Background
Methods
Design
Setting
Participants
Procedure
Student focus groups
Health care provider and administrator interviews
Data analysis
Member checking
Results
Participants | University A | University B |
---|---|---|
Focus Groups (N = 56) | ||
Male Students | 10 | 9 |
Female Students | 14 | 12 |
LGBTQ Students | 6 | 5 |
Total | 30 | 26 |
Key Informant Interviews (N = 7) | ||
Administrators | 1 | 1 |
Physicians | 3 | 0 |
Nurses | 1 | 1 |
Total | 5 | 2 |
COM-B | TDF Domain | Themes | Belief Statements | Participanta | |
---|---|---|---|---|---|
Students | HCP/Admin | ||||
Capability | Knowledge | 1. Limited sexual health knowledge and awareness | Knowledge and awareness of the services is important to know when and how to access First year students lack sexual health-related knowledge and find it difficult to remember where to go or how to access services Students have questions but do not know where to go, which can lead to a cycle of misinformation Students have go-to informants for sexual health information, including Residence Assistants (RAs) and the internet | ✔ | ✔ |
2. Lack of clarity for LGBTQ students | LGBTQ students do not always understand what they are at risk for or what services they should be accessing Some health care providers do not feel confident providing sexual health care to LGBTQ students | ✔ | ✔ | ||
Memory, Attention, Decision-Making Processes | 3. Visibility of sexual health services | Certain prompts and reminders help students to remember to access their sexual health services, including emails, posters, Facebook groups Sexual health service use can be a game of hide and seek – students have to go searching for information related to the health clinic | ✔ | ✔ | |
Opportunity | Social Influences | 4. Health care provider interaction | Students favour seeing the same health care provider for continuity in their care Student-HCP interaction (both positive and negative) during a sexual health visit impacts their experience with care and willingness to return | ✔ | ✔ |
5. Peer influence | Supportive friends promote access of sexual health services There is a stigma related to accessing sexual health services which prevents service use Seeing classmates at the clinic is uncomfortable Female students felt a sense of responsibility to access sexual health services to protect both themselves and their partner’s health. | ✔ | – | ||
Environmental Context and Resources | 6. Campus culture | University culture promotes sexual experimentation and exploration, risk taking behaviour, and avoidance of health promotion behaviours such as sexual health service use It is important to have sexual health services available in an environment that promotes risk-taking behaviour | ✔ | – | |
7. Accessibility of services | Financial access: students are paying into the wellness fund, so they feel as so they should use the services Hours of operation can help or hinder students’ access depending on their flexibility Location of services is an important characteristic Wait times hinder students’ access; students are forced to miss class due to wait times | ✔ | ✔ | ||
Motivation | Beliefs about Consequences | 8. Period of exploration and experimentation | University is a time of sexual exploration and risk-taking behaviours; it is important to have these services available during this period | ✔ | – |
Optimism | 9. Normalizing sexual health | Some students are seeing trends towards normalizing sexual health and access of sexual health services There is a trend towards sex-positivity which supports service use | ✔ | ✔ | |
Beliefs about Consequences and Emotions | 10. Stigma, privacy and confidentiality | There is still a stigma related to accessing sexual health services Students feel a range of emotions when accessing sexual health services (awkward, discomfort, frustration, shame) Services that value privacy and confidentiality can mitigate the negative emotions | ✔ | ✔ |
Barriers and Enablers | COM-B and TDF Domains | ||||||
---|---|---|---|---|---|---|---|
Capability | Opportunity | Motivation | |||||
Psychological | Social | Physical | Reflective | Automatic | |||
K | MAD | SI | E | CO | OP | EM | |
Limited Sexual Health Knowledge | ✔ | ||||||
Lack of Clarity for LGBTQ Students | ✔ | ||||||
Visibility of Sexual Health Services | ✔ | ||||||
Health Care Provider Interaction | ✔ | ||||||
Peer Influence | ✔ | ||||||
Campus Culture | ✔ | ||||||
Accessibility of Services | ✔ | ||||||
Period of Exploration and Experimentation | ✔ | ||||||
Normalizing Sexual Health | ✔ | ||||||
Stigma, Privacy and Confidentiality | ✔ | ✔ |
Capability
Limited sexual health knowledge and awareness
“And a lot of students come from out of province, and they’re here, and they’re just like, ‘Wait, I have to go to the hospital to do this?’ And it becomes like a cycle of misinformation. And it took me a long time to figure out all those things.” – University A FG #1
“I found that when I was a resident at least, and this was only a year ago, that the RAs [Residence Assistants] were great with making us aware of like consent and sexual health awareness and stuff like that…the RAs are primarily where I got the information about where to go and who to see.” –University B FG #2.
Lack of clarity for LGBTQ students
“I found there’s been like an interesting assumption that like I know what I need to be tested for. Like I’ve been asked like, ‘Oh, do you want to be tested for HIV, do you want…’ And I’m like, ‘I don't know what I need to be tested for.’ Especially because like as a woman who sleeps with women, it’s like I don’t really know. We don’t really have a lot of education around what we could be exposed to. So I’m just kind of like, ‘Test me for what you think I need to be tested for.’” - University A FG #3
“And sometimes for me, like I don’t have a lot of experience with like the trans community and those different types of communities. So sometimes I’m uncomfortable.” – University B Health Care Provider Interview
Visibility of sexual health services
“Like my partner and I have like actually searched for it, and we couldn’t find it. So we ended up just going to the doctor. But we’ve actually been looking for it and we just didn’t know where to check.” – University A FG #1
Opportunity
Health care provider interaction
“I’ve had like situations where… well, like the doctor that I see regularly, he always is like if there's something wrong like I’ll call you. And I guess I have a relationship with him that way so I don’t mind waiting in that way.” – University A FG#2
“I had a bad experience with one particular doctor, and I didn’t know which days they would be working. And if I needed to go that day, and there were the only one working, then I wouldn't want to go there.” - University B FG #1
“Even though I go to the same doctor, she often forgets that I’m gay. And so I repeatedly have to come out to her in terms of like if … Like she’ll just see my file and see that I’m not on birth control, and she’ll be like, “Why aren’t you on birth control?” … And I have to like disclose again. And it’s just kind of uncomfortable because it’s like why don’t you remember this?” - University A FG #3
“I think being able to talk to a student in a language…. to be able to find a common language. Because you know, if you’re just using very medical terminology, that doesn’t always…it’s not always understood by the patient.” – University A Health Care Provider Interview.
Peer influence
“Any time that I know that there’s a pop-up clinic or anything going on, like I’ll text my roommates and be like what’s happening. I mean it’s not related to that but like it’s just… it’s kind of a fun thing to do together…. and you know, you can make a little date out of it with friends.” – University A FG#1.
“I mean there's still a stigma around people going to access these services and just people as sexual human beings. So I think when you have it on campus, there's always a fear that you're going to bump into someone that you know, and you don't know how they’re going to receive that. I think most of the people are like, “Good for you.” Like that’s a good thing to go do. But you never really know how people are going to react and who you’re going to see there.” – University A FG #3
Campus culture
“And I agree, like I think it’s super important at this stage especially just because like of different things that come with the culture and experimenting.” – University A FG #2
“Like obviously if you’re like sexually active and like you're engaging in multiple partners, like because this is university and everyone’s so out there and experimenting with so many different things, that like it’s good to go get yourself checked out and like make sure your partners are checked out.” – University B FG #3
Accessibility of services
“At the same time, I like accessing services on campus because I feel like campus is a safe place. Like I’m here every day and I love it, I’m familiar with it. So I like it in that sense.” – University B FG #1
“It’s right underneath [Building Name]. So like it’s right underneath like a res[idence]. And it’s like it’s just an awkward placement. And it’s not really like there it is. Like you have to like really walk by and then see it.” – University B FG #2
“The only time I went to the on campus health clinic for sexual health, I waited there for probably about an hour and a half or 2 h. And I was missing my classes. And I went up to the receptionist and I said, you know, I’m missing my classes. You know, I have a quiz today. I can’t just, you know, skip my quiz but I need this [STI] test. And she said, “Oh, like I can try but I can’t do anything for you.” So I left and I never went back there. Because like when can you find the time to again skip your classes” – University B FG #1
Motivation
Period of exploration and experimentation
“It’s needed, point blank. Especially I think at this age where, I don't know, people I guess are maybe experimenting.… And like trying different things like meeting people and all that kind of stuff. So it puts you in situations where you need those kind of services maybe more so than at other stages in your life.” – University A FG #1
Normalizing sexual health matters
“I think I’m optimistic just because of how normalized it is around campus. And I think like the pop-up clinics do a really good job of normalizing it. And like I know res[idence] life and having those like let’s talk about sex things, it really opens the conversation.” – University A FG #1
Stigma, privacy and confidentiality
“I don’t like seeing other students, especially if I’m there for sexual health reasons. And I’ve had bad experiences in the past where they would say out loud that like I’m there for a pap test. And it's a small place. So like people in the waiting room could hear that. And it just made me uncomfortable.” – University B FG #2
“Because there’s an awful lot of personal anxiety around sexual health. Clearly there are barriers to conversation and communication. So obviously stressing confidentiality and expressing some comfort in conversation is important for them to open up about their own anxiety and concern.” – University B Health Care Provider Interview