Unplanned Pregnancy and Sexually Transmitted Disease Risk Possible Predictors of Contraceptive Use Among College Students

INFORMATION TO USERS
This manuscript has been reproduced from the microfilm master. UMI
films the text directly from the original or copy submitted. Thus, some
thesis and dissertation copies are in typewriter free, while others may be
from any type of computer printer.
The quality of this reproduction is dependent upon the quality of the

copy submitted. Broken or indistinct print, colored or poor quality
illustrations and photographs, print bleedthrough, substandard margins,
and improper alignment can adversely affect reproduction.
In the unlikely event that the author did not send UMI a complete
manuscript and there are missing pages, these will be noted. Also, if
unauthorized copyright material had to be removed, a note will indicate
the deletion.
Oversize materials (e.g., maps, drawings, charts) are reproduced by

sectioning the original, beginning at the upper left-hand comer and
continuing from left to right in equal sections with small overlaps. Each
original is also photographed in one exposure and is included in reduced
form at the back of the book.
Photographs included in the original manuscript have been reproduced

xerographically in this copy. Higher quality 6” x 9” black and white
photographic prints are available for any photographs or illustrations
appearing in this copy for an additional charge. Contact UMI directly to
order.
UMI
A Bell & Howell Information Company
300 North Zeeb Road, Ann Arbor MI 48106-1346 USA
313/761-4700 800/521-0600
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
ABSTRACT
UNPLANNED PREGNANCY AND SEXUALLY TRANSMITTED DISEASE

RISK: POSSIBLE PREDICTORS OF CONTRACEPTIVE USE
AMONG COLLEGE STUDENTS
This study investigated unplanned pregnancy and sexually transmitted
disease (STD) risk as possible predictors of contraceptive use. A sample of
377 undergraduate students was taken from California State University,
Fresno during the fall 1997 and spring 1998 semesters. Seven null
hypotheses were tested through an anonymous, 33-item questionnaire.
Hypotheses 1 through 3 explored the links between unplanned pregnancy
and STD history and contraceptive use. Hypotheses 4 through 7 tested
associations between gender, age, ethnicity, and marital status and
behaviors and attitudes. This study illustrated that a previous unplanned
pregnancy and/or a history of STD infection did have some impact on
contraceptive use. College students were found to exhibit high-risk sexual
behaviors and low knowledge levels regarding contraception and STDs.
Implications for contraception education for college students are discussed.
Elizabeth Angulo
December 1998
UNPLANNED PREGNANCY AND SEXUALLY TRANSMITTED DISEASE
RISK: POSSIBLE PREDICTORS OF CONTRACEPTIVE USE
AMONG COLLEGE STUDENTS
by
Elizabeth Angulo
A thesis
submitted in partial
fulfillment of the requirements for the degree of
Master of Public Health
in the School of Health and Human Services
California State University, Fresno
December 1998
UMI Number: 1394575
UMI Microform 1394575

Copyright 1999, by UMI Company. All rights reserved.
This microform edition is protected against unauthorized

copying under Title 17, United States Code.
UMI
300 North Zeeb Road
Ann Arbor, MI 48103
APPROVED
For the Department of Health Science:
Vickie D. Krenz Health Science
Sherman Sowby Health Science
Kelli Beingesser Fresno Women’s Medical Group
For the Graduate Committee:
Dean, Division of Graduate Studies
AUTHORIZATION FOR REPRODUCTION
OF MASTER’S THESIS
I grant permission for the reproduction of this thesis in part

or in its entirety without further authorization from me, on
the condition that the person or agency requesting
reproduction absorbs the cost and provides proper
acknowledgment of authorship.
Permission to reproduce this thesis in part or in its entirety

must be obtained from me.
Signature of thesis writer:.
ACKNOWLEDGMENTS
First and foremost I would like to thank the Lord for bestowing upon me
His wonderful blessings.
I would like to express my sincere gratitude to the members of my thesis
committee, Vickie D. Krenz, Ph.D., Sherman Sowby, Ph.D., and Kelli
Beingesser, MD. Their guidance and expertise are reflected in this thesis.
I would also like to thank all of the professors and undergraduate
students at California State University, Fresno, who participated in this
study. This thesis was made possible and credible because of their interest
and candor.
I am sincerely grateful to Wade Dickinson for believing in me. His
constant encouragement has allowed me to accomplish many academic and
professional dreams.
Lastly, I dedicate this thesis to my parents, who have lovingly supported
all of my educational endeavors.
TABLE OF CONTENTS
Page
LIST OF TABLES.........................................................................................viii
LIST OF F I G U R E S ................................................................................ x
Chapter
1. INTRODUCTION..................................................................... 1
The Problem.......................................................................... 4
Purpose of the S t u d y .......................................................... 7
Significance of the S tu d y ...........................................................10
Research D e s i g n ..................................................................... 11
D efin ition of T e r m s ................................................................ 14
Scope of the S tu d y ..................................................................... 17
L im itations................................................................................ 17
S u m m a r y ................................................................................ 18
2. REVIEW OF RELATED L ITERA TU RE..................................... 20
Sexual Behaviors of College S tu d e n ts ..................................... 20
Unplanned Pregnancy Risk for College Students . . . 23
Sexually Transmitted Disease Risk for College

S tu d en ts................................................................................24
College Students’ Contraceptive Practices................................ 28
VI
Chapter Page
Changing Students’ B e h a v io rs................................................ 35
Summary..................................................................................... 39
3. RESEARCH DESIGN AND METHODOLOGY...........................41
S e t t i n g ..................................................................................... 41
Subject S e le c tio n ..................................................................... 42
S a m p l e ..................................................................................... 42
Instrumentation.......................................................................... 43
Ethical Considerations................................................................45
Data Collection.......................................................................... 46
Pilot Test..................................................................................... 46
Data A n a ly s is ...........................................................................47
Summary..................................................................................... 47
4. RESULTS AND ANALYSIS OF THE DATA................................ 49
Demographic Characteristics of Students in the

S a m p l e ................................................................................50
Knowledge About Contraception and S T D s ...........................57
Results for the H y p o th e se s..................................................... 60
Summary..................................................................................... 67
5. D ISCU SSIO N ................................................................................68
Demographic D a ta ..................................................................... 68
Sexually Transmitted Disease (STD) H istory...........................76
Unplanned Pregnancy H is to r y ................................................ 78
vii
Chapter Page
A t t i t u d e s ............................................................................... 78
Implications................................................................................79
Recommendations for Further S t u d y ..................................... 81
S u m m a r y ................................................................................82
6. SUMMARY AND CONCLUSIONS...............................................85
REFERENCES............................................................................................... 90
APPENDIX.................................................................................................... 98
LIST OF TABLES
Table Page
1. Sample Distribution by Demographic Characteristics 51
2. Student Responses to Attitude Q uestions...............................57
3. Distribution of Correct, Incorrect, and Not Sure

Answers to Questions About Contraception, STDs,
HIV/AIDS know ledge.......................................................... 59
4. Pearson Chi-Square Summary for Hypothesis 1:

History of Unplanned Pregnancy and Use of
C o n tracep tio n.....................................................................60

History of Unplanned Pregnancy and/or STD
Infection and Use of Combined Contraceptive
M eth o d s................................................................................62

History of STD Infection and Use of Contraception. . . . 63

Age, Ethnicity, and Marital Status and the Use
of C ondom s.......................................................................... 64

Age at First Intercourse and History of STD
Infection................................................................................65

Attitudes About Contraceptive Issues by Gender,
Age, and Marital S t a t u s ..................................................... 66

Perceived Susceptibility to SIDs or HIV/AIDS
by Age, Gender, and Marital Status....................................67
11. Type of Contraceptives Used by RelationshipStatus . 71
ix
Table Page
12. Number of Sexual Partners in Lifetime

by G e n d e r................................................................................74
13. Type of Contraceptives Used by E t h n i d t y ............................... 77
LIST OF FIGURES
Figure Page
1. Results for survey question 17: Unplanned pregnancy

outcomes..................................................................................... 54
2. Distribution results for survey question 12: Do you/your

partner use contraception or protection - - by relationship
statu s...........................................................................................54
3. Type of contraceptive used by persons with history of

unplanned pregnancy................................................................ 61
4. History of STD infection by type of contraceptive

currently u s e d ...........................................................................63
5. Results to survey question 9: Have you ever had sex with

someone you just met that day or n i g h t ? ................................ 73
6. Condom use patterns among ethnic g r o u p s ................................ 75
Chapter 1
INTRODUCTION
This study examines the contraceptive practices of sexually active
college students. Based on a survey sample of undergraduate students, the
study analyzed unplanned pregnancy and sexually transmitted disease
(STD) risk as possible predictors of contraceptive use. This study also
assessed levels of knowledge regarding contraception and STDs.
According to a national survey, 66.5 % of women age 20 to 24 and
72.1% of women age 25 to 29 are at risk of becoming pregnant (Hatcher et al.,
1994). Galavotti et al. (1995), in a study of the relationship between
contraceptive method of choice and beliefs about Human Immunodeficiency
Virus (HIV) and pregnancy prevention, reported that Acquired
Immunodeficiency Syndrome (AIDS) became the fourth leading cause of
death among women age 15 to 44 years in 1992.
This study had two goals. The first was to examine the contraceptive
practices among college students as they relate to the students’ perceptions of
risk of pregnancy and STD infection. The second was to determine whether
contraceptive behavior is related to knowledge, concerns, and attitudes about
STDs or pregnancy.
Reproduced with permission o f the copyright owner. Further reproduction prohibited without permission.
2
Of the many studies that have examined college students’ sexual risk
taking behaviors, few have examined students’ contraceptive practices in
light of these risks. Research suggests that a woman is at greater risk of
acquiring an STD than she is of having an unplanned pregnancy. However,
in a study conducted by Fleisher, Senie, Minkoff, and Jaccard (1994), the
researchers found the study population more concerned with contraception
for pregnancy prevention than for disease prevention. At present, “safe sex”
practices are presumed to provide protection from both unintended
pregnancy and STDs, including HIV.
The decision for college students to become sexually intimate requires
the practice of “safer sex,” especially in light of the fact that sexually
transmitted diseases are prevalent among this population. In fact, numerous
studies show that sexually active college-age men and women are at the
highest risk for contracting STDs (Beckman, Harvey, & Tiersky, 1996;
DiClemente, Forrest, & Mickler, 1990; Helweg-Larsen & Collins, 1994).
However, the fear of becoming pregnant and/or contracting HTV and other
STDs can be present in any heterosexual relationship regardless of
educational status. McGregor and Hammill (1993) maintained that
unintended pregnancy and STDs are parallel complications of sexual
activity.
Contraception becomes an important topic when examining the risks
associated with being sexually active. Individuals who have recently had
3
babies, women who have recently had abortions, and men and women who
may have been exposed to an STD have special needs for contraceptive and
reproductive health information.
Today, women of reproductive age can choose from a variety of
contraceptive methods, including hormonal contraception, intrauterine
devices, barrier methods, and sterilization. Hormonal contraceptives such as
“the pill” and the contraceptive injection “Depo-Provera” are highly effective
in pregnancy prevention but are ineffective in providing protection against
contracting STDs such as chlamydia and HIV infection. Some
contraceptives, such as the condom and the diaphragm, can have both
prophylactic (preventing disease) and contraceptive advantages.
Consideration of contraceptive methods must go beyond simple pregnancy
prevention; students today must also consider the health risks associated
with being sexually active.
This thesis examines decision making about contraceptive use in light
of the possibility of contracting an STD or having an unplanned pregnancy.
The major research objectives of this study were: (a) to examine
contraceptive adoption for the two related behaviors of pregnancy prevention
and the prevention of STDs and (b) to assess how perception of risk
contributes to positive behavior change.
4
The Problem
Unplanned pregnancies and sexually transmitted diseases have been
recognized as public health problems among the college population.
Rosenberg, Davidson, Chen, Judson, and Douglas (1992) reported that, in
1988, an estimated 12 million new cases of STDs occurred in the United
States, most among young people. Because 70% of college students are
sexually active and have more than one partner per year, increasing
numbers of college students are at risk for HTV infection (Jadack, Hyde, &
Keller, 1995). Richie and Getty (1994) pointed out “the average time between
infection with HTV and development of advanced HIV disease is about 10
years” and concluded that “many of those diagnosed in their twenties with
advanced disease became infected when they were teenagers.”
High risk behaviors and lack of perceived susceptibility place a large
percentage of young persons between 13 and 19 years of age at risk for HIV
infection (Hays & Hays, 1992; Hernandez & Smith, 1990; Strader &
Beaman, 1991). Lewis, Malow, and Ireland (1997) found that, although
college students are highly knowledgeable about basic HTV/AIDS facts, they
retain some misperceptions about disease transmission from casual contact
and the importance of safer sex practices. On the other hand, Jadack et al.
(1995) found that young adults do have accurate knowledge about major HTV
transmission routes and effective prevention methods. However, both
5
studies concurred that knowledge and intention are not good predictors of
sexual behaviors.
Although students may be knowledgeable about ways of reducing their
risk of contracting AIDS and other STDs and of becoming pregnant, many do
not translate this information into behavior (O’Leary, Goodhart, Jemmott, &
Boccher-Lattimore, 1992; Sheehan, Ambrosio, McDevitt, & Lennon, 1990).
Substantial evidence suggests that today’s college students are more
knowledgeable about how to reduce their risk of contracting a disease or
becoming pregnant, but little documentation exists to demonstrate positive
behavior change as a result of that knowledge. Carroll (1991), in a study of
gender differences in sexual behaviors, reported that AIDS knowledge among
women was not associated with increased condom use, less frequent sex, or
sex with fewer partners. However, Carroll conceded that the relationship
between knowledge about AIDS and the practice of safer sex may vary
widely. Jadack et al. (1995) observed that, despite increased knowledge
about HIV infection and AIDS, knowledge has not been strongly linked with
safer sexual behaviors.
On the other hand, some support the presence of a relationship
between increased knowledge of contraception and STDs and healthy
behavior changes (Turner, Korpita, Mohn, & Hill, 1993; Valois & Waring,
1991). Research indicates that college students are becoming more socially
aware of the factors associated with unsafe sexual behavior.
6
Perhaps more important than knowledge in changing behavior is
perception of risk. Researchers have theorized that college students who
have histories of unplanned pregnancy or STDs, may be more inclined to
change their sexual behaviors than students without such histories.
Sheehan et al. (1990) suggested that most young people view themselves to
be at some risk for unplanned pregnancy and thus use contraception to
protect themselves. Similarly, Hatcher et al. (1994) concluded that
approximately 90% of women who are at risk of pregnancy use
contraception. The authors emphasized that the concern over AIDS and
STDs has resulted in increased use of condoms among women at risk of
pregnancy.
Separate from the issue of whether college students use contraception
is the concern of which contraceptive method should be used. Some protect
against pregnancy but not STDs. Barrier contraceptives, such as male and
female condoms, diaphragms, cervical caps, and vaginal spermicides, can
reduce STD transmission to both women and men by directly reducing
genital contact (McGregor & Hammill, 1993). These mechanical and
chemical contraceptive barriers are distinct in that their functions are to
protect against an unwanted pregnancy while also providing a prophylactic
advantage. Consistent and correct use of all contraceptive methods is crucial
to reduce the potential for failure.
7
Studies have suggested that one possible effect of encouraging men
and women to use condoms for STD protection is that the women may
discontinue use of their hormonal methods. However, data from those
employing effective family planning interventions may refute this theory.
According to a report by the Centers for Disease Control (1997), most women
using hormonal contraceptive methods continued to use them following
receipt of an HIV/STD prevention intervention. This report also indicated
that consistent condom use increased among women who were encouraged to
use condoms. In addition, Stanton, Li, Galbraith, Feigelman, and Kaljee
(1996) found that, after receipt of an acquired immunodeficiency syndrome
(AIDS) education intervention, many sexually active individuals used
condoms and prescription or nonprescription contraceptives simultaneously.
Stanton et al. (1996) observed that individuals are now opting to use
more than one method simultaneously to protect against both pregnancy and
HIV. However, not enough people are practicing simultaneous protection.
Beckman et al. (1996) found that, “for many college students, using condoms
or the Pill is an either-or choice rather than complementary behaviors, both
of which are required for maximal protection against STDs and unwanted
pregnancy” (p. 249).
Purpose of the Study
The primary purpose of this study was to investigate the effect of
college students’ perceptions of the risk of pregnancy and sexually
8
transmitted diseases on contraceptive practices. The sufficiency of
information available about pregnancy and STD prevention precautions led
to a basic assumption: College students who are at risk for pregnancy and
STDs will use effective hormonal or barrier contraceptive methods. However,
the lack of agreement among investigators as to whether students are
adequately using contraception raises an important question: Is there an
association between contraceptive use and a history of unplanned pregnancy
or STDs? The answers to this and other questions posed in this research will
help health-care workers to design interventions that will enable them to
meet national goals for the year 2000.
In 1990, the United States Public Health Service established national
health promotion and disease prevention objectives for the year 2000 (Lewis,
Goodhart, & Bums, 1996). Healthy People 2000 targets were set to reduce
the number of unintended pregnancies and the spread of sexually
transmitted diseases. The national health objectives specifically called for
HIV education for students and staff in at least 90% of American universities
(Schneider et al., 1994). The U.S. Department of Health and Human
Services Healthy People 2000 Midcourse Review (1995) listed the following
objectives for family planning, HTV infection, and sexually transmitted
diseases:
Reduce to no more than 30% the proportion of all pregnancies that are
unintended (Healthy People 2000 objective 5.2). Increase to at least
90% the proportion of sexually active, unmarried people aged 15-24 who
use contraception, especially combined method contraception that both
9
effectively prevents pregnancy and provides barrier protection against

disease (Healthy People 2000 objective 5.6). Increase to at least 95%
the proportion of all females aged 15-44 at risk of unintended pregnancy
who use contraception (Healthy People 2000 objective 5.12). Confine
the prevalence of HIV infection to no more than 400 per 100,000 people
(Healthy People 2000 objective 18.2). Reduce the proportion of
adolescents who have engaged in sexual intercourse to no more than
15% by age 15 and no more than 40 percent by age 17 (Healthy People
2000 objective 18.3). Increase to at least 50% the proportion of sexually
active and unmarried people who used a condom at last sexual
intercourse (Healthy People 2000 objective 18.4). Increase to at least
90% the proportion of students who received HTV and other STD
information, education, or counseling on their college or university
campus (Healthy People 2000 objective 18.11). Reduce the prevalence
of Chlamydia trachomatis infections among young women (under the
age of 25 years) to no more than 5% (Healthy People 2000 objective
19.2). Reduce primary and secondary syphilis to an incidence of no
more than 4 cases per 100,000 people (Healthy People 2000 objective
19.3). (pp. 187-251)
Guyton et al. (1989) described the National Health Objectives for the
Year 2000 priority areas (for preventive interventions) as: (a) the prevention
and control of HIV infection and AIDS, (b) the prevention and control of
sexually transmitted diseases, and (c) reduction of adolescent pregnancy and
improvement in reproductive health.
Sarvela, Huetteman, McDermott, Holcomb, and Odulana (1992) listed
the following National Health Promotion and Disease Prevention Objectives
aimed at individuals between the ages of 15 and 24:
1. Reduce the number of teenage pregnancies.
2. Reduce the number of unintended pregnancies.
3. Reduce the number of adolescents and young adults participating
in unprotected sexual intercourse.
10
4. Increase the occurrence of abstinence among adolescents and young
adolescents who have previously been sexually active.
5. Increase the effective use of family planning methods.
6. Increase the use of condoms among those who engage in sexual
intercourse.
Effective use of contraception for the prevention of pregnancy and
STDs is crucial to the attainment of these objectives. Some data show that
counseling about family planning and disease prevention can result in
increased contraceptive and planned condom use (Frank, Poindexter, Cox, &
Bateman, 1995). Much effort has been directed toward educating college
students about STDs and promoting “safe-sex” behavior. Most of the
education has occurred in college classrooms. Have these attempts at
education increased students’ knowledge or changed their behavior in regard
to contraception? This research begins to answer that question.
Significance of the Study
Research has shown that college students engage in unsafe sexual
behaviors. Perhaps research of college student’s sexual behaviors would help
health education professionals to develop health education programs that
effectively focus attention on high-risk sexual behaviors. Risky sexual
behavior can be minimized by providing appropriate contraceptive education.
Guyton et al. (1989), noting that college and university students represent
5% of the United States population, observed that “students in higher
11
education encounter potentially serious threats to mental and physical
health” (p.9). The researchers suggested that “interventions at the time of
the developmental transition from youth to adulthood can influence long
term behavior patterns" (Guyton et al., 1989, p. 9). Unwanted pregnancies
and STDs among college students are very serious problems. Thus, the main
question to be answered by this study - - What influences college students to
use contraception? - - is very important. The answer to this question is
critical in designing educational programs to limit the number of unplanned
pregnancies and the spread of HIV/AIDS and other STDs.
In their study, Sarvela et al. (1992) reported that, in order to meet the
Healthy People 2000 objectives for college-aged people, the use of effective
contraception methods needs to be promoted. Thus college peer educators
should consider using Healthy People 2000 as a tool when implementing
student family planning and STD programs on the college campus. Colleges
may also benefit by focusing more academic attention on providing students
with information regarding the use of a combination of contraceptives for
utmost protection. This information can be incorporated into many of the
health, science, and physical exercise courses.
Research Design
The basic question to be answered by this observational study was:
“Does the perceived risk of pregnancy and/or STD affect an individual’s
contraceptive method of choice, particularly the decision to use a certain
12
method for a particular sexual practice or activity?” A sample (377 students)
was taken from a population of 14,768 undergraduate college students
registered at California State University, Fresno during the fall 1997 and
spring 1998 semesters. Only students enrolled in general education courses
were utilized for this study because these students were thought to be
representative of the university student body. In addition to exploring the
main problem, an effort was made to provide an understanding of the
students’ sexual practices, their social attitudes about family planning and
their knowledge of contraception.
Research Hypothesis
This study took three basic problems into consideration. The first was
the effect of pregnancy risk on contraceptive practices. This issue was
explored through the following null hypotheses:
Hypothesis 1: There is no significant difference between the use of
contraception and a history of unplanned pregnancy.
combined contraceptive methods and a history of unplanned pregnancy
and/or a history of STD infection.
The second problem involved the relationship between sexually
transmitted disease risk and contraceptive practices. This issue was
analyzed through the following hypotheses:
13
contraception and a personal history of STD infection.
Hypothesis 4: There is no significant, difference between age, ethnicity
and marital status and the use of condoms for protection of STD infection.
The third problem explored the relationships of sexual behaviors and
personal STD history, students attitudes about contraception and perceived
susceptibility of STD infection. These issues were analyzed through the
following hypothesis:
Hypothesis 5: There is no significant difference between age at first
intercourse and a history of STD infection.
Hypothesis 6: There is no significant difference in attitudes about
contraceptive issues among gender age and ethnic groups.
Hypothesis 7: There is no significant difference between age, gender
and marital status and perceived susceptibility of STD or HIV/AIDS
infection.
Subsidiary to these seven hypotheses were questions that assessed the
relationships of age, ethnicity, sexual activity, and marital status to
contraceptive attitudes and practices. In addition, questions were raised
concerning students’ beliefs about the effectiveness of contraception and their
perceived fears about using them. Although these research questions and
hypotheses are not presented here, findings on these topics were incorporated
into the results and discussion chapters of the thesis.
14
Assumptions
Two assumptions underlie this study:
1. The researcher assumed that contraceptive knowledge and behavior
can be measured by responses to a written questionnaire.
2. The researcher assumed that participants would complete the
questionnaire honestly.
Definition of Terms
The following is a list of terms used throughout this study together
with their definitions:
1. Barrier contraceptive: The 1992 edition of Contraceptive
Technology defined barrier contraceptive as follows:
A contraceptive method that establishes a physical barrier between the

sperm and ovum, for example, condom, diaphragm, foam, sponge,
cervical cap. Some of the barrier contraceptives are used in conjunction
with a spermicidal agent. (Hatcher et al., 1992, p.590)
2. Coitus Interruptus: Removing the penis from the vagina just prior
to ejaculation; also called withdrawal or pulling out (Hatcher et al. 1992, p.
592).
3. Condom:
A cylindrical sheath of latex or sheep intestine worn over the penis

during intercourse as a barrier method of contraception and as a
prophylactic against sexually transmitted disease. Some condoms
contain a spermicide to kill sperm to decrease the risk of pregnancy
should a condom break or should semen leak over the outer rim of the
condom. Also called a rubber. (Hatcher et al., 1992, p. 592)
15
4. Contraception: Prevention of conception, as by use of a device,
drug, or chemical agent (American Heritage Dictionary, 1994).
5. Depo-Provera: Hormonal contraceptive given by injection.
Injectable medroxyprogesterone acetate (Hatcher et al., 1992, p. 597).
6. Diaphragm: Contraceptive Technology defines the diaphragm as
follows: The soft, rubber, dome-shaped device worn over the cervix and used
with spermicidal jelly or cream for contraception. Diaphragms are circular,
shallow, rubber domes with a firm but flexible rim (Hatcher et al., 1992, p.
593). The dome of the diaphragm acts as a barrier by covering the cervix,
thereby decreasing the access of sperm. The diaphragm is not as effective as
the male or female condom in preventing STD transmission since it covers
less epithelial surface of the lower reproductive tract. Vaginal barrier
contraceptive methods have been depicted by medical writers for more than
three centuries. The authors of Contraceptive Technology noted that, when
Margaret Sanger and Emma Goldman visited Europe in the early 1900s in
search of effective contraception, they found a wide variety of diaphragm
models. Stein (1993) added that the diaphragm along with other approved
devices gives women greater control and confers on them a social advantage
that could be considerable.
7. Female Condom: In 1993, the Food and Drug Administration
approved the female condom. The female condom is a lubricated
polyurethane sheath with a ring on each end. This vaginal contraceptive is
16
an effective mechanical barrier to viruses such as HIV. A pregnancy
prevention study reported the female condom failure rate to be
approximately 11% for an estimated 12-month period (Centers for Disease
Control [CDC], 1993).
Stein (1993) reported that the female condom was met with
disapproval when it made its debut. However, Stein concluded that the
reaction was premature and suggested that the woman’s condom, if properly
promoted, may well be the method of choice for many women.
8. Non-prescription methods are condoms, sponges, foam or
spermicidal jelly, and withdrawal.
9. Norplant: Levonorgestrel implants.
10. Oral Contraceptives (OCs):
Various progestin / estrogen or progestin compounds in tablet form

taken sequentially by mouth; the pill. Estrogenic and progestational
agents have contraceptive effects by influencing normal patterns of
ovulation, sperm or ovum transport, cervical mucus, implantation, or
placental attachment. (Hatcher et al., 1994, p. 600)
11. Prescription methods are oral contraceptives, the diaphragm,
cervical cap, intrauterine device, levonorgestrel implants, and Depo-Provera.
12. Spermicides:
A chemical substance that kills sperm, particularly foam, creams,

jellies, and suppositories used for contraception. The spermicides used
in almost all currently marketed spermicides are surfactants, surface-
active compounds that destroy sperm cell membranes. (Hatcher et al.,
1992, p. 604)
17
13. Sterilization: A surgical procedure that leaves the male or female
incapable of reproduction. Sterilization is the most commonly employed
method of birth control in the world (Hatcher et al., 1992).
Scope of the Study
Since the results of this study are from a nonrandom sample from a
single college campus, inferences should not be made about college students
elsewhere. The following factors should be taken into consideration before
generalizations are made from this study:
1. The population sample was comprised of undergraduate students
enrolled at California State University, Fresno. Graduate students were not
included in the study.
2. The sample was taken from students enrolled in the fall 1997 and
spring 1998 semesters.
3. Students who were taking two or more required undergraduate
courses simultaneously were advised to complete only one questionnaire.
Lim itations
1. The research was based on sexual activity and contraceptive
behavior data that were self-reported. One must consider the difficulty in
assessing college students’ unplanned pregnancy and STD risk on the basis
of self-reported behavior. The researcher thought, however, that the
18
difficulty did not produce problem with the data. The data presented here
are consistent with data obtained from other studies in similar settings.
2. This study did not include a follow-up survey to analyze consistency
of contraceptive behavior.
3. This study did not extensively evaluate attitudes and perceptions
that might explain some of the observed inconsistencies in contraceptive use.
4. Males in this study might be misinformed about the contraceptives
used by their female partners.
Summary
The principal intent of this study was to investigate the effect of the
perception of the risk of pregnancy and sexually transmitted disease on
contraceptive practices among college students. The number of women of
childbearing age who use some form of birth control has increased in recent
years. Due to realistic concerns about the dangers of sexual intercourse,
including the possibility of HIV infection, more women are also electing to
use a combination of more than one method.
The choices college students make about contraception can affect not
only their health but their lives. An understanding of how information on
contraception and STDs impacts students’ sexual conduct is important from a
public health perspective. Researchers need to understand what motivates
women to use barrier contraceptives. Katz, Frazer, and Wilson (1993)
reported that sexual anxiety is increasing among college students. However,
19
they also warn that, although sexual fears may be on the rise, the sexual
practices of this population have not necessarily changed.
Research suggests that women need a clear message. Oftentimes,
providing women with information regarding contraceptives other than
condoms may create confusion as to what is important--pregnancy prevention
or STD prevention. However, as Stein (1993) observed, “to deprive women of
knowledge of the full range of options open to them is to diminish and
depreciate women” (p. 1381).
College students today must consider the simultaneous use of more
than one birth control method for prevention of both pregnancy and STDs.
What makes this challenging is the fact that they must understand which
methods protect against pregnancy and which help prevent the spread of
STDs.
Chapter 2
REVIEW OF RELATED LITERATURE
Are the risks of unplanned pregnancy and/or a history of sexually
transmitted disease (STD) possible predictors of contraceptive usage among
college students? What motivates individuals to use more than one
contraceptive method? Why are college students not more careful in view of
the consequences of sexual activity? Which persons are more likely to use
contraception? These are simple questions with complex answers. Choosing
a method of contraception can be difficult. Answers that might be helpful in
reducing the number of unplanned pregnancies and the incidence of STDs in
the college population begin with an examination of a number of issues: (a)
the sexual behaviors of college students, (b) the actual and perceived
pregnancy and STD risks to those students, (c) the contraceptive practices of
college students, and (d) the effectiveness of various attempts to produce
change in students’ sexual behaviors.
Sexual Behaviors of College Students
Many college students are independent of their parents and families
while attending college. For many, the college years are times of
experimentation with such things as drugs, alcohol, and sex (Hays & Hays,
1992). MacDonald et al. (1990) suggested that students who lived alone or
21
with roommates were more likely to be sexually active than those who lived
with their families or relatives.
Oswalt and Matsen (1993), in a study of condom use among college
students, observed that sexual activity among college students has increased
significantly in the last 15 years. In addition to the fact that more students
are engaging in more sexual activity, the types of sexual behaviors practiced
by today’s college students place them at great risk for pregnancy and
disease. Thomas, Gilliam, and Iwrey (1989) and Hays and Hays (1992)
reported that college students are choosing to engage in risky behaviors such
as having multiple sex partners.
Wiley et al. (1996), assessing the health behaviors of Texas college
students, found that 81% of the 1,408 students surveyed reported that they
had had sexual intercourse at least once, and one fourth of the sexually
active men had had more than 10 partners. In a separate study, Oswalt and
Matsen found that 26% of the college students they surveyed had four to six
sexual partners concurrently.
The more typical relationship pattern for college students is “serial
monogamy,” the practice of having one sexual partner exclusively for a period
of time, then another, then another. Beckman et al. (1996) observed that
“this behavior involves heightened risks for STDs because of exposure to
many different partners” (p. 243).
22
Jadack et al. (1995) noted another problem with serial monogamy.
They pointed out that:
a woman may have a different perception of what constitutes monogamy

and put herself at risk by believing that unprotected sex in this
relationship is safer. Her male partner may not perceive this
relationship as exclusive. Therefore, women may engage in similar
levels of risky behavior, yet perceive less risk in their sexual situations,
(p. 321)
In a study conducted by Strader and Beaman (1991), college students
reported more intentions to engage in a variety of risky sexual practices,
including anal intercourse, when compared to other study populations. The
practice of anal intercourse among college students is of concern to health
care providers because of its association with HIV transmission in people
with multiple partners.
The results of the aforementioned studies are shocking. The findings
of Carroll and Carroll (1995) are even more alarming. In their study of
alcohol use and risky sex among college students, they found that 37% of
responding college students had had sex with a stranger and 30% indicated
that they had had sex with a stranger when intoxicated. Similar findings
were reported by Wiley et al. (1996), who indicated that 19% of survey
respondents had had sexual intercourse with a stranger or a casual
acquaintance.
Young adults may hold a false sense of invulnerability when engaging
in high-risk sexual behavior. Nevertheless, sexual behavior can be
dangerous if it includes having multiple sexual partners, not using condoms,
23
not knowing the sexual history of sexual partners, having a bisexual partner,
having “one-night stands,” or having anal intercourse. The tendencies of
college students to engage in frequent sexual activity, have a number of
partners, and practice dangerous behaviors place them at high risk for
unplanned pregnancies and sexually transmitted diseases.
U nplanned Prpgnanry Risk for College Students
In an early study conducted by the New York State Family Planning
Program on unintended pregnancy, 36.2% of the women surveyed reported
that their last pregnancy had been unintended (Centers for Disease Control,
1991b). The study also found that women age 15 to 24 years were
substantially more likely to report an unintended pregnancy than were
women age 25 to 34 years. Delbanco (1996) reported that, “in 1987, 57% of
pregnancies in the United States were unplanned; of a total 5.4 million, 3.1
million were either mistimed or unwanted” (p. Is).
One might think that an individual who does not want to become
pregnant would take appropriate steps to ensure the use of contraception.
Nonetheless, the incidence of unplanned pregnancies among adolescents
continues to increase. Although consistent use of reliable contraception could
greatly reduce rates of unwanted pregnancy, many college students do not
use any contraception, use inadequate methods, are inconsistent in their
contraceptive behavior, or are not even aware of the variety of birth control
options available to them. Unplanned pregnancies often result from
24
ineffective use of contraceptives. Williams et al. (1996) reported that 80% of
impoverished teens get pregnant because of lack of contraceptive knowledge.
The AIDS Weekly (“College Students,” 1994), reported that 40% of
college students surveyed were sexually active but did not use birth control.
The report noted that the college population contributes to the approximately
3.6 million un intended pregnancies that occur each year.
Some studies, such as the one conducted by Grimley, Riley, Beilis, and
Prochaska (1993), concluded that “most young people view themselves to be
at some risk for unplanned pregnancies, and thus use contraception methods
to protect themselves” (p. 467). Williams et al. (1996) posited that “about
90% of women at risk for unintended pregnancy use contraception. However,
the remaining 10% use no method and account for more than half of all
unintended pregnancies” (p. 337). These studies clearly show where focused
educational efforts need to occur.
Sexually Transm itted D isease Risk

for College Students
In a study of sexual behaviors of university freshmen, Pepe, Sanders,
and Symons (1993) reported that almost 12 million cases of sexually
transmitted diseases occur annually, 86% of them in people age 15 through
29 years. Hale and Trumbetta (1996) added that increased experimentation
with alcohol, drugs, and sexual activity places adolescents, and particularly
women, at risk for STDs. Helweg-Larsen and Collins (1994) noted that STDs
25
are widely considered to be at an epidemic level in the United States among
individuals between 15 and 30 years of age. In 1992 AIDS became the fourth
leading cause of death among women ages 15 to 44 years (Grimley et al.,
1993). These findings are alarming. Zena Stein (1993) called for “the
development, testing, and distribution of prophylactic methods on which
women might rely to protect themselves from heterosexual transmission of
the human immunodeficiency virus and help stem the epidemic” (p. 1379).
Mulvihill (1996) felt that the only effective protective measures against
AIDS transmission are “education, the use of safer sex practices, and
screening of the blood supply" (p. 11).
The reason for the high incidence of STDs in the college population is
that sexually active college students engage in high-risk sexual relations
(Hernandez & Smith, 1990; Sheehan et al., 1990). In a current study of sex
behaviors among college students, Hawkins, Gray, and Hawkins (1995)
found that a substantial number of students still report “at risk” behaviors
such as having multiple sex partners. The AIDS Weekly publication noted
that 37% of undergraduate female collegians who participated in a national
survey had unsafe sex in the prior academic year (“STDs,” 1994). The college
population is entering a phase of life during which sexual activity is greatly
increased. Given their high-risk sexual behavior patterns, it is not
surprising that one out of every five college students has a history of being
infected with an STD (Seal & Palmer-Seal, 1996).
26
In 1981, the first cases of acquired immunodeficiency syndrome were
reported by health-care providers in California and the Centers for Disease
Control (CDC, 1991a). Today, the prevalence of HIV on college campuses is
approximately 0.1-0.2% (McGuire, Shega, Nicholls, Deese, & Landefeld,
1992). In a recent study of HIV/AIDS risk in heterosexual college students,
authors Lewis, Malow, and Ireland (1997) suggested that, it is likely many
adults with AIDS were infected when they were college students because of
the extended latency period for developing observable HIV-related symptoms.
Hatcher et al. (1992) recognized that choice of contraception has a
direct impact on STD risk. The use of condoms, diaphragms, and
spermicides, can protect against most STDs, including gonorrhea, chlamydia,
pelvic inflammatory disease, and cervical neoplasia. McGregor and Hammill
(1993) confirmed the Hatcher et al. observation, finding that most
spermicides tested in vitro have potent antimicrobial and antiviral effects
against all agents tested, including Neisseria gonorrhea, Chlamydia
trachomatis, Trichomonas vaginalis, bacteria associated with bacterial
vaginosis, herpes simplex virus, and HIV. Many other researchers concluded
that consistent use of condoms among sexually active people is the most
effective way to protect against STDs such as chlamydia, gonorrhea, syphilis,
and herpes simplex (Cates & Stone, 1992; Rosenberg et al., 1992; Seal &
Palmer-Seal, 1996).
27
Despite this conclusion, only 40% of sexually active college students
reported using a condom at last intercourse (Wiley et al., 1996). Many
researchers have concluded that, in spite of increased knowledge of HIV and
STDs, college students believe they are less likely than most to get AIDS and
thus do not use condoms when engaging in penetrative intercourse (Adame,
Taylor-Nicholson, Wang, & Abbas, 1991; McGuire et al. 1992; Seal & Palmer-
Seal, 1996). College students consistently rate other students’ chances of
contracting HTV/STDs as higher than their own (see Seal & Agostmelli,
1996).
Perceived risk may be consequential to STD prevention because,
unless college students feel susceptible to STDs, they may not carry out safer
behaviors. Seal and Agostmelli (1996) concluded that:
College students’ perceptions of relative invulnerability to HTV/STD

infection, stemming from their over-exaggerated perceptions of other
students’ actual risk, may have an inhibiting effect on positive health
behavior by reducing their perceived need to protect themselves against
negative consequences of unprotected sexual intercourse, (p. 454)
In their study of high-risk STD/HIV behavior among college students,
MacDonald et al. (1990) found that condom use tended to decline with the
increase in number of partners for female respondents. The authors also
emphasized that “neither fear of acquiring AIDS or an STD nor knowledge
about HIV or STD appeared to significantly influence the decision to abstain
from coital activity” (p. 3156).
28
Adame et al. (1991) concluded that “the most efficient way of
preventing the acquisition and transm ission of HTV is behavior change aimed
at reducing the risk of exposure, particularly behavior associated with sexual
practices” (p. 204). The AIDS Weekly publication concurred with this view.
In 1994, this publication cited the following statement by Secretary of Health
and Human Services Donna E. Shalala: “If I could design any preventive
tool, I would design human beings more in control of their lives, and
themselves” (“Shalala Says,” p. 12,1994).
College Students* Contraceptive Practices
Numerous studies have investigated contraceptive practices among
college students (Radius, Joffe, & Gall, 1991; Seal & Palmer-Seal, 1996).
These studies have shown that many college-age women do not use any
contraception or use inadequate methods.
Grimley et al. (1993) found that the use of contraceptives usually
follows a developmental pattern beginning with no method of contraception,
moving to condoms, and progressing to a method focused on pregnancy
prevention such as oral contraceptives. With this pattern, however, young
adults become more protected from pregnancy and less protected from STDs.
29
Factors Affecting Contraceptive

Choice
Different authors have described a number of factors that influence an
individual’s decision as to whether to use contraception. This study is
concerned with the effect of perception of pregnancy and STD risk as a strong
determinant. Williams et al. (1996) suggested that the decision to have
children is strongly swayed by one’s culture and has significant social
implications. According to these authors, “Reproductive capability can be
powerful and empowering, and each woman’s perception of herself as a
reproducer and mother is shaped by factors such as psychology, culture,
class, and race” (p. 336).
Another study reported that contraceptive use among college-age
women depends on three general factors: (a) a critical level of psychosexual
maturity, which is a function of physical and emotional maturation, social
norms, parental standards, and sexual experience; (b) perceived advantages
and disadvantages of contraception and risk of pregnancy and STDs; and (c)
the situational factors surrounding the episode of intercourse (Kusseling,
Wenger, & Shapiro, 1995).
The decision as to what contraception to use is also influenced by
perceived barriers and/or obstacles. For example, Williams et al. (1996)
suggested that some women decide not to use hormonal contraception
because these methods would necessitate a medical care process that
includes a physical examination. Cramer (1996) found that the adverse
30
effects of some contraceptive methods contributed to a decision to discontinue
use of contraception.
In a study about attitudes about condoms, Beckman et al. (1996)
suggested that “convenience, absence of health problems and side effects, and
reputation (i.e., physicians’ recommendation, long-time use) are relatively
stable dimensions of attitudes toward birth control methods” (p. 244).
Galavotti and Schnell (1994) theorized that women’s beliefs about the
effectiveness of a contraceptive method for pregnancy prevention may
generalize to beliefs about the efficacy of the method for disease prevention.
In a similar study, McGuire et al. (1992) found that safer sexual practices
were not associated with increased knowledge, but rather with a more
heightened personal concern about AIDS.
According to Sarvela et al. (1992), attitudes toward a particular
contraceptive option may play an important role in acceptance of and
predisposition toward a given method. Sarvela et al. (1992) noted that
attitudes concerning the acceptability of various contraceptive methods have
changed over the years. The mean scores on overall desirability of
contraceptive options revealed the following order of preference: oral
contraceptives, abstinence, condom, and diaphragm. The researchers
concluded that, although an individual may have a favorable attitude toward
a contraceptive option, actual use might not reflect that attitude.
31
Contraceptive Choices
Consistent and correct use of contraceptive methods is essential in
preventing both unplanned pregnancies and STDs. As a rule, prescription
methods are more effective than condoms and other nonprescription methods
for prevention of pregnancy and hormonal methods are ineffective against
HIV and other STDs. Barrier methods such as condoms are effective in
preventing STDs. Because condoms are not as effective in preventing
pregnancy as are the hormonal contraceptive methods or surgical
sterilization, health-care professionals recommend using condoms
adjunctively with spermicides. Hatcher et al. (1994) reported that as many
as 10% of selected populations use supplementary condoms in high-risk
settings to prevent STDs in addition to another contraceptive method.
Spermicides and vaginal barriers together with condoms are the only
available contraceptive products that may help reduce STD transmission
rates. McGregor and Hammill (1993) pointed out that past epidemiological
studies suggest that spermicides can also reduce the incidence of gonorrhea
and chlamydial infection as well as pelvic inflammatory disease.
Additionally, laboratory studies show that vaginal use of nonoxynol-9
without condoms reduces gonorrhea risk by 89% (Centers for Disease
Control, 1993). W illiams et al. (1996) stated that most spermicides contain
nonoxynol-9, which may offer some protection against HIV. However, Stein
32
(1993) argued that nonoxynol-9 may not protect those who have very
frequent sexual encounters.
Because the combination of hormonal contraceptives with condoms
provides protection against both unintended pregnancy and STD/HIV,
pharmaceutical companies such as Wyeth-Ayerst Laboratories are now
promoting the use of condoms in addition to their hormonal contraceptive
products. Wyeth-Ayerst, for example, has initiated a campaign called the
“Safer Sex Initiative.” The use of condoms in conjunction with other forms of
contraception to protect against pregnancy and STDs simultaneously is
receiving increasing encouragement. Frank et al. (1995) observed that “the
relationship between contraception and the prevention of STDs has become
more prominent with greater emphasis on the use of condoms to prevent
unplanned pregnancy as well as to protect from disease” (p. 32).
Whether condoms are used for disease prevention generally varies
with choice of contraceptive method for pregnancy prevention. In a study of
condom use, the American College of Obstetricians and Gynecologists found
that women who used hormonal contraception were less likely to have used
condoms. The study also found that women who had been surgically
sterilized were also less likely to use condoms (“Condom Use,” 1996).
McGuire et al. (1992) suggested that, although college students have
increased knowledge about AIDS, their understanding of some important
issues is limited. Researchers report that students do not “believe in”
33
limiting sexual activity, limiting the number of partners, or using condoms
(Strader & Beaman, 1991). Galavotti et al. (1995) pointed out that those
protected from pregnancy through sterilization are five times less likely to
use condoms than their nonsterilized counterparts.
In their study of condom use among college students, Wendt and
Solomon (1995) listed the following barriers to condom use:
Embarrassment about buying condoms, difficulty of discussing condom

use with a partner, interference with sexual pleasure, a low perceived
need to use condoms when oral contraception is used for birth control,
poor communication and assertiveness skills, concerns about friends’
perceptions, decrease in intimacy, and general lack of acceptance of
condoms, (p. 105)
In separate studies, Beckman et al. (1996) and Pepe et al. (1993)
conceded that, even though college students are engaging in risky sexual
activities that increase the probability of both STDs and unintended
pregnancies, few use condoms to lower their risk. Similarly, in a study of
Canadian college students, Oswalt and Matsen (1993) reported that only one-
quarter of their study population used condoms whenever they had
intercourse. In contrast to the aforementioned reports, Hatcher et al. (1994)
found that condom use increased among 15-19 year old women at risk of
pregnancy, generally because of the concern over AIDS and other STDs.
Grimley et al. (1993) warned that “each time an individual chooses a
method of contraception other than the condom, that person may be at risk,
because this individual is now sexually active, not concerned about
pregnancy, and unprotected from STDs” (p. 468). Wendt and Solomon (1995)
34
reported that men and women who use oral contraceptives are less likely to
feel a need to use condoms. This suggests that the condoms may be viewed
primarily as a means of protection against pregnancy but not as protection
against STDs.
Contraceptives that prevent pregnancy do not necessarily prevent the
spread of STDs. Many college students today are transitioning from condom
use to using alternative methods of pregnancy prevention as their
relationships become more committed and monogamous. For example, the
CDC reported in 1992 that surgical sterilization was used by 28% of women
age 15 to 44 years (CDC, 1992). However, at-risk women who are protected
against an unplanned pregnancy by any contraceptive method may be less
likely to use condoms for disease prevention.
In a study of HIV prevention, Stein (1993) suggested th at women
choose not to use hormonal contraceptives because of social and moral as well
as biological issues. Ironically, hormonal contraceptives are the method of
choice for pregnancy prevention. In their study of contraceptive use among
female college students, Radius, Joffe, and Gall (1991) stated that, although
oral contraceptives are not the preferred method of preventing STDs, they do
provide birth control and are easier to use than other methods. A high
percentage of teenagers and university students choose to use oral
contraceptives (OCs). Although many women may not be aware that OCs
provide protection against ovarian and endometrial cancer, salpingitis,
35
ectopic pregnancy, benign breast disease, dysmenorrhea, and iron deficiency
anemia (Williams, Watkins, & Risby, 1996).
On the other end of the spectrum, one set of researchers found that
even among religious female students, 48% chose abortion as a means to
prevent an unwanted pregnancy (Notzer, Levran, Mashiach, & Soffer, 1984).
Kusseling, Wenger, and Shapiro (1995) reported that women aged 18 to 24
years account for more than one third of reported pregnancy terminations.
Another fact to consider is that many young women regularly switch
the contraceptives they use, and this may lead to diminished effectiveness
and higher failure rates for preventing both pregnancy and STDs. In their
study of contraceptive use among college students, Kusseling et al. (1995)
found substantial contraceptive switching during a relatively short follow-up
interval. Additionally, Galavotti et al. noted that, as more providers urge
women to use barrier methods in conjunction with hormonal ones, women
may become confused about method effectiveness. According to the Centers
for Disease Control, one possible effect of encouraging women to use condoms
for HTV/STD prevention is that women may discontinue use of hormonal
contraceptive methods.
Changing Students’ Behaviors
Galavotti et al. (1995) observed that, as people change their behavior,
they move through a sequence of five stages. They summarized the content
of their transtheoretical model as follows:
36
In the precontemplation stage, people are not seriously thinking about

changing their behavior. In the contemplation stage, they are thinking
about changing within the foreseeable future (usually within 6 months).
During the preparation stage, people have an intention to change, and
they are seriously planning to change within the very near future.
People in the action stage have changed their behavior, but the change
is fairly recent. Maintenance is the stage of long-term change during
which people have consistently performed a new behavior for a given
period, usually 6 months or more. (p. 571)
In applying their theory to the possibility of modifying behavior to effect
consistent use of condoms, Galavotti et al. concluded that “maintaining
condom use may require more continued cognitive and emotional effort than
may be required for maintenance of other behaviors and that the risk of
relapse may remain high” (p. 576).
In a study of condom use in conjunction with other contraceptive
methods, Frank et al. (1995) found that use of combined contraceptive
methods could be increased through educative counseling. They reported:
Twenty-eight percent of the study sample had used condoms in the past,
at least occasionally, in conjunction with oral contraceptives, IUD,
diaphragm, cervical cap, implants, Depo Provera or when one partner
had undergone surgical sterilization. This increased to 42% after
counseling. Only 6% stated that they had always used condoms in
conjunction with another method prior to the visit, but 22% stated that
they planned to do so after, (p. 36)
The Frank et al. (1995) study clearly shows that clinical contact offers
an important opportunity for intervention relating to the prevention of STDs.
Additionally, this study reveals that condom use in conjunction with other
contraceptive methods can increase following appropriate contraceptive
counseling and education.
37
In a study of college students’ sexual attitudes and behaviors,
Feigenbaum, Weinstein, and Rosen (1995) suggested that college students’
sexual behavior may change after completion of a human sexuality course.
In this particular study, Feigenbaum et al. (1995) found that, after taking a
human sexuality course, more students reported that they would use
condoms and spermicides for STD and pregnancy prevention. In their study,
Stanton et al. (1996) concluded that knowledge about AIDS was positively
associated with use of more effective contraceptive methods.
On the other hand, Beckman et al. (1996) described the failure of
education to reduce risky behavior:
Previous research indicates that knowledge of risk alone does not

change sexual practices among undergraduates and that more complex
psychological factors may be involved. Although most young adults are
aware that human immunodeficiency virus (HTV), which causes AIDS,
can be transmitted through sexual intercourse, the majority have not
consistently altered their sexual behaviors in response to the threat of
AIDS. (p. 243)
Radius, Joffe, and Gall (1991) also noted that little evidence exists to
support the success of educational efforts. Mulvihill (1996) indicated that
although gay males have had the best record for positive behavioral
modification, recent reports show that risky behavior among this group
continues to exist.
Changing sex behavior is a complex venture. Mulvihill (1996)
suggested that “U.S. AIDS-education efforts are confounded by the public
perception that AIDS is a ‘gay plague’ or an addict’s disease.” The author
38
suggested that attitudes such as these prevent people from making behavior
modifications that would lower their personal risk.
A possible explanation for some of the failure of education to change
the behavior of college students was suggested by Wenger, Kusseling, and
Shapiro (1995). In their study of safer sex practices, they concluded that the
term “safer sex” is often misunderstood among sexually active adults. This
misunderstanding likely compromises the value of the education and places
individuals at increased risk of contracting an STD.
O’Leary et al. (1992) listed several factors they felt should contribute
to safer sexual behavior: “strong perceptions of the ability to negotiate safer
sexual behavior with a new partner, greater expectations of positive
outcomes of condom use (e.g., preventing HIV infection), and lower
expectations of negative outcomes from condom use (e.g., reduced pleasure or
negative partner response)” (p. 254).
Many studies have noted that considerable changes in behavior have
been reported by college students (DiClemente et al. 1990; Simkins, 1994).
Valois and Waring (1991) reported that educating college students about
methods of contraception has helped slow the birthrate in several college
population study groups. According to DiClemente et al. (1990), many
students have decreased their high-risk behavior in response to the threat of
AIDS. The authors found that students’ personal perception of susceptibility
to AIDS was strongly related to an increase in health-promoting behaviors.
39
Carroll and Carroll (1995) indicated that nationwide concern over the AIDS
epidemic may be associated with sexual behavior changes among college
students. Simkins (1994) found that the spectre of AIDS has resulted in a
clear shift toward more conservative sexual practices compared to the casual
lifestyles during the pre-AIDS era and the early 1980s. Wiley et al. (1996)
indicated that adolescents and young adults can establish protective patterns
of health behavior that could last well into adulthood.
Summary
The literature reveals an urgent need to provide contraceptive
education to college students. Family planning, reduction of HIV infection,
and control of other sexually transmissible diseases all require effective use
of contraceptive methods.
Contraceptive use among female college students is inconsistent.
Interventions to prevent pregnancy and STDs among college students should
focus on the consistency of contraceptive use. All young women should be
counseled about contraceptive methods that also decrease STD risk,
particularly those methods within the women’s control. Ideally, family
planning counselors should come from the same cultural background as the
students.
Although family planning and STD education is available for college
students, contraceptive misconceptions persist. Students often think that
any birth control method, such as foam or birth control pills, is just as
40
effective as condoms in preventing AIDS. Health professionals must be sure
that college students recognize that, because they are susceptible to HIV and
other STDs, they should use both barrier methods and oral contraceptives.
Concentrating on pregnancy prevention alone is not sufficient for protecting
the overall health of college students.
Fortunately, the situation is improving. Both knowledge and use of
contraceptives has increased among college students. Although knowledge
alone does not necessarily lead to changed behavior, knowledge may serve as
a catalyst for adopting healthier practices.
Chapter 3
RESEARCH DESIGN AND METHODOLOGY
The influence of an individual’s perception of pregnancy and sexually
transmitted disease (STD) risk on contraceptive practices was examined
through a survey of college students. The procedures of the study, a
description of the study sample and the methodology by which the data were
collected and analyzed are presented here.
This study had two primary objectives: (a) to assess the relationship
between college students’ contraceptive practices and their perceptions of
their risk of pregnancy, and (b) to assess the relationship between college
students’ contraceptive practices and their perceptions of their risk of
acquiring a sexually transmitted disease (STD).
Setting
This study was conducted at California State University, Fresno
(CSUF) during the fall 1997 and spring 1998 semesters. According to the
Office of Institutional Research, Planning and Assessment, the college
student population at CSUF during this time consisted of 14,768
undergraduate students and 3,345 graduate students (7,903 men and 10,210
women).
42
The ethnic distribution was Caucasian (10,222 students, 56.4%),
Hispanic (4,704 students, 26%), followed by Asian (1,980 students, 11%),
African American (989 students, 5.4%) and American Indian (218 students,
1.2%). Only students regularly enrolled in an undergraduate academic
program were included as part of the sample.
Subject Selection
Because general education (GE) courses are required of all students for
graduation, the study sample consisted of students enrolled in GE classes in
the Natural Sciences and Health and Social Work schools of CSUF. Using
GE courses ensured a more representative sample of students. Specifically,
students in the Mathematics and Health Science department undergraduate
courses were targeted.
Sample
The criteria for subject inclusion in this study were (a) status as a
regular student in an undergraduate academic program at CSUF and (b)
enrollment during the fall 1997 or spring 1998 semester. This sampling
methodology was selected because of the accessibility of the target population
and the ease of administration. Undergraduate students attending CSUF
were considered representative of the college population enrolled in a public
university.
43
The survey instrument was administered by the instructor to the
students during class time. Participation was completely voluntary and
questionnaire administration procedures were designed to protect the
anonymity of the students. To ensure anonymity, the questionnaires were
returned in sealed envelopes.
The pilot sample consisted of 42 students. The final sample consisted
of 335 students. A total of 376 students participated in the study.
Instrumentation
The anonymous, self-report survey instrument (Appendix A) was
designed specifically for this study and was distributed and collected during
the fall 1997 and spring 1998 semesters. The 33-question instrument
solicited basic demographic information such as participants’ age, gender,
ethnicity, and current relationship history. It also solicited significant
information, including: (a) students’ sexual behavior history (age at first
intercourse, number of sexual partners, and sexual practices); (b) general
risk behavior, including past STD infection and/or unplanned pregnancy
outcomes; (c) a detailed history of contraception utilization patterns,
including why a particular method was used and if communication about
contraception occurred in the relationship; and (d) knowledge regarding
contraception and STDs.
The instrument was designed primarily for young, sexually active,
heterosexual college students who may be at risk for an unplanned
44
pregnancy. Because this study was also concerned with STD risk among
college students, the tool was designed to apply to all students regardless of
their sexual orientation.
The instrument utilized categorical questions to analyze students’
ideas about what constitutes risky sexual behavior and the motivational
factors that influence contraceptive use were also investigated. Likert-type
scale questions were applied to assess attitudes and knowledge regarding
contraception and STDs.
Contraceptive methods used with current or last sexual partner were
categorized in the survey questionnaire as none, condom, condoms with foam,
diaphragm, cervical cap, intrauterine device (IUD), Norplant, Depo-Provera,
spermicides, oral contraceptives, emergency contraception, coitus
interruptus, sterilization, fertility awareness, abortion, and other. Reliable
contraception was defined as oral contraceptives, condom, condom with foam,
diaphragm, cervical cap, intrauterine device (IUD), Norplant, Depo-Provera,
spermicides, and sterilization. Unreliable contraception were defined as
coitus interruptus, fertility awareness, and no method.
With respect to attitudes and opinions, participants responded to three
Likert scale questions by indicating: (1) Agree, (2) Disagree, or (3) No
opinion. Additionally, students were asked to indicate the reason(s) they vise
or do not use contraception and whether they have changed their
contraceptive behavior as a result of the threat of AIDS. Because this study
45
was also concerned with college students’ formal education in health
promotion and disease prevention, the questionnaire also asked about
knowledge of contraception, HIV, and other STDs.
Eleven items measured knowledge in the following areas:
Transmission of HTV and other STDs (3 items), actions that reduce the risk of
acquiring an STD or HTV (2 items), actions that reduce the risk of pregnancy
(1 item), and basic benefits of contraception (5 items). The term AIDS was
used with the double meaning of both the clinical m anifestation and the
etiologic agent (HIV). Students were asked to evaluate the correctness of
each statement given the Likert scale parameters: (1) True, (2) False, or (3)
Not sure. A knowledge score was assigned, based on the percentage of
correct responses. In addition, students were asked if they had ever attended
a family planning or STD lecture in a college course.
Ethical Considerations
Approval for investigation of human subjects was obtained from the
university’s Human Subjects Committee, the university’s internal review
board. Approval to utilize the survey questionnaire was granted in February
1998 (Appendix A).
Of the six university professors initially contacted, all agreed to
cooperate in the data collection procedure. Introductory discussions were
conducted with the professors willing to participate and a timeline was
established for a dm inistering the survey.
46
Data Collection
A 3-page, 33-item survey instrument was utilized to assess the
relationship between college students’ contraceptive practices and their
perceptions of risk of pregnancy and sexually transmitted diseases (Appendix
B). The self-report survey instrument was administered in a classroom
setting to 145 male and 231 female undergraduate students ages 17 to over
35 who were enrolled at California State University, Fresno.
Since the survey questionnaire contained items pertaining to sexual
and contraceptive behavior, it was vital to provide privacy while students
were completing the survey and to have the responses be anonymous.
Consequently, students were asked not to write their names on the
questionnaire and to place it in an envelope when finished. The researcher
or class professor collected the completed questionnaires.
Pilot Test
To assure that the questions were understandable, the survey tool was
pilot tested during the 1997 fall semester. Forty-two students participated in
the pilot test. Pilot test participants were provided with the survey
questionnaire and were asked to indicate the items that were unclear by
placing a question mark next to the item. Based upon their
recommendations, minor changes in wording were made to questions 6,10,
14, 27, and 32. A final sample of 335 students was retained during the
47
spring 1998 semester. The questionnaire took approximately 6 minutes to
complete.
Data Analysis
The data were analyzed for statistical significant differences, using
Pearson’s chi-square with Yates correction factor. The responses of each of
the separate Likert scales are summed to yield the students’ attitude and
knowledge scores. The question regarding STD perceived susceptibility also
utilized a Likert scale. The items in this question received a numerical
value: 1 point was assigned for Agree and 2 points for Disagree.
A level of significance of .05 was selected to test the hypothesis of this
study.
Summary
The relationship between the risk of pregnancy and STDs on
contraceptive practices among college students was examined through a
survey of undergraduate college students at California State University,
Fresno, in February and March of 1998. The research hypotheses were
tested by administrating a three-page questionnaire asking about sexual and
contraceptive behaviors, contraceptive and STD related knowledge, attitudes
regarding contraception, and perceived STD risk. A total of 376 students
48
(including pilot participants) completed the questionnaires. The data were
scored and analyzed using Pearson’s chi-square with Yates correction factor.
Chapter 4
RESULTS AND ANALYSIS OF THE DATA
This chapter presents a compilation and analysis of the data collected
from the study population through the survey questionnaires. A preliminary
version of the survey instrument was tested with 42 undergraduate students
in a pilot survey. To assure that the questions were understandable,
students were asked to place a question mark next to any confusing item.
Confusing questions were eliminated or revised.
The revised questionnaire was administered exclusively to
undergraduate students enrolled in general-education courses during the
1998 spring semester. The anonymity of the questionnaire itself and of the
survey setting reduced potential embarrassment and feelings a respondent
might otherwise have of being "singled out."
Three hundred seventy-six usable questionnaires were returned. The
convenience sample represented 3% of the undergraduate population of
California State University, Fresno. At the time the survey was
administered, 14,768 undergraduate students were enrolled.
The main purpose of the study was to examine the contraceptive
practices of college students. The results of the research are presented in
three main sections in this chapter. The first describes the demographic
50
characteristics of the student sample. The second presents the findings
regarding knowledge about contraception and STDs. Finally, this chapter
describes the results for Hypotheses 1 through 7, which explored how
students' contraceptive practices correlate with their unplanned pregnancy
and STD histories. The relationships between students' attitudes and beliefs
and their sexual behaviors are also explored.
Demographic Characteristics of
Students in the Sample
Concerning gender, the final sample consisted of 231 women (61.4%)
and 145 men (38.6%).
The students ranged in age from 17 to over 35 years, with the majority
(41.5%) aged 20 or younger. Thirty-eight percent (n = 143) fell into the
category of 20 to 23 years of age, 9% (n = 34) were between 24 and 27, 4.5%
(n = 17) were between 28 and 31, 2.4% (n = 9) were between 32 and 35, and
4.5% (n = 17) reported themselves as other.
Ethnic diversity in the student sample was high, with 40.1% (n = 150)
of the sample being Caucasian. A total of 31.6% (n = 118) of the students
were Hispanic; 11.5% (n = 43) Asian/Pacific Islander; 9.4% (n = 35) African-
American; 0.5% (n = 2) Native American/Alaskan Native; and 7.0% (n = 26)
represented other ethnic groups, including Russian/Eastern European. The
demographic characteristics of the survey population are given in Table 1.
51
Table 1
Samnle Distribution bv Demographic Characteristics
Frequency Percent
Characteristic (a) (%)
Ethnicity
Caucasian 150 40.1
Hispanic 118 31.6
Asian/Pacific Islander 43 11.5
African-American 35 9.4
Native American/Alaskan Native 2 .5
Other 26 7.0
Gender
Male 145 38.6
Female 231 61.4
Age Group
17-20 156 41.5
20-23 143 38.0
24-27 34 9.0
28-31 17 4.5
32-35 9 2.4
Other 17 4.5
52
In terms of sexual preference, the rate of students identifying
themselves as homosexual or bisexual was low. It is not known whether
homosexual and bisexual students chose not to answer the survey, not
participate, or answer untruthfully. In their study, Turner, Korpita, Mohn,
and Hill (1993) suggested that individuals in age categories predominant in
this research may have not yet clarified their sexual orientation. Nearly all
of the participants (98.9%) preferred sexual activity with a member of the
opposite sex, although one student (0.3%) preferred sexual activity with a
member of the same sex and three (0.8%) preferred sexual activity with
persons of either sex.
In regard to relationship history, 106 (28.5%) individuals reported that
they were steadily dating, 81 (21.8%) were casually dating, 73 (19.6%) were
not dating, 47 (12.6%) reported being married, 40 (10.8%) were living with
their partner, 18 (4.8%) were engaged, 6 (1.6%) were separated, and 1 (1.6%)
was widowed. No students indicated that they were divorced and four
individuals did not give responses.
Of the 376 students sampled, 232 (62%) said they engaged in sexual
intercourse. Of those, 193 reported being in a monogamous relationship.
Twelve students indicated that they engage in anal sex in order to avoid
pregnancy. Thirty-eight percent reported not being currently sexually active.
When asked if they had ever had sex with someone they had just met that
53
day or night, 81 participants (22.8%) answered "Yes," 233 (65.6%) answered
"No," 41 (11.5%) indicated "Not Applicable," and 21 (5.6%) did not respond.
One hundred ten students (58.5%) reported having only partner in the
past year. However, 25 students (13.3%) said they had three partners in the
past year, and one student had 20 sexual partners in the past year. The
mean numbers of sexual partners students reported was 1.005 at the present
time, 1.915 in the past year, and 8.363 partners over a lifetime to date.
Over half the sample (61.8%) reported that their first intercourse
experience occurred by the time they were 17 years of age. Age at first
intercourse varied from as young as 11 to over 26 years. The mean age at
first intercourse was 16.895 years.
Overall, 35 of the sexually active students (9.5%) reported having had
at least one diagnosis of an STD. STD history increased with students who
became sexually active between the ages of 14 and 17.
Concerning pregnancy history, 68 (18.4%) of the sample reported that
an unplanned pregnancy had occurred in one of their relationships. Forty-
six percent of these pregnancies resulted in childbirth, 44% resulted in
abortion, and 10% ended in miscarriage. These results are illustrated in
Figure 1.
Regarding contraceptive history, 219 (59.9%) of the students indicated
that they or their partner used contraception. (See Figure 2 for association
between use of contraception and relationship status.) Of these, 188 (84.3%)
54
10 % □ Miscarriage
□ Pregnancy/
Childbirth
□ Abortion
Figure 1. Results for survey question 17: Unplanned pregnancy outcomes.
Figure 2. Distribution results for survey question 12: Do you/your partner

use contraception or protection -- by relationship status.
55
stated that they used contraception consistently. Of those students who
reported not currently using contraception, the reasons indicated were:
health risks of contraception (n = 7, 1.9%), religious reasons (n = 6, 1.6%),
embarrassment about purchase and/or use (n = 5, 1.3%), cultural reasons
(n = 1, 0.3%), do not engage in sexual intercourse (n = 28, 7.4%), and other
(n = 30, 8.0%). When asked whether the participants discussed contraception
with their partners, 228 (81.5%) answered "Yes" and 40 (14.9%) answered
"No."
Self-reported change in contraceptive behavior was measured by
asking, "Have you changed your contraceptive behavior as a result of your
question, 162 (44.1%) answered "No," and 107 (29.2%) indicated "Not
Applicable."
Concerning contraceptive practices, when asked why students use
contraception, 136 (37%) indicated for pregnancy prevention only, 5 (1.3%)
indicated for STD/HIV prevention only, 114 (31.3%) indicated for both
pregnancy and STD/HIV prevention, 111 (30.3%) indicated that the question
did not apply. Ten students did not respond to this question. When asked
whether the participant used a condom to lower STD risk, 22.2% answered
"Always," 20% answered "Sometimes," 27.2% answered "Never," and 30.6%
indicated "Not Applicable."
Condoms were the most frequently used contraceptive: 41% of the
participants used the condom alone. The next most frequently used
56
contraceptive methods were oral contraceptives (35.6%) and coitus
interruptus (i.e., withdrawal) (8.8%). Four percent of the participants
indicated that either they or their partner had been sterilized; 3.5% used
Depo-Provera; 2.1% used condoms in conjunction with contraceptive foam;
2.1% practiced fertility awareness (i.e., calendar "rhythm" method, basal
body temperature method, cervical mucous method); 1.9% used spermicides
(i.e., foam, film, jellies); 1.3% used the diaphragm; 0.8% used Norplant; 0.5%
had used the morning-after pill; and 2.4% did not use contraception. Of
particular interest is the fact th at 1 student indicated "abortion" as the
respondent's choice for birth control. Only 15.9% reported that they used
condoms in conjunction with another method to protect themselves from
disease.
In regard to attitudes, the majority of the students (92.5%) disagreed
with the statement that contraception is solely the woman's responsibility.
Fifty-seven percent agreed that non-prescription contraceptives should be
made available in vending machines in public bathrooms, 21.6% disagreed,
and 21.4% had no opinion. The last question read, "I am less likely than
most people to get an STD or HIV/AIDS." One hundred seventy-eight
(58.2%) said "True," 125 (40.8%) answered "False," and 3 (1%) said they were
not sure. This exemplifies the perception of invincibility among college
students. Student responses to these questions are shown in Table 2.
57
Table 2
Student Responses to Attitude Questions
Agree Disagree No opinion Missing

Question n (%) n (%) n (%) n (%)
Contraception is solely the

woman's responsibility 10 (2.7) 344 (91.5) 18 (4.8) 4 (1.1)
Non-prescription contraceptives
should be made available in
vending machines in public
bathrooms 211 (57.0) 80 (21.6) 79 (21.4) 6 (1.6)
I am less likely than most people

to get an STD or HTV/AIDS 78 (58.2) 125 (40.8) 3 (1.0) 70(18.6)
Knowledge About Contraception and STDs
The general knowledge portion of the survey consisted of 11 items in
which students were asked to report whether statements about contraception
and STDs, including AIDS, were true or false or they were not sure about the
answer. Three hundred forty-four (93.2%) of the 369 students who responded
reported that they had participated in a lecture at which STDs and family
planning were discussed.
Contraceptive knowledge was assessed by having participants answer
questions relating to the benefits and risks of using contraception. Five
items asked about contraceptive measures that students may believe
(correctly or incorrectly) prevent pregnancy and/or sexual transmission of
58
diseases. The remaining items asked about behavioral measures that
persons may believe prevent pregnancy or the sexual transmission of Herpes
and HTV. The distribution of correct and incorrect answers to each of the test
questions is given in Table 3.
A high percentage of the students responded accurately to the
following items pertaining to contraception: "The pill protects against STDs
including HTV" (94.9%), "Depo-Provera is an injectable method that protects
against pregnancy" (60.6%), "Norplant is an effective contraceptive method
that also protects against HIV/AIDS" (77.6%), and "Using foam and condoms
during sex can decrease the risk of pregnancy and AIDS" (83.6%). Few
students, however, answered correctly the statement "The pill protects
against osteoporosis and ovarian cancer" (17.5%). Only 51.9% of the students
answered accurately the question "The pill is more hazardous to your health
than pregnancy." Similarly, only 57.4% of the students knew that "A
condom, when used with spermicidal foam, has increased effectiveness
against STDs."
The majority of students correctly responded that "Herpes can be
acquired during oral sex" (84.4%), "You can get AIDS from someone who is
infected but does not have any symptoms" (94.9%), and "A woman can get
pregnant even if the man withdraws his penis before he ejaculates" (83.8%).
59
Table 3
Distribution of Correct. Incorrect and Not Sure Answers to Questions About

Contraception. STDs. HTV/AIDS Knowledge
Correct Incorrect Not sure

Test Question n % n % n %
The pill protects against STDs, including HIV 353 94.9 7 1.9 12 3.2
The pill is more hazardous to health than

pregnancy 193 51.9 63 16.9 116 31.2
Depo-Provera is an injectable method that

protects against pregnancy 225 60.6 15 4.0 131 5.3
Using foam and condoms during sex can

lower the risk of pregnancy and AIDS 310 83.6 41 11.1 20 5.4
A woman can get pregnant even if the man

withdraws his penis before he ejaculates 311 83.8 32 8.6 28 7.5
A condom, when used with spermicidal foam,

has increased effectiveness against STDs 213 57.4 80 21.6 78 21.0
A person can get AIDS by having anal

intercourse even if neither partner is
infected with the AIDS virus 198 53.5 102 27.6 70 18.9
You can get AIDS from someone who is

infected but does not have any symptoms 351 94.9 7 1.9 12 3.2
The pill protects against osteoporosis and

ovarian cancer 65 17.5 145 39.1 161 43.4
Norplant is an effective contraceptive method

that also protects against HTV/AIDS 287 77.6 12 3.2 71 19.2
Herpes can be acquired during oral sex 313 84.4 12 3.2 46 12.4
60
However, only 53.5% of the students answered accurately the question: "A
person can get AIDS by having anal (rectal) intercourse even if neither
partner is infected with the AIDS virus."
Results for the Hypotheses
Hypothesis 1 states: There is no significant difference in the
association between the use of contraception and a history of unplanned
pregnancy. The Pearson chi-square test indicated a significant difference at
the .05 level in the association between the use of contraception and a history
of unplanned pregnancy. The chi-square result of 197.76 with 4 degrees of
freedom and a probability of .00001 illustrates high significance. The matrix
is shown in Table 4. Figure 3 illustrates the types of contraceptives used by
persons in the study with a history of unplanned pregnancy.
Table 4
Pearson Chi-Sauare Summary for Hypothesis 1: History of Unplanned
Pregnancy and Use of Contraception
x2 £
197.76 4 .000001
Note. Significant at a = 0.05
association between the use of combined contraceptive methods and a history
of unplanned pregnancy and/or a history of STDs. According to the Pearson
61
CO
-t- J
cQ)
3
co
S co uce 3
CO
c
CO
© CO
Figure 3. Type of contraceptive used by persons with history of unplanned

pregnancy.
Note. Figures total more than 100% because some respondents checked more
than one.
62
chi-square test, the null hypothesis can be rejected. Consequently, there are
significant differences in the correlations between the use of combined
contraceptive methods and both a history of unplanned pregnancy and a
history of STDs. Table 5 shows the results of the Pearson chi-square test for
Hypothesis 2.
Table 5
Pearson Chi-Square Sum m ary for Hypothesis 2: History of Unplanned

Pregnancy and/or STD Infection and Use of Combined Contraceptive
Methods
Variable X" dfi U
History of unplanned pregnancy 208.18 4 .00001
History of STD infection 101.68 4 .00001
Hypothesis 3 is: There is no significant difference in the relationship
between the use of contraception and a personal history of STDs. The
Pearson chi-square result of 100.29 with 4 degrees of freedom and a
probability of .00001 showed a significant association between the use of
contraception and a personal history of STDs. Table 6 shows the Pearson
chi-square test results for Hypothesis 3. Figure 4 illustrates the types of
contraceptives used by persons with a history of STDs.
63
Table 6
Pearson Chi-Sauare Summary for Hypothesis 3- H istory of STD Infection

and Use of Contraception
X2 M E
100.29 4 .00001
2 30
i J I I 1
o co C3
£o 1m
-c 09
au a0909
*■ 5
CS >
c N ox
S
o cuc oo Im On
09
c
o CO 09
09 a
Figure 4. History of STD infection by type of contraceptive currently used.
64
association between age, ethnicity, or marital status and the use of condoms
for protection against STD infection. According to the chi-square values for
age, ethnicity, and marital status (p = .00086, .01433, and .00001,
respectively), there is sufficient evidence to reject the hypothesis that age,
ethnicity, and marital status are independent of the use of condoms for
protection against STD infection (see Table 7).
Table 7
Status and the Use of Condoms

->
Characteristic t cLf P
Age 38.14 15 .00086
Ethnicity 29.39 15 .01433
Marital status 155.06 21 .00001
association between age at first intercourse and a history of STD infection.
The result showed a significant relationship (p = .00001) between these two
variables at the level of .05 (see Table 8).
Hypothesis 6 is: There is no significant difference in the association
between attitudes about contraceptive issues and gender, age, or ethnic
65
Table 8
Pearson Chi-Square Summary for Hypothesis 5: Age at First Intercourse and
Historv of STD Infection
X2 dl £
101.68 4 .00001
group. For the survey item "Contraception is solely the woman's
responsibility," the responses showed a Pearson chi-square probability of_p =
.846, p = .944, e = -076, respectively, for gender, age, and ethnicity. When
asked if non-prescription contraceptives should be made available in vending
machines in public bathrooms, the responses yielded probabilities for gender,
age, and ethnicity of e = .221, e = •188, and e = -408. These data indicate
that the null hypothesis could be retained. The results showed no significant
difference in attitudes about contraceptive issues among gender, age, and
ethnic groups (Table 9).
association between age, gender, and marital status and perceived
susceptibility to STD or HIV/AIDS infection. The probability values of
E = .374 and e = 826, respectively, for gender and age verified that there is
no significant relationship between these variables and perceived
susceptibility to STD or HIV/AIDS infection. However, the Pearson chi-
square test of independence between marital status and levels of perceived
66
Table 9
Pearson Chi-Square Summary for Hypothesis 6: Attitudes About

Contraceptive Issues bv Gender. Age, and Marital Status
Attitude and characteristic t M
Attitude: Contraception is solely

the woman's responsibility
Gender 0.33 2 .846
Age 4.07 10 .944
Attitude: Non-prescription contraceptives

should not be made available in
vending machines in public bathrooms
Gender 3.01 2 .222
Age 13.68 10 .188
Note. Not significant at a = 0.05
67
susceptibility to STD or H3V/AIDS infection revealed a calculated chi-square
probability value of .016 with 14 degrees of freedom. Table 10 presents the
chi-square results for Hypothesis 7.
Table 10
STDs or HTV/AIDS bv Aee. Gender, and Marital Status

*>
Characteristic 1' dl U
Gender 1.97 2 .37437
Age 5.87 10 .82619
Note. Gender and age not significant at a = 0.05; marital status significant
at a = 0.05.
Summary
This chapter presented the data gathered from the study participants
through the research questionnaire. The study sample consisted of 376
undergraduate students enrolled at California State University, Fresno. The
sample was predominantly female, Caucasian, and 20 years old or younger.
The majority of the students indicated that they had taken a health class or
been to a lecture at which contraception and STDs were discussed. The
hypotheses were analyzed through the use of Pearson chi-square with Yates
correction factor. Significant differences were found for Hypotheses 1,2, 3,4,
and 5. Hypotheses 6 and 7, however, were rejected.
Chapter 5
DISCUSSION
This study is an assessment of unplanned pregnancy and STD risks,
contraceptive practices and experiences, and sexual behaviors in a college
population. In this chapter, the results are interpreted in relationship to the
review of literature. Recommendations for further research are also given in
this chapter.
Demographic Data
An evaluation was conducted of use of contraception by relationship
status and ethnicity. Comparisons between gender and age groups were also
noted for sexual intercourse activity and contraceptive use.
Differences in Relationship
Status
Among the 80 students who were "casually dating," 65% reported that
they were not monogamous. In contrast, of the students who were in a
steady relationship, 72.4% were reportedly monogamous. Of the 40 students
who indicated they were living with their partner, only 3 (7.5%) reported not
being monogamous. All of the students who reported being either married or
engaged (with the exception of 3 who did not respond) were in monogamous
relationships.
69
Students who were steadily dating were more likely to use
contraception (34.3%), followed by students who were casually dating (22.7%)
and those who were living with their partner (15.7%). Students with lower
rates of contraceptive use were not dating (6.9% of respondents who used
contraceptives were "not dating"), were engaged (6.5%), or were separated
(1.9%). Single students (i.e., those casually dating and steadily dating) were
more likely to use more than one contraceptive method.
Married students were among those who reported the lowest levels of
condom use. In contrast, 66.2% of single students used condoms. The
greater reported use of condoms among young, primarily un m arried students
is encouraging. However, students who were steadily dating were also more
likely than any other group to use coitus interruptus (withdrawal).
In order of descending frequency, students reporting the highest levels
of oral contraceptive use were those who were steadily dating, living with
their partner, and casually dating. Not surprisingly, students who were
married were more hkely to have had sterilization. Unfortunately, more
students used unreliable methods such as withdrawal as opposed to reliable
methods (i.e., sterilization, Depo-Provera, and Norplant). As the
relationships became more secure (i.e., married, steadily dating, living with
partner), there was a strong shift away from condom use as use of oral
contraceptives increased. Students who were steadily dating were more
70
likely to use more than one birth control method. Table 11 illustrates the
distribution of types of contraceptives used by relationship status.
Comparisons Among Age Groups
No significant gender effect was found for age at first intercourse (x2 =
1.044, <L£. = 3, p = .79058). The majority of both men and women had
initiated intercourse between the ages of 14 to 17 years. Eight men (7.2%)
and 9 women (5.2%) reported having first experienced intercourse between
the ages of 11 and 13. There was, however, an indication of potential delay
in sexual involvement. Nine percent of men and 10.3 % of women reported
their first sexual intercourse experience at 20 years of age. The reasons for
the delay in sexual involvement were not explored.
Students who were between the ages of 17 and 23 were more likely to
be either steadily or casually dating. Students who were 24 years old and
above were more likely to be married.
Age of participants was significantly associated with both
contraceptive use and a history of unplanned pregnancy (x2 = 19.905, dX =
10, p = .03017 and x2 = 47.642, d j. = 10, e = -00001, respectively). The
highest rates of contraceptive use were among students age 24 to 27 (78%).
The lowest rates of use were among students age 28 to 31 (47%). The low
rates may be attributed to the fact that the majority of the students in the 28-
30 age group were married and may have been attempting to have children.
Table 11
Type of Contraceptives Used bv Relationship Status
Type of Casually Living with Not Steadily

Contraceptive dating partner Married dating dating Engaged Separated Total
Condom 48 20 5 17 52 6 3 151
Oral contraceptive 22 24 19 7 52 9 1 134
Coitus interruptus 5 1 5 2 17 3 — 33
Sterilization 1 — 11 2 — — 1 15
Depo-Provera 2 3 2 1 5 — — 13
Fertility awareness — 1 3 2 — 1 1 8
Spermicides 2 1 — 1 3 — — 7
Diaphragm 2 — 1 — 1 — — 4
Norplant 1 1 — — 1 — — 3
Emergency contraception 1 — — — 1 — — 2
72
No major differences were apparent in terms of knowledge. However,
most students in all age groups answered incorrectly the question "Is the pill
more hazardous to your health than pregnancy?" Of the three age categories
(21-23, 24-27, and 28-31), the group that answered inaccurately to the
greatest number of questions was between 17 and 20 years old. This age
category was also more likely to indicate "not sure" to the test questions. The
28-31 age category was most likely to accurately answer the questions.
Comparisons Between Women

and Men
The Pearson chi-square analysis did not indicate a strong relationship
between gender and sexual intercourse activity (p = .653). The results
showed that 63.4% of men and 61.1% of women in the study sample engaged
in sexual intercourse.
Significantly more men than women reported engaging in risky
behaviors, such as having intercourse with someone they had just met that
day or night (see Fig. 5) and engaging in anal intercourse (7.7% of men vs.
2.5% of women). No significant difference between genders was found with
regard to history of STD infection (%2 = 197.76, dfi = 4, p = .10049). The
proportions of people reporting STDs were 9.3% for men and 9.6% for women.
Although no significant gender differences were found regarding some
of the sexual history items, women did report fewer sexual partners than
males. Eight percent of males versus only 1.9% of women reported having
had 20-30 partners in their lifetime. One hundred forty-two students (77.6%
of the women, 72.2% of the men) reported having only one current sexual
partner. However, 8.3% of men and 1.7% of women reported currently
having sex with two partners, and 5.6% of men indicated having three
current partners (see Table 12 ).
II Yes I
□ No [
Men Women
Figure 5. Results to survey question 9: Have you ever had sex with someone
you just met that day or night?"
Regarding contraception and STD knowledge, a significant overall
effect was found for gender. Women were more likely to respond correctly to
the test questions. However, when compared with women, men were more
likely to respond correctly to test question number 26, "A woman can get
pregnant even if the man withdraws his penis before he ejaculates," and
number 28, "You can get AIDS from someone who is infected but does not
have any symptoms." More women than men responded "not sure" to the
74
statement "A condom, when used with spermicidal foam, has increased
effectiveness against STDs."
Table 12
Number of Sexual Partners in Lifetime hv Gander
1-5 partners partners

6 -1 0 11-15 partners 20-30 partners >30
Gender n % n % n % n % n %
Male 48 48.0 26 26.0 15 15.0 8 8 .0 3 3.0
Female 123 77.8 27 17.1 4 2.5 3 1.9 1 0 .6
Note. Pearson chi-square result of .00001 with 4 degrees of freedom is

significant at a = .05.
Comparisons Among Ethnic

Groups
Some differences among ethnic groups were discovered on various
factors. In comparison with Caucasians and Hispanics, African-Americans
were more likely (14.8%) to initiate sexual intercourse between the ages of 11
and 13 (Caucasians, 6.2% and Hispanics, 3.3%). In contrast, Hispanics were
more likely to begin sexual intercourse at an older age. In fact, 12% of
Hispanics started having sexual intercourse at the age of 20, 10.3% of
AsianTPadfLc Islanders initiated sexual intercourse at this age, and 8 .8 % of
Caucasians.
75
Contraceptive use patterns differed by ethnic groups. Asian/Pacific
Islanders were more likely than any other ethnic group to indicate using
condoms every time for STD prevention. Hispanics and Caucasians were
more likely to indicate "Never" using condoms. The proportions of
participants in each ethnic category according to pattern of condom use are
displayed in Figure 6 .
H Always
□ Sometimes
■ Never
Caucasian Hispanic Asian/Pacific African-

Islander American
Figure 6 . Condom use patterns among ethnic groups.
Caucasian students were more likely to report using oral
contraceptives as opposed to any other method. Condoms were most
frequently indicated as the method of choice by Hispanic, Asian/Pacific
Islander, and African-American students. The third most frequently used
birth control for Caucasians, Hispanics, and Asians was coitus interruptus
(i.e., withdrawal). Coitus interruptus is the least effective method of birth
control, especially when compared to sterilization, Norplant, and Depo-
76
Provera. Table 13 illustrates the types of contraceptives used by ethnicity of
students.
Ethnicity had no significant impact on the reported history of
unplanned pregnancy (p = .1555). However, when compared to other ethnic
groups, more African-Americans did report a history of unplanned pregnancy
(22.9%), followed by Hispanics (19.7%), Asians (16.3%), and Caucasians
(15.3%).
The ethnic group reporting the most high-risk sexual behaviors was
African-American. This group had the greatest portion of people who said
they had intercourse with someone they had met that day (29%). The next
greatest was Caucasian (22.2%), then Hispanics (21.9%), and Asian/Pacific
Islanders (15.8%). African-Americans also reported higher total numbers of
lifetime sexual partners. The ethnic group reporting the largest number of
multiple sex partners at the time of the survey was Hispanic followed, in
order of descending number of sexual partners, by African-American,
Caucasian, and Asian students. Ethnic differences in knowledge were not
evident.
Sexually Transm itted D isease (STD) History
Approximately 9.5% of the sample reported having been diagnosed
with an STD at one time (22 women, 9.6%, and 13 men, 9.3%). Among ethnic
groups, 17.1 % of African-Americans reported having had an STD diagnosed
77
Table 13
Type of Contraceptives Used bv Ethniritv
African- Native-
Caucasian Hispanic Asian American American Other
Contraceptive
Condom 54 47 24 17 — 11
Oral contraceptive 63 42 7 10 1 11
Coitus interruptus 15 10 6 — — 2
Sterilization 7 3 — 1 — 4
Depo-Provera 3 5 — 3 — 2
Spermicides 4 1 2 — — —
Diaphragm 1 1 1 1 — —
Norplant 1 — 1 — —
Abortion 1 — — — — —
78
at least once compared with only 7.5% of Caucasians. Hispanics and
Asian/Pacific Islanders reported identical rates of STD infection.
The majority of students with a past history of STD infection used
contraception. Forty percent of those who had a prior history of STDs were
more likely to use condoms. However, only 14.3% indicating a personal
history of STD infection used more than one method of birth control.
U nnlanned Preenanr.v History
A significant difference was identified in the association between use
of contraception and a history of unplanned pregnancy (x2 = 197.76, dX = 4, p
= .0 0 0 0 1 ). approximately 6 6 .2 % of those who had a history of unplanned
pregnancy used contraception. Only 16.4% of students who said they had
experienced an unplanned pregnancy indicated using more than one birth
control method simultaneously. The majority of students were more likely to
use hormonal contraceptives as opposed to less effective barrier methods.
Figure 2 (p. 54) illustrates the types of contraceptive methods used by
persons who had prior unplanned pregnancies.
Attitudes
Attitudes toward contraceptives were more consistently influenced by
ethnicity than by gender differences. Men and women differed slightly on
just one of the three comparisons made; men were more likely than women to
agree that non-prescription contraceptives should be available in vending
79
machines (62.7% vs. 53.3%). Surprisingly, Hispanics generally perceived
contraceptive vending machines more positively than did Caucasians and
other ethnic groups. More surprisingly, 59.7% of the students age 17-20 did
not perceive themselves at risk for contracting an STD or HTV. Table 9 (p.
66) illustrates the Pearson chi-square results to questions about attitude.
Implications
Previous experience with unplanned pregnancies and STDs did appear
to play a role in contraceptive activity. However, consistent with the
literature, most students did not see themselves at risk for unplanned
pregnancy or an STD infection.
Many studies regarding high-risk sexual behavior and contraceptive
practices have been conducted in the university setting (Ewald & Roberts,
1985; Goldman & Harlow, 1993; Reinisch, Sanders, Hill, & Ziemba-Davis,
1992). Although there is a growing need for research regarding the
relationship between contraceptive knowledge and the perception of risk of
unplanned pregnancy and STD infection in the college student population,
only a few studies (Sarvela et al., 1992; Seal & Agostinelli, 1996) have
addressed this issue.
The results of this study confirmed the need for developing family
p lann ing educational programs attractive to and appropriate for the college
student population. In their study of an AIDS peer education program,
Richie and Getty (1994) suggested that a college AIDS education program
80
does in fact positively influence behavior change. The authors found the
following:
Those who attended an AIDS Peer Education Program during their first
year of college reported that they were more likely than those who did not
to:
• ask new sexual partners about their previous partners,
• ask a new, or first, sexual partner to be tested for HIV antibodies
before having sex,
• ask a first, or new, sexual partner to have sex only with them,
• ask a first, or new, sexual partner to avoid using drugs or alcohol if
the partner thought he or she might be having sex later, stop sexual
activity while a partner went to get a condom, if no condom were
available, (p. 164)
The identification of the relationship between contraceptive and STD
knowledge and high-risk behaviors is a good starting point for implementing
a peer education program at any university.
The findings of this study demonstrate that knowledge clearly
constitutes a primary issue for college students. Although the majority of
college students in the research had participated in a lecture during which
STDs and family planning were discussed, their incorrect responses to some
of the test questions demonstrated the need for additional sex education
programs.
Perceived pregnancy and STD susceptibility appears to be another top
priority for health promotion efforts in the college student population.
According to the results, 58.2% of the student sample did not perceive
themselves to be at risk for unplanned pregnancy or STD infection.
Likewise, the majority had not changed their contraceptive behavior based
81
on their concern with AIDS. This is unfortunate, especially in light of the
fact that 35 students reported having had at least one diagnosis of STD
infection, 68 had had an unplanned pregnancy, and 81 indicated that they
had intercourse with someone they had just met that day.
Recommendations for Further Study
Health care professionals and university officials must reexamine the
effectiveness of the current sex education programs aimed at college
students. Carroll and Carroll (1995) indicated in their study that, although
educational campaigns may have increased public knowledge, they have not
had the desired effect on high-risk behavior. Fleisher, Senie, Minkoff, and
Jaccard (1994) suggested that the provision of family planning services in
less traditional but appropriate settings may be both cost-effective and
efficacious. Consideration should also be given to examining methods of
intervention that can be used with students at risk for disease who
nevertheless discontinue condom use when they are provided with a
pregnancy-preventing alternative such as “the pill” or Depo-Provera.
The results demonstrate that family planning and STD counseling can have
a positive impact on contraceptive use. Sex education is a critical need on the
college campus for the students who are putting themselves at risk for an
unplanned pregnancy and STD infection.
For sex education, Nokes (1996) suggested utilizing nurse educators.
This author reasoned that “nurse educators can create interventions that
82
both educate college students about HTV primary prevention and provide
unique learning opportunities for undergraduate nursing students.”
Summary
In this research, I began to examine age, gender, and ethnic
differences in contraceptive practices. These variables along with others,
such as relationship status, were related to attitudes, knowledge, and beliefs.
Unfortunately, over half (58.2%) of the respondents did not consider
themselves at risk for HTV, nor did they indicate they were concerned about
AIDS. Of particular interest was the number of persons (65%) who reported
not being in a monogamous relationship. A greater number of these students
did not practice the safest sex behavior, which is using barrier and hormonal
contraceptives simultaneously. This supports the conclusion that, for many
college students, using condoms or the pill is an either-or choice rather than
a practice of complementary behaviors, both of which are required for
maximal protection against STDs and unwanted pregnancy.
Of those students who had sexual intercourse at least once, 15.7%
were not consistently using any contraceptive method. Although 62% of the
students were sexually active, over half (58.2%) thought that they were less
likely than most people to contract a sexually transmitted disease.
Men reported more lifetime sexual partners than women. The mean
number of current sexual partners for the student sample was 1.005.
83
There were serious knowledge gaps between the gender groups. For
example, more women than men correctly answered 9 of the 11 questions.
The majority of both men and women were not knowledgeable about
optimal effects of certain contraceptive methods. The difference in
knowledge between males and females may be partially due to increased
availability of contraceptive options to women. Jadack et al. (1995) studied
the variance in knowledge about HTV between genders. The authors
concluded that, because the proportion of women acquiring HIV is increasing,
there is a growing need to understand gender differences and similarities in
knowledge and behavior associated with transmission of HTV.
In his study of sexual behavior of college students, Carroll (1991) also
concluded that there are gender differences in the ways in which college
students adjust their behavior in response to AIDS. The data from Carroll’s
study confirms previous findings that number of sexual partners and age at
first intercourse are predictive of STD acquisition (Jadack, Hyde, & Keller,
1995).
Contraceptive use patterns among the different ethnic and
relationship status groups were presented in this chapter. Condom use
patterns were similar for most ethnic groups. It is of concern that, when
compared to sterilization, Depo-Provera, and Norplant, more students
(especially unmarried) used the “withdrawal” method. Surprisingly, 23.5%
84
(n = 16) of students who had a prior unplanned pregnancy did not use
contraception.
Chapter 6
SUMMARY AND CONCLUSIONS
The difficult challenge of encouraging college students to use
contraception involves several conflicting goals: encouraging people to
protect themselves from both disease and unwanted pregnancy,
understanding the connection between contraceptive risks and benefits, and
teaching students that contraceptives are effective only when used correctly
and consistently.
The need to develop and implement effective programs to prevent
unintended pregnancies and HIV and other STDs is now widely recognized.
Researchers agree that simply disseminating information about family
planning and STDs may not be enough to change college students’ unsafe
sexual behaviors. In order for attitude and behavior change to occur, more
education and interventions are necessary (Hawkins et al., 1995). In
addition, encouraging evaluation of high-risk behaviors and personalizing
the risks of pregnancy and STDs may be more effective strategies for
achieving behavior change.
Beckman et al. (1996) and Turner et al. (1993) suggested designing
prevention interventions that are appropriate for specific groups, according
to their culture, gender, and sexual orientation. Pepe et al. (1993)
86
recommended developing a 30-hour course addressing sexuality issues. In
their summary report of college students and national health objectives for
the year 2000, Guyton et al. (1989) found that
university-wide committees of administrators, facility, students, and

health service professionals were seen as the keys to planning for broad-
based health promotion and education approaches on campus.
Respondents said health services should be strongly linked with
academic programs as well as with athletic departments, food services,
residence halls, and social organizations, (p. 12 )
This present study investigated the contraceptive practices of college
students in light of the possibility of becoming pregnant and/or acquiring an
STD. The information presented in this report was based on data collected
from a 33-item questionnaire that was administered to 376 undergraduate
students at California State University, Fresno, during the fall 1997
semester. All participating students were informed that the survey was
sensitive in nature and concerned questions about sexual issues. Levels of
knowledge were assessed by analyzing responses to 10 test questions.
Students were assured that their responses were completely anonymous.
A total of seven null hypotheses were tested in this study. Hypotheses
1 through 3 explored the lin ks between unplanned pregnancy and STD
history and contraceptive use. Hypotheses 4 through 7 tested associations
between gender, age, ethnicity, and marital status and behaviors and
attitudes.
Hypotheses 1 , 2, 3, 4, and 5 were rejected at the 0.05 level of
significance. The Pearson chi-square results confirmed a significant
87
difference in the relationship between the use of contraception and a history
of unplanned pregnancy and STD infection. The Pearson chi-square test also
demonstrated significance in the associations between age, ethnicity, and
marital status and the use of condoms. Age at first intercourse was also
positively associated with a personal history of STD infection. Hypotheses 6
and 7 were accepted at alpha 0.05. Independence of gender, age, ethnicity,
and marital status to contraceptive attitudes and perceived susceptibility to
STD was demonstrated.
Several important findings emerged from this study. First, that
college-age men and women were found to exhibit sexual behaviors that
could facilitate the spread of HIV and increase the risk of an unplanned
pregnancy. This finding is in agreement with previous literature that noted
that, “of the 13 million college students in the United States, mostly
adolescents and young adults, many indulge in alcohol, drug, and sexual
behaviors that place them at increased risk” (Schneider et al. 1994, p. 11).
Second, the desire to avoid unplanned pregnancies appears to be a stronger
motivator for contraceptive use than fear of acquiring an STD in this sample
of college students. Data also illustrate that fear of STDs is a major factor in
motivating condom use. The strong association between decreasing
contraceptive use and increasing stability in a relationship is of concern but
is consistent with findings of previous reported studies. Many stable
88
relationships are jeopardized by unplanned effects of unprotected
intercourse.
The need to develop effective strategies that encourage safe sex
behaviors among college students is dear. Safe behaviors can indude
postponing sexual activity and consistently and correctly using contraception
during intercourse. Health-care providers need to counsel individuals on
disease prevention when recommending methods of birth control. Cramer
(1996) suggested that the occasion of administering an injection of Depo-
Provera is an opportunity for a health professional to reinforce messages
about contraception and AIDS prevention. The author noted that the cost of
receiving injections from a professional is lower than that of prenatal care for
an unplanned pregnancy.
Understanding the cultural issues of individuals and groups is an
important aspect of health-care counseling. W illiams et al., in a study of
reproductive decision making and determinants of contraceptive use in HIV-
infected women, observed that “in providing healthcare and reproductive
counseling to women of different ethnic backgrounds we, as healthcare
providers, must be culturally sensitive and refrain from making decisions,
assumptions, and recommendations based solely on our own personal beliefs
and principles” (p. 335). Cramer (1996) added that folklore that accompanies
contraceptive usage in all cultures contains many myths and factual errors
that are widely believed and passed from one generation to another.
89
Contraception education for college students remains a major public
health challenge. Education of all college students about pregnancy and
STDs is critical to controlling this problem. In a study by the Centers for
Disease Control, women who were provided with intervention that
encouraged condom use for HIV/STD prevention increased their condom use
while continuing the use of their hormonal contraceptive (CDC, 1997). Many
colleges now provide condom vending machines, which may be located in
dormitories, rest rooms, or student centers.
This study showed that a previous unplanned pregnancy and/or a
history of STD infection did, in fact, have some impact on college students’
decisions to use contraception and their decisions to use a particular birth
control method. Health-care providers and others p lann ing interventions
must identify the extent to which these factors influence contraceptive use
behavior.
REFERENCES
REFERENCES
Adame, D. D., Taylor-Nicholson, M. E., Wang, M., & Abbas, M. A. (1991).

Southern college freshman students: A survey of knowledge,
attitudes, and beliefs about AIDS. Journal of Sex Education &
Therapy, 17, 196-206.
American heritage dictionary (3rd ed.) (1994). Boston: Houghton Mifflin.
Beckman, L. J., Harvey, S. M., & Tiersky, L. A. (1996). Attitudes about

condoms and condom use among college students. Journal of
American College Health, 44, 243-249.
Carroll, L. (1991). Gender, knowledge about AIDS, reported behavioral

change, and the sexual behavior of college students. Journal of
Carroll, J. L., & Carroll, L. M. (1995). Alcohol use and risky sex among
college students. Psychological Reports, 76, 723-726.
Cates, W., & Stone, K. M. (1992). Family planning, sexually transmitted

diseases and contraceptive choice: A literature update - Part I.
Family Planning Perspectives, 24, 75-84.
Centers for Disease Control. (1991a). The HIV/AIDS epidemic: The first 10
years. Morbidity and Mortality Weekly Report, 40, 357.
Centers for Disease Control. (1991b). Unintended pregnancy: New York,

1988-1989. Morbidity and Mortality Weekly Report, 40, 723-725.
Centers for Disease Control. (1992). Surgical sterilization among women

and use of condoms: Baltimore, 1989-1990. Morbidity and Mortality
Weekly Report, 41, 568-575.
Centers for Disease Control. (1993). Update: Barrier protection against HIV
infection and other sexually transmitted diseases. Morbidity and
Mortality Weekly Report 42, 589-591, 597.
92
Centers for Disease Control. (1997). Contraceptive practices before and
after an intervention promoting condom use to prevent HTV infection
and other sexually transmitted diseases among women: Selected
U.S. sites, 1993-1995. Morbidity and Mortality Weekly Report, 46,
373-376.
College students need sex education. (1994, April 25). AIDS Weekly,
pp. 1 1 - 1 2 .
Condom use: Lower for disease prevention than contraceptive. (1996,

November). American College of Obstetricians and Gynecologists
Newsletter, 40, 8-9.
Cramer, J. A. (1996). Compliance with contraceptives and other treatments.

American College of Obstetricians and Gynecologists, 88, 4s-12 s.
Delbanco, S. F. (1996). Improving the use of contraceptives: The challenge

continues. American College of Obstetricians and Gynecologists, 88,
ls-3s.
DiClemente, R. J., Forrest, K. A., & Mickler, S. (1990). College students’

knowledge and attitudes about AIDS and changes in HIV-preventive
behaviors. AIDS Education and Prevention, 2, 201-212.
Ewald, B. M., & Roberts, C. S. (1985). Contraceptive behavior in college-age

males related to Fishbein model. Advances in Nursing Science,
63-69.
Feigenbaum, R., Weinstein, E., & Rosen, E. (1995). College students’ sexual
attitudes and behaviors: Implications for sexuality education.
Journal of American College Health, 44, 112-118.
Fleisher, J. M., Senie, R. T., Minkoff, H., & Jaccard, J. (1994). Condom use
relative to knowledge of sexually transmitted disease prevention,
method of birth control, and past or present infection. Journal of
Community Health, 19, 395-407.
Frank, M. L., Poindexter, A N., Cox, C. A., & Bateman, L. (1995). A cross-
sectional survey of condom use in conjunction with other
contraceptive methods. Women & Health, 23, 31-46.
93
Galavotti, C., Cabral, R. J., Lansky, A., Grimley, D. M., Riley, G. E., &
Prochaska, J. 0. (1995). Validation of measures of condom and
other contraceptive use among women at high risk for HIV infection
and unintended pregnancy. Health Psychology, 14, 570-578.
Galavotti, C., & Schneli, D. J. (1994). Relationship between contraceptive

method choice and beliefs about HTV and pregnancy prevention.
Sexually Transmitted Diseases, 21, 5-8.
Goldman, J. A., & Harlow, L. L. (1993). Self-perception variables that

mediate AIDS-preventive behavior in college students. Health
Psychology, 12, 489-498.
Grimley, D. M., Riley, G. E., Beilis, J. M., & Prochaska, J. 0. (1993).

Assessing the stages of change and decision-making for contraceptive
use for the prevention of pregnancy, sexually transmitted diseases,
and acquired immunodeficiency syndrome. Health Education
Quarterly, 20, 455-470.
Guyton, R., Corbin, S., Zimmer, C., O’Donnell, M., Chervin, D. D., Sloan, B.
C., & Chamberlain, M. D. (1989). College students and national
health objectives for the year 2000: A summary report. Journal of
Hale, P. J., & Trumbetta, S. L. (1996). Women’s self-efficacy and sexually

transmitted disease preventive behaviors. Research in Nursing &
Health, 19, 101-110.
Hatcher, R. A., Stewart, F., Trussell, J., Kowal, D., Guest, F., Stewart, G. K.,
& Cates, W. (1992). Contraceptive technology (15th rev. ed.). New
York: Irvington.
Hatcher, R. A_, Trussell, J., Stewart, F., Stewart, G. K., Kowal, D., Guest, F.,
Cates, W., & Policar, M. S. (1994). Contraceptive technology (16th
rev. ed.). New York: Irvington.
Hawkins, M. J., Gray, C., & Hawkins, W. E. (1995). Gender differences of

reported safer sex behaviors within a random sample of college
students. Psychological Reports, 77, 963-968.
Hays, H. E., & Hays, J. R. (1992). Students’ knowledge of AIDS and sexual
risk behavior. Psychological Reports, 71, 649-650.
94
Healthy People 2000 Midcourse Review (1995). U.S. Department of Health
and Human Services, Public Health Service.
Helweg-Larsen, M., & Collins, B. E. (1994). The UCLA multidimensional

condom attitudes scale: Documenting the complex determinants of
condom use in college students. Health Psychology, 13, 224-237.
Hernandez, J. T., & Smith, F. J. (1990). Inconsistencies and misperceptions

putting college students at risk of HIV infection. Journal of
Adolescent Health Care, 11, 295-297.
Jadack, R. A., Hyde, J. S., & Keller, M. L. (1995). Gender and knowledge
about HIV, risky sexual behavior and safer sex practices. Research
in Nursing & Health, 18, 313-323.
Katz, R. C., Frazer, N., & Wilson, L. (1993). Sexual fears are increasing.
Psychological Reports, 73,476-478.
Kusseling, F. S., Wenger, N. S., & Shapiro, M. F. (1995). Inconsistent

contraceptive use among female college students: Implications for
intervention. Journal of American College Health, 43, 191-195.
Lewis, D. F., Goodhart, F., & Bums, W. D. (1996). New Jersey college
students’ high-risk behavior: Will we meet the health objectives for
the year 2000? Journal of American College Health, 45, 119-126.
Lewis, J. E., Malow, R. M., & Ireland, S. J. (1997). HTV/AIDS risk in

heterosexual college students: A review of a decade of literature.
Journal of American College Health, 45, 147-158.
MacDonald, N. E., Wells, G. A., Fisher, W. A., Warren, W. K., King, M. A.,
Doherty, J. A., & Bowie, W. R. (1990). High-risk STD/HIV behavior
among college students. Journal of the American Medical
Association, 263, 3155-3159.
McGregor, J. A., & Hammill, H. A. (1993). Contraception and sexually

transmitted diseases: Interactions and opportunities. American
Journal of Obstetrics and Gynecology, 168, 2033-2041.
McGuire, E., Shega, J., Nicholls, G., Deese, P., & Landefeld, C. S. (1992).
Sexual behavior, knowledge, and attitudes about AIDS among
college freshmen. American Journal of Preventive Medicine, 8,
226-234.
95
Mulvilii'll, C. K. (1996). AIDS education for college students: Review and
proposal for a research-based curriculum. AIDS Education and
Prevention, 8, 11-25.
Nokes, K. M. (1996). Intervention to promote safer sexual behaviors and

educate peers about HIV/AIDS. Journal of Nursing Education, 35,
227-229.
Notzer, N., Levran, D., Mashiach, S., & Soffer, S. (1984). Effect of religiosity
on sex attitudes, experience and contraception among university
students. Journal of Sex & Marital Therapy, 10, 57-62.
O’Leary, A., Goodhart, F., Jemmott, L. S., & Boccher-Lattimore, D. (1992).

Predictors of safer sex on the college campus: A social cognitive
theory analysis. Journal of American College Health, 40, 254-263.
Oswalt, R., & Matsen, K. (1993). Sex, AIDS, and the use of condoms: A
survey of compliance in college students. Psychological Reports, 72,
764-766.
Pepe, M. V., Sanders, D. W., & Symons, C. W. (1993). Sexual behaviors of

university freshmen and the implications for sexuality educators.
Journal of Sex Education and Therapy, 19, 20-30.
Radius, S. M., Joffe, A , & Gall, M. J. (1991). Barrier versus oral

contraceptive use: A study of female college students. Journal of
Reinisch, J. M., Sanders, S. A , Hill, C. A, & Ziemba-Davis, M. (1992).

High-risk sexual behavior among heterosexual undergraduates at a
midwestem university. Family Planning Perspectives, 24, 116-121.
Richie, N. D., & Getty, A (1994). Did an AIDS peer education program
change first-year college students’ behaviors? Journal of American
College Health, 42, 163-165.
Rosenberg, M. J., Davidson, A J., Chen, J., Judson, F. N., & Douglas, J. M.
(1992). Barrier contraceptives and sexually transmitted diseases in
women: A comparison of female-dependent methods and condoms.
American Journal of Public Health, 82, 669-674.
96
Sarvela, P. D., Huetteman, J. K., McDermott, R. J., Holcomb, D. R., &
Odulana, J. A. (1992). Connotative meanings assigned to
contraceptive options. Journal of American College Health, 41,
91-97.
Schneider, D., Greenberg, M. R., Devanas, M., Sajja, A., Goodhart, F., &
Bums, D. (1994). Evaluating HTV/AIDS education in the university
setting. Journal of American College Health, 43, 11-14.
Seal, D. W., & Agostinelli, G. (1996). College students’ perceptions of the

prevalence of risky sexual behavior. AH)S Care, 8, 453-466.
Seal, D. W., & Palmer-Seal, D. A. (1996). Barriers to condom use and safer
sex talk among college dating couples. Journal of Community &
Applied Social Psychology, 6, 15-33.
Shalala says women need alternative to condom. (1994, April 25). AIDS
Weekly, p. 12.
Sheehan, E. P., Ambrosio, A., McDevitt, T. M., & Lennon, R. (1990). An

examination of change in reports of AIDS-related knowledge and
attitudes in 1986 and 1988. Psychological Reports, 77, 963-968.
Simkins, L. D. (1994). Update on AIDS and sexual behavior of college

students: Seven years later. Psychological Reports, 74,208-210.
Stanton, B. F., Li, X., Galbraith, J., Feigelman, S., & Kaljee, L. (1996).
Sexually transmitted diseases, human immunodeficiency virus, and
pregnancy prevention. Archives in Pediatric and Adolescent
Medicine, 150, 17-24.
STDs: 37 percent of female undergrads had unsafe sex. (1994, September

26). AIDS Weekly, pp. 13-14.
Stein, Z. (1993). HTV prevention: An update on the status of methods

women can use. American Journal of Public Health, 83, 1370-1381.
Strader, M. K., & Beaman, M. L. (1991). Comparison of selected college

students’ and knowledge about AIDS, risk behaviors and beliefs
about condom use. Journal of Advanced Nursing, 16, 584-590.
97
Thomas, S. B., Gilliam, A G., & Iwrey, C. G. (1989). Knowledge about
AIDS and reported risk behaviors among black college students.
Journal of American College Health, 38,61-66.
Turner, J. C., Korpita, E., Mohn, L. A , & Hill, W. B. (1993). Reduction in

sexual risk behaviors among college students following a
comprehensive health education intervention. Journal of American
Valois, R. F., & Waring, K. A. (1991). An analysis of college students’

anonymous questions about human sexuality. Journal of American
Wendt, S. J., & Solomon, L. J. (1995). Barriers to condom use among

heterosexual male and female college students. Journal of American
College Health, 4 4 ,105-110.
Wenger, N. S., Kusseling, F. S., & Shapiro, M. F. (1995). Misunderstanding

of “safer sex” by heterosexually active adults. Public Health Reports,
110, 618-621.
Wiley, D. C., James, G., Jordan-Belver, C., Fumey, S., Calsbeek, F.,
Benjamin, J., & Kathcart, T. (1996). Assessing the health behaviors
of Texas college students. Journal of American College Health, 44,
167-172.
Williams, H. A , Watkins, C. E., & Risby, J. A (1996). Reproductive decision

making and determinants of contraceptive use in HIV-infected
women. Clinical Obstetrics and Gynecology, 39, 333-343.
APPENDIX
99
CONTRACEPTIVE PRACTICES OF THE COLLEGE STUDENT

- QUESTIONNAIRE -
The information obtained from this questionnaire will be used as data for a California State University,
Fresno, Masters’ Thesis. This study is concerned college students’ contraceptive practices, sexually
transmitted disease (STD) risks, and their general knowledge about contraception and STDs. Your
responses are private and confidential. Completing this survey is completely voluntary and anonymous
and will under no circumstances affect your course grade or academic career.
1. Gender 2. Age
GMale G Female G 17-20 G 21-23 G 24-27
Q 28-31 G 32-35 G Other
3. Ethnicity
G Caucasian G Hispanic/Latino G Armenian G Japanese
G Chinese G Asian G A < ia n /P a r if ir T glan rip r G Southeast Asian
G African Decent G African-American G Native American/Alaskan Native
G Russian/Eastern European G Other;
4. What do you prefer? G Not dating

5. Are yon now?
G sexual activity with a member of the
G Casually dating G Steadily during’
opposite sex
G sexual activity with a member of the G Living with partner G Engaged
same sex G Married G Separated
G sexual activity with persons of either sex G Divorced G Widowed
0 Unsure_______________________
7. Are you in a m onogam ous relationship
(one longtim e sexual partner)?
6. Do you currently engage in sexual
intercourse? O Y es QNq O N/A_______________
□ Yes 0 No 8. Do you (or your partner) use a condom

to low er your risk o f getting a STD?
a) If YES, do you or your partner
0 Always 0 Sometimes 0 Never 0 NA
engage in an al sex in order to avoid
pregnancy? 9. H ave you ever had sex w ith someone
G Yes G No G N/A you had ju st m et that day/night?
□ Yes G No Q N/A
10. Since becom ing sexually active, how m any partners have you had?
(please place a number next to each item)
lifetim e Past Year At This Time______ NA
11. What w as your age a t first intercourse?_______ NA
100
12. Do you/your partner use contraception (birth control) or protection?

□ Yes □ No □ N/A
a) If NO. w hy not? (Please indicate all that apply)

G Health risks of contraception D Religious reasons D Cultural reasons
D Do not engage in sexual intercourse D Embarrassment about purchase and/or use
D Other:____________________________________ __________________________
b) If YES, do you/your partner use it consistently?
D Yes D No
c) Do you discu ss contraception w ith your partner?
□ Yes □ No
13. If applicable, w hich contraceptive m ethod(s) do you/your partner use?

(indicate all that apply)
_ None D Condom G Condoms with foam
_ Diaphragm G Cervical Cap G Intrauterine Device (IUD)
_ Norplant (5 year implants) G Depo-Provera (3 month injection)
u Spermicidal foam/film/jellies G Oral Contraceptives (birth control pill)
G Emergency contraception (morning after pill) G Coitus interuptus (Withdrawal)
U Sterilization (Tubal ligation or Vasectomy) G Abortion
Fertility Awareness: Calendar “rhythm” Method f l Other:
Basal Body Temperature
Cervical Mucus Method
14. Do you u se m ore th in one birth control 15. Have you changed your
m ethod sim ultan eou sly during sex? contraceptive behavior as a result
(e.g. the pill & condom at the same time) o f your concern about AIDS?
□ Yes □ No □ N/A □ Yes □ No □ N/A
a) If YES, please lis t m ethods:
17. H ave you or your partner ever

experienced an unplanned
16.Why do you/your partner use pregnancy?
contraception?
□ Yes □ No □ N/A
G Pregnancy prevention only
a) I f YES, w hat w as the outcome?
□ STD/HIV prevention only G Miscarriage D Abortion
G Both pregnancy & STD/HIV prevention D Pregnancy & Childbirth
Q N/A
□ Adoption_________________ __
R e p r o d u c e d with permission of the copyright owner. Further reproduction prohibited without permission.
__________________________ HU
18. Have you ever had a sexually 19. H ave you ever taken a health class or
transm itted disease (STD) / infection? been to a lecture where contraception
and STDs w ere discussed?
□Yes □ No □ N/A
□ Yes G N o
20. Contraception is solely th e woman’s responsibility.

G Agree G Disagree G No opinion
21. Non-prescription contraceptives (condom , foam s, suppositories) should be m ade

available in vending m achines in pub lic bathroom s.
G Agree G Disagree G No opinion
22. “The pill” protects against STDs in clu d in g HIV.

G true G false G not sure
23. The pill is m ore hazardous to your h ealth than pregnancy.
24. Depo- Provera is an injectable m ethod that protects against pregnancy.
25. U sing foam and condom s during sex can low er the risk o f pregnancy and AIDS.
26. A woman can get pregnant even i f th e man withdraws h is penis before he
ejaculates (before he “com es”).
□true G false G not sure
27. A condom, when used w ith sperm icidal foam, has increased effectiveness against
STDs.
28. A person can get AIDS by having an al (rectal) intercourse even if neither partner is
infected w ith th e AIDS virus.
29. You can get AIDS from som eone w ho is infected but doesn’t have any symptom s.
30.The pill protects against osteoporosis and ovarian cancer.
31.Norplant is an effective contraceptive m ethod that also protects against HIV/AIDS,
32.H erpes can be acquired during oral sex.
□ true □ false G not sure
3 3 .1 am less likely m ost people to g et an STD or HIV/AIDS. G Agree G Disagree
IMAGE EVALUATION
TEST TARGET (Q A -3 )
150m m
IM /4G E. Inc
1653 East Main Slreet
Rochester, NY 14609 USA
Phone: 716/482-0300
Fax: 716/288-5989
O '9 9 3 . A pplied Im a g e . Inc.. All R ig h ts R e s e r v e d

Unplanned Pregnancy and Sexually Transmitted Disease Risk Possible Predictors of Contraceptive Use Among College Students

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Unplanned Pregnancy and Sexually Transmitted Disease Risk Possible Predictors of Contraceptive Use Among College Students

Uploaded by

Copyright:

Available Formats

INFORMATION TO USERS

The quality of this reproduction is dependent upon the quality of the

Oversize materials (e.g., maps, drawings, charts) are reproduced by

Photographs included in the original manuscript have been reproduced

UNPLANNED PREGNANCY AND SEXUALLY TRANSMITTED DISEASE

This study investigated unplanned pregnancy and sexually transmitted

disease (STD) risk as possible predictors of contraceptive use. A sample of

377 undergraduate students was taken from California State University,

hypotheses were tested through an anonymous, 33-item questionnaire.

Hypotheses 1 through 3 explored the links between unplanned pregnancy

and STD history and contraceptive use. Hypotheses 4 through 7 tested

associations between gender, age, ethnicity, and marital status and

behaviors and attitudes. This study illustrated that a previous unplanned

pregnancy and/or a history of STD infection did have some impact on

contraceptive use. College students were found to exhibit high-risk sexual

behaviors and low knowledge levels regarding contraception and STDs.

Implications for contraception education for college students are discussed.

RISK: POSSIBLE PREDICTORS OF CONTRACEPTIVE USE

AMONG COLLEGE STUDENTS

fulfillment of the requirements for the degree of

Master of Public Health

in the School of Health and Human Services

California State University, Fresno

UMI Microform 1394575

This microform edition is protected against unauthorized

For the Department of Health Science:

Vickie D. Krenz Health Science

Sherman Sowby Health Science

Kelli Beingesser Fresno Women’s Medical Group

For the Graduate Committee:

Dean, Division of Graduate Studies

I grant permission for the reproduction of this thesis in part

Permission to reproduce this thesis in part or in its entirety

Signature of thesis writer:.

His wonderful blessings.

I would like to express my sincere gratitude to the members of my thesis

committee, Vickie D. Krenz, Ph.D., Sherman Sowby, Ph.D., and Kelli

I would also like to thank all of the professors and undergraduate

students at California State University, Fresno, who participated in this

I am sincerely grateful to Wade Dickinson for believing in me. His

constant encouragement has allowed me to accomplish many academic and

Lastly, I dedicate this thesis to my parents, who have lovingly supported

all of my educational endeavors.

Purpose of the S t u d y .......................................................... 7

Significance of the S tu d y ...........................................................10

D efin ition of T e r m s ................................................................ 14

Scope of the S tu d y ..................................................................... 17

2. REVIEW OF RELATED L ITERA TU RE..................................... 20

Sexual Behaviors of College S tu d e n ts ..................................... 20

Unplanned Pregnancy Risk for College Students . . . 23

Sexually Transmitted Disease Risk for College

College Students’ Contraceptive Practices................................ 28

Changing Students’ B e h a v io rs................................................ 35

3. RESEARCH DESIGN AND METHODOLOGY...........................41

Subject S e le c tio n ..................................................................... 42

4. RESULTS AND ANALYSIS OF THE DATA................................ 49

Demographic Characteristics of Students in the

Knowledge About Contraception and S T D s ...........................57

Results for the H y p o th e se s..................................................... 60

5. D ISCU SSIO N ................................................................................68

Sexually Transmitted Disease (STD) H istory...........................76

Unplanned Pregnancy H is to r y ................................................ 78

Recommendations for Further S t u d y ..................................... 81