Increasing Awareness and Knowledge among Adult Latinos regarding Sexually Transmitted Infections

Abstract Latinos in the United States are disproportionately affected by Human Immunodeficiency Virus and sexually transmitted infections (STIs). They account for about 24 % of newly diagnosed AIDS cases each year and are two to three times more likely to develop STIs when compared with non-Latino whites. Limited knowledge of STIs has remained one of the contributing factors to the disparity. The purpose of this study was to implement an educational bundle and evaluate its effectiveness in increasing STI knowledge and consistent condom use among adult Latinos seen in an outpatient clinic that serves low income patients. A pre- and post-test design was used to evaluate changes in STI knowledge and consistency of condom use. The educational bundle consisted of YouTube STI-related videos, a pre-designed one to one educational session, provision of condoms and STI-related educational materials. Self-administered questionnaires were used to collect data at baseline and one week post implementation of the educational bundle. Forty-six Latinos (18 females and 28 males) ranging in ages 19 to 60 years participated in the project. The total mean STI knowledge and condom use frequency improved from pre-test (M = 1.67, M = 3.09) to post-test (M = 3.80, M = 5.33). Results of paired samples t-tests demonstrated statistically significant differences between total mean STI knowledge (t(45) = –15.48, p < 0.001) and condom use frequency (t(45) = –7.09, p < 0.001) at pre-test and post-testing. The educational bundle was effective in increasing STI knowledge and consistent condom use among adult Latinos in an outpatient clinic. Further study needs to be done to determine the long-term effect of this mode of education for this population.


Introduction
The World Health Organization (WHO, 2016) describes Sexually Transmitted Infections (STIs) as a hidden global epidemic. Based on the WHO data, more than one million STIs are diagnosed worldwide each day, accounting for 357 million new cases annually. The Center for Disease Control and Prevention (CDC, 2015a) stipulates that over 110 million individuals in the United States (U.S.) have STIs. Approximately 20 million new cases of STIs are diagnosed annually in the U.S (CDC, 2016). There are eight common STIs contracted by individuals across the nation which include chlamydia, gonorrhea, hepatitis B virus (HBV), herpes simplex virus type 2 (HSV-2), human immunodeficiency virus (HIV), human papillomavirus (HPV), syphilis, and trichomoniasis (CDC). Of these, HIV, chlamydia, gonorrhea, and syphilis are routinely reported to the health department across all 50 States.
The treatment of STIs is most successful when detected early. Untreated STIs can result in multiple health complications, such as psychosocial disorders, genitourinary disorders, hepatic disorders, cancers, sexual dysfunctions, infertility, pregnancy complications, enhanced HIV transmission, and maternal-child health issues (Gottlieb et al., 2014).(). Over 20,000 women become infertile each year as a result of untreated or undiagnosed STIs (CDC, 2016).STIs are additionally known to facilitate the risk for HIV infections, and individuals infected with STDs are two to five times more likely than uninfected individuals to acquire HIV infection. The treatment of STI-related complications can be costly to the STI sufferer, family, community, state, nation, and the world at large. In the U.S, the annual cost of STIs (direct medical cost) is approximately $16 billion (CDC, 2015a). In light of the potential health and economic burdens, STIs are considered to be a significant public health issue.
When compared with other racial or ethnic groups, Latinos in the U. S. are disproportionately affected by STIs most specifically HIV (CDC, 2014). Of all the racial and ethnic groups, Latinos account for about 24 % of newly diagnosed AIDS cases each year in the U.S (CDC, 2015b). Latinos are two to three times more likely to develop STIs (gonorrhea, chlamydia, and syphilis) as compared to non-Latino whites. In 2014, the rate of chlamydia cases per 100,000 people was 380.6 among Hispanics, which was 2.1 times the rate among whites (CDC, 2014). Given that the Latino population in the U.S is rapidly growing and is projected to represent one third of the U.S population by 2060 (U.S Census Bureau, 2012), addressing the high prevalence of STIs among Latinos is critically important.
Multiple factors including culture and socioeconomic status contribute to the disparity (Gindi, Erbelding, & Page, 2010;Lee, Dancy, Florez, & Holm, 2013). Promoting the cultural concept of gender inequality ("machismo and marianismo") has been shown to enhance sexual risky behaviors (Lee et al., 2013;Martinez, Roth, Kelle, Downs, & Rhodes, 2014). For example, "Machismo" empowers men to prove manhood through risky behaviors such as having multiple sexual partners, low condom use, and substance abuse (Rhodes et al., 2011). "Marianismo" on the other hand relegates women to the position of maid, negating their rights including negotiation for safe sex (Martinez et al., 2014). Other contributing factors may include, but are not limited to, knowledge deficit, beliefs, attitudes, misconceptions, alcoholism, values, financial constraints, language, health insurance, and immigration problems (Martinez et al., 2014;Trans et al., 2013).
There have been attempts to educate the public regarding STIs, which resulted in limited behavior changes (Clifton, Penrose, Prien, & Farooqi, 2015;Folasayo et al., 2017;Matovu & Ssebadduka, 2013). Although knowledge has shown to have a limited effect on behavioral change, education remains the vital component of sexual health (Samkange-Zeeb, Spallek, & Zeeb, 2011. Improving one's knowledge of STIs has been found to enhance healthy sex behaviors such as increasing condom use (Colón-López et al., 2012;Lee et al., 2013;Tran et al., 2013). Educational interventions available in the literature mostly focus on educating the adolescent population about STIs with limited tools available to educate adult Latinos on this topic.
The primary care providers (PCPs) at the study clinic were challenged as how to reduce the rate of positive STI tests in their patient population. Ninety-five percent of the clinic population were Latino with only 10 % reporting consistent condom use when this question was asked as part of intake information collected on all adult patients. With 200 patients tested for STIs each month over a one year period, approximately 25 % were positive for STIs. It was evident that engaging in unprotected sex had resulted in a high rate of positive STI screening tests among Latinos in the clinic. The PCPs noted that the majority of patients diagnosed with STIs also had low general knowledge of STIs and limited education was provided about STIs and their transmission during their patient visit. Providers posited that providing a culturally appropriate education bundle would increase patient awareness and knowledge of STIs, and thus decrease the vulnerability of this population. Therefore, the purpose of this study was to implement an educational bundle and evaluate its effectiveness in increasing STI knowledge and consistent condom use among adult Latinos seen in an outpatient clinic.

Design
This study used a pre-and post-test design. It involved assessment of adult Latinos' STI knowledge and consistent condom before and after implementation of an educational bundle during a family planning visit. The educational bundle focused mainly on common STIs and high risk sexual behaviors. Data were collected over a four week period of time.

Setting
The study was conducted at a privately-owned clinic in a large urban city located in Southwestern U.S. The clinic provides medical care to a large population of patients, which includes pediatric, adolescent, adult, and geriatric patients. The majority of the services provided at the clinic involve STI screenings and family planning. Each year, over 2,400 patients enrolled in the clinic's Family Planning, Access, Care, and Treatment (Family PACT) program are screened for STIs.

Sample
The clinic serves patients who are low income and on Medicaid, have limited formal education, and live in the urban city. Approximately 95 % of the patient population consists of Latinos with limited English proficiency. The remaining 5 % of the population consists of African-Americans and Asians. For the purposes of achieving the project's goals, patients were recruited using a convenience sample. Because attrition is anticipated in every project, this project targeted a minimum sample size of 40 participants. Participants had to be 18 years or older, male or female, and self-reported as being sexually active. Non-Latinos were excluded from this project.

Ethical considerations
The study was approved by the Institutional Review Board (IRB) at a local university. The administrator of the clinic granted written consent for implementation of the project. Informed consent was obtained from each patient willing to participate in the project. Informed consent clearly indicated the patient's freedom to stop their participation in the project at any time without penalty. To maximize confidentiality, the teaching sessions as well as assessment questions were individually delivered to participants during their routine office visit. Patient-related demographic data were de-identified and results were reported in aggregate form to ensure confidentiality.

Key stakeholders
The study stakeholders included the clinic administrator, physician, the author, a physician assistant (PA), patients, and medical assistants. The clinic PA is bilingual and assisted in data collection and implementation of the educational activities with those patients who preferred Spanish. For consistency among participants, the PA received training about the educational bundle as well as the self-administered questionnaires for pre-test and post-test. The author, who is the clinic Nurse Practitioner, conducted the educational bundle and ensured that the self-administered questionnaires were given to the participants who were English speaking. The medical assistants were involved in recruiting participants for this project and were oriented about their recruitment role.

Measures
The participant's social demographic data including race, age, gender, and language preference are part of the usual data collected at the clinic during the intake procedure and were retrieved from the medical record. The two primary outcomes that were assessed included STI knowledge and consistent condom use (behavioral change).
The study instrument was a self-administered questionnaire which comprised two parts: part A and part B. Part A comprised a 4-item STI knowledge questionnaire modified from the Folasayo et al. (2017) 14-item questionnaire. Participants were assessed on knowledge of the following: (1) common STIs, (2) clinical features of STIs, (3) sources of STI transmission, and (4) prevention of STIs. Participants were asked to respond "yes" or "no" or "I'm not sure" to the questions. Each correct "yes" answer was assigned a score of 1. The wrong "no' or "I'm not sure" answer was assigned a score of 0.
Part B comprised a one-item consistent condom use question modified from the work of Manning, Flanigan, Giordano, and Longmore (2009). The consistent condom use was assessed by the question: "In the last 6 months, how often did you or your partner use a condom when you had sex?" The participants were provided with six options: "every time we had sex", "almost every time we had sex", "most of the time", "half of the time", "some of the time", and "a few times". Similar to the Manning, Giordano, and Longmore' study, participants' responses were coded as "every time we had sex" = 100 %, "almost every time we had sex" = 90 %, "most of the time" = 60-80 %, "half of the time" = 50 %, "some of the time" = 20-40 %, and "a few times" = 1-10 %. Coding in percentages was used to increase the objectivity of this study.
This self-administered 5-item questionnaire was the same one used during pre-test and post-test. However, the Part B was modified in post-test to capture the actual variable (consistent condom use). It was comprised of an additional "yes" or "no" question making it a 6-item questionnaire. Each participant was asked: "have you had sex since the last visit?" Participants who responded "yes" moved on to the next question as in pre-test. Those who responded "no" to this additional question were not required to respond to the next question.

Educational bundle
In order to address Latino patient's knowledge deficit regarding STIs and low condom use in the clinic setting, an educational bundle was implemented. The educational bundle consisted of the following. First, two YouTube STI-related videos, including 4 minutes and 53 seconds long (Spanish version) and 4 minutes and 3 seconds (English) renditions, were played alternately in the waiting room on a repeated loop during the project implementation. Overall, the YouTube videos focused mostly on STIs and its prevention.
Second, the author and the PA provided a 10 to 15-minute pre-designed educational session to participants on a one to one basis during the clinic visit. The brief education was based on the STDs and HIV-CDC Fact Sheet. It covered six main sections, highlighted as: (1) common STIs, (2) important facts about STIs, (3) source of transmission, (4) clinical features, treatments, complications, STI tests, and prevention strategies, (5) protection of the sex partners, and (6) available resources. The education took place in a private location in the clinic to accommodate the cultural sexual silence. With respect and a non-judgmental attitude, the clinic PA or the author reviewed the aforementioned CDC Fact sheet with all participants. After the education, participants were given an opportunity to ask questions to dispel any misconceptions or myths they may have held regarding STI.
Other CDC STI-related educational materials in the form of handouts, pamphlets and brochures were handed to the participants after the one to one education.

Procedure
The project flyers were displayed in a prominent place in a clinic waiting room. During the regular office visit, the medical assistant included the project flyer as part of the registration package provided to patients. As the patient returned the completed registration package, the medical assistant inquired if the patient had read the flyer and wished to participate in this project. The medical assistant obtained written consent from individuals who voluntarily demonstrated interest to participate. Prior to the implementation of the brief one to one education, the NP or the PA distributed the 5-item self-administered questionnaire to assess the participants' baseline knowledge about STIs and consistent condom use (pre-test). The participants were seen again by the author or the PA in one week upon their return for lab results, which is a routine part of Family Planning visits and STI screening paid for by the Medicaid under Family PACT program. During the second office visit, the participants were given the same 5-item self-administered questionnaire as in the pre-test to assess whether there were changes in their STI knowledge and consistent condom use (post-test). All forms were provided in both English and Spanish. The Spanish translation was performed by a certified Language specialist.

Data analysis
Data were analyzed using the Intellectus Statistics™ software. Descriptive statistics were used to describe participants' socio-demographic data as well as their scores on STI Knowledge and Consistent Condom Use questionnaire. A paired t-test was used to evaluate whether there was a significant change between pre-test and post-test mean scores. For this project, a p-value 0.05 was considered to be statistically significant at the 95 % confidence interval. Other statistical tests conducted included Independent sample t-tests and Chi-Square tests.

Demographic data
Forty-six adult Latino patients participated in this project. The majority were males (n = 28, 61 %), while the remaining were females (n = 18, 39 %). Most of the participants indicated their language preference as Spanish (n = 40, 87 %), only a few participants (n = 6, 13 %) indicated English language as their preference. The age group of the participants ranged from 19 to 60 years old with the mean age of 36.30 (sd = 10.24). The sociodemographic characteristics of the participants are presented in Table 1 (race, gender, and language preference) and Table 2 describes the age variable.  An independent sample t-test was conducted to examine whether the mean age was significantly different between the male and female categories of gender. Interestingly, the result was statistically significant, (t(44) = -2.06, p = 0.045). The mean age of the male participants was significantly lower than the mean age of the females. Table 3 presents the results of the independent samples t-test.

STI knowledge
The participants' total mean STI knowledge score significantly improved from 1.67 (sd = 0.87) at pre-test to 3.80 (sd = 0.54) at post-test (see Table 5). The result of the paired samples t-test was significant, (t(45) = −15.48, p < 0.001), suggesting that the difference between the means of total pre-test and total post-test knowledge scores was true and statistically significant. The improvement was also observed in the individual STI knowledge items. The mean scores of question one (knowledge of chlamydia as one of the STIs) increased from 0.54 to 0.98; question two (knowledge of not all STIs give warning signs) increased from 0.20 to 0.91; question three (knowledge of acquiring gonorrhea through oral sex) increased from 0.11 to 0.91, and question four (knowledge of condom use in reducing the risk of STIs) increased slightly from 0.98 to 1. The item analysis revealed that most participants did not know the sources of STI transmission prior to the educational session. At baseline, the majority did not know that gonorrhea could be acquired through oral sex (pre-test mean = 0.11). Surprisingly, a good number of the participants knew that use of a condom could reduce the risk of STIs (pre-test mean score = 0.98, post-test mean score = 1). Table 4 depicts the paired sample t-test for the difference between the means of total pre-test and post-test knowledge scores. Figure 1 presents the means of total pre-test (A) and post-test (B) STI knowledge scores Table 5 summarizes the individual mean pre-test and post-test knowledge scores.   An independent sample t-test was conducted to examine whether the mean of total pre-test and post-test knowledge scores were significantly different between male and female genders. The results of the independent sample t-test were not significant in both pre-test knowledge scores t(44) = -1.36, p = 0.182, and post-test knowledge scores t(44) = 0.26, p = 0.793, suggesting that gender was not associated with the number of correctly answered STI knowledge questions.

Condom use frequency
Forty-two out of 46 participants completed both pre-test and post-test condom use frequency questions. During the one week follow up visit, four participants, who responded "no" to the question "Have you had sex since the last visit?" were not required to participate in the post-test condom use frequency question. Over all, the participants' total mean condom use frequency remarkably improved from pre-test (M = 3.09) to post-test (M = 5.33). The result of the paired samples t-test was significant, (t(45) = -7.09, p < 0.001), suggesting that the difference in the means of pre-test condom use frequency and post-test condom use frequency was statistically significant. Table 6 presents the paired sample t-test for the difference between the means of pre-test and post-test condom use frequency. Figure 2 depicts the means of pre-test condom use frequency (A) and post-test condom use frequency (B).  There were two levels of condom use frequency. The level 1 included non-frequent condom users who had scores of 1 to 3 in the one-item consistent condom use question. The level 2 constituted the frequent condom users, who scored between 4 and 6 in the one-item consistent condom use question. An independent sample t-test was conducted to examine whether the mean of total pre-test STI knowledge scores was significantly different between the 1 and 2 categories of pre-test condom use frequency. The result of the independent sample t-test was significant (t(44) = -2.18, p = 0.035), indicating that the difference in the means of total pre-test STI knowledge scores was statistically significant between the 1 and 2 categories of pre-test condom use frequency. The mean of total pre-test STI knowledge scores in the category 1 of pre-test condom use frequency was significantly lower than the mean of total pre-test STI knowledge scores in the category 2. Table 7 presents the results of the independent samples t-test for the difference between the total-Pre-Test STI Knowledge Scores in the two categories of condom use frequency. In regard to gender differences, findings suggested that gender was not associated with the frequency of condom use. The results of the independent samples t-tests that were conducted to examine whether the means of both pre-test and post-test condom use frequency differed between males and females were not statistically significant. A Chi-Square Test of Independence was conducted to examine whether gender and "Have you had sex since the last visit" had a significant relationship. The result was not statistically significant, suggesting that the two variables were not dependent on each other. For the purpose of data analysis, age was categorized into two groups. The group 1 constituted participants who were within the age of 36 and younger. The group 2 included participants who were 37 and older. A Chi-Square Test of Independence was conducted to examine whether there was a relationship between age and pre-test condom use frequency. The results of the Chi-Square test were not significant, χ 2 (1) = 0.23, p = 0.632, suggesting that the two age groups and two categories of pre-test condom use frequency could be independent of one another. This implies that the observed frequencies were not significantly different than the expected frequencies.

Sexually transmitted infections in the study population
Of the total number of subjects in this project, 13 out of 46 (28.3 %) were found to have STIs. Ten (21.7 %) individuals tested positive for chlamydia and three (6.5 %) were diagnosed with gonorrhea. Eight (28.6 %) of the 28 males and 5 (27.8 %) of the 18 women tested positive for either chlamydia or gonorrhea. Of interest, both genders have similar percentages of STIs. This information was reported in the aggregate and not linked to any specific subject.

Discussion
The findings related to lack of knowledge and the need for education noted in this study were consistent with those noted in other studies (Colón-López et al., 2012;Folasayo et al., 2017;Lee et al., 2013;Martinez et al., 2014;Rhodes et al., 2011;Samkange-Zeeb, Mikolajczyk, & Zeeb, 2012;Samkange-Zeeb, Spallek, & Zeeb, 2011;Tran et al., 2013) and suggest the need to educate sexually active individuals about STIs. The pretest results reflected the low knowledge of STIs among the participants. At baseline, only a few responded correctly (M = 0.20) that not all STIs do give warning signs. The majority did not know they could be infected with a STI without symptoms being present. Most participants did not know that oral sex was a route for STI transmission. A small number of participants (M = 0.11) knew they could acquire gonorrhea through oral sex. Of note, a high percentage of participants in this sample who engaged in oral sex did not realize this behavior is linked to transmission of disease. This finding is supported by the CDC (2017) report that over 85 % of sexually active adults, ranging from 18 to 44 years old had engaged in oral sex at least once with a partner of the opposite sex.
Findings from this study suggest that education had a positive impact on STI knowledge and consistent condom use. These results corroborate with the previous studies (Colón-López et al., 2012;Tran et al., 2013). The total mean scores for both STI knowledge (from 1.67 at pre-test to 3.80 at post-test) and condom use frequency (from 3.08 at pre-test to 5.33 at post-test) significantly (p < 0.001) improved in one-week post implementation of the education bundle. In contrast to the pre-test result (M = 0.20), a higher number of participants responded correctly in post-test (M = 0.91) that STIs could be asymptomatic. The number of participants who identified oral sex as a possible route for the transmission of STIs also increased in post-test (M = 0.91).
Similar to other studies (Clifton et al., 2015;Matovu & Ssebadduka, 2013;Samkange-Zeeb et al., 2011), the knowledge of the protective role of condom use was consistently high in both pre-test and post-test (M = 0.98 and 1.0, respectively). Thirty-eight participants in pre-test and 46 participants in post-test responded correctly that condom use could decrease their risk for acquiring STIs. This can be linked to the continued extensive global awareness campaign on condom use since the discovery of HIV disease in the mid 1980's.
Consistent with other studies (Colón-López et al., 2012;Lee et al., 2013;Tran et al., 2013) higher levels of STI knowledge were found to be associated with more frequent condom use. At baseline, the mean total STI knowledge scores for category 1 of pre-test condom use frequency (non-frequent condom users) was significantly lower than the mean total STI knowledge scores for category 2 (frequent condom users). However, this is contrary to the findings in some studies (Clifton et al., 2015;Folasayo et al., 2017;Matovu & Ssebadduka, 2013;Samkange-Zeeb et al., 2012) where knowledge did not have impact on the frequency of condom use.
Gender did not have influence on STI knowledge score. As earlier stated, the independent sample t-tests conducted in both pre-test and post-test did not show statistically significant results. This finding is in contrast to other studies (Folasayo et al., 2017;Samkange-Zeeb et al., 2011) where gender differences were observed in STI knowledge.
There is no age-related difference in condom use. Unlike in the Sahay et al. study, where older participants showed more inconsistent condom use than the younger ones, age did not show statistical difference in condom use frequency among the participants in this study.

Limitations
The participants in this study were homogeneously Latinos, limiting the generalizability of the findings to other races. Convenience sampling was used in this study. The dependence on self-reporting is another limitation to be considered. Using self-reporting for data collection often triggers the risk of social desirability bias. There is a tendency that the participants may have over-reported or under-reported the frequency of condom use. In addition, the post-testing took place only one week after the education bundle; therefore, the results may not represent future long term use of condoms. Repeating this with a longer time frame between education and collecting post test data could change the results.

Conclusion
The findings reflected the positive impacts of education on STI knowledge and condom use frequency. The education bundle is promising. It was found efficacious in increasing STI knowledge and consistent condom use among adult Latinos in an out-patient setting. This study presents an example of how to access this vulnerable population in a culturally appropriate manner. Further study needs to be done to determine the long-term effect of this mode of education for this population that comprised primarily of Latinos of low income.

Implications for practice
The elevated total mean scores of both STI knowledge and condom use frequency (post-test results) may be an indication that the education bundle was effective. The findings reinforced the need for health education on STIs, particularly for this clinic population. Healthcare providers need to use a variety of educational tools including handouts and videos to educate their patients on STIs and consistent condom use. Although knowledge does not always predict behavior change, patient education on STI remains a necessity for the prevention of STIs. Incorporating brief one to one health teaching about STIs during routine clinical visits as well as using population specific video resources in the patient waiting area may help to sustain the knowledge.