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Foundations of life-long sexual
health literacy
Allyson Stella Graf and Julie Hicks Patrick
Department of Psychology, West Virginia University, Morgantown,
West Virginia, USA
Received 30 December 2013
Revised 2 March 2014
1 May 2014
Purpose – Sexual education in adolescence may represent the only formal sexual information
Accepted 16 May 2014
individuals ever receive. It is unclear whether this early educational experience is sufficient to promote
lifelong sexual health literacy. The purpose of this paper is to examine the influence of the timing and
source of sexual knowledge on current safe sex knowledge and risky sexual behaviours among
middle-aged and older adults in the USA.
Design/methodology/approach – Participants (n ¼ 410, mean age ¼ 53.9, 50.7 per cent female)
reported whether and when they received sexual knowledge from various sources. They were asked
about their current safe sex knowledge and their lifetime sexual risk behaviours.
Findings – Most of the participants (61.5 per cent) received formal sexual education in adolescence
and 20.2 per cent reported formal sexual education post-adolescence. Across the life span, friends were
the most common source of sexual information. The sample scored in the upper mid-range on the scale
indexing safe sex knowledge (M ¼ 6.69, SD ¼ 1.64, range ¼ 0-8). Participants reported engaging in an
average of approximately four (out of 16) risky sexual behaviours across their lifetime. Those with
formal sex education in adolescence scored significantly higher on safe sex knowledge. However,
they also engaged in more risky sex behaviours.
Originality/value – This study is among the first to situate the normative, formal sexual education
experience of adolescence within a life span context that not only accounts for time, but also multiple
sources of influence. It would appear that there are more things to learn about the long-term influence
of sexual education programmes during the formative years by studying adult sexual health
and knowledge.
Keywords Adolescents, Safer sex, Risk, Knowledge, Sex education, Adult education, Adults,
Health literacy
Paper type Research paper
Health Education
Vol. 115 No. 1, 2015
pp. 56-70
© Emerald Group Publishing Limited
DOI 10.1108/HE-12-2013-0073
In the USA, most adolescents receive formal sexuality education from teachers or
school nurses prior to graduating from high school (National Center for Health
Statistics, 2010). This experience may set the foundation for lifelong sexual health
literacy and behaviour (Irvine, 2004). Health literacy broadly represents a skill set that
bridges health knowledge and behaviour ( Jones and Norton, 2007). Sexual health
literacy refers to the ability to not only access and understand sexual knowledge,
but also to incorporate information into the sexual decision-making processes that
govern behaviour.
Over the past several decades, research has focused on the effectiveness of schoolbased sexual education to improve adolescent sexual decision making and to decrease
risky sexual behaviours. Such programmes have focused on curriculum content,
timing, and the context in which this information is provided, including who does the
teaching (Coleman, 2008; Kirby et al., 2007; Lindberg and Maddow-Zimet, 2012; Selwyn
and Powell, 2007; Shin et al., 2011; Sieg, 2003; Walker et al., 2003). Some have begun to
examine the long-term effects that these educational experiences have on future sexual
health, but often this exploration is amongst primarily college-aged participants thus
extending only as far as younger adulthood (Marshall, 2011; Shin et al., 2011). Failing to
examine sexual education beyond adolescence poses serious public health consequences
for the growing number of middle-aged and older adults throughout the world, who may
not have access to or make use of formal sexuality education resources (Marshall, 2011;
Olshansky et al., 2009). This issue is of particular relevance now with the growing rates of
sexually transmitted infections (STIs) in those over the age of 50 years (Fang et al., 2010;
Public Health England (PHE), 2013; von Simson and Kulasegaram, 2012). It is unclear
how limited exposure to school-based sexual education experiences relates to sexual
health literacy beyond adolescence or whether later sexual education can make up for or
supplement what sexual knowledge individuals possess as adults. Thus, the current
study examined the effects of the timing and source of sexual information on the current
knowledge of safe sex practices and engagement in risky sexual behaviours among
410 middle-aged and older adults (40+ years).
Sexual behaviour risks among middle-aged and older adults
A long-standing concern among medical professionals, educators, and researchers alike
has been the high rates of sexually transmitted infections (STIs) among members of
racial and ethnic minority groups (CDC, 2011; Lindau and Gavrilova, 2010). Recently,
however, older age has also emerged as a risk factor for contracting STIs. Although the
highest rates of STI-diagnoses remain among adolescents and young adults, rates
among middle-aged and older adults have increased dramatically (Fang et al., 2010;
PHE, 2013; von Simson and Kulasegaram, 2012). In 2010, adults over the age of
45 years represented 20 per cent of all new HIV diagnoses in the USA (Center for
Disease Control and Prevention, CDC, 2012). Similarly, in the UK, HIV rates among
those age 50+ years doubled between 2003 and 2012. Therefore, although STIs have
traditionally been associated with younger people (Orel et al., 2005), recent trends
indicate these risks are present across the life span.
In addition, many sexual risk factors, including poor sexual knowledge, are
consistent across age groups. Henderson et al. (2004) found that women aged 50+ years
had relatively poor HIV knowledge, answering only about one-third of their knowledge
test questions correctly. Younger participants and those with more education tended to
answer more items correctly. In qualitative studies, sexual risk knowledge is not
always explicitly assessed, but emerges in interviews. For instance, among postmenopausal women aged 58-93 years, nearly a quarter of those who were sexually
active with a partner did not believe condom usage was necessary when pregnancy
was no longer a concern (Lindau et al., 2007).
Having more knowledge of sexual risks relates to some safer sexual practices
among young and old, alike (Holcomb et al., 2004; Kirby et al., 2007; Maes and Louis,
2003; Vivancos et al., 2013). In a sample of Trinidadian adults ranging in age from 17 to
80 years, education, but not age, predicted HIV knowledge (Norman and Carr, 2003).
Greater HIV knowledge was associated with communicating with one’s partner about
safe sex practices and with having condoms available. Those who readily had
protection available were the ones who were most likely to engage in consistent
condom use with their sexual partner. Thus, across ages, accurate knowledge is often a
precursor to minimizing risky sexual behaviour.
Sexuality education as a life span issue
From a sociological perspective of the development of sexual practices and norms
(see Delamater, 1987) and consistent with a life span approach (Baltes, 1987), personal
sexual health
sexual knowledge and behaviours may be best understood when situated within the
greater cultural and historical contexts in which they emerge. Although there is debate
over many specific aspects of sexual education in the formal school system, most agree
that it is a necessity during adolescence (Bleakley et al., 2006). However, this has not
always been the case. Those who are now in late middle-age and early older adulthood
may have received limited or even no formal sexual education. Thus, generational
cohort may be an especially important correlate of sexual health literacy.
One of the earliest comparisons of cohort differences in sources of sexual information
compared the Kinsey data from the 1950s and 1960s with data from the mid-1970s
(Gebhard, 1977). Not surprisingly, substantial differences were found between younger
and older cohorts. Specifically, for children and adolescents in the 1970s, formal sources
of sexual education (e.g. teachers, nurses, etc.) were more common than in the previous
historical cohorts. In addition, in the 1970s, people received more informal sexual
information and at younger ages than did those in the 1950s and 1960s. Yet, even in this
era of changing sexual norms in the USA and elsewhere (Treas, 2002), some were still not
receiving school-based sexual education in adolescence (Gebhard, 1977).
Among middle-aged and older adults who have received school-based sexual
education during adolescence, their knowledge base may no longer be accurate or
adequate (Marshall, 2011). Opportunities for formal sexual education after leaving the
traditional education setting, however, are usually limited to medical and other
health professionals and formal services, such as Planned Parenthood and the Centers
for Disease Control and Prevention (CDC; Orel et al., 2005). But these resources are
generally underutilized. For example, although adults indicate that they prefer to
receive sexual health information and guidance from their primary physicians, few
individuals initiate such conversations and most expect their healthcare providers to
inquire (Gott et al., 2004). Yet, not all primary physicians approach sexual health
concerns and risks with their adult patients (Moreira et al., 2005). The likelihood of
physician-initiated interactions decreases even further for females and those over age
50 years (Lindau et al., 2007).
Beginning as young as adolescence, people tend to use more passive sources of
sexual information, such as magazines and pamphlets, rather than to actively seek
sexual advice (Selwyn and Powell, 2007). However, many of the sexual information
resources provided through health centres and organizations are not applicable to
middle-aged and older adults, although efforts are under way to make these materials
more appropriate for older audiences (Garrity, 2010; Orel et al., 2005). Therefore, sexual
education during adolescence may represent the only formal sexual information most
individuals receive in their lifetimes. Middle-aged and older adults with low sexual
health literacy may not update their knowledge as new information about sexual health
and risks emerges, or they may fail to alter their behaviour to reflect this new
information (Marshall, 2011). Thus, the accessibility of age-appropriate resources and
whether information is even sought post-adolescence is a public health concern
(Marshall, 2011), as evidenced by the high rates of sexually transmitted diseases
and infections among middle-aged and older adults (Fang et al., 2010; PHE, 2013;
von Simson and Kulasegaram, 2012).
The current study
This study examined the associations between early sexual education and current
sexual risk knowledge and behaviours among a sample of middle-aged and older
adults living in the USA. Our first research goal concerned describing the sources and
timing of sexual education for these adults. Exploring such descriptive data provides
the context in which other behaviours may be evaluated. We hypothesized that
those with formal sexual education would demonstrate better knowledge of safe sex
practices as adults compared to those without formal sexual education. In addition,
we anticipated that formal sexual education would relate to sexual behaviours, such
that those with formal sexual education in adolescence and those with greater knowledge
of safe sex would engage in fewer risky sexual behaviours across the life span. The
underlying assumption is that those with this foundational sexual education experience
develop sexual health literacy skills that foster a lifelong ability to integrate sexual risk
knowledge into reduced sexual risk behaviour. Understanding the link between early
sexual education and later knowledge and behaviour extends the current literature on
the long-term effects of school-based sexual education beyond adolescence.
Data for the current analyses were derived from an online and anonymous survey
that was approved by the Institutional Review Board of West Virginia University
(USA). The sample was recruited through Amazon’s Mechanical Turk (MTurk).
Through MTurk, individuals register as “workers” and can select available tasks,
such as research surveys, document editing, or web site verification, to complete for
payment. MTurk and other online venues provide access to large, diverse participant
pools. Recent studies have found the resulting data to be comparable to other
recruitment and survey methods (e.g. Buhrmester et al., 2011; Johnson and Borden,
2012; Mason and Suri, 2012). For sensitive topics, including sexual knowledge and
behaviours, online data collection may yield more valid responses than other
methods of data collection (Al-Tayyib et al., 2012; Dillman, 2000).
A sample of 502 adults living in the USA completed an online survey regarding
health behaviours and health knowledge. Sexual experiences, attitudes, and knowledge
were included as domain-specific aspects of health. From the current analyses, we
excluded 92 participants who were younger than age 40 years. Participants had 90
minutes to complete the survey and received USD2.00 in Amazon credit. The average
completion time was 40.4 minutes.
The current sample included 410 adults between the ages of 40 and 77 (mean age ¼ 53.9
years, SD ¼ 8.1). Just over half (50.7 per cent) of the sample were female. About half of
the participants (50.5 per cent) self-identified as White and 25.6 per cent identified as
Black. Among those remaining, 20.7 per cent identified as Latino, no race specified and
3.2 per cent identified as some other racial or ethnic affiliation. Most of our sample
(79.5 per cent) had some post-secondary education, with 47.1 per cent having earned at
least a Bachelor’s degree. Thus, these adults were more highly educated than their
average age-peer, of whom 23-29 per cent have earned Bachelor’s degrees (US Census,
2012). Most participants were married or cohabitating (62 per cent) and identified as
exclusively heterosexual (82.4 per cent).
Sources of sexual education. We modified Tobin’s (2011) Sexual Attitudes and
Experiences Scale (SAES) to develop a list of specific sources of sexual information.
sexual health
Items drawn from the SAES included receiving formal sex education, informal sex
education via discussions with parents/relatives, informal sex education through
discussions with friends, and use of legal, sexually explicit materials (i.e. videos
or magazines). Informal sexual education from non-explicit sources, such as books,
magazines, television, and web sites, was also included. In addition to indicating
whether they had used each source of information during their adolescence (ages 12-19
years), participants indicated whether such sources had been used in early adulthood
(ages 19-40), middle-adulthood (ages 41-64 years), and when applicable, later adulthood
(age 65+ years). Most (61.5 per cent) reported receiving formal sexual education in
adolescence. About 18.3 per cent reported formal sexual education in younger
adulthood, 5.4 per cent in middle-age, and only 0.2 per cent after age 65 years. Because
of the relatively low rates in middle-age and later life, we combined all post-adolescence
education to a single measure. Thus, 20.2 per cent had formal sexual education
post-adolescence. Figure 1 displays the per cent using a particular source, including
informal sources, by timing (never, adolescence, post-adolescence).
Similarly, we examined whether and when adults reported exposure to more
informal sources. Although about one-third (31 per cent) reported never speaking with
family about sexuality information, 56.3 per cent did so during adolescence, and 68.8
per cent did so post-adolescence. Relatively few (3.4 per cent) reported never having
acquired information from friends, with the majority sharing sexuality information
with friends during adolescence (74.9 per cent) and younger adulthood (69.5 per cent).
About 40.2 per cent relied on friends as a source of information in mid-life, and
2.7 per cent reported such discussions in late life. Virtually all (95.6 per cent) reported
gaining sexuality information from friends post-adolescence. Regarding print and
video materials, few reported having never used sexuality educational materials
(10.8 per cent); most (61 per cent) reported using such informal materials during
adolescence, 55.8 per cent reported these materials during younger adulthood, 25.1 per
cent during mid-life, and 8.3 per cent during late life. In total, 57.5 per cent reported
using informal media post-adolescence. Approximately 21.4 per cent reported
never having used sexually explicit media as a source of sexuality information. Half
(50.9 per cent) reported using explicit material during adolescence, 62.5 per cent during
younger adulthood, 37 per cent during mid-life, and 14.6 per cent during late life.
Percentage Reporting
Figure 1.
Sources of sexual
experienced by
age period
Discussions Discussions
Note: The age period of adolescence reflects experiences between ages
12 and 19. Post-adolescence refers to any experience after the age of 19
A majority (66.5 per cent) reported using sexually explicit materials as a source of
sexuality information after adolescence.
Safe sex knowledge. Safe sex knowledge was assessed using a composite scale
comprising of two open-ended items and two true/false questions pertaining to
knowledge of contraceptive effectiveness in preventing STIs (“Contraceptive pills
protect against STIs” and “Condoms are the only contraceptive protecting against
STIs”). Consistent with previous research (Part et al., 2008), participants were asked to
list all the contraceptive methods they knew. These were coded using categories
designated by Planned Parenthood (2014). A majority listed a male condom (92 per cent)
and hormonal birth control pills (86 per cent) as contraceptive methods. Fewer mentioned
intrauterine devices (44 per cent), diaphragms (20 per cent), spermicides (17 per cent),
abstinence (15 per cent), and surgical sterilization (15 per cent). Fewer than 15 per cent
listed other hormonal methods (e.g. injections vaginal ring, patches, implants), barrier
methods (e.g. vaginal sponge, female condom, cervical cap), and timing (i.e. rhythm/
Natural Family Planning).
We also asked participants to list as many “Sexually transmitted infections (STIs)/
Venereal Diseases (VDs)/Sexually transmitted diseases (STDs)” as possible. Although
adding the terms STD and VD was a modification to previous research (Part et al., 2008),
we believed that it was important to address cohort differences in the terminology used to
refer to these diseases in the 1950s through to the 1980s. To code the resulting list of
STIs, the CDC (2010) distinctions were used. The majority listed HIV/AIDS (71 per cent)
and gonorrhoea (69 per cent) as STIs. More than half listed herpes (59 per cent) and
syphilis (54 per cent), and 42 per cent listed chlamydia as STIs. Fewer mentioned pelvic
lice (17 per cent), genital warts (17 per cent), human papillomavirus (HPV: 15 per cent), or
hepatitis (9.0 per cent). Fewer than 3 per cent included trichomoniasis, bacterial vaginosis,
chancroid, pelvic inflammatory disease, or non-specific urethritis.
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