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University students are at risk for acquiring sexually transmitted infections and suffering other negative health outcomes. Sexual health services offer preventive and treatment interventions that aim to reduce these infections and associated health consequences. However, university students often delay or avoid seeking sexual health services. An in-depth understanding of the factors that influence student use of sexual health services is needed to underpin effective sexual health interventions.
In this study, we aim to design a behavior change intervention to address university undergraduate students’ use of sexual health services at two universities in Nova Scotia, Canada.
This mixed methods study consists of three phases that follow a systematic approach to intervention design outlined in the Behaviour Change Wheel. In Phase 1, we examine patterns of sexual health service use among university students in Nova Scotia, Canada, using an existing dataset. In Phase 2, we identify the perceived barriers and enablers to students’ use of sexual health services. This will include focus groups with university undergraduate students, health care providers, and university administrators using a semistructured guide, informed by the Capability, Opportunity, Motivation-Behaviour Model and Theoretical Domains Framework. In Phase 3, we identify behavior change techniques and intervention components to develop a theory-based intervention to improve students’ use of sexual health services.
This study will be completed in March 2018. Results from each phase and the finalized intervention design will be reported in 2018.
Previous intervention research to improve university students’ use of sexual health services lacks a theoretical assessment of barriers. This study will employ a mixed methods research design to examine university students’ use of sexual health service and apply behavior change theory to design a theory- and evidence-based sexual health service intervention. Our approach will provide a comprehensive foundation to co-design a theory-based intervention with service users, health care providers, and administrators to improve sexual health service use among university students and ultimately improve their overall health and well-being.
Progressing from adolescence to adulthood can be a challenging time for young adults who leave home for the first time to start university [
Many university and college campuses offer a range of sexual health services to promote healthy sexual behaviors (eg, health education, condom distribution) [
Based on a review of the literature, Bender and Fulbright [
One strategy for addressing students’ use of sexual health services is to use behavior change theory in the design, implementation, and evaluation of sexual health interventions [
Incorporation of theory into the development and evaluation of complex interventions facilitates behavior change and provides an explanation of the mechanisms of change [
This paper describes the study protocol for using the BCW to design an intervention to address university undergraduate students’ use of sexual health services at two universities in Nova Scotia, Canada. The study will address the following four research objectives through three phases. Phase 1 will describe the pattern of university undergraduate students’ use of sexual health services at two Nova Scotia universities in 2012 using an existing quantitative dataset. Phase 2 will identify university students’, health care providers’, and university administrators’ perceived barriers and facilitators for student use of sexual health services and will examine how the qualitative data related to the perceived barriers and facilitators to service use help better explain the patterns of student sexual health service use. Phase 3 will identify intervention components and/or strategies that can be used by service providers, university decision makers, policy planners, and students to facilitate the use of sexual health services
An explanatory sequential mixed methods research design [
BCW stages and study design diagram.
To understand the pattern of university students’ sexual health service, we will conduct a secondary analysis of data collected during the online Undergraduate Student Sexual Health Survey in the fall of 2012 [
For the purpose of this study, a secondary analysis of a subset of the data collected from sexually active male and female undergraduate students aged 18-25 at two universities in Nova Scotia will be conducted. Both universities provide general health services in addition to sexual health specific services. These two universities were chosen for three reasons. First, University A is a large urban university, with approximately 13,600 undergraduate students (45% male, 55% female) and University B is a small rural university, with about 3500 undergraduate students (42% male, 58% female) [
Many factors at the individual, social, service, and policy levels influence young adult and university students’ use of sexual health services [
Variables of interest for Phase 1 secondary analysis.
Variable of interest | Survey item | Psychometric properties | Composite variable for analyses |
Age | What is your age in years? | Pearson correlation =.98 [ |
Continuous variable (18-25) |
Ethnic/Racial background | What ethnic/racial background do you consider yourself to be? | New question; no retest performed | 0=Caucasian descent (white) |
Residential status | What are your living arrangements? | New question; no retest performed | 0=On campus |
Sexual orientation | People have different feelings about themselves when it comes to questions of being attracted to other people. Which of the following best describes your feelings? | Kappa=.8 [ |
0=Heterosexual |
Sexual health knowledge [ |
Please indicate whether you believe each of the following statements are true or false by checking the appropriate response. | Cronbach α=.71 [ |
Continuous (0-12) |
Barriers to help seeking [ |
Please indicate how much you disagree or agree with the following statements by checking the appropriate number on the 5-point scale, where 1 = “Strongly disagree” and 5 = “Strongly agree” | Cronbach α=.93 [ |
Continuous (0-40) |
Social support [ |
Please describe how true you believe each of the following statements about your social relationships and support networks, where 1 = “not true at all” and 5 = “completely true”. | Cronbach α=.86 [ |
Continuous variable (0-105) |
Sexual health service use |
Have you ever seen a health professional in order to obtain the following services? |
New question; no retest performed | Males: |
Since males and females use sexual health services for different reasons and with different frequencies [
Findings from this phase will be used in two ways. First, we will develop a detailed description of the pattern of university undergraduate students’ use of sexual health services on campus. Second, we will incorporate findings into a theory-based semistructured focus group guide to use in Phase 2.
We will use a qualitative descriptive design [
For the focus groups, we will use a stratified purposive sampling strategy [
Since the topic of sexual health and use of health services might be a sensitive one for university students [
We will conduct separate semistructured focus groups with university undergraduate students, health care providers, and university administrators at each university. We will develop a semistructured focus group guide, informed by the COM-B model and TDF to guide the behavioral analysis and probe participants on their perceived barriers and enablers to sexual health service use among university students [
We chose to conduct semistructured focus groups using a theory-based guide for three reasons. First, focus groups are a useful method for obtaining qualitative data on social and psychological processes [
The principal investigator, who has been trained in conducting focus groups and using the BCW (COM-B and TDF) to conduct behavioral analyses and design interventions, will facilitate the focus groups using the theory-based focus group guide. The focus groups will take place on the university campus and the research assistant will be present to take notes on group dynamics and nonverbal participant observations. Focus groups discussions will be audiorecorded and are expected to last approximately 45-60 minutes. Participants will be offered a Can $30 grocery store gift card in appreciation of their time.
Audiorecordings from the focus groups will be transcribed verbatim and coded using directed content analysis [
Document analysis is a systematic procedure for reviewing documents that involves skimming, reading, and interpreting the text. It is often combined with other qualitative research methods as a way to seek convergence and corroboration or identify inconsistencies and provide data on the context in which the health system operates [
Findings from this phase will be used in two ways. First, we will use the data to provide a detailed description of students’, health care providers’, and administrators’ perceived barriers and facilitators to sexual health service use among university students. Second, we will use the findings in Phase 3 to develop a theory-based behavior change intervention to address the target behavior (sexual health service utilization).
We will integrate the quantitative and qualitative data from Phases 1 and 2 using a triangulation protocol to examine convergence, divergence, and discrepancies from the different data sources [
Using the data obtained from Phases 1 and 2, we will develop a theory- and evidence-based intervention that encompasses BCTs aimed at overcoming the identified barriers and enhancing the enablers to sexual health service use by university students. The intervention will be developed through a series of advisory committee meetings which will be guided by Stages 2 and 3 of the BCW. In each meeting, we will use the nominal group technique to generate ideas, identify potential problems, structure the decision-making process, and achieve consensus [
The research team will meet to review Phases 1 and 2 findings and identify intervention functions and content. The BCW outlines which types of intervention functions are likely to be effective in bringing about behavior change in each COM-B component and TDF domain [
We will form an advisory committee at each university consisting of 3-5 students and 3-5 health care providers and university administrators. Participants who provided consent to be followed up in the Phase Two focus groups will be contacted via email and invited to participate in the advisory committee. The objective of the meeting is to review the findings from Phases 1 and 2 and the results from the BCT mapping exercise (Step One) and further refine the intervention design. Through discussion, the advisory committee will identify potential modes of intervention delivery and apply the APEASE criteria to explore its feasibility. The advisory committee will also discuss optimal intervention content, provider, setting, recipient, intensity, duration, and fidelity.
Following the advisory committee meetings, we will collate the meeting results to produce a summary of the final intervention design that could be delivered in the university setting to improve students’ use of sexual health services. A copy of the intervention design findings will be sent via email to the participants of each advisory committee.
Phase 3 will culminate with a co-designed [
Phases 1 and 2 are complete, and Phase 3 intervention design is ongoing. Results from each phase and the finalized intervention design will be reported in 2018.
Increasing university students’ use of sexual health services is important given the need to prevent their risk of STI transmission and associated negative health consequences. This study will follow a systematic, theory-based approach using a mixed methods research design to develop a behavior change intervention aimed at improving university students’ use of sexual health services. The mixed methods approach will allow for an integration of both numerical findings and qualitative text from the perspective of university students, health care providers, and university administrators to enhance our understanding of sexual health service use among university undergraduate students. This study is guided by the BCW, which uses the COM-B model and TDF as theoretical approaches to understanding the target behavior in context and designing theory-based interventions. The BCW has been used extensively in health services research [
All findings from this study will be interpreted with the following limitations in mind, among others that may arise. First, the two universities included in the Phase 1 secondary analysis had response rates of 31.2% and 23.8%. These response rates are lower than the primary researchers had anticipated, as previous Web-based survey research with Canadian university students had a mean response rate of 40.9%. Further, Web-based sexual health research with US college students yielded response rates that ranged from 24% to 55%. This can result in nonresponse bias that may impact generalizability of the study findings. Second, the Phase 1 data were collected in 2012, which may result in findings that are no longer relevant today. For example, with recent developments in health service technologies (eg, online booking, electronic notification of results, online provision of sexual health information), there may be differences in the accessibility and acceptability of sexual health services among university students. However, our Phase 2 focus groups with students, health care providers, and university administrators will provide an opportunity to follow up on the 2012 data and describe any differences in the accessibility and acceptability of sexual health services during this period of time. Last, a limitation of secondary analyses is that researchers must work with the available data, which may not have been collected to address the research question. The only measures of sexual health service use in the secondary dataset are STI testing, HIV testing, Pap testing, and pregnancy testing. The Phase 2 focus groups will allow for further exploration of a more comprehensive definition of sexual health services, including sexual health promotion initiatives.
Overall, the methods presented in this paper demonstrate a theoretically robust and evidence-based approach to design an intervention to improve university students’ use of sexual health services. The BCW will be used to understand the behavior in greater detail, identify intervention options, content, and implementation strategies. Future pilot testing in university settings will be needed to evaluate the effectiveness of the proposed intervention.
Survey questions.
Existing Peer-Review Report.
behavior change techniques
Behaviour Change Technique Taxonomy Version 1
Behaviour Change Wheel
Theoretical Domains Framework
None declared.