Sexual health literacy, parental education, and risky sexual behavior among college students in Sierra Leone

Abstract The primary aim of this study was to investigate the intricate relationship between sexual health literacy, parental education, and risky sexual behavior among male and female college students in Sierra Leone. Employing a cross-sectional design, we sampled 338 university students (mean age = 24.3 years, SD = 5.63 years) from two colleges in Sierra Leone during May and June 2017. The study utilized structural equation modeling with a maximum likelihood estimation approach to explore the interplay between students’ knowledge of sexually transmitted infections (STIs), sexual and reproductive health, and gender violence. Our findings revealed significant associations between parental education and sexual risk behavior. Specifically, father’s education (loading factor = .843, p = .0001) and income (loading factor = .695, p = .0001) emerged as the strongest contributors to sexual health literacy among college students. Moreover, our analyses unveiled the influence of education on sexual risk (β = -.128, p = .05) and the impact of STI knowledge on sexual risk (β = -.160, p = .05).These outcomes underscore the pivotal role of parental education in shaping sexual health literacy and ultimately influencing risky sexual behaviors among college students in Sierra Leone. Our study emphasizes the need for targeted efforts to equip college students with accurate sex education information, with consideration given to the role of parental education in this context.


Introduction
Recent research highlights the propensity of college students in specific contexts to engage in risky sexual behaviors, which can lead to a range of adverse outcomes.Such behaviors include early marriage, increased HIV risk, higher rates of abortion, unprotected sex, multiple sexual relationships, and the transmission of sexually transmitted infections (STIs).For instance, early marriage has been identified as a significant contributor to the high prevalence of HIV infections in sub-Saharan Africa (SSA) (Aluisio et al., 2022;Yoosefi Lebni et al., 2023).Early marriage tends to increase coital frequency, reduce condom usage, and compromise a young married woman's ability to negotiate safe sex (Yoosefi Lebni et al., 2023).Recent data from Demographic and Health Surveys (DHS) collected in multiple African countries reveal that, on average, a significant percentage of sexually active girls aged 15-19 are currently married (UNICEF, 2022).Furthermore, a study conducted in sub-Sahara Africa found that married adolescent girls in urban centers had higher rates of HIV infection compared to their sexually active, unmarried counterparts (Petroni et al., 2017).Additionally, adolescent brides are more likely to enter polygamous unions, which further increases the risk of disease (Melesse et al., 2021).
Sexual health is a paramount concern among college students in sub-Saharan Africa (SSA) (Anwar et al., 2010;Gebresilassie et al., 2023;Melesse et al., 2020).Research indicates that 26% of college students in South Africa have reported experiencing pregnancy or fathering a pregnancy, a rate significantly higher than their U.S. counterparts (Heeren et al., 2007).Moreover, 15% of South African university students reported a history of STIs, compared to just 2% of U.S. students.In Sierra Leone, a country that has endured years of civil conflict and the recent Ebola crisis, adolescents aged 15-19 report significantly higher rates of early childbearing compared to the United States (Amin et al., 2022).Approximately 39% of Sierra Leonean youth marry before the age of 18, with 13% marrying before the age of 18 (UNICEF, 2018).
Despite their enrollment in higher education, college students in Sierra Leone may still lack essential sexual health knowledge and STI prevention skills (Mulwo & Chemai, 2015;Small et al., 2021).Notably, parents, as co-educators, play a pivotal role in shaping their children's knowledge on health issues (Amin et al., 2022).Parental education is highly influential, as it directly correlates with a child's ability to acquire and process information (Martinez et al., 2022).However, the relationship between education and knowledge about certain diseases, such as HIV/AIDS, is complex.In some cases, education does not correlate positively with knowledge (Zajacova & Lawrence, 2018).Additionally, research conducted in Zambia and Tanzania demonstrates that education has an inverse relationship with the risk of HIV infection (Hargreaves & Howe, 2010;Msisha et al., 2008), implying that educated individuals may engage in unprotected sex despite their awareness of HIV risks.It's crucial to note that HIV is the leading cause of death among young people globally, particularly among those aged 10 to 25 years in SSA (The Joint United Nations Programme on HIV and AIDS (UNAIDS, 2023;WHO, 2023).
In 2022, there were 39.0 million people living with HIV, 37.5 million were adults (15 years or older), including college students, with the majority (82%) living in sub-Saharan Africa (UNAIDS, 2023).Nearly 300,000 newly diagnosed HIV infections in adolescents aged 15-19 occur annually, with the majority (68%) of these cases emerging in SSA (UNAIDS, 2023).Given this context, universities represent critical knowledge hubs that can help bridge the gap in addressing sexual health literacy.Sexual health literacy encompasses a range of behavioral, cultural, and environmental components related to safe sex and reproductive health outcomes (Bogale et al., 2009).Sex education encompasses vital aspects of sexuality development, reproductive health, interpersonal relationships, affection, intimacy, body image, and gender roles (Lukolo & van Dyk, 2014).It also addresses the biological, socio-cultural, psychological, spiritual, cognitive, affective, and behavioral domains of individuals (Taris, 2000;Yabiku & Newmyer, 2022).Comprehensive sex education equips young women in SSA with the tools to prolong their education, reduce fertility rates, and empower them to negotiate safer sexual practices (Petroni et al., 2019).Specific interventions targeting individual behaviors, such as engaging in sex under the influence of alcohol or failing to use condoms to protect against STIs, can effectively reduce HIV incidence among college students in SSA (Melesse et al., 2020).
In the specific context of Sierra Leone, characterized by elevated rates of early childbearing and marriage, along with a complex socio-political history (Amin et al., 2022;UNICEF, 2018), this research aims to examine the relationships between education, sexual health literacy, sexual risk behavior, students' educational status, and parental education levels.As evidenced in prior studies (Aluisio et al., 2022;Amin et al., 2022;Anwar et al., 2010;Gebresilassie et al., 2023;Yoosefi Lebni et al., 2023), early marriage and risky sexual behaviors among college students have been associated with adverse outcomes, such as increased HIV risk and negative reproductive health consequences.The objectives of this study encompass a comprehensive analysis of these complex relationships to enhance our understanding of the factors influencing sexual health knowledge and behaviors among college students in Sierra Leone.This research seeks to provide empirical insights that can inform the development of targeted interventions and evidence-based policies to strengthen sexual health education and promote safer sexual practices in Sierra Leone.

Theoretical framework
The study applies the health literacy framework, which posits that individuals make informed health choices based on the information and knowledge they have acquired (Squiers et al., 2012;von Wagner et al., 2009).This acquired knowledge may stem from various external influences, including family (Batool et al., 2023), educational institutions (Amin et al., 2022), community (Kooli, 2021a), culture (Zrieq et al., 2022), and media (Kooli, 2021b).The framework comprises four fundamental components, each playing a crucial role in the decision-making process: (1) external factor stimuli, which encompass the various sources of health-related information and cues; (2) health-related stimuli, referring to the specific health information or cues that individuals encounter; (3) health literacy skills, necessary for comprehending the received stimulus and executing the associated tasks effectively; and (4) mediators that function as bridges between an individual's health literacy and the resulting health outcomes (Squiers et al., 2012).
The presented conceptual model (Figure 1) derives from the Centers for Disease Control and Prevention (CDC) framework for disease prevention in 2022.This model, often termed the Socioecological Model or Socioecological Framework, comprehensively integrates diverse ecological factors, including culture, community resources, family dynamics, and college status, to elucidate students' health knowledge.It elucidates the intricate interplay of determinants influencing an individual's health behaviors and outcomes, encompassing not only individual-level attributes but also the broader societal and environmental milieu (CDC, 2022).
In our study, we apply this model to assess students' sexually transmitted infection (STI) risk, considering health literacy skills, demographic variables (e.g., college education and family income), behaviors (specifically, sexual risk behaviors), and individual health literacy knowledge.We hypothesize that pursuing a college education fosters the development of crucial health literacy proficiencies, spanning areas such as comprehension (e.g., reading, writing, numeracy), communication (e.g., listening, speaking), and information-seeking, as delineated by Tavousi et al. (2022) and Rodgers et al. (2019).Additionally, we anticipate an inverse association between college education and STI and HIV behavioral risks.These risks include engaging in sexual activities under the influence of alcohol or drugs, inconsistent condom use, and involvement in multiple or concurrent sexual partnerships.

Study design and sample
Participants were recruited from two colleges in Sierra Leone between May and June 2017.One college was in the southern province of Sierra Leone, Bo, while the other was situated in the northern part of the country, Makeni.Ethical approval for the study was obtained from the first author's Institutional Review Board in August 2016 and the Sierra Leone Office of Ethics and Scientific Review Committee in May 2017.The selection of these two universities was based on their geographic accessibility to the researcher.
Prior to the survey, class instructors informed students about the study, and the survey was distributed during regular class periods.Informed consent was obtained from all participants, and participation was entirely voluntary, with no impact on students' course grades.Eligible participants were 18 years or older and enrolled at one of the two institutions, with the ability to read and write in English.The survey took approximately 40 to 60 minutes to complete.
To encourage participation, incentives were offered in the form of a lottery system, where students could pick a numbered ticket from a stack.Winning tickets, marked with a smiley face sticker, entitled the participant to a USB stick.Non-winning tickets were accompanied by a message expressing regret.Students were also informed that they could discontinue the survey if they felt uncomfortable and contact information for psychological counseling was provided.The study posed limited or no risks to the participants.

Data
The primary data collection for this study was conducted in 2017.Despite the temporal gap, the dataset retains its scientific relevance and significance for several compelling reasons.First, the enduring salience of the sex education and sexual and reproductive health awareness issue is unmistakable (UNAIDS, 2023).These concerns represent perennial subjects of societal and individual well-being, and their continued relevance underscores the enduring importance of the 2017 findings.They continue to shed light on the state of sex education and the knowledge landscape pertaining to sexual health, aspects that persist as ongoing concerns in the present scientific context.
Second, the limited progress made in addressing issues concerning sex education and sexual health knowledge among college students in Sierra Leone since 2017 is noteworthy (Robinson, 2015).The persistence of these issues serves as a critical indicator of the dataset's importance.It serves as a baseline against which the trajectory of developments and interventions in this domain over the years can be assessed.
Lastly, the dataset collected in 2017 holds substantial potential for long-term impact analysis.The comprehension of the status of sex education among college students during that period remains a valuable reference point for gauging potential enduring consequences.Through a comprehensive analysis of this dataset in the context of subsequent developments and initiatives, it becomes feasible to evaluate the efficacy and broader impact of policies and programs aimed at enhancing sex education and awareness of sexual and reproductive health.

Measurements
In our model, three latent constructs were considered: family socioeconomic status (SES), sexual knowledge, and sexual risk behavior (Table 1).Family socioeconomic status was gauged using the following questions: "What is your father's level of education?""What is your mother's level of education?"and "How would you describe your family income?"Educational levels were categorized as "no formal education," "primary education," "secondary education," "university education," and "postgraduate education."If a participant reported that their father or mother had an education level above high school, "parental education" was coded as "educated," while levels below high school were coded as "no education."Family income was classified as "lower than average," "higher than average," or "similar to the average family income."The SES construct demonstrated good internal consistency (α = 0.70).
Sexual knowledge was measured using the Sexually Transmitted Infections Knowledge Questionnaire (STI-KQ), a 27-item survey instrument (Jaworski & Carey, 2007).Participants answered questions by marking "correct" (1) or "incorrect" (0), assessing fundamental aspects of health literacy risk.The score was presented as a percentage of total correctly answered items to questions such as "There is a cure for gonorrhea," "It is easier to get HIV if the person has another STI," and others.The sexual knowledge construct exhibited strong internal consistency for our sample (Cronbach's α = 0.751).
Sexual risk behavior was evaluated using the Student Sexual Risks Questionnaire, which included inquiries such as "Have you ever had sexual contact?" "During the past 3 months, with how many people did you have sexual intercourse?""Have you ever received anything such as money or gifts from someone you would have sex with?" and others.The latent construct of sexual risk behavior demonstrated good internal consistency with a Cronbach's α of 0.69

Statistical analysis
We employed confirmatory factor analysis to assess how well the observed variables represented the three latent constructs: STI knowledge, sexual risk behavior, and family socioeconomic status.Structural equation modeling (SEM) was conducted with a maximum likelihood estimation method to evaluate the model's fit, applying specific criteria: an insignificant p-value in the chi-square test, indicative of an acceptable model; comparative-fit index (CFI) and Tucker-Lewis index (TLI) both exceeding 0.90, along with a root mean square error of approximation (RMSEA) less than 0.07.Data were analyzed using SPSS version 23.0 (IBM Corp., Armonk, NY, USA) and AMOS 19.0.Descriptive statistics were used for summarizing participant characteristics and the observed variables.In cases of missing data, a mean imputation procedure was employed (Dodeen, 2003).

Study framework
Our study drew from Coombe and Kelly's (2001) findings, which highlight that formal education enhances individuals' sexual knowledge and skills, enabling them to protect themselves from HIV infection.Based on this, our hypotheses posited that demographic characteristics (specifically, education and income), preexisting knowledge (conceptual understanding of sex education), and personal capabilities (the ability to make informed decisions about sexual matters) play a determining role in the development, refinement, and application of health literacy competency skills.Our research was guided by the following inquiries: (1) To what extent does the presence or absence of sex education influence the sexual behavior of university students in Sierra Leone?(2) To what extent do family income and education moderate a student's sexual risk behavior?(3) What is the level of STI knowledge within this sample of Sierra Leonean students, and to what extent does it influence sexual risk behavior?The primary objective of this study is to introduce a health literacy model to elucidate the sexual risk behaviors of college students in Sierra Leone.

Sample size estimation
To determine an adequate sample size for statistical power, we conducted a post hoc power analysis using the GPower method (Faul et al., 2007).Nineteen factor variables were deemed suitable for a sample of 338 students.The post hoc analysis revealed that the statistical power for this study was adequate, with a value of 0.40 for detecting small effect sizes and 0.99 for detecting moderate to large effect sizes.Our sample met this condition and had more than sufficient power (i.e., power > 0.80) for detecting moderate to large effect-size statistical power.

Sample characteristics
A total of 338 respondents successfully completed the survey, with the majority being women (61.3%).The mean age of the participants was 24.3 years (SD = 5.63 years).A significant portion of the respondents identified as college freshmen (84.8%), and when describing their family income, 44.8% considered it lower than average, while 47.9% regarded it as average.Regarding their parents' educational background, 5.7% of fathers and 14.9% of mothers had a primary-level education, 20.8% of fathers and 21.6% of mothers had a secondary-level education, and 38.9% of mothers and 29.9% of fathers had received no formal education.

Sexual risk behaviors
Participants self-reported various sexual risk behaviors, such as receiving gifts or favors for sex (25.0%) and having agreed to engage in sex because they were too afraid to say "No" (24.8%).Notably, most participants (87.8%) had engaged in sexual intercourse before the study, and 82.4% were either currently in a dating relationship or had been in one during the past year.Half of the participants (50.5%) reported never using condoms during sexual activity.Approximately 43.9% of the respondents admitted to having engaged in sexual activity with more than one partner, and 11.3% disclosed having sex under the influence of alcohol or drugs.A striking observation was that 55.6% of participants reported never being tested for HIV/AIDS and not knowing where to access such testing (80.3%).

Sexual risk knowledge
The participants' sexual risk knowledge was assessed using the Sex Education Literacy Scale.Approximately 80% of the respondents were aware that gonorrhea is a treatable disease, whereas 55.5% were not aware that being diagnosed with an STI is a risk factor for acquiring HIV.Moreover, 64.6% did not know that a woman with genital herpes could transmit the infection to her child.Surprisingly, 85.8% believed that a man must have vaginal sex to contract genital warts, and 83% thought that the human papillomavirus can cause genital warts (Table 2).These responses indicated a concerning deficiency in sex risk literacy among this specific group of college students.

Structural equation modeling (SEM)
SEM was employed to test the measurement model (Beran & Violato, 2010), examining the relationships among family income, parental education, students' level of education, sexual behavior, and knowledge about STIs.Using the maximum likelihood estimation method, the SEM model exhibited the best fit with composite factor scores.The statistical indicators revealed that the model fit well: X2(df = 101) = 121.030,p = .085,RMSEA = 0.024, TLI = .961,and CFI = .971(see Figure 1).In this analysis, no further modifications were made to the model to enhance its fit.All factor loadings exceeded .4,except for HIV testing (.102, p = .130),fear of saying "No" to sex (.195, p = .0001),and mother's education (.356, p = .0001).Father's education (.843, p = .0001)and income (.695, p = .0001)exhibited the strongest loadings for family status items.The factor loadings for sexual risk, STI risk, and sexual knowledge demonstrated a robust association between each loading and its respective items.The relationships between the latent constructs revealed a significant negative impact of education on sexual risk (β = −.128,p = .05)and STI knowledge on sexual risk (β = −.160,p = .05).

Discussion
This study aimed to explore the connections between college students' knowledge of sexually transmitted infections (STIs), parental education, and students' sexual risk behaviors.The results underscore a significant link between sex education knowledge and parental educational and income levels.Notably, fathers' educational attainment wields a more substantial influence on adolescents' sexual literacy compared to maternal education.These findings align with the National Responsible Fatherhood.gov (n.d.), which emphasizes that paternal involvement, particularly in children's education, leads to increased learning, better academic performance, and healthier behavior.It's crucial to recognize that although some research may indicate a stronger impact of fathers' education on adolescents' sexual literacy in specific contexts, it is not a universal rule, and various factors, including both parents and other elements, can significantly shape a child's sexual education.
The most concerning revelation is the knowledge deficit regarding sexually transmitted diseases among college students in Sierra Leone.What exacerbates this issue is the high prevalence of risky sexual behaviors among these students, such as engaging in unprotected sex (71.9%), having multiple sexual partners (21.2%), and never testing for HIV (55.6%).Additionally, a third of the students were unaware of the increased HIV risk associated with a diagnosis of an STI.This knowledge gap poses a serious problem, especially in a region with a high HIV prevalence, like sub-Saharan Africa (SSA).
These findings are consistent with previous research (Kanyemba et al. 2023;Lungu et al., 2022;Small et al., 2021) showing that college students often engage in risky sexual behaviors.To Another critical aspect that warrants attention is the gender disparity in education within Sierra Leone.Recent data indicates that male parents tend to have higher education levels compared to their female counterparts in developing countries (Le & Nguyen, 2022).This gender education gap is of paramount concern, given its substantial influence on students' sex education outcomes.Research has shown that parental education levels, especially those of fathers, can significantly affect the depth and quality of sex education students receive.
Furthermore, it's crucial to acknowledge the prevalence of gender-based violence among college participants in Sierra Leone (Robinson, 2015).This distressing issue underscores the urgent need to address deeply rooted cultural norms of male dominance and gender inequality within the sex education curriculum.Incorporating discussions about healthy relationships, consent, and gender equality into sex education can be instrumental in reducing the occurrence of gender-based violence and promoting safer and more equitable environments for students A substantial portion of the participants reported experiencing some form of violence, consistent with findings from Robinson (2015).Interventions aimed at addressing cultural norms that perpetuate gender-based violence and gender inequality should be an integral part of sex education.Since Sierra Leone still lacks reproductive health services for women living with HIV, this should be a priority area for the Sierra Leone government to improve women's reproductive health.

Limitations
This study was conducted at two universities in different geographic locations in Sierra Leone, which may limit the generalizability of the findings due to potential regional variations in knowledge and attitudes about sex.Furthermore, the cross-sectional design employed in this study restricts our ability to establish causal relationships.We also acknowledge the potential for limitations related to social desirability response bias and other factors that might influence self-reports of sexual and HIV risk behaviors.
In addition, it's important to note that our study exclusively focused on one aspect of sex education, specifically health risk behaviors associated with sexually transmitted infections (STIs).It's crucial to recognize that sex education encompasses a broader range of topics, including values, beliefs, and relationship skills, which were beyond the scope of this investigation.

Implications for Global Public health
Our study highlights the dearth of comprehensive sexual education and its adverse consequences, especially in resource-poor settings like Sierra Leone, which grapple with escalating chronic illnesses such as HIV/AIDS (UNAIDS, 2023; WHO, 2023).To address this, there is an urgent imperative to integrate robust sexual education programs into higher education curricula.These programs should encompass pivotal subjects, including HIV prevention, healthy relationship dynamics, consent, and gender equality, making use of established pedagogical techniques such as participatory education (Robinson, 2015).Moreover, parental education, notably paternal education, plays a substantial role in shaping students' sexual literacy (Le & Nguyen, 2022).Enhancing parental education is indispensable to enhance the quality and breadth of sex education received by students.These implications advocate for a multifaceted approach to elevate sexual health literacy among college students in Sierra Leone and akin sub-Saharan African regions.
Additionally, expanding the scope of sex education beyond sexually transmitted infections is imperative.A comprehensive approach should encompass a broader spectrum of subjects, including values, beliefs, and interpersonal skills.This comprehensive strategy aligns with the intricate nature of sexual health literacy, equipping students with the knowledge to make informed choices regarding their sexual health and well-being.For these interventions to be effective and evidence-based, a collaborative effort is requisite, involving the Sierra Leonean government, healthcare professionals, and educators.This collective endeavor is indispensable to institute a sustainable public health approach that mitigates the perils associated with risky sexual behaviors among college students.These implications are also pertinent to analogous regions in sub-Saharan Africa grappling with analogous issues relating to heightened HIV prevalence and precarious sexual behaviors (Bogale et al., 2009;Melesse et al., 2020;UNAIDS, 2023).

Conclusion
In light of the research findings and the prevailing challenges within Sierra Leone's college student population, it is evident that there is a pressing need for comprehensive and targeted interventions to address the concerning gaps in sexual health knowledge and behaviors.This study has revealed a significant lack of understanding about sexually transmitted infections (STIs) among college students, which, coupled with the high prevalence of risky sexual behaviors, poses a formidable public health challenge, particularly in a resource-poor country like Sierra Leone.It is imperative that the government, in collaboration with educational institutions, health professionals, and policymakers, takes concrete steps to address these concerns, thereby fostering a more sustainable approach to public health in Sierra Leone and similar contexts.Education, particularly sex education, remains a critical tool in mitigating the risks associated with risky sexual behaviors, empowering young individuals with the knowledge and skills needed to make informed choices about their sexual health.

Figure
Figure 1. Materials and Methods.

Have you ever received anything such as money, gifts, clothes, a cell phone or something else from someone so you would have sex with him/her?
(Coinco, 2010)ssue, a college curriculum that incorporates sex literacy knowledge is imperative.Participatory pedagogy, as suggested by previous researchers should integrate HIV/AIDS into the curriculum.Moreover, broad-based sex education should extend to all levels of education, including secondary education, as demonstrated by a UNICEF study in Sierra Leone(Coinco, 2010), which highlighted community practices and norms that posed health risks to teenage youth.