Sexual behaviour,drugs and alcohol use of international students at a British university: a cross-sectional survey

Abstract

The aim of the study was to determine whether international students have greater risk-taking behaviours that could lead to importing novel and resistant strains of sexually transmitted infections (STIs). We conducted a cross-sectional web-based survey of university students' sexual behaviour, alcohol and drug use, and self-reported diagnosis of STIs and compared these between British and international students. In all, 827 students completed the survey, of whom 123 (15%) were international students. International students were less likely to have ever drunk alcohol (95.4% versus 87.8%, P = 0.002) and used drugs (56.4% versus 41.5%, P = 0.002). International students were on average almost two years older at first intercourse (18.7 versus 17 years; P < 0.001). There were no differences in the number of sexual partners between national and international students. On a discriminant analysis model, international students were characterized by being older and from a non-white background, less likely to use cocaine, they drank alcohol less frequently and were more likely to have had unprotected intercourse with two or more partners in the previous year. In conclusion, international students tend to drink more moderately and use fewer recreational drugs than British students. However, they exhibit higher sexual risk behaviours that could lead to importing novel and resistant strains of STIs.

Keywords

travel sexually transmitted infections foreign students university commercial sex work

INTRODUCTION

Sexually transmitted infections (STIs) incidences are increasing across Europe.¹ Higher rates of transmission of chlamydia and genital warts in the UK are among young adults,² probably as a result of changing sexual behaviours in this age group.³ A number of studies have highlighted the higher prevalence of casual sex and more risk-taking behaviour among long-stay travellers. Although quinolone-resistant strains of Neisseria gonorrhoeae in the UK are normally associated with infections acquired abroad, they have now become endemic in the UK.⁴ Also different strains of human immunodeficiency virus (HIV) circulate in Africa compared with those in Europe and North America and are imported here.^5–8

We conducted a sexual, drug and alcohol behaviours survey of university students and compared these between national and international students to determine whether the later have higher risk-taking behaviours that could lead to importing novel and resistant strains of STIs.

METHODS

We conducted a survey of sexual attitudes and behaviours, alcohol and drug use of university students at the University of East Anglia in June 2006. All students (full-time, part-time, undergraduate and postgraduate) registered with the University for the 2005/2006 academic year were invited to complete a baseline questionnaire including questions on alcohol and drug use, and sexual behaviour and past history of STIs, which were based on similar questions asked in the NATSAL 2000 questionnaire.³ Students were sent an invitation to participate in the study with a link to an online questionnaire. Two reminders were sent at weekly intervals. Students completed the questionnaire online, as this is a medium that has been shown to yield a good response in researching sensitive behavioural topics.^9,10

Participants

At the time of the survey there were 14,047 students registered for studies at the University. About 62% of students were aged 17–25 and 61% were women. Seventy-five percent were British students.¹¹ The baseline characteristics of the sample, including sexual behaviour, drug and alcohol use, have been described in more detail elsewhere.¹²

The University provides Internet and email access to all students at various sites throughout the campus. The University Information Technology services hold mailing lists for all registered students. Although most students have university email addresses, some register other addresses. Although the coverage of these lists is thought to be very complete, it is not certain what proportion may be missed. These lists were used to invite students to take part.

Statistical analysis

We compared demographic (i.e. age, sex, ethnic background and marital status) and behavioural (e.g. alcohol and drug use, sexual partnerships) characteristics between British and international students by calculating chi-square test, or Fisher's exact test where appropriate, Mann-Whitney rank sum test for categorical variables and t-test for continuous variables. All demographic and behavioural factors identified as significant at the P < 0.2 level were included in a discriminant analysis model to determine the characteristics that differentiate British students from those from other countries.

Finally, the risk associated with different self-reported STIs, comparing international with British students, was estimated by calculating odds ratios and 95% confidence intervals. These were adjusted for differences in demographic characteristics.

RESULTS

Eight hundred and twenty-seven students completed the online questionnaire. Information about students' nationality was available for all of them except for one student. There were 123 (14.9%) international students from different countries: 68 (56.7%) from Europe, 21 (17.5%) from Asia, 15 (12.5%) from Central and South America, 10 (8.3%) from North America, four (3.3%) from Africa and two (1.7%) from Australia and New Zealand. Information on the country of origin was missing for three students.

There were no differences in the proportion of female students, the marital status or reported sexual attraction between British and international students (Table 1). However, international students were older than British students (25.6 years versus 22.6, P < 0.001) and there was a much greater proportion of people from non-white ethnic backgrounds (33.3% and 3.9%, P < 0.001).

Table 1

Differences in demographic characteristics between British and foreign students

	British n = 703	Foreign n = 123	P value
Gender (female)	485 (69.2%)	78 (62.4%)	0.204*
Age – mean (SD)	22.57 (0.23)	25.57 (0.5)	<0.001^†
Ethnicity (white)	676 (96.1%)	82 (66.7%)	<0.001*
Sexual attraction
Opposite sex only	416 (59.2%)	82 (66.7%)	0.126^‡
Both sexes	261 (37.1%)	37 (30.1%)
Same sex only	19 (2.7%)	3 (2.4%)
Relationships (single without a regular partner)	242 (34.4%)	46 (37.4%)	0.523*

*Pearson's χ²

^† t-test

^‡Mann Whitney U test

SD = standard deviation

A greater proportion of British students reported ever drinking alcohol (Table 2). International students drink alcohol less frequently than British students and when they drink, they do so in more moderate quantities. Also a smaller proportion of international students claim to have ever tried any recreational drugs, and as a result they are also less likely to have used them in the previous month. Although there is no difference in the use of cannabis or speed after adjustment for age and ethnic background, there is marked difference in the use of cocaine (1.6% and 9.1%, P = 0.001).

Table 2

Behavioural differences between British and international students

	British n = 703	Foreign n = 123	P value
Alcohol and drug use
Ever drunk alcohol	670 (95.4%)	108 (87.8%)	0.002*
Alcohol frequency
Never	16 (2.3%)	8 (6.6%)	<0.001^†
Monthly or less	66 (9.4%)	27 (22.1%)
2–4 times per month	217 (31.0%)	40 (32.8%)
2–3 times per week	267 (38.1%)	40 (32.8%)
4 or more times per week	134 (19.1%)	7 (5.7%)
Alcohol quantity
One to two	354 (51.2%)	81 (68.1%)	0.001^†
Three to four	187 (27.1%)	26 (21.8%)
Five to six	85 (12.3%)	3 (2.5%)
More than six	42 (6.1%)	3 (2.5%)
Ever used drugs	394 (56.4%)	51 (41.5%)	0.002*
Used drugs in past 4 weeks	308 (43.8%)	41 (33.3%)	0.03*
Cannabis	300 (42.7%)	38 (30.9%)	0.017*
Speed	43 (6.1%)	1 (0.8%)	0.006^‡
Cocaine	64 (9.1%)	2 (1.6%)	0.001^‡
Sexual partnerships
Age of first intercourse [mean (SD)]	17 (2.04)	18.7 (3.02)	<0.001^§
Number of partners ever
0–1	167 (24.5%)	32 (26.9%)	0.71^†
2–4	224 (32.8%)	36 (30.3%)
5–8	137 (20.1%)	26 (21.8%)
9 or more	155 (22.7%)	25 (21.0%)
Number of partners in last 4 weeks
None	178 (26.3%)	38 (31.7%)	0.159^†
1	456 (67.4%)	77 (64.2%)
2 or more	43 (6.4%)	5 (4.2%)
Ever paid for sex	8 (1.2%)	8 (6.6%)	0.001*
Condom use/risk perception
Number of unprotected partners in last year
None	39 (8.0%)	5 (6.7%)	0.14^†
1	343 (70.7%)	48 (64.0%)
2 or more	103 (21.2%)	22 (29.3%)
Two or more heterosexual or homosexual partners in the past year and inconsistent condom use in the past 4 weeks	73 (10.4%)	14 (11.4%)	0.75*
Perceived at risk of HIV/STI	326 (47.5%)	63 (52.1%)	0.35*
Behaviour change because of fear over STIs	416 (60.3%)	56 (45.9%)	0.004*

*Pearson's χ²

^†Mann-Whitney U test

^‡Fisher's exact test

^§ t-test

HIV = human immunodeficiency virus; SD = standard deviation; STI = sexually transmitted infection

British students are on average two years younger when they have their first intercourse (18.7 and 17 years, P < 0.001). Despite this there are no differences in the number of lifetime or recent sexual partners. However, international students are more likely to have ever paid for sex (1.2% and 6.6%, P < 0.001) (Table 2). As there were no women who had ever paid for sex, either British or international, the likelihood of having ever paid for sex among male international students is greater (3.8% and 17.8%, P = 0.002).

With regard to preventive behaviour, although in our sample there was a greater proportion of international students who had had two or more partners with whom they had unprotected intercourse, there were no statistical differences (Table 2). Similarly, a smaller proportion of international students admitted to having modified sexual behaviour because of the fear of STIs or HIV, but this difference was statistically non-significant.

In the discriminant analysis, after adjustment for demographic and behavioural characteristics significant in the univariable analysis (P < 0.2), international students are characterized by being older, from a non-white ethnic background, drinking less frequently than British students, less likely to use cocaine, and more likely to have had unprotected intercourse with two or more partners (Table 3).

Table 3

Discriminant analysis model of demographic and behavioural characteristics associated with foreign students

Step	Variable entered	Wilks' lambda	Exact F
Step	Variable entered	Wilks' lambda	Statistic	df1	df2	P value
1	Ethnicity (white versus non-white)	0.895	63.569	1	541	<0.001
2	Age	0.856	45.558	2	540	<0.001
3	Use of cocaine in previous 4 weeks	0.847	32.493	3	539	<0.001
4	Number of partners in the last year with whom there was inconsistent condom use	0.838	25.989	4	538	<0.001
5	Alcohol frequency	0.830	21.921	5	537	<0.001

In our sample there were no significant differences in the cumulative incidence of most STIs reported by students (Table 4). However, the cumulative incidence of genital herpes simplex reported by international students was higher (4.1% and 0.7%, adjusted odds ratio 5.04, confidence interval 1.25–20.32).

Table 4

Cumulative incidence of self-reported sexually transmitted infections in international and British students

	British n = 703	Foreign n = 123	OR	aOR
Ever diagnosed with an STI	54 (7.7%)	12 (9.8%)	1.30 (0.67–2.51)	1.16 (0.57–2.39)
Chlamydia	26 (3.7%)	2 (1.6%)	0.43 (0.10–1.84)	0.34 (0.07–1.63)
Genital warts	17 (2.4%)	3 (2.4%)	1.01 (0.29–3.50)	1.30 (0.37–4.56)
Genital herpes	5 (0.7%)	5 (4.1%)	5.92 (1.69–20.75)	5.04 (1.25–20.32)

OR = odds ratio; aOR = adjusted odds ratio

DISCUSSION

Our survey of university students suggests that international students drink alcohol more moderately and use less recreational drugs than British students. Conversely, they are more likely to engage in risky sexual behaviour, such as sex with commercial sex workers and unprotected intercourse. With higher rates of STIs and HIV in other countries, this could result in a route for introducing novel and resistant strains of STI in the UK.

A number of studies of people travelling internationally have identified those who stay for longer periods abroad at a higher risk of getting involved in new sexual partnerships and casual sex.^13–16 Couple of studies also suggest that those who have paid for sex in the past are also more likely to develop sexual partnerships abroad,^16,17 and others highlight the role that dugs and alcohol may have in enhancing sexual behaviour in long-stay travellers.^18,19 In our sample we did not find higher rates of alcohol intake and drug use among international students, and, despite sexual behaviours, in respect of the number of partners and frequency of intercourse, being similar to British students, we noted higher rates of unprotected intercourse and of paying for sex in international students.

One other study that looked at knowledge and behaviour of international students in Australia noted that Asian students had less knowledge of the risks of HIV and how it is transmitted, and that they were likely to underestimate the prevalence of this in their home countries.²⁰ In our sample of university students, we also suggest that there may be differences in risk perception and that behaviour change may occur as a result of fear of STIs; however, these differences were not statistically significant.

In this study we did not find significant differences in the cumulative incidence of self-reported STIs between British and international students, except for genital herpes. However, we cannot rule out that these exist, as our study was not sufficiently powered to detect such differences. With higher sexual risk-taking behaviour exhibited by international students, there is a possibility that this could act as a route for importing STIs into the UK. Also, with higher rates of chlamydia in the UK compared with other countries,¹ it is possible that international students could export some STIs acquired in the UK back into their home countries.

This survey has some limitations. Our sample was self-selected, and although it appears as a representative of the student population, it has a much lower proportion of international students. Also, we had a relatively low uptake. It is possible that because the survey was conducted during the exam period and close to the summer holidays, this could have resulted in a low response. However, we do not believe that our survey attracted more people with higher risk-taking behaviour, as the behaviours of our sample are consistent with those of other studies.

International students have more moderate health risk behaviour with respect to drugs and alcohol; however, they are likely to have riskier sexual behaviours which could lead to introducing novel and resistant strains of STIs. International students account for approximately one-quarter of university students and are generally easily targeted as they normally register with a general practitioner or the university medical services during their induction period, where sexual health promotion could be delivered.

Footnotes

ACKNOWLEDGEMENTS

We thank the study participants, Tony Dyer for the help in designing the web version of the questionnaire and database and Allan Clark for the statistical advice.

This research project was approved in full by the University's Institute of Health Ethics Committee.

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