Sutton et al., 2011). Likewise, contraceptive knowledge is relatively high among African American women (Craig, Dehlendorf, Borrero, Harper, & Rocca, 2014; Rocca & Harper, 2012). Furthermore, research demonstrates that African American college women have the requisite self-efficacy and confidence to use condoms, assertiveness, and communication skills to negotiate condom use (Braithwaite & Thomas, 2001; Jenkins & Kennedy, 2013; Norwood & Zhang, 2015). However, this knowledge and skills may not translate to behavior.

Lewis, Melton, Succop, and Rosenthal (2000) found that about 24% African American college women attending a state university reported “always using a condom.” Additionally, condom use rates are lower among African American college women than African American college men and European American college women (Bazargan, Kelly, Stein, Husaini, & Bazargan, 2000; Walsh, Fielder, Carey, & Carey, 2013). Studies have identified several correlates to reduced condom use among African American college women including less favorable attitudes toward condoms, perceptions of irregular condom use among friends, being in a monogamous relationship, as well as substance use (Bazargan et al., 2000; El Bcheraoui, Sutton, Hardnett, & Jones, 2013; Hayes et al., 2009; Lewis et al., 2000; Roberts & Kennedy, 2006). Moreover, African American college women may not perceive themselves to be at risk. In a study of unintended and intended pregnancies among U.S. women, the most cited reason for not using any form of contraception was “didn’t think I could get pregnant” (Mosher et al., 2012). African American women are more likely to underestimate the risk of conception from unprotected sexual intercourse (Biggs & Foster, 2013). A similar underestimation is found for HIV. Bazargan et al. (2000) found an inverse relationship between perceived vulnerability and HIV knowledge. African Americans students attending HBCUs report low-risk perceptions of HIV and perceptions are lower among women than men (Adefuye, Abiona, Balogun, & Lukobo-Durrell, 2009; Annang et al., 2009; Chng, Carlson, & Toynes, 2006; Payne et al., 2006; St. Rose, 2008; Sutton et al., 2011; Thomas et al., 2008; Voetsch et al., 2010). The information gleaned from quantitative studies, suggest risk perception as target for further investigation and intervention. However, few studies have qualitatively evaluated risk perception in African American college students. In Thompson-Robinson et al. (2005) exploration of how knowledge and perceptions of partner risk influences condom decision making, African American college students (males and females) report love as a factor for unprotected sexual intercourse. Ferguson, Quinn, Eng, and Sandelowski (2006) found that African American students perceived a gender–ratio imbalance at HBCUs, which students felt put college women at an environmental risk of HIV. Personal risk was not ascribed in either study. Among a diverse sample of African American, European American, and Latina students, inconsistent/nonuse of condoms and contraceptives were supported by students’ faulty risk evaluation, faulty evidence evaluations, endorsement of less reliable methods, focus on superficial side effects/positive effect of unprotected sex, dismissing risk, or ignoring risk (O’Sullivan, Udell, Montrose, Antoniello, & Hoffman, 2010). Previous studies have not examined African American college women exclusively. Additional qualitative studies are needed for this vulnerable population to ensure that sexual health interventions address the issues concerning them. Qualitative studies allow researchers to determine if observations found in quantitative studies are in the right domain for targeted prevention and intervention (Kanekar, Sharma, & Wray, 2009). To this end, the objective of this study is to describe African American college women’s perception of pregnancy and STI risk and assess how their perceived risk affects their condom use.

Method

Study Design

A phenomenological qualitative research design guided this assessment of the role of risk perception in condom use among African American college women. This design is recommended when the goal of the research is to understand the meaning of human experiences or the “lived experience” (Creswell, 2007). The current study received approval from the institutional review board (IRB 12-MED-56) from the university where research enrollment commenced.

Participants

A total of 100 women were recruited from an urban HBCU in the mid-Atlantic region of the United States for a study of risk and protective factors related to condom use. Eligibility criteria included (a) self-identification as Black or African American, (b) heterosexual orientation, (c) between the age of 18 and 24 years, and (d) sexually active within the last 90 days.

As previously reported (McLaurin-Jones, Lashley, & Marshall, 2016), the mean age of the women was 20.4 years and predominantly comprised African Americans (74%). Other cultural groups included Caribbean (19%) and Africans (7%). Most were upper classmen, with 37% seniors, 29% juniors, 24% sophomores, and 10% freshmen. Less than one third of the sample reported “always use a condom.” About 35% reported a history of an STI.

Measurement

Data for the present analysis were collected via focus groups. The use of focus groups as a method of qualitative data collection is appropriate for exploring perceptions, feelings, and thinking about issues/ideas and is the most common method of data collection in qualitative health care research (Gill, Stewart, Treasure, & Chadwick, 2008; Krueger & Casey, 2015). Our groups were facilitated with the assistance of a semistructured interview guide. Semistructured interviews not only contain essential questions that define the area of exploration but it also allows the interviewer to deviate in order to pursue in detail an idea or a response given by the interviewee (Britten, 1999). An open-ended format was developed in advanced to increase discovery and improve consistency across groups (Zohrabi, 2013). The interview guide contained four discussion domains: college dating, alcohol/substance use, risk perception, and condom negotiation. An independent qualitative researcher not affiliated with the current study critiqued and helped refine the interview questions (Merriam, 1998). After the first focus group, we reviewed the responses and revised/made adjustments to any unclear or obscure question to increase measurement validity. Key questions from the risk perception domain are presented for the current analysis:

Given your experience with college dating, how susceptible are you to getting pregnant?

What are your methods for birth control?

Giving your experience with college dating, how susceptible are you to getting an STI?

How do you reduce your risk of getting an STI?

How does your perception of risk (pregnancy or STI) influence your decision to use condoms?

Study Procedures

Thirteen focus groups were conducted with a range of 6 to 8 participants per group. Focus group sessions were prescheduled for data collection and participants chose the focus group based on their availability. The lead author obtained written informed consent and moderated all focus group discussions. Participants were encouraged to share their experiences, values, and preferences regarding condom use. To provide anonymity, participants used a fictitious name throughout the discussion and were requested to abstain from sharing any information from the focus group with family or friends. Each focus group, which lasted about 2 hours, was audio recorded. During times in which the discussion represented a limited set of viewpoints, the facilitator probed group members in an effort to capture the full spectrum of narratives. Participants received a $50 gift card as reimbursement for time spent in research activity.

Data Analysis

An independent transcription company transcribed each audio recording verbatim. All authors verified the accuracy of the transcripts against the original recordings (Krueger & Casey, 2015). Copies of the focus group transcripts were sent to participants to provide feedback and confirm credibility and trustworthiness of the data (Merriam, 1998). To capture the meaning of African American college women’s experiences, we analyzed the data using a thematic approach. Guided by the work of Braun and Clarke (2006), a thematic analysis involves (a) familiarization of the data, (b) generating codes, (c) searching for themes, (d) reviewing themes, and (e) defining and naming themes. Accordingly, researchers read transcripts independently and made notes about potential codes. Researchers then met collectively to develop a preliminary list of codes. Each researcher coded each transcript individually using the preliminary list of codes. Researchers met periodically to review coded segments and develop new codes. Any discrepancies were resolved through discussion until consensus was reached (Ulin, Robinson, Tolley, & Speizer, 2005). Once all transcripts were coded, comparative analysis of the transcripts was undertaken to describe commonalities and differences in responses. Researchers systematically organized data into categories through iterative rounds of data analysis, yielding themes and subthemes. Themes constituted a higher level of categorization of emerging phenomenon providing a meaningful pattern. In contrast, the subthemes constituted further explanation of pattern for the emerged theme. Each theme and subtheme represented the participants’ voices that presented across multiple focus groups. Researchers selected specific quotes as exemplary units representing the thoughts and perceptions portrayed by the focus group participants. Direct quotes are presented within the original context to add richness to the data analysis and form the basis of trustworthiness and credibility of the research (Patton, 2002; Ponterotto & Geiger, 2007).

Researcher Characteristics and Reflexivity

As researchers, it is important to express the experiences we bring to the field and our research, which may influence the research process (O’Brien, Harris, Beckman, Reed, & Cook, 2014; Patton, 2002). All members of the research team are affiliated with HBCUs as trainees, graduates, staff, and/or faculty and have engaged in community studies with participants who self-identify with the African Diaspora. We are all African American women who feel connected to the female college population through shared cultural and educational experiences. As Black feminists/researchers, we seek to give voice to minority women and empower them to take control of their mental, physical, and sexual well-being. Our resolve to give voice to minority women may have informed our approach to data collection. One member of the team, a clinical psychologist, facilitated the groups and was involved in the face-to-face contact with all participants. Participants’ knowledge of researcher’s professional background and affiliation with a graduate program may have influenced women’s willingness to participate in the study. To provide a nonjudgmental environment, the facilitator disclosed limited personal information which may have motivated participants’ disclosure or may have shaped their narratives. After each focus group, the facilitator debriefed with a member of the research team to discuss observations and reactions to the group process. Serving as facilitator help the researcher understand how women feel and think about their sexual health and motivated/reinforced ideas about female empowerment. Racial, gender, and educational similarities between researchers and participants may have inspired interpretation of the data.

Results

Through thematic analysis of the data, insight was obtained into intrapersonal and contextual factors of risk and condom use. Findings resulted in a detailed account of data distilling into broad patterns of perceived types of important factors when dealing with sexual health. Four main themes emerged: (a) pregnancy fear greater than HIV/STI fear; (b) monogamous relationships, low risk, low condom use; (c) casual relationship, high risk, high condom use; and (d) behavioral protective strategies. Broad definitions and illustrations of themes and subthemes are presented to provide a deeper understanding of the role of pregnancy and STI risk perception in condom decision making among African American women.

Pregnancy Fear Greater Than HIV/STIs

This theme is defined as thoughts and perceptions representing the emotional overtone (concern, worry, fear, shame) about the possibility of getting pregnant versus having an STI. Overall, there was a prevailing sense of fear of pregnancy. A majority of participants expressed pregnancy as an unwanted outcome that was at the forefront of many college students’ minds, including males. Pregnancy was judged negatively, bringing about shame, fear, and guilt to themselves and their families, and viewed as something that was under the purview of their control. Pregnancy was therefore viewed as more serious than getting STIs or HIV as captured by the following quotes:

Worrying about pregnancy is so much bigger than the worrying about STDs.

I just also feel like, and this is myself included, I just feel like a lot of people’s concerns is more so with being pregnant than getting STDs, and that’s bad, but I feel like that’s everybody’s initial thinking is like, “Oh shoot, I’m—oh shoot, I don’t want to get pregnant,” not, “Oh shoot, I don’t want to get an STD.”

So I just don’t think there’s an excuse, if you’re having sex, why not to get on birth control, because pregnancy is the biggest—I mean, we’re afraid of STDs, AIDS, and all that, too, but pregnancies, like you said, abortions are expensive. You don’t want to go through that. You don’t want to go through the emotional stress.

Accordingly, women were generally proactive about contraception. When discussing methods of protection, condoms was expressed 33 times, hormonal contraception (pills, patch, shot, implants) was also voiced 33 times, and natural planning methods (tracking ovulation/menstrual cycles and withdrawal) was cited 23 times. Although several participants engaged in multiple methods, pregnancy fears persisted in spite of their contraceptive behavior.

Even though I am on birth control, I’m always paranoid.

I think for me personally, I am terrified of being pregnant . . . so I take all of the cautionary measures to make sure that I’m not about to be put in a situation that will have me worried. So like I have the app on my phone that says when I’m ovulating, I have the birth control, I have condoms.

Yeah, anytime, I’m always at risk regardless if there’s a condom used, it could come off in the middle. You never know. It can break. The guy may—say that the boyfriend you were with all that time, that y’all don’t use condoms, and he may use the withdrawal method or whatever, he may not that one time, and even if you take birth control, say that was the time that you forgot to take it. And you’re still at risk, so that’s why I say the risk is very high, regardless of if I take those precautionary measures, it can happen.

Women’s risk and fears of pregnancy appeared to be supported by emerging subthemes including (a) a sense of fertility, (b) self-care conceptualization, and (c) condom failure experiences.

Sense of Fertility

Sense of Fertility subtheme represented thoughts and perceptions regarding the capacity and capability to bear multiple children at a young age. In discussing the threat of pregnancy, some participants referred to coming from a fertile family which presented as a risk as captured in the following quotes:

In my mind, I just feel like I’m really fertile.

I come from a family—every woman in my family has had a child before, by 18 pretty much.

Because my entire family is so fertile. Like it’s like everybody’s popping out kids left and right. So I’m like, where’s my period, why isn’t it here? And I think that’s why I know I’m doing what I should to protect myself with birth control . . . I feel like I’ll probably—I feel like I could pop out 15 kids.

Self-Care Conceptualization

Stated reasons for avoiding pregnancy that relate to one’s sense of well-being, abilities, and/or resources needed for a responsible adult and professional defined the self-conceptualization subtheme. Postponing beginning a family was a priority for participants. Participants felt that they were unprepared because they lacked the maturity and emotional/financial resources required for parenting. They wanted to grow and develop more as an adult and as a professional. This subtheme is demonstrated in the following quotations:

Right now I would—I’m not ready for a baby because—I’m not going to say I’m a baby myself because I’m a young lady but I’m still working on myself, I feel like if I brought somebody into the world we’d still—we’d be—like I’d have to raise them and still raise myself, if that makes sense, not—I mean my mom’s still helping me and stuff like that but I’m learning stuff from—every day I’m learning new things about myself and just about life and getting ready for after college life and paying bills because I’m not yet—I don’t have—I’m not good at paying my own bills and stuff like that so I am getting—you getting ready for that next step in life.

And I think the end goal in sight is like, so important to—what you envision your life looking like, and does a child factor into that? Because I want the fairytale life, I want to get married and then I want to have kids after I get married and have my own successful career and make like, six figures and we have our own house, so there’s no way to accomplish that if you are not taking the proper precautions.

Condom Failure

The condom failure subtheme denotes women’s descriptions of personal experience in which an attempt to use a condom during a sexual encounter resulted in a tear or breakage as well as comments about the reliability and effectiveness of condoms as a contraceptive method. While many participants shared that they use condoms, an uncertainty and anxiety remained about the effectiveness of condom use to prevent pregnancy. Women spoke of their personal experiences concerning condom failure as illustrated in the following examples.

So like I’m—that’s the one thing about just using condoms that makes me nervous, is that like if it breaks, like, and, you know, typically speaking, statistically speaking, it doesn’t break. It’s a very rare thing to happen. Like I don’t know anyone else who’s had a condom break, but it happened to me. It’s just—one time is one time too many.

But like I’ve had a condom break, and so like almost every time that I’ve ever had sex, I’ve just basically been like, please, God, don’t let me get pregnant. Like even though I use a condom, and like even the time when the condom broke, like it’s just like—I had to sit there and think of like all the possible outcomes, like all the things that could go wrong with a condom breaking, and all of the possible consequences of that.

If you’re just using condoms I don’t feel like that’s—I feel that’s another high risk because oftentimes condoms aren’t effective. Say it breaks and you’re not on birth control. College students might just have one plan I guess—Not a plan but one method. And sometimes that puts you at higher risk as well.

Many participants described their risk and behavior within the context of their sexual relationship. Participants made a distinction between monogamous and casual sex and the risk associated with each.

Monogamous Relationship, Low Risk, Low Condom Use

This theme is defined as being comfortable in a monogamous relationship and not worried about using condoms. When discussing monogamous relationships, women spoke of engaging in lower condom use.

I feel like being in a monogamous relationship is more of a reason I guess for people to think not to use condoms, but I don’t know if it’s like personal preference.

I don’t like having sex without one [a condom] unless I’m in a monogamous relationship.

I think it was in the beginning when we first started having sex. I was very big on condom use. But, I think getting comfortable with him kind of like has made me shy away from it. So, I don’t really care as much as I did before. But, it’s just because now I’m very comfortable. I’m not saying that’s a good thing at all, but yeah. It has changed.

Lower condom use in monogamous relationships centered around three emerging subthemes: (a) HIV/STI testing, (b) relationship trust, and (c) hormonal contraception.

HIV/STI Testing

As a subtheme, HIV/STI testing reflected women’s accounts of the availability of HIV/STI testing kits and clinics, experiences getting tested, and experience receiving/sharing information with partner. Several participants shared the importance of knowing their partner’s status as it relates to HIV/STIs. Many felt that their risk was low because there was tangible evidence of partner’s status as illustrated by the following quotations:

I’ve only had sex with him, and I wouldn’t have sex actually until he got tested. It’s like, “Bring the papers.” So, I mean, unless he is having sex with someone else right now, I’m pretty 99 percent sure he isn’t. Then it [risk] would be low.

The guy I’m with now, we’ve been together for like seven months, but I remember the first time we ever had sex without a condom, like before, we went—we both had to go to the clinic to get our papers done. That doesn’t protect against pregnancy, but at least we know like we’re clean.

If we’re having a sexual conversation that’s one of the main things that I say that I need, like just to like have a STI test done. Thank God we have OraQuick. So if you just say, “Oh, well I’ve got to go to my doctor, no, because we could go to Walgreen, Target, anywhere that has OraQuick and just take the test, it’s like kind of pricey but still it’s like my life.”

Relationship Trust

Another factor that reduced condom use in monogamous relationships is trust. Relationship trust as a subtheme is distinguished as women’s confidence, faithfulness, and assurance of themselves and their partner while in a monogamous relationship. Women described the thought and consideration given before starting a monogamous relationship and the expectation that their partner will remain faithful.

I know that we should use condoms, but when I’m in a monogamous relationship—it takes a long time before I decide I want to be with someone. So, once that decision has been made, it’s because I definitely wholeheartedly trust them, and we’ve been tested and everything. And, to be honest, I’m not gonna use a condom the majority of the time we have sex . . .

I’m in a monogamous relationship, and I trust him, so I don’t think that I’d be catching anything any time soon.

A few participants acknowledged the risk involved in monogamous relationships and potentially being careless in careless in protecting themselves as expressed as follows:

Now that I’ve thought about it and listened I really now seriously do think it’s more risky to be in a relationship. It’s like when I’m in a relationship and I trust you and I have feelings for you and I believe in you then it’s like I get careless with things.

Other participants shared that if there was some doubt in the relationship concerning trust, they had to be proactive and take precautions. This thought was summed up as follows:

If I suspected you of cheating all of a sudden we need to use condoms again.

Hormonal Contraception

Hormonal contraception refers to women’s statements about their use of birth control pills, skin patches, vaginal rings, or injections to prevent pregnancy. Women viewed monogamous relationships as having only one concern—to prevent pregnancy. Hormonal contraception was typically viewed as most effective. Women who were in a monogamous relationship and using condoms did so primarily as a birth control method as they were unable to use hormonal contraception due to side effects or personal beliefs against hormonal contraception, as illustrated below.

But I think my condom use personally, because I’m in a monogamous relationship. We use condoms. I told you I don’t want to get pregnant. I’m not on any type of birth control or anything like that.

Casual Relationship, High Risk, High Condom Use

As monogamy was viewed as protective, casual sex was viewed as the biggest risk factor for HIV/STI. This theme comprised women’s beliefs that casual sex entails multiple partners which increase risks for pregnancy and HIV/STIs. Women talked about not knowing the HIV/STI status of casual sex partners and the geographic location of the campus in a community with an HIV rate above the national average.

And I think if you’re having casual sex with someone, there’s no reason why you should slip up and not use a condom. Like that’s not a question. That’s what you need to do.

And casual sex I think kind of makes it—and I’m not saying anything’s wrong with people who have casual sex; I just feel like personally your risk goes up because how can you ask somebody who you’re just having casual sex with and they’re not your partner to get tested.

And I feel like a lot of people, because I know [city] is really populated with HIV and STDs and STIs, and I feel like a lot of people are really more focused on HIV.

Because of the perceived risk associated with casual sex, women emphasized the importance of self-respect and assertiveness to ensure that a condom is used.

I’m not scared to tell and individual to use condoms, like I’m very like—some people say it’s aggressive but like if I let’s say we’re in the moment and I’m not okay with something I don’t care who you are—Tina is going to tell you no, or what’s going to happen. That’s just me as an individual and I’m never scared to tell anybody, “Oh, pull out a condom, or we will stop and you will go to CVS, Kroger—what do you all have here?—Safeway or whatever to find a condom.”

Theme: Behavioral Protective Strategies

Behavioral protective strategies theme represents women’s experiences and thoughts about proactive measures (i.e., education, testing, personal responsibility) regarding sexual health. In lieu of the perceived risk associated with casual sex, participants offered several suggestions to reduce risk.

So I think you just need to—especially if you’re having sex, you need to take responsibility for your own health, because he’s not going to do it. Nobody’s going to do it. This is your body. This is your health. You need to take the necessary precautions.

Your health is your own health; you protect yourself first and foremost. Like when I ask somebody to use a condom you, um, yeah, I mean of course I care about your health if I’m sleeping with you I must care about you. But it’s 100 percent about myself, my health, my future that I’m worried about.

You have to take care of yourself. You have one body. That’s it. So like you really should have precautions on yourself.

Several participants cautioned against engaging in other risky behaviors, such as alcohol and drug use, that may alter thinking and create spontaneous casual sex.

I would say make sure you know what you’re doing when you have sex. Don’t have drunk sex, like be at a party and just choose to have sex with someone because you wouldn’t think about all the other factors. You wouldn’t be thinking about getting a STD if you’re just drunk at a party. Be conscious of what you’re doing.

Other participants talked about being aware of the number of sexual encounters and suggested limiting sexual partners or promoted abstinence to alleviate risk, as demonstrated in the following excerpts:

I think that another way to reduce risk is reducing your number of partners.

If you limit your partners and, um, protect yourself every time you have sex your risk of getting STI will be really low.

I’m going to be real honest, I feel like if you don’t want to get pregnant, you don’t want STDs, you don’t have sex, period.

So I just feel like the safest way is just to not do it and just—if you’re with the right person, that person is going to wait on you because they love you. That’s so small to what you will have, so that’s just honestly how I feel about it.

Other strategies participants perceived as important were utilization of campus health services. Participants noted that these facilities were a focal point for college health that included health exams, HIV testing, and educational materials:

If you’re having sex, you’re going to be susceptible to infections and diseases. But I really feel like you need to make sure you’re getting checked, because I get checked every three, four months. They do it for free at school. You go to the health center, Wednesdays, this time. So, I mean, it’s here for us. Because if we’re having sex, even with condoms, because there’s still diseases that you can catch through the skin to skin contact that condoms won’t help you. So you just need to be on your health, period, but especially when it comes to STDs and STIs. Just go get checked.

Discussion

The present study adds to the body of knowledge concerning pregnancy and STI risk perception in an exclusive sample of African American college women. Our findings suggest that African American college women perceive themselves to be at high risk for pregnancy and their fears may outweigh the risk for STIs. Women’s thoughts about their fertility and their future support their beliefs. Thus, women may engage in a variety of contraception methods to prevent disappointment in the family and the Black community at large. Finding parallels similar findings that women consider pregnancy prevention as paramount importance to STI (Grady, Klepinger, & Nelson-Wally, 1999). Interestingly, African American women perceived condoms as having a high failure rate, in spite of evidence to support condoms are 98% effective when used consistently and correctly (Trussell, 2011). Women, in general, show less favorability in the effectiveness of condoms to prevent pregnancy (Grady et al., 1999). To engage women in greater condom use, intervention efforts may want to highlight the effectiveness of dual method contraception. Dual method contraception includes a barrier method (male/female condom) and a hormonal method (Cates & Steiner, 2002). The combination increases contraceptive effectiveness (Pazol, Kramer, & Hogue, 2010). Negative perceptions about condom breakage were in part due to women’s own experiences and the experiences of others. The risk of condom failure is higher for African American women and for women younger than 30 years (Kost, Singh, Vaughan, Trussell, & Bankole, 2008). Perhaps the experiences reflected in the study are related to incorrect usage. Clifton, Penrose, Prien, and Farooqui (2015) found that 67% of college students did not apply the condom correctly during a practical demonstration.

Another critical finding, women’s perception of their HIV/STI risk was tied to the type of sexual relationship. In particular, monogamy was perceived as less risky. A similar observation was found by Foreman (2003). Monogamy itself does not offer protection and women’s failure to understand this may place then at risk (Bazargan et al., 2000). Studies suggest that college women’s noncondom use may reflect their compliance with male preferences (Ferguson et al., 2006). Yet our findings suggest that college women may justify their noncondom use because of an emotional attachment as reported by Thompson-Robinson et al. (2005). Trust was a salient issue for noncondom use as observed in other young women (Bolton, McKay, & Schneider, 2010). Conversely, casual sexual relationships were perceived as risky and participants emphasized condom use as a sign of self-respect. The perceptual link between condom use and self-respect has been noted among minority women (Sobo, 1995).

Given the magnitude of HIV/AIDS in the African American population, the strategies offered (cautioning against alcohol use, limiting the number of sexual partners) may reflect college women’s understanding of risk in terms of probability in light of the geographic location of the campus. As previously reported, 88% of the sample had been tested for HIV (McLaurin-Jones et al., 2016), whereas other studies report lower testing rates among African American students (Payne et al., 2006; Thomas et al., 2008). The high rate of testing in this sample may be related to the perception that HIV testing is a protective measure as well as the availability of services. The targeted university offers a testing clinic with daily access. Additionally, the university is conveniently located to retail stores that carry testing kits. While testing helps individuals assess their level of risk, students may need to be advised against using testing in lieu of protection.

Limitations

Although the current research offers insight into African American college women’s perception of risk and condom use, their views may not be applicable to those African American women attending predominately White institutions or other HBCUs. Additionally, sexual health is shaped by upbringing and culture. Themes emerged from the sample as a whole may differ by cultural heritage. However, we were not able to conduct a cross-cultural comparison. Future studies may stratify women based on cultural heritage to deepen our understanding within the African diaspora.

Implications for Health Equity Research and Practice

While offering a rich cultural history and rigorous academics, HBCUs may play an institutional role in providing sexual health promotion and affecting behavioral change. Most sexual health education and prevention programs are directed at high school students and young adults have limited access after high school (O’Sullivan et al., 2010). Thus, the creation of a safe and supportive environment for the health and mental well-being is very important. Colleges and universities offer health services, but the onus remains with the student to access these services. Institutions of higher learning may consider mandatory requirements for graduation where students can receive specific instructions as evidence in high school programs (CDC, 2015b). This type of initiative will provide our youth with information to make healthy decisions during their collegiate tenure. Specifically, African American college students may benefit from sexual health education that includes demonstration and practice to ensure correct condom usage while making the connection between correct usage and condom effectiveness. Additionally, HIV testing should be offered along with counseling. Student who present for frequent HIV testing may need a behavioral risk assessment.

For equity, health and counseling services should be offered with cultural adaptations regarding sexual orientation, gender identity, race/ethnicity, culture, and/or religion. Spirituality/religiosity may play an important role of how sexual health is promoted. Christian universities may look to faith-based approaches to sexual health. Services can be offered with collaborative partnerships established with academia, clinical practitioners, stakeholders, and community-based organizations. Sororities, fraternities, and other student organizations should be engaged to reach a broader audience and can be trained as peer educators for sexual health promotion.

Potential policies, guidelines, and recommendations must take in consideration the multilevel and contextual factors of HBCUs, including limited resources. Intracollegiate collaborations may be formed to maximize resources. Entities must work together to advance the field of sexual health promotion by recognizing risk and protective factors through public health education, research, and training to facilitate the development of effective interventions.

Footnotes

Authors’ Note

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research reported in this publication was supported by the National Institute on Drug Abuse of the National Institutes of Health under Award Number R24DA021470.

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