MATERIAL AND METHODS

Sixteen year old girls commencing their upper secondary school education in a middle sized Swedish city participated in a 2 year study about sexuality and STDs, as described previously.⁵ Seven years later, women who completed all aspects of the teenage study⁵ were invited to take part in a follow up assessment. The women were assessed at the age of 23 years using the same techniques as in the assessments at 16 and 18 years of age—that is, a face to face interview about family, sexuality, knowledge and attitudes to contraceptives and STD, and a standardised self administered multiple choice questionnaire which included relevant, practical questions about how to identify and avoid STD, consequences of STD, and forms of treatment. The numbers of correct answers were added up in a score, in order to compare the level of knowledge over time. A visual analogue scale (VAS) was used to assess subjective feelings.

RESULTS

Seventy nine of the 88 women (90%) who completed all aspects of the previous 2 year study participated in the 7 year follow up. There were no statistical differences between the responders and non-responders with regard to family background, sexual experience, and socioeconomic status (assessed at the age of 18 years). The mean age of the 79 women was 22.8 years. Two women were still virgins (2.5%), 29 had been pregnant (37%), and 23 women (29%) had given birth. Mean age for coitarche was 15.7 years. The mean number of lifetime sexual partners was 5.9 (compared to 3.9 at the 2 year control). Sixty five women (82%) had a steady partner for a mean period of 3.5 years. Seventy one women (90%) reported sexual intercourse within the past 6 months, of whom 17 (24%) reported sex with a new or occasional partner. Nineteen women (24%) mentioned a history of STD. Most women had left school after 12 years and 57% had a job.

The anxiety of becoming infertile was much higher than the anxiety of being at risk for contracting an STD (expressed as 4.6 and 2.2 respectively, p<0.001, on a visual analogue scale from 0–10). The knowledge score reflecting awareness of how to identify and to avoid STD, consequences of STD, and forms of treatment are shown in table 1. All women knew that chlamydia can be spread during coitus when not using a condom. All but three knew that the partner has to attend for an examination if a chlamydia infection is diagnosed. Eighty per cent of the women were aware of the possibility of finding asymptomatic carriers of a chlamydia infection. Contrary to the findings regarding chlamydia, only 49% and 38% respectively knew that HPV and herpes could occur non-symptomatically. Only two women could imagine the possibility of having transmitted an STD infection to their partner at the last coitus, and only one woman could imagine the corresponding risk of transmission to her. Half of the women had received information about STD during the past year, the majority by reading papers and books. However, no differences in knowledge were seen regarding reported recent information about STD or not.

A higher level of knowledge regarding STD was associated with an experience of more partners, a history of STD, smoking, and the more frequent use of alcohol (table 2). The use of condoms was no more common among women with recent new partners than among women with a steady partner for more than half a year. Among 17 women reporting a new or occasional partner during past 6 months, four women reported use of a condom at some time during that period. These four women had a high total level of knowledge (mean 9.0).

DISCUSSION

This study has shown fairly good and consistent knowledge about genital chlamydia infections but inferior knowledge regarding viral infections, especially HPV. Although good knowledge is a necessary prerequisite for safe sexual behaviour it does not in itself ensure an adequate protective behaviour. Most women seem to have been at a higher risk for STD transmission as teenagers and at the age of 23 most of them reported a steady partner.

A history of more risky behaviour was associated with a higher level of knowledge about STD. Nevertheless, only 24% of the women who reported a new or occasional partner during past 6 months reported the use of a condom at some time during this period, indicating as in previous studies⁵ that knowledge did not affect their behaviour.

One of the most important findings was the low awareness of HPV and herpes as asymptomatic infections. Information has to focus more on the possibility of asymptomatic transmission, motivating the use of condoms. The concerns about how to act with regard to asymptomatic transmission is alarming, especially with viral infections, as these infections cannot be managed by diagnostics, treatment, and contact tracing. An indistinct policy by physicians can contribute to this uncertainty.⁶

The tendency towards an underestimated perceived relative risk for STD transmission represents an important reason for inappropriate behaviour.⁷ Traeen and Lewin focused on the fact that adolescents in the Nordic countries are good at contraception but appear to have problems in taking adequate STD precautions.⁸ They proposed that young people find it “natural” to perceive themselves and their partners as fecund but do not accept as “natural” that they or their partner may be carriers of an STD. The paradoxical association between a higher level of knowledge about STD and the experience of more partners and histories of STD indicates that the resultant contact with the healthcare system probably is one of the most effective educational tools.