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Group membership and STI knowledge among adolescents: a ten-year window.

Abstract: STI knowledge levels of 3680 fifteen and sixteen year olds from the same schools were assessed four times over a ten-year time span. Results showed that STI knowledge levels among adolescents increased over the ten-year period. Lowest scores were found among African American males and highest scores were found among Caucasian females. Results indicate that knowledge of disease specific symptoms showed the greatest gains in correct responses. Health education and promotion programs should include symptomolgy as part of sex education curricula focusing on specific and non-specific symptoms of STI's.


Sexual practices and other risk related behaviors among adolescents continue to be a major national concern. According to the CDC's 1999 surveillance report, half (49.9%) of all high school students have initiated sexual intercourse (Centers for Disease Control and Prevention, 2000). Sexual activity coupled with multiple partners and poor condom utilization has resulted in the occurrence of sexually transmitted infections (STI's) in this age group; and by age 21, approximately one in five young people have acquired a sexually transmitted infection. Estimates are that about 15 million Americans become newly infected with an STI each year (Centers for Disease Control and Prevention, 2000; U. S. Department of Health and Human Services, 1992). STI's are among the top ten causes of death with HIV infection and AIDS listed as the sixth leading cause of death among young persons aged 15 to 24 years. Given the actual death rates, the long incubation period (8 to 10 years) may be masking the magnitude of the actual magnitude of the epidemic among adolescents. (Centers for Disease Control and Prevention, 2000)

Several determinants, including behavior, social, medical and institutional factors, contribute to HIV/ STI in adolescents (Rural Center for AIDS/STD Prevention, 2000). An underlying consideration that impacts greatly on the relationship between STI's and the need for services is the awareness of a pre-existing STI problem or potential problem. Subsequently, knowledge of symptoms is a prerequisite for treatment. Previous studies have measured adolescents' knowledge of methods for contracting AIDS and knowledge of STI symptoms with more emphasis on AIDS knowledge. Brown and colleagues (1990) found that students were most knowledgeable on items examining issues of disease transmission. Poorest scores in this area examined whether one could contract AIDS through kissing or mosquito bites (Brown, Nassau & Barone, 1990). Some group features may also help to explain knowledge levels. For example, Millstein and associates (1993) examined AIDS knowledge among high, moderate and low at risk females and found that females in a moderately high-risk group (i.e. having multiple partners, having unprotected sex as opposed to drug injection users) had significantly less HIV knowledge than any other group (Millstein, Moscicki & Broering, 1993). It appears that not all groups are equally knowledgeable with regard to AIDS.

Knowledge of HIV symptoms may also be related to ethnic issues. Hispanic adolescent females were found to have significantly less knowledge than Caucasians or African-Americans (Smith, Weinman & Mumford, 1992). Additional ethnic comparisons showed that African-American adolescents had lower knowledge levels than Caucasians (Smith et al., 1992).

Although research on AIDS has focused on symptomology, few studies have examined general knowledge of STI symptoms among adolescents. Wright, Gabb and Ryan (1991) concluded that the asymptomatic or the "silent" nature of STI's and their consequences was poorly understood by adolescents. Only one in ten students agreed that an infected person could continue to feel well and only one in two had heard about pelvic inflammatory disease (Wright et al., 1991). Johnson, Rozmus and Edmission (1999), analyzed STI knowledge among 170 rural high school students. They found that questions regarding STI's knowledge and beliefs revealed more correct than incorrect knowledge among participants, with 11th and 12th graders scoring highest (Johnson et al., 1999).

The purpose of this study was to examine adolescent STI knowledge levels and determine whether knowledge levels had changed over a ten-year time span. A secondary purpose was to examine group characteristics and determine whether changes in knowledge level were a characteristic of group membership.


Data were collected using the Alabama Adolescent Survey (AAS). This is a modified version of an instrument originally derived from the National Adolescent Student Health Survey (NASHS). Surveys were conducted in 1988, 1990, 1993 and 1998. The 1998 version retained a core of items from previous surveys that have demonstrated acceptable test--retest reliability levels. Additional items in all surveys examined a variety of factors including; demographics, health behaviors, knowledge, attitudes, perceptions and social norms.

Methodology was similar for recruitment over all four waves of data collection. The 1988, 1990 and 1993 waves collected data on 8th and 10th grades and the 1998 wave collected data on 9th and 10th grades. School districts involved in the survey consisted of a voluntary sample. Four of the original six districts wished to participate and were joined by four additional school systems that volunteered when contacted. In all, sixteen school districts were invited to participate. The main reason provided by school superintendents for not participating was the perception that the disclosure of sexual behavior information might draw negative public attention to their participation in the study. The participating sample was largely representative of counties in the mid part of the state and State Health Department data on adult mortality and morbidity rates show these districts to be similar to surrounding counties. The sample consisted of two rural school districts, two semi-rural districts, and two urban school districts.

All students present on the day of testing were included. A week before the survey was administered, students were provided with letters to take home informing parents about the study. If parents elected not to involve their child in the study they were required to return a signed letter indicating their decision. Less than 1% of the students returned signed letters. This pattern has been consistent in all of the AAS surveys.

Data were collected from all students in the rural districts. In larger districts, schools were randomly selected and at least 250 students were included from randomly selected classes. Occasionally, several intact classes were assembled in a cafeteria, gymnasium, or auditorium and the instrument was administered to all the classes. Students were seated and were allowed to respond unobserved by other students or members of the research team. They were provided with a questionnaire, a computer answer sheet, and a pencil. The instructions were read aloud by a member of the research team and informed students that they could elect not to participate or could discontinue at any time. Students were also informed of the purpose of the data collection.

When completed, students submitted their answer sheet and referral form in a large, enclosed collection box. The referral forms were given to the principal by the research team. A school administrator and counselor were required to be present during the administering of the survey to identify students in need of assistance for mental duress. No duress cases were identified.

The AA has attempted to retest the same school districts during each wave of the study. School districts are included or removed from the sample cohorts each year based upon superintendent interest. As many as thirteen counties have participated over the length of the study with five counties in all waves of data collection.

In the current study, data are drawn from 15 and 16 year olds from the same counties who answered all the survey items (N=3680). This was done to limit variance based on cognitive maturity, as well as possible ethnic or geographical influences. The sample was derived from 15 and 16 year old adolescents. The ethnicity of the population primarily consisted of Caucasians and African Americans and other ethnic groups were not included in the analyses.


The average gender and ethnic breakdown of the sample consisted of Caucasian females (31%), Caucasian males (24%), African-American females (27%) and African-American males (18%). Group membership was relatively stable and varied less than ten percent over the four testing periods. Age of students was almost equally divided among 15 year olds (52%) and 16 year olds (48%). With respect to average age of initiation of sexual intercourse, 44 percent have never had sex, 41 percent initiated sexual intercourse before age 15 (early initiators) and the remaining 15 percent were classified as late initiators. Table 1 shows the ranges of the study variables over the study periods.

Knowledge of sexually transmitted infection symptoms was measured on a scale from 0 to 7 with 0 being the lowest knowledge score. The scale was derived from ALS items pertaining to true/false questions on 7 different statements of symptoms of sexually transmitted disease. Mean scores for STI knowledge were calculated for each year by group (Table 2). The highest mean score was found in Caucasian females for 1998(2.85), and the lowest score was found among African American females in 1990(5.01).

Comparisons of scores based on age showed that 15 and 16 year olds did not differ on their knowledge scores. The highest mean knowledge scores occurred in 1998 (2.99) while the lowest occurred in 1990(4.85). Sexual initiation status comparisons also showed minimal differences. Knowledge scores were highest in 1998 (2.91) for virgins and this same group had the lowest score in 1990 (4.79).

Each of the individual items on the knowledge scale were analyzed by gender/ethnicity for each year by recording the percentage of correct answers. Clear patterns for low and high percentages of correct answers were found. Correct responses increased over the duration of the study period. In addition, nonspecific symptoms such as headache and cough, being signs of STI symptoms, had consistently low correct percentages while specific symptoms such as discharge, genital sore, and pain with urination reported much higher correct percentages overall (Table 3).


This study examined a unique group of adolescents; students going to the same schools over four different time periods during a ten-year time span. In addition, these schools were in a rural southern state. Results should be interpreted with caution given these unique characteristics.

The main finding from the study was that knowledge levels of STI symptoms have increased substantially over the ten-year period. This finding was consistent across all measures and all groups. During the first three waves of data collection mean STI knowledge scores were similar, however the 1998 wave showed substantial improvements that were clearly evident. Although it is beyond the scope of this study to identify the reasons for these improved knowledge scores, it is clear that improved education about STI symptomology occurred among adolescents who were in the study schools.

When examining group characteristics such as gender/ethnicity, age and sexual initiation, changes in knowledge level were consistent across the demo: graphic markers. Each year showed continuous increases for each study group. The highest knowledge scores occurred among Caucasian females who exhibited higher STI knowledge scores than any other group over all four waves of data collection. This result supports the finding of Smith and colleges (Smith, Weinman & Mumford, 1992) who found that African American adolescents showed lower knowledge levels than Caucasians.

Previous work by Millstein and associates (1993) indicated a significant relationship with risky sexual activity and low knowledge among female adolescents (Millstein et. al., 1993). Results from this study did not support Millstein's (1993) findings; there did not appear to be any meaningful relationship between STI knowledge scores and coital status. Findings did support work by Johnson and colleagues (1999) where results showed that virgin adolescents tended to answer more correct than incorrect items addressing STI knowledge (Johnson, Rozmus & Edmission, 1999). However, the differences in mean scores for this study were relatively modest.

A review of the individual knowledge items identified where the gain in STI knowledge scores was occurring. Symptoms that were easily associated with STI's such as pain with urination and sore on the genitals had higher percentages of correct responses than other symptoms. Non-specific symptoms that could also occur with other infections were found to have the least correct answers over each wave. It appears that the vast majority of adolescents are aware of specific symptoms that are unique to STI and are not very aware of other possible symptomology that may not be as disease specific. This result is similar to Wright and associates (Wright, Gabb & Ryan, 1991) who concluded that knowledge of STI's was inadequately understood by adolescents.

Although some non-specific symptoms of STI's have not shown sizeable improvements, this study shows that adolescent's overall knowledge of STI symptoms improved during the last testing period. Given the different profiles based upon gender and ethnicity, there is clear evidence for the tailoring of intervention programs that should address gender and ethnicity issues. Future research with STI knowledge should also focus on psychological and other social markers that may assist to identify high-risk groups and identify potential intervention considerations.

In conclusion, results from this study show that there is still need for education about symptomology of STI's. Effective treatment programs require that adolescents recognize STI symptoms as the first step in accessing treatment.
Table 1. Demographic characteristics of the sample. (N=3680)

 % Of entire Year with Year with
 sample highest %. lowest %.

 * C-F 31 32 (1998) 24 (1988)
 C-M 24 28 (1998) 22 (1988)
 A-F 27 32 (1990) 24 (1998)
 A-M 18 25 (1988) 14 (1990)

 15 yrs 52 72 (1988) 50 (1998)
 16 yrs 48 50 (1998) 28 (1988)

** Never 44 63 (1990) 36 (1993)
 Early 41 47 (1993) 28 (1990)
 Later 15 9 (1990) 18 (1998)

* C-F; Caucasian Female, C-M; Caucasian Male, A-F; African-American
Female, A-M; African-American Male.

** Never; Never had sex, Early; sexual initiation 14<, Late; sexual
initiation 15+.

Table 2. Average knowledge scores by group.

 1988 1990 1993 1998

 * C-F 4.6 4.4 4.1 2.9
 C-M 4.8 4.5 4.9 3.2
 A-F 4.7 5.0 4.7 3.0
 A-M 4.8 4.9 4.6 3.3

 15 yrs 4.7 4.9 4.6 3.1
 16 yrs 4.7 4.4 4.5 3.0

** Never 4.7 4.8 4.6 2.9
 Early 4.7 4.6 4.5 3.2
 Late 4.8 4.5 4.6 3.0

* C-F; Caucasian Female, C-M; Caucasian Male, A-F; African-American
Female, A-M; African-American Male.

** Never; Never had sex, Early; sexual initiation 14<, Late; sexual
initiation 15+.

Table 3. Percent answering STI symptom question correct.

 Survey Year * C-F C-M A-F A-M

Abdominal Pain
 1988 32 26 22 21
 1990 37 33 25 24
 1993 41 23 26 26
 1998 67 60 64 56
 1988 29 27 26 22
 1990 35 32 25 28
 1993 31 21 28 27
 1998 52 42 51 46
 1988 50 43 44 38
 1990 52 45 37 28
 1993 62 43 49 40
 1998 77 71 67 62
 1988 12 15 13 12
 1990 12 18 14 15
 1993 9 13 12 14
 1998 19 27 27 31
 1988 9 16 11 14
 1990 13 22 13 18
 1993 11 14 7 16
 1998 34 32 40 31
 1988 59 48 51 43
 1990 57 45 42 32
 1993 66 49 54 36
 1998 80 74 71 66
Pain With Urination
 1988 50 44 42 37
 1990 52 44 36 27
 1993 63 42 48 39
 1998 80 70 73 65

* C-F; Caucasian Female, C-M; Caucasian Male A-F; African-American
Female, A-M; African-American Male.


Brown, L. K., Nassau, J. H., & Barone, V.J. (1990). Differences in AIDS knowledge and attitudes by grade level. Journal of School Health, 60(6), 270-275.

Centers for Disease Control and Prevention. (2000). Youth Risk Behavior Surveillance Report. 49(SS05); 1-96.

Centers for Disease Control and Prevention. (2000). CDC Issues National Report Card on STDs.

Centers for Disease Control and Prevention. (2000). 1999 Sexually Transmitted Disease Surveillance Report--by section.

Johnson, L.S., Rozmus, C., & Edmission, K. (1999). Adolescent sexuality and sexually transmitted diseases: attitudes, beliefs, knowledge, and values. Journal of Pediatric Nursing, 14(3), 177-85.

Millstein, S. G., Moscicki, A. & Broering, J. M. (1993). Female adolescents at high, moderate, and low risk of exposure to HIV: Differences in knowledge, beliefs, and behavior. Journal of Adolescent Health, 15,133-142.

Rural Center for AIDS/STD Prevention. (2000). Fact Sheet.

Smith, P., Weinman, M., & Mumford, D. (1992). Knowledge, beliefs, and behavioral risk factors for human immunodeficiency virus infection in inner city adolescent females. Sexually Transmitted Diseases, 19(1), 19-24.

U. S. Department of Health and Human Services. (1992). Healthy People 2000; National Health Promotion and Disease Prevention Objectives. Sadbury, MA: Jones and Bartlett Publishers.

Wright, S. M., Gabb, R. G., & Ryan, M. M. (1991). Reproductive health: Knowledge, attitudes and needs of adolescents. Medical Journal of Australia, 155, 325-328.

Patti A. Murphey, MAE is a Doctoral Candidate in the Department of Health Science at The University of Alabama.

Stephen Nagy, PhD is a Professor in the Department of Health Science at The University of Alabama. Address all correspondence to Patti A. Murphey, Department of Health Science, Box 870311, The University of Alabama, Tuscaloosa, AL 35487-0311; PHONE: 205.348.2486; FAX: 205.348.7568; E-MAIL:
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Article Details
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Title Annotation:survey of 3,680 15 to 16-year-old students over 10 year period; sexually transmitted infection
Author:Nagy, Stephen
Publication:American Journal of Health Studies
Geographic Code:1USA
Date:Sep 22, 2002
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