Changes over time in college student's family planning knowledge, preference, and behavior and implications for contraceptive education and prevention of sexually transmitted infections

College students today face new challenges in family planning. A mail survey with multiple follow-ups was used to assess changes in college students' knowledge, use, and preference about family planning from 1969 to 1996 at the same university. Data from a representative sample of undergraduates indicate that students in 1996 preferred fewer children than in 1969 and women preferred more children than men did. Knowledge about all contraceptive methods increased and more women were knowledgeable about sterilization than men. In 1996, knowledge of relatively newer methods (e.g., implants and injectables) was less than knowledge of the pill. The condom remained the most commonly used method, followed by abstinence and the pill. The pill was most preferred for spacing births. These results suggest that although efforts to educate young people about sexually transmitted infections (STI) prevention have had an impact on knowledge and behavior, increasingly comprehensive education about contraception and STIs is necessary.

The sexual behaviors and beliefs of young adults in the United States today are considerably different from 30 years ago. The children of the American "sexual revolution," today's college students face new challenges in sexuality and family planning. Studies of college and university students conducted between the 1970s and 1980s indicated that 75-80% of males and 60-70% of females had engaged in sexual intercourse, with a general trend of increasing prevalence over time (Reinisch, Sanders, Hill, & Ziemba-Davis, 1992). Not only are more young people deciding to engage in sexual activity without the intention of childbearing, but these decisions can have consequences beyond unplanned pregnancy. Young adults today must factor the risk of contracting the human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs) into the sexual decision-making process (Caron, Davis, Halteman, Stickle, 1993). The Centers for Disease Control and Prevention (CDC) estimated that two-thirds of STIs occur in people 25 years or younger (CDC, 1998). Latest estimates indicate that more than 15 million Americans per year become newly infected with an STI and individuals who are infected with an STI are at least 2-5 times more likely than uninfected individuals to acquire HIV in exposure to the virus through sexual contact (Cates, 1999; CDC, 2000).

The prevalence rates for other STIs such as herpes, genital warts, and chlamydia are higher than for HIV. An estimated 1 in 5 men and 1 in 4 women in the total adolescent and adult population carries genital herpes, or the herpes simplex virus (HSV) (CDC, 2000). An estimated 20 million people are infected with the human papilloma virus (HPV), the virus that causes genital warts, and studies have found that from 28% to 46% of women under the age of 25 are infected with HPV (CDC, 2000). Chlamydia, affecting over 3 million people each year, is the most common STD in the United States (CDC, 2000). Increases in the prevalence of sexual activity among young Americans place today's college and university students at a high risk for contracting an STI. Moreover, consistent use of protection is lacking. Results from the National College Risk Behavior Survey indicate that 84% of college men and 88% of college women report ever having had sexual intercourse. Among the 68% who reported having intercourse in the 3 months prior to the survey, however, only 26% of women and 35% of men reported using a condom at last intercourse. Only one-third reported consistent condom use (Douglas, Collins, Warren, Kann, Gold, et al, 1997). Longitudinal data indicate that condom use may drop off abruptly over the time of a college relationship. In one study, nearly half (43%) of college women reporting condom use at baseline no longer reported condom use at a 6-month follow-up (Kusseling, Wender, & Shapiro, 1995).

Improved technology for contraception and safer sex presents more options for students, particularly women. At the same time, however, these options further increase the complexity of the decision and the resources that are necessary to make and carry out sexual health and family planning choices. For instance, relatively new contraceptives such as progestin-only and combined estrogen-progestin injectables, contraceptive patches, and vaginal contraceptive rings expand options for highly effective, long-term birth control methods for women, but offer no protection against STIs. Male methods which serve both contraceptive and infection-prevention purposes remain limited to the condom, the effectiveness of which is largely dependent upon the knowledge and practice of users.

Since young men and women in their late teens and early twenties face a "high-risk" environment and new challenges in family planning, it is important to understand the knowledge, attitudes, and behaviors of college students. Moreover, data collected while young people are in college are important because it is at this time that sexual values are being further explored and solidified. Understanding how knowledge, attitudes, and behaviors have changed will help the current generation of educators and service-providers meet the family planning needs of college students. The research reported in this paper used the unique opportunity to compare "snapshots" of students' family planning knowledge, attitudes, and behavior in 1969 with those of students in 1996. Two questions guided the research: "What family planning knowledge, attitudes, and behavior have changed between 1969 and 1996?" and "How can understanding these changes help enhance family planning services to college students?"

Several studies have examined changes in sexual attitudes and behavior among college students since the 1970s. Whereas two studies found a peak in the permissive sexual attitudes and behavior of college men and women in the late seventies (Murstein, Chalpin, Heard, & Vyse, 1994; Murstein & Mercy, 1994), another identified no significant differences (DuBuono, Zinner, Daamen, & McCormack, 1990). On the other hand, a general trend among college men and women toward increasing sexual permissiveness between 1965 and 1985 has also been identified (Robinson, Ziss, Ganza, Katz, & Robinson, 1991).

Several studies have assessed contraceptive use among college students. A recent survey at one university found the condom to be the preferred method at first intercourse and also the most commonly used method for current sexual activity. Use of the pill increased with students' age. Almost half of the women and men surveyed said both pregnancy and infection prevention were their primary goals in choosing a contraceptive method. Younger women were more trusting of their partners' declaration of monogamy, although trust levels of both men and women increased with age (Siegal, Klein, Roghmann, 1999).

In terms of changes across time, studies have found that condom use among college students increased between the early 1970s and the 1990s (Murstein, et al, 1989; DuBuono, et al, 1990). These data indicate that, in 1991, the condom was ranked as the most preferred method by college men and women, followed, in rank order, by the pill and withdrawal. Use of the diaphragm, sponge, rhythm method, suppositories, and IUD decreased. A comparative study of college student contraceptive preferences showed that students in 1990 were more favorable toward the condom and the diaphragm than students in 1985, but less favorable toward the rhythm method, contraceptive foam, male sterilization, and IUDs. Oral contraceptive pills remained the most popular (McDermott, Sarvela, Gold, & Holcomb, Huetteman, & Odulana, 1993).

The most recent nationally representative data on contraceptive use in the United States come from the 1995 National Survey of Family Growth (NSFG) (Abma, Chandra, Mosher, Peterson, & Piccinino, 1997). Among women ages 15-44, the three methods used most frequently were female sterilization (17.8%), pill (17.3%), and condom (13.1%). An analysis of the NSFG data over previous years indicates that since 1982, use of the pill and diaphragm decreased, while condom use increased among unmarried U.S. women. This trend suggests that concerns about HIV and other STIs are changing patterns of method use among unmarried women (Piccinino & Mosher, 1998).

While nearly all of the research on college students has examined attitudes and behavior regarding sexual activity and contraception, we found none that assessed knowledge or changes in knowledge of contraceptive methods, including sterilization, over time. Moreover, we found none that assessed preferred family size. This paper presents such information, which is critical in designing and planning for appropriate family planning education on college campuses.