Electronic Journal of Human Sexuality, Volume 15, November 2, 2012

www.ejhs.org

Emergency Contraceptive Pill, Contraceptive, and Sexually Transmitted Infection Service Availability among U.S. College Health Centers

Scott M. Butler, PhD, MPH
Department of Kinesiology, Georgia College & State University

David R. Black, PhD, MPH, HSPP, CHES, CPPE, FASHA, FSBM, FAAHB, FAAHE
Department of Health and Kinesiology, Purdue University

George Avery, PhD, MPA
Independent Consultant

Contact Author: Scott M. Butler, PhD, MPH, Department of Kinesiology, Georgia College & State University, Campus Box 112, Milledgeville, GA 31061
scott.butler at gcsu.edu 478-445-1218

Author Note: This publication was supported in part by a grant provided by the Georgia College & State University Foundation.

Abstract

Objective: Assess the availability of contraceptive and sexually transmitted infection (STI)-related services among college health centers nationwide. Participants: Data were collected from 358 colleges and universities. Method: Using a cross-sectional design, a questionnaire was mailed and emailed to a geographically representative group of 1,200 colleges and universities. Results: Majority of health centers offer key contraceptive and STI services including emergency contraceptive pills (ECPs), hormonal contraceptives, HIV testing, and the human papillomavirus (HPV) vaccine, while the minority offer HIV swab and rapid tests. Multivariate assessment of variables revealed relationships between institutional demographics and service availability, with campus student population as the most frequent statistically significant predictor. Conclusions: Results provide a useful assessment of critical sexual health services among health centers nationally. Findings may be used to establish benchmarks for colleges and universities nationwide and may influence campus policies.

Emergency Contraceptive Pill, Contraceptive, and Sexually Transmitted Infection Service Availability among U.S. College Health Centers

In the U.S., sexually transmitted infections (STIs) and unintended pregnancy are associated with a variety of medical, public health, and economic factors (Centers for Disease Control and Prevention [CDC], 2011; Chesson, Blanford, Gift, Tao, & Irwin, 2004; Institute of Medicine, 1995; Monea & Thomas, 2011). The Patient Protection and Affordable Care Act of 2010 (PPACA; U.S. Department of Health and Human Services, 2010) has facilitated national discourse regarding the role of sexual healthcare availability and coverage among U.S. colleges and universities. In addition to other preventative services, the PPACA provides coverage of FDA-approved contraceptive methods and contraceptive counseling, HIV screening and counseling, as well as STI counseling for sexually active women (U.S. Department of Health and Human Services, 2011a). The PPACA also provides consumer benefits to students who purchase student health plans through their college or university (U.S. Department of Health and Human Services, 2011b).

Despite the importance of sexual healthcare availability among colleges and universities, few studies have been conducted to assess the prevalence of sexual health services among college health centers. The identification of these trends may be useful to college health clinicians, prevention specialists, and administrators who advocate for comprehensive sexual healthcare within their institution and may influence health center policy by identifying key service-related disparities nationally. In addition, large-scale national investigations are needed to establish sexual healthcare benchmarks among colleges and universities.

Finer and Zolna (2011) estimated that 51% of the pregnancies in the U.S. are unintended. A similar study by Finer and Henshaw (2006) reported an unintended pregnancy rate of 104/1,000 among women 20 - 24 years old, a rate twice that of the overall population (51/1,000). According to the 2010 Sexually Transmitted Disease Surveillance Report, 19 million or 6.1% of Americans are diagnosed with an STI each year (CDC, 2011). Adolescents and young and adults 15 - 24 years old represent significant STI-related disparities and account for nearly half of all new infections (Weinstock, Berman, & Cates, 2004).

Recent findings of the Spring 2011 American College Health Association (ACHA): National College Health Assessment II Survey revealed that 70.8% of college students have had vaginal, anal, or oral sex with at least one partner over the last 12 months (ACHA, 2011a). Among those who had sex with at least one partner during that time, collegiate men reported a M of 2.52 (SD = 4.33) sexual partners and women a M of 1.87 (SD = 2.07) partners. Among students who were sexually active, 60.6% used birth control pills to prevent pregnancy. In addition, 16.0% of participants reported that they (or their sexual partner) had used emergency contraceptive pills (ECP) within the last 12 months.

A national study of 358 institutions conducted by McCarthy (2002) indicated that 52.2% of schools nationally offer ECP. Recent studies by Miller (2011) and Miller and Sawyer (2006) have indicated that nearly half (43% and 49%, respectively) of colleges and universities in Mid-Atlantic States offer ECP to their students. According to the 2011 study by Miller, 56.9% of schools offering ECP to students are public institutions, 43.1% were private, 100% were 4-year institutions, and none were faith-based institutions. In addition, faith affiliation and institutional ideology have been reported as significant barriers to condom and safer sex product availability within colleges and universities in rural settings (Butler, Procopio, Ragan, Funke, & Black, 2010).

Another study by Koumans and colleagues (2005) assessed STI-related services including testing and education strategies among higher education institutions. Of the 910 colleges selected for participation, the investigators received completed questionnaires from 736 institutions (81% response rate). Results indicated more than 75% of health centers currently offered common STI testing for students including chlamydia (91%), gonorrhea (90%), herpes simplex virus (HSV; 81%), and HIV (78%). Similarly, 88% of all schools offered Pap tests for students. However, only 38% currently offered syphilis testing. An assessment of demographic variables indicated that when compared to 2-year colleges and universities, 4-year institutions were more likely to offer six of the eight key STI testing services (p < .05) including bacterial vaginosis, chlamydia, gonorrhea, herpes simplex virus, and trichomonas testing, as well as Papanicolaou (Pap) tests. Institutions with on-campus residential housing also were more likely to offer 6 of the 8 services (p < .05) including bacterial vaginosis, chlamydia, gonorrhea, herpes simplex virus, and trichomonas testing, as well as Pap tests  Private institutions were less likely to offer HIV testing when compared to non-faith-based schools (83% vs. 71% respectively; p < .05).

According to the 2010 American College Health Association Pap Test and STI Survey (n = 174), 97.7% of colleges and universities surveyed nationally offer routine STI screening for asymptomatic women and 92.4% for asymptomatic men (ACHA, 2011b). Nearly all (85.1% - 96.0%) offer chlamydia, gonorrhea, HIV, and syphilis screening for asymptomatic students and just over half (57.5%) offer HSV screening. With regard to HIV testing, three-quarters (75.9%) offer standard blood tests, while the minority offer HIV rapid blood and HIV rapid oral tests (23.6% and 21.3%, respectively).

The purpose of the present study was to assess ECP, hormonal and barrier contraceptive, and STI services within college health centers nationwide. Specifically, the foci of the study are four-fold and assessed the following: (a) percentage of college health centers nationally that distribute ECP to their student population with and without prescription, (b) percentage of college health centers that offer key barrier and hormonal contraceptive services, (c) percentage of college health centers that offer STI-related services including testing and vaccinations, and (d) ability of college and university demographics to predict  presence of the aforementioned services among college and university health centers.

Method

Recruitment Procedures

Permission was received from the University Institutional Review Board prior to conducting this study and collecting data. A geographically representative sample of 1,200 colleges and universities with student health centers was identified (see Butler et al., 2011a). Questionnaire and consent forms were both mailed and emailed to the directors of the student health center. Within 2-weeks, a reminder card was mailed to each of the student health center directors who had not returned the completed questionnaire. All recruitment procedures were completed by May 2009. Of the initial 1,200 institutions in the sampling frame, 358 (29.8%) completed the questionnaire. [See the Statistical Power Estimates and Sample Frame sections of our previous report by Butler and colleagues (2011a) for additional details regarding preliminary power assessments and construction of the sampling frame, which indicated sufficient power to detect a significant differences, if they existed.]  Data were collected as part of a large-scale national study of ECP, hormonal and barrier contraceptive, and STI vaccination and testing; as well as health center sexuality employee availability and prevalence/duties of sexuality peer educators. For the purpose of the present report, only data regarding ECP, contraceptive, and STI service availability were included in the final analyses. [See Butler, Black, and Coster (2011a) and Butler and Black (2011) for additional reports assessing condom availability and use of sexuality peer educators.]

Measures

Directors of the participating student health centers completed the Sexual Health Services Questionnaire (SHSQ) developed by Butler, Black, Avery, Kelly, and Coster (2011b). The SHSQ is a valid and reliable instrument specifically designed to comprehensively assess the availability of contraceptive and STI vaccination and testing as well as sexuality employee and peer-helper prevalence rates. As reported by Butler and colleagues (2011b), the SHSQ was reviewed by college health, public health, and human sexuality experts during developmental stages. In addition, the overall internal consistency of the instrument was .94, with internal consistency for individual subscales from .62 - .93. The internal consistency for the hormonal and barrier contraceptive items was .89 and STI vaccine and testing items were .92.

A test-retest assessment of 28 participants indicated a 87.37% reliability across all service-related items. The SHSQ includes 2 items regarding ECP distribution (with prescription and without prescription), 11 items assessing  hormonal and barrier contraceptives, 2 items  STI vaccines (HPV and Hepatitis B), 11 items  STI testing availability, 4 items assessing gynecological and post-sexual assault services, and 12 items regarding participant and institutional demographics. Contraceptive and STI items are dichotomous (yes/no) with 1 scored as yes and 0 for no.   

Data Analyses

Descriptive analyses were conducted on the contraceptive, STI, and participant demographic items. Mean and standard deviations were computed for the student population variable. Values from this variable were then converted to a categorically-based ordinal scale of measurement to assess the prevalence rate of contraceptive and STI services by population group. Multivariate logistic regression analyses were computed to assess the ability of the institution demographic variables to predict the availability of nine selected key sexuality-related services including the following: ECP with prescription, ECP without prescription, hormonal transdermal skin patch, hormonal vaginal ring, HIV testing (of any type), HIV rapid testing, HIV swab testing, HPV vaccine, and HPV DNA test for women.

Included in the analyses were the following demographic variables: region (South, Northeast, Midwest, West), type of institution (public, private), setting (urban, suburban, small town, rural), student population size (< 5,000, 5,000-9,999, 10,000-24,999, > 25,000), and religious affiliation (non-faith-based, faith-based).

Results

Table 1

Regional, Institutional, and Setting Demographics of Participant Institutions (n = 358).

Type of Institution

Setting

Student Population Size

Residential Characteristic

Religious Affiliation

_________________________________________________________________________

ECP, Hormonal, and Barrier Contraceptive Availability

Overall, 80.2% of all student health centers prescribed some form of hormonal contraception, with just over half offering ECP with and without prescription (52.9% and 52.1%, respectively). In addition, 50.6% of centers prescribe at least one non-hormonal contraceptive and 80.1% provide contraceptive counseling. Data regarding the percentage of institutions that offer hormonal and non-hormonal contraceptives are in Table 2.

Table 2
ECP, Hormonal, and Non-Hormonal Contraception Prescriptions (n = 357).

Results of the multivariate logistic regression analyses indicated that schools in the West were more likely than schools in the South to offer ECP by prescription (OR = 3.07, CI = 1.44 -6.55, p = .004). In addition, faith-based institutions were less likely to offer ECP by prescription than non-faith-based schools (OR = .18, CI = .07 - .44, p < .001). When compared to institutions with student a population of > 5,000, schools with populations of 10,000 - 24,999 and those with greater than 25,000 were more likely to offer ECP without prescription (OR = 4.50, CI = 2.19 -9.14, p < .01; OR = 16.72, CI = 5.00 - 55.92, p < .01, respectively). The final models for
demographic predictors of ECP by prescription and ECP without prescription are contained in Tables 3 and 4. Additional data regarding predictive ability of demographics for the hormonal implant, hormonal vaginal ring, and hormonal patch are contained in Tables 5 - 7.

Table 3
Demographic Predictors of ECP with Prescription Availability (n = 347).

______________________________________________________________________________

Table 4
Demographic Predictors of ECP without Prescription Availability (n = 347).

______________________________________________________________________________

Table 5
Demographic Predictors of Hormonal Implant Availability (n = 347).

______________________________________________________________________________
*p < .05. **p < .01.

Table 6
Demographic Predictors of Hormonal Vaginal Ring Availability (n = 347).

______________________________________________________________________________
*p < .05. ** p < .01.

Table 7
Demographic Predictors of Contraceptive Patch Availability (n = 347).

______________________________________________________________________________
*p < .05 **p < .01

STI and Gynecological Services

The majority of the participants (99.7%) reported data regarding their STI vaccination, testing, and gynecological services. Nearly three-quarters of institutions (71.1%) offered at least one type of HIV testing. However, less than half offered HIV swab and HIV rapid tests (30.3% and 23.0%, respectively). When compared to schools in the South, institutions in the West were more likely to offer at least one type of HIV testing (OR = 3.80, CI = 1.42 - 10.12, p < .05). In addition, when compared to schools with student populations of < 5,000, institutions with populations of 5,000-9,999, 10,000-24,999 and > 25,000 were more likely to offer at least one type of HIV testing (OR = 2.42, CI = 1.12-5.21, p < .05; OR = 4.21, CI = 1.88 – 9.47, p < .001; OR = 6.07, CI = 1.78 – 20.74, p < .001, respectively). Finally, commuter schools were less likely to offer at least one form of HIV testing when compared to residential institutions (OR =.42, CI = .20 - .86, p < .05). Similarly, nearly three-quarters (72.3%) offer HPV vaccination. Schools in the West were more likely to offer HPV vaccination when compared to those in the South (OR = 2.85, CI = 1.15 – 7.02, p < .05) and faith-based schools were less likely to offer HPV vaccination when compared to non-faith-based schools (OR = .29, CI = .13 - .64, p < .01). Finally, when compared to schools with student populations of < 5,000, institutions with populations of 10,000-24,999 and > 25,000 were more likely to offer the HPV vaccination (OR = 3.70, CI = 1.67 – 8.23, p < .01; OR = 27.00, CI = 3.33 – 218.00, p < .01, respectively).

The majority of institutions (73.7%) reported having a Clinical Laboratory Improvement Amendment (CLIA) certificate, whereas 22.7% did not have a CLIA certificate, and 2.5% were unsure. With regard to gynecological services, 85.7% offered clinical breast examinations, 82.6% Pap tests, 79.8% bimanual pelvic examinations, and 17.9% colposcopy services. In addition, 21% of student health centers conducted post sexual assault examinations and testing for students. Additional data regarding the availability of STI vaccination and testing are in Tables 8 - 13.

Table 8
Prevalence of STI Testing and Vaccine Availability (n = 357).

______________________________________________________________________________

Table 9
Demographic Predictors of HIV Testing (n = 346).

______________________________________________________________________________
*p < .05. **p < .001.

Table 10
Demographic Predictors of HIV Rapid Testing (n = 346).

______________________________________________________________________________
*p < .05. **p < .01.***p < 001.

Table 11
Demographic Predictors of HIV Swab Testing (n = 346).

______________________________________________________________________________
*p < .05. **p < .01.

Table 12
Demographic Predictors of HPV DNA Testing (n = 346).

______________________________________________________________________________
*p < .05. **p < .01.***p < .001.

Table 13
Demographic Predictors of HPV Vaccine (n = 346).

______________________________________________________________________________
*p < .05. **p < .01.

Discussion

Findings from this national study reveal that the majority of college health centers nationwide offer key contraceptive and STI services including hormonal contraceptives, ECP with/without prescription, HIV testing, and the HPV vaccine. These results indicate that college and university health centers have adapted to the availability of innovative sexual health products such as the vaginal ring, the transdermal patch, HPV DNA testing, and the HPV vaccine. However, of all the contractive services assessed, only the oral contraceptive pill was reported in > 75% of health centers nationally and less than half of all centers offer each of the non-hormonal contraceptive services. Similarly, only 5 STI services (gonorrhea, chlamydia, syphilis, trichomoniasis, and HSV testing) were reported among > 75% of health centers nationally. While the majority of centers offer at least one form of HIV testing (71.1%), less than one third offer HIV swab testing (30.3%) as well as HIV rapid testing (23.0%). Overall, findings suggest that the present service availability among health centers may not be sufficient to the meet the sexual healthcare needs of students and that additional initiatives are needed to increase availability.

The present study provides insight about the predictive ability of demographic variables of nine key sexual services. With regard to contraceptive services, significant differences were observed among institutions by region, student population, residential characteristic, and faith-based affiliation. Specifically, the Western region was more likely to offer ECP with prescription as well as the hormonal vaginal ring when compared to the South. In addition, institutions with larger student populations were more likely to offer ECP without prescription, the hormonal vaginal ring, and the contraceptive patch. Schools whose campus was primarily residential were more likely to offer the hormonal implant when compared to commuter schools and residential/commuter schools. Finally, faith-based institutions were less likely to offer ECP with prescription, ECP without prescription, and the hormonal vaginal ring.

Similar results were found with regard to STI-related services. Colleges and universities and universities with larger student populations were more likely to offer key services including HIV testing, HIV rapid testing, HIV swab testing, HPV DNA testing, and the HPV vaccine. Similarly, institutions with primarily residential student populations were more likely to offer HIV testing and HIV rapid testing and faith-based schools were less likely to offer HPV DNA testing and the HPV vaccine. When considering all of the multivariate comparisons in concert, student population size was the statistically significant predictor found in 80% of comparisons across both contraceptive and STI services. Overall, these findings suggest that student population size, geographic location, residential characteristic, and faith affiliation are associated with barriers to contraceptive services.

Findings of the present study are consistent with previous investigations of STI services among colleges and universities. For example, McCarthy (2002) found that 52.8% of student health centers nationally offer ECP by prescription, whereas the present study indicates that 52% offer ECP with/without prescription. While the present study is not a direct follow-up assessment to of the McCarthy (2002) study, findings suggest that the availability of ECP by prescription among U.S. college health centers has remained constant since 2002. In addition, results of present investigation are consistent with those of Miller and Sawyer (2006) as well as Miller (2011) who reported ECP availability among 49% and 43%, respectively within the Mid-Atlantic region of the U.S and those of Koumans and colleagues (2005) who reported HIV testing availability among 78% of colleges and universities nationwide. Koumans and colleagues (2005) investigation also reported less frequent HIV testing availability among private institutions as well as a positive relationship between STI prevention efforts and student population. Finally, findings from the present study are consistent with our previous reports (Butler & Black, 2011; Butler, Black, & Coster, 2011a), which found statistically significant differences among condom availability, number of condoms distributed/year, and use of sexuality peer educators across demographic characteristics among colleges and universities.

The present study has limitations to consider. First, the data procured are based upon self-reported assessment of the ECP, contraceptive, and STI service availability among college and university health centers. Given the overarching purpose of the investigation, self-report was the most viable option for a nationwide assessment. Second, while the sample size of the present study met the statistical assumptions associated with our sample size estimations (cf. Butler, Black, & Coster, 2011a), there may be limitations in generalizing findings from institutions with low demographic representation (e.g, Historically Black Colleges and Universities). However, the present investigation is consistent with that of McCarthy (2002), Miller and Sawyer (2006), Miller (2011), as well the 2010 ACHA Pap Test and STI Survey (ACHA, 2011b) that reported sample sizes of 174 - 358. Third, data were collected prior to the passing of the PPACA and therefore this legislation had no impact upon service availability. However, the present study may serve as a viable national assessment of service availability prior to PPACA and therefore, could be used for future pre- and post-comparisons. Finally, while the overarching purpose of the present study was to assess the availability of selected sexual health-related services on campuses, as well as demographic predictors of these services, no data were collected on the overall utilization of services by the student population or the prevalence rates of university employees who refer students to outside agencies for sexual healthcare when services are not available on campus.

Future research is needed to further investigate the availability of sexual health services among health centers. Specifically, representative studies with large sample sizes would be beneficial in identifying service-related disparities among college and university health centers. In addition, studies are needed to assess factors which influence the availability of services such as resource allocation, institutional ideology, policy development and implementation, as well as social and physical environmental factors.

There is a dearth of published investigations to assess the prevalence of sexuality-related services among U.S. college health centers. Findings from the present investigation provide a comprehensive assessment of services on a national level and have implications for prevention programs among colleges and universities. In addition, this study is the first to provide multivariate assessments of the predictive ability of key university demographic variables. Overall, these findings can assist in the establishment of contraceptive and STI service benchmarks among health centers nationally and corresponds with the recent focus on prevention recently passed by the Supreme Court.

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