The relationship found between knowledge regarding sexual issues and behavior in university students is significant, although weak. We found that students presented satisfactory knowledge scores (3.74 out of 5.00), meaning that sexual education programs succeeded in transmitting information, but these appear to fail at enabling students to apply this knowledge on a daily basis. Under the concept of health literacy, a stronger association between knowledge and behaviour in sexual health could be expected. Indeed, a higher knowledge rate should be translated itself in a practice of safer sex [16, 17], although this type of knowledge does not necessarily reflect a higher level of health literacy, as described by Nutbeam (2000) [18].
Our results are consistent with previous studies. Kirby (2010) showed that inconsistent use of condoms and contraceptives is not directly related to a scarcity of knowledge. [19] Weinstein (2008) even found that greater knowledge was associated with less consistent condom use. [20] This phenomenon could be justified by the fact that having sexual risk behaviors are related to feelings of threat. Threat here refers to an eventual behaviour perceived as risky or which may thus lead to an active demand for information. In this model, risky experiences are the motive for improving information, inverting the cause-effect relationship. Conversely, the practice of safe sex and the consequent low risk perception may justify some indifference to the need to keep informed, thus conditioning less knowledge. [21] This interactive pattern emphasizes that knowledge is an important, but insufficient, determinant to adequate health literacy. The link between knowledge and behavior relies on working on the intrinsic individual characteristics, including their personal beliefs as well as perceived benefits, barriers and efficacy of education. [22] Changing behaviors must not only depend on the general threat of an undesired pregnancy or contracting an infectious illness, but also through understanding these individual characteristics and their interactions. This may lead to a real possibility to integrate safer practices into a daily routine. [16] Training the youth to become peer educators is a feasible strategy to reach the desired goals through the creation of a confidential, informal and judgmental environment while allowing the shared exploration of the different dimensions of sexual health.
Additionally, we identified population characteristics influencing knowledge and behavior. Knowledge scores were higher in older students and in those attending a health-related course. Only female gender was shown to be associated with better behavior. The behavior of students undertaking health-related courses may be considered paradoxical, as the behavior demonstrated did not match the increased information available to these students. Frank et al (2008), in the USA, [23] demonstrated a similar level of knowledge in medical students, however, Fayers (2003) [24] and Warner (2018) [25] found no relation between better information and better behavior patterns. As may be expected, older students collect more information through lifelong continuous learning, [26] which consequently leads to a greater knowledge base. In this specific context, the admission to college and the perception of autonomy and independence are potential conditioners of better behaviors. [9] Late adolescence and emerging adulthood is a phase of experimentation in several dimensions, including sexuality. [27, 28] Younger ages are generally related to higher rates of ISTs and to risky behaviors, such as multiple sexual partners, sexual intercourse under alcohol or drugs consumption, [29] and the perception of being free of disease regardless of the risks. [30] An apparent lack of improvement with age in college students may be justified as a functional feature related to financial dependence and student status, which may extend risk behaviors until graduation. Although not significant, we noticed a tendency for better behavior with higher socioeconomic status, in accordance with the literature. [30-33]
Gender is the only factor significantly associated with sexual behavior. As described in other studies, [7, 9, 13, 34-36] we found males to be more prone to engage in sexual risk-taking behaviors, based on a balance between evolutionary psychology and social role perspectives. Evolutionary theory defends that this difference is largely innate and biologically-based due to the different mating strategies of men and women. [37, 38] In contrast, social roles are mostly acquired and resultant from both formal and informal education. [39] More recently, a holistic approach for gender differences takes in account both of these dimensions. [7] It proposes that gender-typed behavior is a product of the respective reproductive activities and physical attributes in conjunction with the organizational demands of societies. [7] Although societies are evolving to be more permissive, a negative connotation towards sexuality is still enrooted in some women, perpetuating the social double-standards by which judgmental-free sexuality preferentially relates to men. [40] Women are expected to engage in long-lasting relationships, while men are expected to value sexual experiences. [41] Males are not prejudiced when engaging in sexual interactions and masturbation, while females may be conflicted about embodied sexual feelings. [42]
Religion and spiritually are usually significant factors in in the experience of sexuality. [23, 30, 34] We assessed this by asking participants their spiritual affiliation. In Portugal, religious questions are restricted for research purposes, which limits the specific characterization of religious denominations. No relationship was found in our population. The impact of spirituality is seen mainly at the beginning of sexual life. Additionally, the strength of spiritual conviction is not equivalent to the concept of participation and religious affiliation, and this analysis should also be different. [43]
Unlike Laura Kann et al (2018), in United States, [44] we found no evidence of the influence of sexual orientation over both knowledge and sexual related behaviors. The Youth Risk Behavior Surveillance — United States, 2017 pointed riskier behaviors in lesbians, gays, bisexuals and transgenders in comparison with heterosexuals. The scholar context of our population, linked to safer practices, [12] may influence this outcome.
Our results must be interpreted while considering the limitations of this study. Firstly, the sample was limited to active students of the University of Porto. These students are part of a higher educated population and the results might be influenced through this social context. Dropping out of school appears to be associated with increased sexual risk-taking behavior [12] such as a lack of consistent use of contraception [45] or unwanted pregnancy. [46] Secondly, these students were asked to participate through dynamic emails. We cannot guarantee that all emails were updated, or that all students have access to institutional emails. Furthermore, the participation in the study was optional. It is likely that students who participated in this questionnaire may present different characteristics to those who did not participate. These students may have a special interest in sexual health, potentially overestimating their level of knowledge and behaviors. Additionally, the questions used, although based on validated and language-adapted questionnaires, may have been misunderstood or misinterpreted. Finally, even though the questions were reliable and verified [15], the composed comparison scores were not, which could insert an error in the statistical analysis. As far as we know, there is no gold standard to evaluate knowledge and sexual behaviors in this population, although numerous scales have been previously used. [20, 21, 47]
In conclusion, although we succeeded in transmitting information to a college population, we are still far from transforming this knowledge into attitudes and skills leading towards better behaviors. This urges us to change the paradigm and to implement strategies to empower emerging adults to put into practice the knowledge acquired, thereby creating a healthy sexual environment. Knowledge, although not sufficient, is a necessary condition for better literacy, and strategic goals must be adapted to the current situation for real improvement of sexual-related behaviors, favoring a sexuality which is healthy, safe, responsible and satisfactory.
Even though it is not possible to extrapolate our results to non-college students, we believe that similar patterns may be present in other populations. As health-care providers, we should reflect on what these results may mean not only for our patients, but also in our personal lives.
Indeed, do we practice what we preach?