Contraceptive methods and knowledge of sexually transmitted diseases in nursing students. Results from a sur vey conducted at the University of Palermo

Background: The main purpose of the study was to evaluatesexual habits, sexual relations and knowledge of sexually transmitted infections (STIs) among the students in the nursing science course of University of Palermo, and to evaluate the use of contraceptive methods. Methods: In April 2019, a survey was provided to students who attend daily lessons in the nursing science course of University of Palermo, that investigate primarily about sexual habits, sexual relations and knowledge of sexually transmitted diseases. A multivariable logistic regression was performed. Results: The sample size consists of 405 students. The average age of the sample is 21.65 years, 69.63% of the interviewees are women. In relation to the question “Do you think you are sufficiently informed to be able to avoid risks of infection from sexually transmitted diseases? No”, the analysis shows that this independent variable is significantly associated with the following independent variables: female gender (aOR 3.11, 95% CI 1.01 - 9.65); “how would you define your knowledge about contraceptive methods? - Poor” (aOR 5.38, 95% CI 1.79 - 16.20); “have you ever received information on sex education and/or sexually transmitted diseases? - No” (aOR 11.59, 95% CI 2.26 - 59.42); “do you know the human papillomavirus (HPV) vaccination? - yes, but I’m not vaccinated” (aOR 3.09, 95% CI 1.12 - 8.51); “do you know that men can also undergo HPV vaccination? - No” (aOR 2.67, 95% CI 1.01 - 7.04). Conclusion: Based on our findings, it is necessary to implement sexual education programs for the improvement of knowledge in terms of STIs and the promotion of health. Improving sexual health outcomes for young people is a priority for the public health.


INTRODUCTION
Sexually transmitted infections (STIs) represent an important public health problem that has a strong impact on society. The World Health Organization (WHO) estimates that there are 357 million new infections each year. A big problem is that most sexually transmitted infections have only mild symptoms and are sometimes asymptomatic and therefore may not be recognized as STIs [1].
About 70% of patients with STIs are included in the range of age between 15 and 24 years and the WHO estimates that one of twenty teenagers contracts a STI during their lifetime [1,2].
University students may be especially vulnerable, in addition they typically exhibit high levels of alcohol [3,4] and stress [5,6] use which is associated with high-risk sexual behaviour and STI diagnosis.
Therefore, it is interesting to understand the level of awareness and knowledge of STIs, protection methods and sexual practices within this group.
This public health problem is also increasing in Italy where, from 1991 to 2013, according to the STIs Surveillance System coordinated by the National Institute of Health (ISS), there were 103,028 new cases [2]. Similarly, from 2005 to 2013, there was a significant trend towards an increase in MTA notifications in Italy with an increase of more than 31% compared to the previous period. It has been suggested that the observed increases could be due, for example, to improvements in test methods, better access to testing and screening, to more complete surveillance [2].
In many cases they can manifest without symptoms and therefore can be transmitted unconsciously during unprotected sexual intercourse, therefore the early detection and treatment of sexually transmitted infections are important to prevent complications, such as pelvic inflammatory disease, infertility, tumors and perinatal damage. Although STIs are often underestimated and little known by young people, they constitute a serious public health problem due to the widespread diffusion and severity of complications. The main causes of their enormous diffusion are: poor perception of the risk of infection, failure to use prevention services and diagnosis and behavioral errors that increase the risk of transmission [2].
From the scientific literature it emerges that very often young adults do not have the necessary knowledge to correctly assess the risks of unprotected sexual relations [7,8] and in many cases have little knowledge of STIs and their methods of prevention [9,10].
In Italy, the population knows that the use of condoms is important to prevent STIs and young people have higher proportions of use. However, this is still far from satisfactory, especially since condom is used as a contraceptive and not as a means to prevent the occurrence of sexually transmitted infections, so their use becomes irregular when other contraceptives are used [11].

OBJECTIVES
The main purpose of the study was to evaluatesexual habits, sexual relations and knowledge of sexually transmitted infections (STIs) among the students in the nursing science course of University of Palermo. Another aim was to evaluate the use of contraceptive methods.

MATERIALS AND METHODS
It's a cross-sectional study. In the first week of April 2019 (1-5 April 2019), a survey was provided to students who attend daily lessons in the nursing science course of University of Palermo of the three years of course, accompanied by informed consent, daily lessons are mandatory to take the exams.The main questions of the questionnaire are shown in Table 1, the questions investigate on: personal information, sexual habits, sexual relations, knowledge of sexually transmitted diseases, the perception of the economic and health status, anti-HPV vaccination.We also investigated about Knowledge and use of contraceptive methods For all variables absolute and relative frequencies have been calculated. A multivariable logistic regression was performed, considering it as a dependent variable "Do you think you are sufficiently informed to be able to avoid risks of infection from sexually transmitted diseases? No",in order to evaluate the role ofallthe variables of Table 1 (Description of the sample). The statistical significance level chosen for all analyzes was 0.05. The results were analyzed using the STATA statistical software version 14 12

RESULTS
100% of the first-year students who received the questionnaire agreed to complete it. 100% of the secondyear students who received the questionnaire agreed to complete it. 93.55% of the third-year students who received the questionnaire agreed to complete it, 6 students refused to complete the questionnaire. Other analysis will be reported in supplementary papers.
The sample size consists of 405 students that agreed to the informed consent and completed the questionnaire. The 69.63% of the interviewees are women, 100% were born in Italy, 46.42% are single, 72.59% report a low perceived economic status, 15 Table 2). Table 3 shows adjusted Odds Ratio (aOR). A multivariable logistic regression model was used based on 325 observations. Each independent variable has been adjusted for all the other independent variables. In relation to the question "Do you think you are sufficiently informed to be able to avoid risks of infection from sexually transmitted diseases? No", the analysis shows that this independent variable is significantly associated with the following independent variables: female gender (aOR 3.11, 95% CI 1.01 -9.65, p= 0.049); "how would you define your knowledge about contraceptive methods? -Poor" (aOR 5.38, 95% CI 1.79 -16.20, p= 0.003); "have you ever received information on sex education and/or sexually transmitted diseases? -No" (aOR 11.59, 95% CI 2.26 -59.42, p= 0.003); "do you know the human papillomavirus (HPV) vaccination? -yes, but I'm not vaccinated" (aOR 3.09, 95% CI 1.12 -8.51, p= 0.029); "do you know that men can also undergo HPV vaccination? -No" (aOR 2.67, 95% CI 1.01 -7.04, p= 0.047).

DISCUSSION
This study investigated the knowledge of contraceptive methods and STDs in a sample of undergraduate nursing students in the city of Palermo.
Although the knowledge of most of the respondents would seem to be adequate about sexually transmitted diseases and contraceptive methods, the percentage of them claiming to have occasionally and permanently unprotected sex is worrying but consistent with the literature [13].
In a study by Hickey and Cleland [14], conducted among female college students ages 18 to 24, they found that over 75% of participants engaging in vaginal intercourse at least four times per week, condoms were only used by 57% of participants.The negligent use of condoms among university students is an alarming behavior that contributes to the spread of STDs and to the occurrence of unwanted pregnancies.   Contraceptive methods and knowledge of sexually transmitted diseases in nursing students. Results from a survey conducted at the University of Palermo Combining these statements with the date of onset to sex life around the age of 16 and the number of partners had (just over 3) in our sample, the young respondents represent a population that is exposed to a great risk both to their sexual health and to have an unexpected pregnancy. The literature explains how this subsection of the population is responsible for more than half of the twenty million new cases of sexually transmitted diseases (STDs) diagnosed each year [15]. The spread of STDs is also favored by the fact that the majority of sexual transmitted infections (STIs) have no symptoms or only mild symptoms that may not be recognized as an STIs [1].
To the question which contraceptive method is able to protect against STDs, although the vast majority of respondents agree on correct answers, a part of them also names the birth control pill (7.54%), next day pill (5.28%), diaphragm (4.27%), and coitus interruptus (2.01%).The students who report these wrong answers show by a part a poor knowledge of the STDs and on the other inevitably they expose themselves to risky behaviors. In this regard, it would be appropriate to intervene with sex education programs to improve knowledge in terms of STI and health promotion, whose importance is reported in the literature [16,17].
The declaration of not having enough information to avoid STDs is significantly associated with the female gender, to consider their knowledge of poor contraceptive methods, and to never have received information on sex education or STDs, and not to know that HPV vaccination can also be dedicated to males. It is important to underline the gender connotation with respect to the STDs that emerge in our sample. There are many biological, cultural and social variables that can explain this difference [18,19] and their analysis goes beyond the aim of this research. The other associated factors denounce a lack of information and education, and the role of sex education for young people by institutions, schools and universities emerges as fundamental, for example, introducing sex education in university courses as compulsory subjects and / or organizing informational and educational events [20].
The voluntary initiatives such as the 3 days "Marathon of Prevention" held in Palermo (Sicily) developed in the context of Hackathon Health Technology Assessment -Never Stop Learning [21], can be very effective in meeting youth basic needs.

Limitations of the study
The results of this study must be evaluated in light of some limitations. Firstly, it is a cross-sectional study, that do not allow to draw any conclusions about causal relationships of the results. Secondly, this study provides a general overview of the sexual behaviors of the nursing university students and it should not be considered as a complete description of the sexual behavior of all young people. For these reasons, although the results are in line with the literature, these should not be generalized to all university students.

CONCLUSIONS
Based on our findings, it is necessary to implement sexual education programs for the improvement of knowledge in terms of STIs and the promotion of health. Improving sexual health outcomes for young people is a priority for the public health.The results of the study showed that the majority of students had quite adequate knowledge about sexually transmitted diseases and contraceptive methods. Although this affects the majority of respondents, the associated behaviors are not consistent with their knowledge and it expose this population to both sexually transmitted diseases and unexpected pregnancies.

Funding
None.