Sexual and reproductive health of university students with a gender and ethnicity focus before and during the COVID-19 pandemic

doi:10.21203/rs.3.rs-3139600/v1

Download PDF

Research Article

Sexual and reproductive health of university students with a gender and ethnicity focus before and during the COVID-19 pandemic

https://doi.org/10.21203/rs.3.rs-3139600/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted

You are reading this latest preprint version

Background

Understanding the sexual and reproductive health practices among university students is crucial due to the transitional phase to adulthood and the potential associated risks. This study aimed to determine sexual and reproductive health practices among university students according to gender, year, and ethnicity.

Methods

A cross-sectional study was conducted between 2018 and 2021 at the University of La Frontera, involving first-year students. The study included 5131 participants, accounting for 58.36% of the total enrolled students. Among the participants, 55.4% were female, and the average age was 18.9 years.

Results

The study revealed that men engaged in higher levels of sexual activity compared to women, with men initiating sexual intercourse at a significantly younger age. Furthermore, women reported lower condom usage in their last sexual encounter and had a higher prevalence of sexually transmitted infections (STIs) within the past 12 months. Women also demonstrated a higher frequency of HIV testing, which was significantly associated with a higher prevalence of sexually transmitted infections (STIs). In terms of ethnicity, students identifying as Mapuche displayed a lower proportion of sexual activity compared to those not identifying as Mapuche. The COVID-19 pandemic led to an increase in sexual activity and the prevalence of STIs, potentially reflecting an annual global trend observed in other research studies as well. Moreover, there was an increasing trend in condom use each year, while HIV testing showed a decline, possibly influenced by the pandemic.

Conclusions

These findings underscore the significance of addressing gender differences, promoting healthy behaviours, and advocating for condom use during sexual encounters. It is essential to implement strategies for STI prevention and encourage regular HIV testing, particularly among high-risk individuals. Additionally, tailored interventions targeting the specific needs of the Mapuche ethnicity should be developed to ensure equitable sexual and reproductive health. The pandemic has significantly impacted sexual activity and sexual health among university students, highlighting the necessity of adapting and reinforcing sexual education and prevention programs in this context.

"Sexual Behavior"[Mesh]

"Sexual Health"[Mesh]

"Reproductive Health"[Mesh]

"Universities"[Mesh]

"Students"[Mesh]

"COVID-19"[Mesh]

"Ethnic and Racial Minorities"[Mesh]

"Chile"[Mesh]

Sexual and reproductive health (SRH) practices among university students are crucial for their overall well-being. This study aimed to assess SRH practices among university students in Chile, considering factors such as gender, year of study, and ethnicity. A total of 5131 participants, representing 58.36% of enrolled students, were included in the study. The findings revealed that men had higher sexual activity than women, and men also reported a younger age at first sexual intercourse. Women had lower rates of condom use and a higher prevalence of sexually transmitted infections (STIs) in the past 12 months. Additionally, women had a higher frequency of HIV testing, and there was an association between testing and STI diagnosis. Among students, those identifying as Mapuche had lower rates of sexual activity. The COVID-19 pandemic resulted in an increase in sexual activity and STI prevalence among university students. It also revealed a positive trend in condom use over the years but a decrease in HIV testing, possibly due to the pandemic. These findings highlight the importance of addressing gender differences, promoting healthy behaviours, and encouraging condom use. Strategies for STI prevention and regular HIV testing, especially among high-risk individuals, should be implemented. Tailored interventions targeting the specific needs of the Mapuche ethnicity are necessary to promote equitable sexual and reproductive health. The pandemic has had a significant impact on sexual activity and sexual health, emphasizing the need to adapt and strengthen sexual education and prevention programs in this context.

The World Health Organization (WHO) defines sexual health as a multifaceted integration of physical, emotional, intellectual, and cultural elements, essential for the growth of personality, intercommunication, and the practice of sexuality devoid of coercion, violence, and discrimination. Also, these factors encompass freedom from the risk of acquiring Sexually Transmitted Infections (STIs) and the occurrence of unwanted or unplanned pregnancies (1). The broader concept of reproductive health is denoted as a state wherein the reproductive process is achieved, reflecting comprehensive physical, mental, and social well-being. This is not only associated with the absence of disease or ailments but is also linked to all aspects tied to the reproductive system (2).

Youth health promotion should consider specific needs, with a special emphasis on Sexual and Reproductive Health (SRH). SRH emerges as a subject of paramount importance as this phase in life marks the onset of sexuality, both biologically and psychologically, during the processes of identity formation and physical development (3).

The transition to university life represents a significant turning point, marking the initiation of adult life and emancipation. This phase is intrinsically tied to the exercise of freedom, the capacity for choice, and the commencement or continuation of sexual activities (4). A body of research has illuminated that this transition can amplify SRH-related risks, particularly those linked to inconsistent condom use, casual sexual encounters, and multiple partners. As a result, These circumstances can potentially lead to unplanned pregnancies and STIs (5).

Chilean data from 2022 indicate that the average age of sexual debut is 17 years, with a significant majority of young people (77.5% - 86.6%) reporting the use of some form of contraceptive during their first sexual encounter (6). Despite this, Chile faces the highest incidence rate of STIs/HIV in Latin America, underscoring the existence of substantial SRH risks (7). Particularly, the age groups between 20 to 29 years present the highest prevalence of HIV, Gonorrhea, Hepatitis B, and Syphilis (8).

Literature suggests the presence of distinct biological and social factors that potentially render women more susceptible to STIs and AIDS than their male counterparts (9). It is noteworthy that Chilean women tend to undertake HIV testing more frequently than men (10). Paradoxically, the data regarding the use of protective methods reveal that despite women exhibiting superior knowledge of protective measures than men, men report a higher usage (11). Within the university population, however, women are found to use condoms more frequently during their first sexual encounter compared to men (12).

Chile is home to 10 indigenous groups, among which the Mapuche is the most populous, accounting for 18.8% of the total indigenous population. As well as A significant proportion of the Mapuche (31.2%) inhabit Araucanía, the region with the highest percentage of indigenous people (13). Regrettably, most SRH research has overlooked the nuances of cultural and ethnic diversity. Considering that indigenous communities maintain specific beliefs and traditions encompassing SRH recommendations (appropriate behaviours within marriage, sexuality, family planning methods, norms, and care during the reproductive life cycle), it is essential to assess the SRH status within the Mapuche population (14).

During the COVID-19 pandemic, as indicated by the Economic Commission for Latin America and the Caribbean (ECLAC), the redirection of monetary and human resources intended for emergency healthcare response led to a neglect of various health dimensions, including SRH. This neglect resulted in numerous difficulties including, limited access to contraceptives (both public and private), scarcity of contraceptives in public services, discontinuation of SRH services, and users' hesitance to attend consultations due to fear of infection (15). Universities, in this scenario, assume a pivotal role in promoting student health, by fostering robust learning, providing healthier experiences, and advocating for health and well-being (4, 5).

The main objective of this study was to determine sexual and reproductive health practices among university students according to gender, year, and ethnicity.

Study design

This research was conducted as a cross-sectional population study.

Population

The target population consisted of all first-year students enrolled at the University of La Frontera, Chile, from 2018 to 2021. The initial year-by-year enrollment was as follows: 2385 in 2018, 2209 in 2019, 2249 in 2020, and 1954 in 2021. In the corresponding years, 1212, 757, 1928, and 1234 students participated in the study, representing 50.8%, 34.3%, 85.7%, and 63.2% of each year's total population, respectively. Cumulatively, the study achieved a 58.3% representation over the entire period, implying that out of 8797 students enrolled in their first year, responses were received from 5131 participants.

Data Collection

An online student health survey was voluntarily undertaken, initiated by the Center for Cardiovascular and Nutritional Epidemiology (EPICYN). The survey incorporated the following variables: age in years; biological gender (female, male); faculty of origin (Medicine and Dentistry, Social and Legal Sciences, Engineering and Agronomy); self-identification of belonging to the Mapuche ethnic group (yes, no); year of university admission (2018 to 2021); educational attainment of the household head (primary, secondary, tertiary); commencement of sexual activity (yes, no); the age of sexual activity initiation (in years); whether a physical breast exam was ever performed (yes, no); use of a condom in the most recent sexual encounter (yes, no); whether the participant has been pregnant or has impregnated someone in the past 12 months (yes, no); whether a Pap test was ever performed (yes, no); whether an HIV test was ever undertaken (yes, no); and whether the participant was diagnosed with a sexually transmitted infection in the past 12 months (yes, no).

Data Analysis

Exploratory data analysis was performed using descriptive statistics and tables. Furthermore, inferential analysis was conducted to study the association between response variables and independent variables, employing Chi-square, Student's T-test, and one-way ANOVA. Additionally, the strength of associations was determined by estimating Odds Ratios with their respective 95% confidence intervals. Finally, analyses were performed using IBM SPSS Statistics, version 28.

Ethical Considerations

Before participation, informed consent was obtained online from all participants, ensuring compliance with the ethical principles outlined in the Declaration of Helsinki. Participants were fully informed about the nature and purpose of the study, their voluntary participation, and their right to withdraw at any time without any consequences. Also, confidentiality and anonymity were strictly maintained, and the data collected were used solely for scientific purposes. The study protocol and procedures were approved by the Scientific Ethics Committee of Universidad de La Frontera (file numbers: 050/17, approval number: 076_2017, and file number: 150/21, approval number: 026_22).

The sample for the period 2018-2021 consisted of 55.4% female participants (n=2840). The year with the highest number of subjects was 2020, accounting for 37.6% of the students (n=1928), followed by 2021 with 24% (n=1234). The average age of the subjects was 18.9 years (+2.2), ranging from 16 to 49 years. Among the responses, 36.7% were from the Faculty of Engineering and Agronomy (n=1853), 31.1% from the Faculty of Medicine and Dentistry (n=1572), and 32.2% from the Faculty of Social and Legal Sciences (n=1630). Regarding educational attainment in the household, 15.9% had primary education (n=313), 47.6% had secondary education (n=938), and 36.5% had tertiary education (n=718). A total of 33.2% identified themselves as having Mapuche ancestry (n=933) (Table 1).

Table 1. General, sexual activity, and related practices data.

Variables	2018 N (%)	2019 N (%)	2020 N (%)	2021 N (%)	Total N (%)
General	1212 (23.6)	757 (14.8)	1928 (37.6)	1234 (24)	5131 (100)
Gender
Female	698 (57.6)	478 (63.3)	1006 (52.2)	658 (53.3)	2840 (55.4)
Male	514 (42.4)	277 (36.7)	922 (47.8)	576 (46.7)	2289 (44.6)
Faculty
Eng. & Agro.	454 (37.5)	285 (37.8)	604 (31.9)	510 (42.6)	1853 (36.7)
Med. & Dent.	395 (32.6)	270 (35.8)	545 (28.8)	362 (30.2)	1572 (31.1)
Soc. & Leg. Sc.	363 (30.0)	199 (26.4)	743 (39.3)	325 (27.2)	1630 (32.2)
Educational attainment
Primary	109 (15.6)	64 (13.4)	140 (17.7)	-	313 (15.9)
Secondary	355 (50.9)	224 (46.9)	359 (45.3)	-	938 (47.6)
Tertiary	234 (33.5)	190 (39.7)	294 (37.1)	-	718 (36.5)
Mapuche ethnic group
No	-	-	1148 (65.7)	732 (68.7)	1880 (66.8)
Yes	-	-	599 (34.3)	334 (31.3)	933 (33.2)
Started sexual activity
Yes	676 (55.8)	415 (54.8)	1232 (63.9)	687 (55.7)	3010 (58.7)
No	536 (44.2)	342 (45.2)	696 (36.1)	547 (44.3)	2121 (41.3)
Sexual activity <15
Yes	68 (10.1)	24 (10.7)	116 (9.9)	81 (12.1)	289 (10.6)
No	603 (89.9)	200 (89.3)	1060 (90.1)	587 (87.9)	2450 (89.4)
Use condom
Yes	-	142 (62.8)	748 (63.0)	469 (70.1)	1359 (65.3)
No	-	84 (37.2)	439 (37.0)	200 (29.9)	723 (34.7)
Conceived last 12 mos.
Yes	-	6 (2.7)	19 (1.6)	8 (1.2)	33 (1.6)
No	-	219 (97.3)	1168 (98.4)	661 (98.8)	2048 (98.4)
PAP test
Yes	-	18 (13.1)	88 (14.9)	52 (15.5)	158 (14.8)
No	-	119 (86.9)	504 (85.1)	284 (84.5)	907 (85.2)
Breast exam
Yes	-	-	88 (14.7)	57 (16.8)	145 (15.5)
No	-	-	511 (85.3)	282 (83.2)	793 (84.5)
STI last 12 mos.
Yes	-	4 (1.0)	12 (1.0)	151 (22.6)	167 (7.4)
No	-	411 (99.0)	1175 (99.0)	518 (77.4)	2104 (92.6)
HIV test
Yes	-	121 (29.2)	383 (32.3)	177 (26.5)	681 (30.0)
No	-	293 (70.8)	804 (67.7)	492 (73.5)	1589 (70.0)

Gender Perspective

Among the female participants, 55.9% reported having had sexual activity (n=1588), while among males, 62% reported sexual activity (n=1420), indicating that males had 1.3 times more sexual activity than females (OR=1.29, 95% CI: [1.15;1.44], χ²=19.58, p<0.001). The average age at first sexual activity was 16.3 years (+1.6) for females and 16.2 years (+1.5) for males (t=2.35, df=2736, p=0.02, 95% CI: [0.02/0.26], d=1.55). 9.9% of females initiated sexual activity before the age of 15 (n=142), compared to 11.3% of males (n=147) (OR=1.16, 95% CI: [0.91;1.48], χ²=1.39, p=0.24). Regarding condom use in the last sexual encounter, 60.1% of females reported using a condom (n=640), while 70.7% of males reported using a condom (n=718), indicating that males used condoms 1.6 times more often than females (OR=1.60, 95% CI: [1.33;1.92], χ²=25.65, p<0.001). Pregnancy or impregnating someone in the last 12 months was reported by 1.9% of females (n=20) and 1.2% of males (n=12) (OR=1.60, 95% CI: [0.78; 3.30], χ²=1.67, p=0.20). 8.5% of females who reported sexual activity were diagnosed with a sexually transmitted infection (STI) in the last 12 months (n=101), compared to 6.1% of males (n=66), indicating that females had 1.5 times higher STI diagnosis than males (OR=1.43, 95% CI: [1.0;1.9], χ²=4.85, p=0.028). Regarding HIV testing, 32.4% of females reported undergoing HIV testing (n=384), compared to 27.4% of males (n=297), indicating that females were 1.3 times more likely to undergo HIV testing than males (OR=1.27, 95% CI: [1.05; 1.52], χ²=6.61, p=0.01).

Ethnicity Perspective

Among students who identified themselves as Mapuche, 53.2% reported initiating sexual activity (n=496), compared to 63.2% among non-Mapuche students (n=1188), indicating that non-Mapuche students had 1.5 times higher sexual activity initiation than Mapuche students (OR=1.51, 95% CI: [1.29;1.77], χ²=26.11, p<0.01). The average age at first sexual activity was 16.36+1.65 for Mapuche students and 16.23+1.52 for non-Mapuche students, with no statistically significant difference between these values (t=1.64, df=1612, p=0.10, 95% CI: [-0.03/0.31]). 10.3% of Mapuche students initiated sexual activity before the age of 15 (n=49), compared to 11.2% of non-Mapuche students (n=128) (OR=1.1, 95% CI: [0.77; 1.55], χ²=0.27, p=0.60). Regarding condom use in the last sexual encounter, 63% of Mapuche students reported using a condom (n=303), compared to 66.6% of non-Mapuche students (n=763) (OR=1.17, 95% CI [0.94; 1.47], χ²=1.99, p=0.16). The percentage of pregnancy among Mapuche and non-Mapuche students was 2.1% (n=10) and 1.1% (n=13) respectively (OR=1.85, 95% CI [0.81; 4.25], χ²=2.16, p=0.14). Mapuche females reported undergoing breast examination in 14.7% of cases (n=40) and Pap smear in 14.2% of cases (n=38), while non-Mapuche females reported undergoing these examinations in 15% (n=79) and 14.8% (n=77) respectively (OR breast examination=1.02, 95% CI [0.68;1.54], χ²=0.009, p=0.923) (OR Pap smear=1.05, 95% CI [0.69/1.59], χ²=0.047, p=0.829). The percentage of Mapuche students diagnosed with STIs in the last 12 months was 7.9% (n=38), compared to 8.3% (n=95) among non-Mapuche students (OR=1.05, 95% CI [0.71/1.56], χ²=0.071, p=0.79). HIV testing was performed by 32.8% of Mapuche students (n=158) and 28.4% of non-Mapuche students (n=325) (OR=1.23, 95% CI [0.98; 1.55], χ²=3.23, p=0.07).

Before and during the COVID-19 Pandemic

When comparing the years 2018 and 2019 with the years 2020 and 2021, it was observed that in the first period, 55.4% had initiated sexual activity (n=1091), compared to 60.7% during the pandemic years (second period) (n=1919) (OR=1.24, 95% CI [1.11/1.39], χ²=13.95, p<0.001). The average age of sexual activity initiation in the first period was 16.29+1.59, compared to 16.26+2.69 in the second period (t=0.42, p=0.68, 95% CI [-0.09; 0.15]). 10.3% of students initiated sexual activity before the age of 15 in 2018 and 2019 (n=92), compared to 10.7% of students during the pandemic (n=197) (OR=1.04, 95% CI [0.80/1.36], χ²=0.10, p=0.75). Regarding condom use in the first period, 62.8% of students used a condom in their last sexual encounter (n=142), compared to 65.6% in the second period (n=1217) (OR=1.13, 95% CI [0.84/1.50], χ²=0.68, p=0.41). Pregnancy in the last 12 months was reported by 2.7% of students in the first period (n=6), compared to 1.5% in the second period (n=27) (OR=1.86, 95% CI [0.76/4.55], χ²=1.89, p=0.17). In the 2018-2019 period, 13.1% of female students underwent Pap smears (n=18), and 29.2% of students underwent HIV testing in general (n=121), while in the second period, 15.1% of female students underwent Pap smears (n=140) (OR=1.18, 95% CI [0.69/1.99], χ²=0.36, p=0.55), and 30.2% of students underwent HIV testing in general (n=560) (OR=1.05, 95% CI [0.83/1.32], χ²=0.14, p=0.70). STIs were diagnosed in 1% of students in the first period (n=4), and in 8.8% in the second period (n=163), indicating 10.78 times more cases in the second period compared to the first (OR=9.89, 95% CI [3.65/26.83], χ²=30.43, p<0.001).

Independent years

Analyzing the years independently, the highest percentage of students who initiated sexual activity was in 2020 with 63.9% (n=1232), while the lowest percentage was in 2019 with 54.8% (n=415), indicating 1.5 times more likelihood of students initiating sexual activity in 2020 compared to 2019 (OR(2020/2019)=1.46, 95% CI: [1.23;1.73], χ²=18.89, p<0.001). The percentages of initiating sexual activity before the age of 15 remained consistent, with the lowest percentage in 2020 (9.9%) (n=116) and the highest percentage in 2021 (12.1%) (n=81) (OR(2020/2021)=1.26, 95% CI: [0.93;1.70], χ²=2.284, p=0.131). The age of sexual activity initiation was similar across all years: 2018 (16.29+1.64), 2019 (16.28+1.45), 2020 (16.32+1.56), and 2021 (16.17+1.49) (F=1.42, p=0.24). The year 2021 reported the highest percentage of condom use, with 70.1% (n=469), while 2019 reported the lowest use, with 62.8% of students using condoms in their last sexual encounter (n=142), indicating 1.39 times more condom use in 2021 than in 2019 (OR(2021/2019)=1.39, 95% CI: [1.01;1.90], χ²=4.13, p=0.042) (Table 1).

The trend of pregnancy in the last 12 months among students remained consistent across the years, with 2.7% (n=6), 1.6% (n=19), and 1.2% (n=8) in 2019, 2020, and 2021 respectively (OR(2019/2021)=2.26, 95% CI: [0.78;6.58], χ²=2.36, p=0.12). Among females who initiated sexual activity, the trend regarding Pap smear examination showed a slight increase, with 13.1% in 2019 (n=18), 14.9% in 2020 (n=88), and 15.5% in 2021 (n=52) (OR(2021/2019)=1.21, 95% CI: [0.68; 2.16], χ²=0.42, p=0.52). Among females who underwent physical breast examination at any time, the trend in 2020 and 2021 was 14.7% (n=88) and 16.8% (n=57) respectively (OR(2020/2021)=1.17, 95% CI: [0.82; 1.69], χ²=0.75, p=0.39) (Table 1).

In 2021, the highest percentage of students diagnosed with STIs in the last 12 months was reported, with 22.6% (n=151), compared to 1% (n=4) and 1% (n=12) in 2019 and 2020 respectively. When comparing 2021 with 2020, there was a 28.54 times higher likelihood of STIs in 2021 (OR(2021/2020)=28.54, 95% CI: [15.71;51.85], χ²=248.26, p<0.001). HIV testing was performed by students in all three years with some variations, with the lowest percentage in 2021 (26.5%) (n=177) and the highest percentage in 2020 (32.3%) (n=383), indicating 1.32 times more HIV testing in 2020 than in 2021 (OR(2020/2021)=1.32, 95% CI: [1.07;1.63], χ²=6.85, p=0.009) (Table 1).

Specific Associations

Furthermore, the association between condom use in the last sexual encounter and being diagnosed with STIs was analyzed, and no association was found (OR=1.14, 95% CI: [0.82;1.59], χ²=0.64, p=0.42). These trends remained consistent across genders, ethnicities, and years.

Moreover, the association between undergoing HIV testing and being diagnosed with STIs was identified, showing an association when analyzing the overall data, with 91% of subjects diagnosed with STIs undergoing HIV testing (OR=30.15, 95% CI: [17.58;51.71], χ²=319.59, p<0.001). Among females diagnosed with STIs, 89.1% underwent HIV testing, compared to 93.9% of males, while 27.1% of females not diagnosed with STIs underwent HIV testing, compared to 23.1% of males (OR females=22.01, 95% CI: [11.61;41.76], χ²=162.29, p<0.001) (OR males=51.58, 95% CI: [18.57;143.26], χ²=156.23, p<0.001). Similar results were observed in both ethnic groups, with STI diagnosis and HIV testing percentages of 86.8% in Mapuche students and 90.5% in non-Mapuche students (OR Mapuche=16.79, 95% CI: [6.41;43.99], χ²=54.53, p<0.001) (OR non-Mapuche=32.43, 95% CI: [16.08;65.40], χ²=196.80, p<0.001). In the pandemic and pre-pandemic years, the same pattern was observed, with 100% of diagnosed cases undergoing HIV testing in the pre-pandemic period and 90.8% in the pandemic period (Fisher's exact test p=0.007) (OR(2020/2021)=30.68, 95% CI: [17.83;52.78], χ²=311.73, p<0.001).

The present study focuses on determining the practices of Sexual and Reproductive Health (SRH) among university students based on gender, year, and ethnicity. Considering the general data on SRH, the percentage of students who had already initiated sexual activity upon entering university was 58.7%, a higher value compared to another study conducted in South Africa where it was reported as 51% in 2012 (16). Unfortunately, more recent figures are not available, nor from any South American country, making it difficult to compare the data. Thus, more evidence is needed to draw accurate comparisons. However, this data can serve as a reference for future comparisons.

Regarding the difference in the percentage of sexual activity initiation between men and women, it was found to be 1.3 times higher in men, which is consistent with previous research (17). Factors such as family structure and support, participation in sports, body image, and overall well-being have been identified as influential factors in the higher initiation rate among men (18). This was further evident when analyzing the significant difference in the age of sexual activity initiation between men and women, with men starting at a younger age.

In the same line, among students identifying with the Mapuche ethnicity, a 1.5 times lower rate of sexual initiation was found compared to non-Mapuche students. While the literature has not extensively addressed the sexual behaviour of Mapuche students, analyzing factors associated with the differences found in our study could provide relevant information to understand how Mapuche culture and customs influence the initiation of sexual activity. For instance, it has been established, based on available data, that among indigenous youth, there is a higher tendency to initiate sexual activity within established relationships compared to non-indigenous youth (19). However, this study did not investigate such specific information.

It is understood that the pandemic is a determining factor in SRH, as highlighted in the study by Garavito and Arboleda (20), where a decrease in sexual activity among university students was observed due to confinement measures. However, our research data does not indicate the same trend, showing an increase of almost 10% from 2020 to 2021. Nonetheless, this increase aligns with the general trend of rising rates of sexual initiation, with an increase from 44% in 2007 to 51% in 2012 (16).

In this study, the average age of sexual activity initiation was found to be 16.3 years, which is similar to the reported average of 16.5 years in a study conducted in 2022 (12). While there is no specific age for starting sexual activity, it is important to consider personal readiness, cultural and religious beliefs, and potential risks associated with early sexual initiation (5, 21). In our study, the percentages of sexual activity initiation before the age of 15 were 10.6% for the entire period. It is crucial to interpret this data in conjunction with the factors associated with early sexual initiation. In Chile, for example, a study found that family factors such as not being raised by both parents, poor parent-child relationships, poor family communication, adolescent motherhood, employed mothers, and family dysfunction were associated with early sexual activity initiation (22). Specifically, regarding sexual activity initiation before the age of 15, there were differences between men and women, with men surpassing women by 1.4 points, consistent with the age difference and findings from global research (18, 21).

At early ages, it is essential to promote the use of contraceptive methods as part of comprehensive sexual education. In this study, 65.3% reported using condoms during their last sexual activity, surpassing the findings of the latest national INJUV survey (6), which reported a percentage of 54.0% of young people using condoms in their last sexual relationship in 2022. Regarding gender differences in condom use during the last sexual encounter, the study found that men used condoms more frequently than women, which aligns with another study conducted among Canadian students (22). The years of study also showed variations, with higher condom use in 2021 compared to 2019. This suggests a positive attitude towards this protective behaviour, which is supported by government policies aimed at providing free distribution of condoms (19). Nevertheless, it is still necessary to consistently promote a culture of responsibility and self-care in SRH.

The incorrect use or lack of use of contraceptive methods increases the risk of contracting STIs. However, this research did not demonstrate an association between these variables, possibly due to the low number of subjects with STIs. Here, only 7.4% of the sample reported having been diagnosed with an STI. National studies in 2018 indicated that 2.7% of Chileans between 20 and 24 years old acknowledged having received an STI diagnosis (23), which is lower than our finding. However, another nationwide study found a 7.5% prevalence of self-reported STI diagnosis among university students (10), which is similar to our study but lower than the prevalence found among young people in Ethiopia, where the prevalence was 18.2% (24). It is important to emphasize the need to study the factors associated with STI transmission in the university population, which, as previously mentioned, is a high-risk group, rather than solely focusing on isolated prevalences.

Regarding the gender-specific diagnosis of STIs, the prevalence of positive test results in the last 12 months was 8.5% for women and 6.1% for men. Interestingly, this study observed a higher proportion of STI cases among women compared to men, which diverges from the findings of the National Plan for the Prevention and Control of HIV/AIDS and STIs 2021-2022 (25). According to this report, in the year 2020, 83.3% of the positive cases of syphilis and gonorrhoea were among men, representing a five-fold higher number of confirmed cases compared to women.

Analyzing the impact of the COVID-19 pandemic on STI diagnoses reveals significant findings. Respondents during the second period showed a higher prevalence rate (8.8%) compared to the first period (2018/2019) (1%). These results were further supported by independent annual analyses, reporting a notable prevalence rate of 22.6% in 2021. Therefore, the pandemic severely disrupted access to sexual health services for young individuals (26), increasing the risk of contracting STIs. Moreover, rates of both symptomatic and asymptomatic STI testing experienced a decline during the initial months of the pandemic (27).

In Chile, syphilis has the highest notification rate among STIs, followed by HIV infection (28). Regarding the number of university women and men who underwent HIV testing, the results show that 32.4% and 27.4%, respectively, had done so. These findings align with the study by Contreras-García (10), in which women showed a higher demand for rapid HIV testing compared to men. However, evidence is inconsistent, as a Canadian study states that when the test is offered, the majority of individuals who decide to take it are men who have sex with men and those who acknowledge engaging in risky sexual behaviours such as unprotected oral, vaginal, or anal sex (29). Specifically, our study did not inquire about the subjects' sexual orientation, so we could not identify if these trends are present. In this study, there was a significant decrease (5.8%) in the percentage of students who underwent HIV testing in 2021, which may also be attributed to the pandemic.

In line with our findings and previous studies, a positive association was observed between having an STI and undergoing HIV testing. This correlation can be attributed to factors such as heightened awareness of sexual health and associated risks among individuals with an STI. Additionally, healthcare providers commonly recommend HIV testing for those diagnosed with an STI due to shared transmission routes and increased vulnerability to HIV infection. This association underscores the importance of proactive screening and early detection of HIV among individuals with an STI, who may be at higher risk (30). As a result, it is expected that the number of individuals seeking HIV testing will continue to increase.

The inadequate use or lack of use of contraceptive methods not only increases the risk of contracting sexually transmitted infections (STIs) but also can lead to unintended pregnancies if appropriate precautions are not taken to prevent them. In this study, 1.9% of women and 1.2% of men reported pregnancy in the last 12 months. Unfortunately, our results, despite appearing lower compared to reported rates (ranging from 13% to 26.3%) (21, 29), are not directly comparable as the reported data do not specifically focus on the last 12 months as in our study. It is worth noting that for young students, pregnancy can often lead to dropping out of university or not pursuing higher education (31), which could be an underlying factor contributing to the low reported figures.

Regarding the PAP test and breast examination, only 14.8% and 15.5% of university students who have initiated their sexual life have undergone them, respectively. These findings reveal lower rates in comparison to a study conducted by Paez et al. (32), which reported a 21.3% self-examination rate among Colombian female university students in health-related fields. In Chile, both the PAP test and mammography are integral components of the National Cancer Program, a publicly-funded initiative offering free access to individuals at risk. However, substantial gaps in coverage rates and a notable prevalence of non-compliance with repeat screenings after abnormal results have been identified (33). Moreover, there is a dearth of evidence concerning the compliance behavior of female university students regarding these preventive examinations in our country. Therefore, it is imperative to augment preventive and early detection measures with educational and awareness programs that promote self-care practices.

Finally, it can be highlighted that sexual and reproductive health (SRH) is a particularly sensitive topic, often regarded as a private matter for the general population, and especially for indigenous communities. The healthcare strategy has aimed to simplify the complexity of incorporating cultural relevance into healthcare practices, thereby presenting a challenge in accurately characterizing the SRH behaviors of Mapuche students. This is particularly significant considering that the location where this research was conducted has the highest proportion of individuals belonging to indigenous communities nationwide.

Limitations of the Study

The main limitations of this study are associated with the characteristics of the cross-sectional design, which prevent causal relationships between variables from being established. Therefore, only associations can be discussed, highlighting the need for further investigation in this field using designs that allow for causal inferences.

Furthermore, this study relied on self-report measures, and therefore, caution must be exercised when interpreting the results, particularly about variables such as ethnic groups. It is important to consider incorporating ethnic measurements in future research to identify subjects' consanguinity with a specific ethnic group and their level of identification with it.

This study examined sexual and reproductive health practices among university students in Chile, considering gender, year of study, and ethnicity. The findings highlight the importance of addressing gender differences and promoting healthy behaviours in sexual encounters. Men were found to have higher sexual activity rates and younger average age at first sexual intercourse compared to women. Women reported less condom use and a higher prevalence of sexually transmitted infections (STIs). Women also had a higher frequency of HIV testing and an association between testing and STI diagnosis. Among students identifying as Mapuche, there was a lower proportion of sexual activity. The COVID-19 pandemic had an impact on sexual activity and sexual health, with an increase in sexual activity and STI prevalence observed. The study emphasizes the need for strategies to promote condom use, STI prevention, and regular HIV testing, especially among high-risk groups. Tailored interventions addressing the specific needs of the Mapuche ethnicity should also be developed. The findings underscore the importance of adapting and strengthening sexual education and prevention programs, particularly in the context of the pandemic. These findings contribute to understanding the sexual and reproductive health landscape among university students and provide insights for future interventions and policies.

WHO: World Health Organization

STIs: Sexually Transmitted Infections

SRH: Sexual and Reproductive Health

HIV: Human Immunodeficiency Virus

AIDS: Acquired Immune Deficiency Syndrome

ECLAC: Economic Commission for Latin America and the Caribbean

EPICYN: Center for Cardiovascular and Nutritional Epidemiology

ANOVA: Analysis of Variance

SPSS: Statistical Package for the Social Sciences

IBM: International Business Machines Corporation

WHO

World Health Organization

STIs

Sexually Transmitted Infections

SRH

Sexual and Reproductive Health

HIV

Human Immunodeficiency Virus

AIDS

Acquired Immune Deficiency Syndrome

ECLAC

Economic Commission for Latin America and the Caribbean

EPICYN

Center for Cardiovascular and Nutritional Epidemiology

ANOVA

Analysis of Variance

SPSS

Statistical Package for the Social Sciences

IBM

International Business Machines Corporation

Acknowledgement

ANID - MILENIO - NCS2021_013

Authors’ contributions

M.C. and T.O. drafted the manuscript. G.M. and T.B. designed the study and collected data. T.O. and A.S. performed the statistical analysis. M.C., T.O. and K.J. prepared the manuscript. N.M. made suggestions to the manuscript. All authors read and approved the final manuscript.

Funding

Author TO received funding for the completion of the manuscript from ANID + SUBVENCIÓN A INSTALACIÓN EN LA ACADEMIA CONVOCATORIA AÑO 2022 + 85220114.

Availability of data and materials

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Ethics approval and consent to participate

Ethical approval was obtained from the Scientific Ethics Committee of Universidad de La Frontera. Acta de evaluación protocolo de investigación. Minutes of research protocol evaluation, file nº 050/17, minutes nº 076_2017 and file nº 150/21, minutes nº 026_22.

Consent for publication

Written informed consent was obtained from the patient for publication of this study. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Competing interests

The authors declare no conflicts of interest.

World Health Organization. Defining sexual health: report of a technical consultation on sexual health, 28–31 January 2002, Geneva. Geneva: World Health Organization. 2006. https://www3.paho.org/hq/dmdocuments/2009/defining_sexual_health.pdf. Accessed May 5, 2023.
World Health Organization. Global strategy for women’s, children’s and adolescents’ health (2016–2030). Geneva: World Health Organization. 2015. Available from: https://globalstrategy.everywomaneverychild.org. Accessed May 5, 2023.
World Health Organization. Promoting sexual health: recommendations for action. Geneva: World Health Organization. 2017. Available from: https://iris.paho.org/bitstream/handle/10665.2/42416/promotionsexualhealth.pdf?sequence=1&isAllowed=y. Accessed May 5, 2023.
Thorpe S, Tanner AE, Kugler KC, Chambers BD, Ma A, Jenkins Hall W, Ware S, Milroy JJ, Wyrick DL. First-year college students' alcohol and hookup behaviours: sexual scripting and implications for sexual health promotion. Cult Health Sex. 2021;23(1):68-84. https://doi.org/10.1080/13691058.2019.1688868.
Arsandaux J, Montagni I, Macalli M, Bouteloup V, Tzourio C, Galéra C. Health Risk Behaviors and Self-Esteem Among College Students: Systematic Review of Quantitative Studies. Int J Behav Med. 2020;27(2):142-159. https://doi.org/10.1007/s12529-020-09857-w.
Instituto Nacional de la Juventud. 10ma Encuesta Nacional de Juventudes [Internet]. Gob.cl; 2022. https://www.injuv.gob.cl/sites/default/files/10ma_encuesta_nacional_de_juventudes_2022.pdf. Accessed May 5, 2023.
Programa Conjunto de las Naciones Unidad sobre el VIH/sida (ONUSIDA). Tendencia de nuevas infecciones por VIH. Unaids.org. 2019. http://dx.doi.org/https://www.unaids.org/es. Accessed May 5, 2023.
Cáceres-Burton K. Informe: Situación epidemiológica de las infecciones de transmisión sexual en Chile, 2017. Rev Chilena Infectol. 2019;36(2):221–33. http://dx.doi.org/10.4067/s0716-10182019000200221
UNAIDS. Women and HIV: a spotlight on adolescent girls and young women. UNAIDS; 2019. https://www.unaids.org/sites/default/files/media_asset/2019_women-and-hiv_en.pdf. Accessed May 5, 2023.
Contreras-García Y, Roa-Garcés J, Alvarado-Figueroa D, Manríquez-Vidal C, Carrasco-Portiño M. Conductas sexuales por sexo en población universitaria chilena que demanda test rápido de VIH. Rev Chil Obstet Ginecol 2022;87(3):194-202. https://doi.org/10.24875/rechog.21000036.
Aldea M, Cerda J, Jaramillo M, Maldonado D, Meriño M, Morales I. Conductas sexuales y realización del test de ELISA en universitarios de Chillán, Chile. RIdEC 2021; 14(2):24-32. https://www.enfermeriacomunitaria.org/web/index.php/ridec/297-ridec-2021-volumen-14-numero-2/2758-originales-3-conductas-sexuales-y-realizacion-del-test-de-elisa-en-universitarios-de-chillan-chile
Moreira LR, Dumith SC, Paludo SDS. Uso de preservativos na última relação sexual entre universitários: quantos usam e quem são? Cien Saude Colet. 2018;23(4):1255–66. http://dx.doi.org/10.1590/1413-81232018234.16492016
Instituto Nacional de Estadística (2018). Síntesis de resultados Censo 2017. http://www.censo2017.cl/descargas/home/sintesis-de-resultados-censo2017.pdf. Accessed June 29, 2023.
Ministerio de Salud. Guía de experiencias significativas y recomendaciones para los equipos de salud: pertinencia cultural en el trabajo con pueblos indígenas en el ámbito de la salud sexual y salud reproductiva. https://www.minsal.cl/wp-content/uploads/2021/07/20210224-GUIA-SSRR-Y-PUEBLOS-INDI%CC%81GENAS.pdf. Accessed May 5, 2023.
Comisión Económica Para América Latina y el Caribe. Los impactos sociodemográficos de la pandemia de COVID-19 en América Latina y el Caribe. 2022. https://www.cepal.org/es/publicaciones/47922-impactos-sociodemograficos-la-pandemia-covid-19-america-latina-caribe. Accessed May 5, 2023.
Blignaut RJ, Jacobs J, Vergnani T. Trends in HIV risk behaviour of incoming first-year students at a South African university: 2007-2012. SAHARA J. 2015;12:39-50. http://dx.doi.org/10.1080/17290376.2015.1086275.
Gomes KR, de Oliveira DC, da Silva MA. Sexual initiation and associated factors among adolescents in a Brazilian municipality. Revista Brasileira de Enfermagem. 2018;71(2), 287-293. http://dx.doi.org/10.1590/0034-7167-2017-0196.
Gazendam N, Cleverley K, King N, Pickett W, Phillips SP. Individual and social determinants of early sexual activity: A study of gender-based differences using the 2018 Canadian Health Behaviour in School-aged Children Study (HBSC). PLoS One. 2020;15(9):e0238515. http://dx.doi.org/10.1371/journal.pone.0238515.
Obach A, Carreño A. Encuentros y tensiones en la atención de salud sexual y reproductiva de población joven mapuche: una aproximación cualitativa. Mat. Actual. 2022;(2):12. http://dx.doi.org/10.22370/revmat.2.2022.3370.
Garavito L, Arboleda L. Narrativas sobre sexualidad en jóvenes universitarios durante la cuarentena por Covid-19. 2021. http://hdl.handle.net/10554/54528. Accessed May 1, 2023.
Lee RLT, Yuen Loke A, Hung TTM, Sobel H. A systematic review on identifying risk factors associated with early sexual debut and coerced sex among adolescents and young people in communities. J Clin Nurs. 2018;27(3-4):478-501. http://dx.doi.org/10.1111/jocn.13933.
Hall WJ, Erausquin JT, Nichols TR, Tanner AE, Brown-Jeffy S. Relationship intentions, race, and gender: Student differences in condom use during hookups involving vaginal sex. J Am Coll Health. 2019;67(8):733-742. http://dx.doi.org/10.1080/07448481.2018.1506788.
Ministerio de Desarrollo Social y Familia. IX Encuesta Nacional de la Juventud INJUV 2018. 2019. https://www.injuv.gob.cl/9encuesta
Kassie BA, Yenus H, Berhe R, Kassahun EA. Prevalence of sexually transmitted infections and associated factors among the University of Gondar students, Northwest Ethiopia: a cross-sectional study. Reprod Health [Internet]. 2019;16(1):163. Disponible en: http://dx.doi.org/10.1186/s12978-019-0815-5
Ministerio de Salud. Gobierno de Chile. Aprueba Plan Nacional para Prevencion y Control del VIH/SIDA y las ITS, para el periodo 2021-2022. https://diprece.minsal.cl/wp-content/uploads/2022/03/RES.-EXENTA-N°-1111-Plan-nacional-VIH-SIDA-e-ITS-2021-2022.pdf. Accessed May 1, 2023.
Bonett S, Teixeira da Silva D, Lazar N, Makeneni S, Wood SM. Trends in sexually transmitted infection screening during COVID-19 and missed cases among adolescents. Public Health. 2022;213:171–6. http://dx.doi.org/10.1016/j.puhe.2022.10.007
Hill BJ, Anderson B, Lock L. Chlamydial infection among adolescents and young adults receiving sexual and reproductive health care during the COVID-19 pandemic. Sex Transm Dis. 2022;49(3):e50–2. http://dx.doi.org/10.1097/OLQ.0000000000001556
Departamento de Epidemiología. División de Planificación Sanitaria, Ministerio de Salud de Chile. National Report: evolution of HIV/AIDS infection in Chile, 1984-2012. Rev Chilena Infectol 2015;32(Suppl1):17-43. http://dx.doi.org/10.4067/S0716-10182015000100003.
Kesler MA, Kaul R, Liu J, Loutfy M, Gesink D, Myers T, et al. Actual sexual risk and perceived risk of HIV acquisition among HIV-negative men who have sex with men in Toronto, Canada. BMC Public Health. 2016;16(1):254. http://dx.doi.org/10.1186/s12889-016-2859-6
Ong JJ, Fu H, Baggaley RC, Wi TE, Tucker JD, Smith MK, Rafael S, Falconer J, Terris-Prestholt F, Mameletzis I, Mayaud P. Missed opportunities for sexually transmitted infections testing for HIV pre-exposure prophylaxis users: a systematic review. J Int AIDS Soc. 2021;24(2):e25673. http://dx.doi.org/10.1002/jia2.25673.
Hernández Quirama A, Cáceres Manrique F de M, Rivero-Rubio C. Estudio y embarazo en la universidad. Un reto difícil de superar. Diversitas. 2020;16(2). http://dx.doi.org/10.15332/22563067.6318
Páez-Esteban ÁN, Urrea-Vega EA, Contreras-Barrios MA, Díaz-Urquijo M. Conocimiento y frecuencia de los factores de riesgo para cáncer de mama en las estudiantes del área de la salud. Investig Enferm Imagen Desarro. 2010;12(2):25–36. https://www.redalyc.org/articulo.oa?id=145217280003. Accessed May 1, 2023.
Rodríguez-Garcés C, Espinosa-Valenzuela D, Padilla-Fuentes G. Cáncer y acción preventiva en Chile: perfilando la abstención a la mamografía y papanicolaou. Rev Med Chil. 2021;149(8):1150–6. http://dx.doi.org/10.4067/s0034-98872021000801150.

No competing interests reported.

Download PDF

Version 1

posted

You are reading this latest preprint version

Sexual and reproductive health of university students with a gender and ethnicity focus before and during the COVID-19 pandemic

Status:

Version 1

Abstract

Background

Methods

Results

Conclusions

Plain language summary

Introduction

Methods

Results

Discussion

Conclusions

Abbreviations

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1