Sexual health knowledge, sources of information, and associated attitudinal disconnects among university studentsSUMMARY
OBJECTIVE: The aim of this study was to evaluate university students’ knowledge, attitudes, and behaviors regarding sexual and reproductive health.
METHODS: This cross-sectional study was conducted using face-to-face questionnaires administered on a voluntary basis to university students aged 18-26 presenting to the Muğla Sıtkı Koçman University Kötekli No. 4 Family Health Center. Data were analyzed using International Business Machines Statistical Package for the Social Sciences Statistics version 26.0. Associations between categorical variables were evaluated using the chi-square and Fisher’s exact tests.
RESULTS: A total of 383 students participated in the study (55.4% female, n=212; 44.6% male, n=171). Of the participants, 42.3% reported having sexual experience, which was significantly higher among males (p=0.002). The most common source of information on sexual and reproductive health was the internet (65.3%). The best-known family planning method was the condom (98.7%). The most commonly known sexually transmitted infection was human ımmunodeficiency virus/acquired ımmunodeficiency syndrome, and the most frequently reported symptom was genital discharge.
CONCLUSION: University students’ level of knowledge regarding sexual and reproductive health is insufficient, and this gap suggests that knowledge alone is insufficient to drive behavior change, and that sociocultural and cognitive barriers—such as stigma, perceived norms, and risk misperception—play a mediating role.
KEYWORDS:
Health literacy; Sexual behavior; Students; Health services accessibility; Health knowledge, attitudes, practice
INTRODUCTION
Youth represents a transitional period from childhood to adulthood characterized by significant physical, psychological, and social changes. During this period, behaviors with long-term health implications are formed, and individuals become increasingly vulnerable to adverse outcomes, particularly in the context of sexual health1,2. Sexuality is a natural component of human development; however, in many societies it remains a sensitive topic that is often surrounded by social taboos and limited communication within families. As a result, young people may obtain information from unreliable sources, which can lead to important knowledge gaps regarding sexual and reproductive health2,3. Insufficient knowledge may increase the risk of sexually transmitted diseases and other health problems4,5. The World Health Organization (WHO) reports that more than one million curable sexually transmitted infections are acquired every day worldwide among individuals aged 15–49, most of which are asymptomatic, and that university youth are often neglected within reproductive health programs6.
This lack of awareness and neglect may increase the likelihood of adverse health outcomes related to sexual contact, including AIDS and other sexually transmitted infections, unintended pregnancies, abortion, and other complications7.
In a healthy sexual life, individuals should be able to consult a physician when faced with sexual health problems and receive the necessary counseling, treatment, or referrals from health professionals2,4,5,6. University students may be considered a risk group because factors such as early initiation of sexual intercourse, having multiple partners, certain sexual preferences, relationships with commercial sex workers or their partners, not using condoms, being unmarried and young, living in large cities, and certain sociodemographic characteristics are associated with a higher risk of sexually transmitted diseases (STDs)7. Given the limited existing literature2,3,7, this study was designed not only to assess the current status of university students in Muğla province but also to examine, within the context of sexual and reproductive health, the role of knowledge in shaping appropriate health behaviors, as well as to observe the presence of misconceptions and the persistence of related negative attitudes.
METHODS
Study design and participants
This cross-sectional descriptive study was conducted between 14 September 2023 and 29 January 2024 among university students aged 18–26 years who applied to the Muğla Sıtkı Koçman University Kötekli No. 4 Family Health Center for any reason. A total of 383 volunteer students meeting the inclusion criteria were consecutively recruited during the study period.
Data collection
The questionnaire was initially developed based on a literature review and was further refined by incorporating the opinions of specialists and faculty members from the gynecology clinic; it was subsequently reviewed by the Department of Family Medicine, after which the ethical approval process was initiated. A structured questionnaire consisting of 44 items was administered face-to-face; (1) sociodemographic characteristics (10 questions), (2) sexual health and family planning (18 questions), and (3) sexually transmitted diseases (16 questions). Participation was voluntary, and informed consent was obtained from all participants prior to the survey. “Sexual experience” was defined as engagement in penetrative sexual intercourse (vaginal or anal) to ensure consistency in interpretation among participants. Some questions allowed multiple responses; therefore, percentages may exceed 100%.
Ethical approval
This study was reviewed and approved by the Medical Sciences Ethics Committee of Muğla Sıtkı Koçman University Faculty of Medicine with decision number 90 dated 28/09/2023 and protocol number 230087. The study was conducted in accordance with the Declaration of Helsinki and in compliance with the ethical standards of our country.
Statistical analysis
Statistical analyses were performed using IBM SPSS Statistics version 26.0. Descriptive statistics were presented as frequencies and percentages. Associations between categorical variables were evaluated using the chi-square test and Fisher’s exact test, and a p<0.05 was considered statistically significant.
Inclusion criteria
*Being 18–26 years of age
*Being a university student
*Voluntarily agreeing to participate in the study
No additional exclusion criteria were applied, and all participants were allowed to respond to all questionnaire items regardless of sexual experience.
RESULTS
The mean age of the participants was 20.6±2.1 years (range: 18–26). Among sexually active participants, the mean age at first sexual intercourse was 18.9±2.0 years. Overall, 42.3% (n=162) reported having sexual experience, which was significantly more frequent among males than females (50.9 vs. 35.4%, p=0.002). Sexual experience was less common among medical students, with 70.7% (n=135) reporting no sexual experience (p<0.001). The internet was the most common source of sexual and reproductive health information (65.3%, n=250), whereas family was the least common (10.2%, n=39). Participants with sexual experience were more likely to obtain information from physicians compared to those without sexual experience (30.2 vs. 17.6%, p=0.004). Most participants indicated that sexual health education should be provided during high school (33.4%, n=128), followed by Family Health Centers (18.2%, n=70). Overall, participants demonstrated a high level of awareness regarding STDs, with human ımmunodeficiency virus/acquired ımmunodeficiency syndrome (HIV/AIDS) (n=293), gonorrhea (n=113), and human papillomavirus (HPV) (n=102) being the most frequently reported. Commonly identified symptoms included genital discharge (n=74), itching (n=55), and genital warts (n=41). Most participants reported no prior STD history (89.8%, n=344).
Although 95% (n=364) correctly identified condom use as the most effective method for STD prevention, misconceptions persisted. Notably, a considerable proportion of participants were unaware that STDs could cause cancer (40.4%, n=155), and those without sexual experience were more likely to lack knowledge about the protective role of condoms (p<0.001). Gender-based differences were evident in both knowledge and attitudes. Women were more likely to associate safe sexual behavior with monogamy (p<0.001) and pregnancy prevention (p=0.023), and to recognize the increased risk associated with multiple sexual partners (p=0.002). They were also more likely to endorse preventive strategies such as having a single partner (p=0.006) and avoiding contact with potentially infected individuals (p=0.001). In contrast, men were more likely to perceive higher STD risk among LGBTQ+ individuals (p=0.004). Condoms were the most commonly known contraceptive method, followed by oral contraceptive pills, emergency contraception, tubal ligation, and intrauterine devices, whereas the lactational method and diaphragm were the least known. Women demonstrated significantly higher knowledge of several contraceptive methods (p<0.05). While students without sexual experience had greater knowledge of oral contraceptive pills (p=0.045), knowledge of withdrawal (p=0.003) and emergency contraception (p<0.001) was higher among sexually experienced participants. Medical students showed higher knowledge of subdermal implants (p=0.011) and vasectomy (p=0.018), but lower knowledge of emergency contraception (p=0.002) compared to students from other faculties. The remaining findings are presented in Tables 1 and 2.
Participants’ knowledge of transmission routes and risk groups of sexually transmitted infections.
Regarding abortion, men were more likely to agree that it should never be performed (p=0.032), whereas women were more likely to consider it a solution for unintended pregnancies (p=0.001). Students without sexual experience were significantly more likely to disagree with abortion as a solution (p<0.001) Table 3.
DISCUSSION
The present study revealed three key findings. First, a relatively adequate level of sexual health knowledge was observed. Second, persistent misconceptions and stigmatizing attitudes coexisted with accurate knowledge. Third, knowledge did not consistently translate into appropriate health-related behaviors.
Sexuality is a natural part of the developmental process; however, initiating sexual intercourse before the age of 16—particularly sexual activity occurring at or before the age of 14—is considered a very early period in terms of physiological development8. The British National Survey of Sexual Attitudes and Lifestyles (Natsal-3) reported that 30.9% of individuals aged 16–24 had their first sexual intercourse before the age of 16, while the international Health Behaviour in School-aged Children report indicated that the age at first sexual intercourse in many European countries is approximately 158. In our study, the observed age at first sexual experience ranging from 15 to 26 years and the rates varying between 16 and 36.4% demonstrate that early sexual experience is a significant public health issue on a global scale7,9,10,11,12.
From a human rights perspective, comprehensive sexuality education is considered a fundamental necessity13. The Sexuality Information and Education Council of the United States emphasizes that schools and families play a crucial role in meeting young people’s informational needs regarding human sexuality13,14. Indeed, sexuality education programs implemented in some countries have been shown to contribute positively to young people’s knowledge and awareness levels1,2,13. In this context, our study suggests that the significantly lower prevalence of sexual experience among medical students may be associated with the role of health literacy in shaping behavior and awareness. Additionally, the finding that individuals with sexual experience were more likely to obtain information from physicians may indicate a tendency to prefer more accurate and professional sources of information rather than passive sources, and may also reflect a shift toward more responsible health-seeking behavior. Furthermore, by demonstrating that a large proportion of participants believe sexual health education should be provided during high school, our findings suggest that young people are aware of their knowledge gaps and have a clear need for structured education in this area. Access to accurate information and comprehensive sexuality education plays a critical role in the development of healthy and safe sexual behaviors; however, some studies have shown that although awareness of sexually transmitted infections is widespread, significant misconceptions and false beliefs regarding modes of transmission and prevention methods persist10,15,16,17. In our study as well, alongside correct knowledge regarding HIV transmission, beliefs such as transmission through handshaking or kissing, and the perception that LGBTQ+ individuals are at higher risk, indicate a clear inconsistency between knowledge and attitudes, and demonstrate that accurate knowledge may coexist with misconceptions and stigmatizing attitudes. Additionally, since a multiple-response format was used in our study—allowing participants to select more than one option—some individuals may have simultaneously selected both correct and incorrect methods. We therefore consider that this may help explain the coexistence of accurate knowledge and misconceptions observed in our findings. This finding further supports the notion that having knowledge about sexually transmitted infections does not necessarily translate into correct and safe behaviors10,17. Although the majority of participants in our study were aware that condoms are protective, 22.7% reported not using a condom during their last sexual intercourse. Similarly, such inconsistencies, also reported in other studies7,18,19, reveal the discrepancy between knowledge and behavior, suggesting that awareness has not been fully achieved and that knowledge does not effectively translate into behavior10,18,20,21. This situation has been associated with individual and social factors such as trust in partners, difficulties in negotiating condom use, fear of social stigma, and a greater focus on preventing pregnancy rather than sexually transmitted infections20. These findings highlight the importance of addressing not only knowledge deficits but also underlying social and cognitive determinants of behavior.
In our study, despite men having higher levels of sexual experience and greater knowledge of emergency contraception, their tendency to view abortion as an option—without prioritizing preventive behaviors—reflects an approach that shifts responsibility away from themselves and resolves outcomes through women’s bodies4,22. This pattern underscores underlying gender norms in which responsibility for reproductive health is implicitly assigned to women, and suggests that women’s agency is often marginalized in sexual health decision-making processes.
In conclusion, although university students have knowledge regarding sexual and reproductive health, they do not always exhibit appropriate attitudes and behaviors. The coexistence of correct knowledge and persistent misconceptions indicates a significant gap between knowledge, attitudes, and behaviors. In this context, sexual and reproductive health requires a holistic approach that should be addressed from the perspectives of gender norms, responsibility, non-maleficence, and human rights.
Limitations
This study has several limitations. First, it was conducted among students who applied to a single Family Health Center; therefore, the generalizability of the findings is limited. Second, the data were based on self-reported responses, which may have introduced reporting bias due to the sensitive nature of sexual behaviors. Third, due to the cross-sectional design, causal relationships cannot be established. Additionally, although the study aimed to assess risky sexual behaviors, behavioral measures were limited and the findings predominantly reflect knowledge and attitudes. Furthermore, participants were recruited from a healthcare setting, which may not fully represent the general student population. Additionally, we clarified this definition in the questionnaire description and acknowledged in the Limitations section that earlier interpretations of the term may have varied among participants, potentially introducing bias. Future multicenter studies involving larger populations are needed to better understand sexual health knowledge and behaviors among university students.
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ETHICS COMMITTEE APPROVAL
This study was reviewed and approved by the Medical Sciences Ethics Committee of Muğla Sıtkı Koçman University Faculty of Medicine with decision number 90 dated 28/09/2023 and protocol number 230087. The study was conducted in accordance with the Declaration of Helsinki and in compliance with the ethical standards of our country.
DATA AVAILABILITY STATEMENT
The datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request.
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Edited by
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Scientific Editor:
José Maria Soares Júnior https://orcid.org/0000-0003-0774-9404
