An Evidence-Based Educational Intervention Utilizing Technology to Provide Sexual Education to College Aged Students 18-24

Sexually transmitted infections (STI's) and sexually transmitted diseases are at their highest levels ever in the United States (US) with annual increases for the past six years. The Department of Human Health and Services (HHS) and the Centers for Disease Control are considering the rise in these levels the next epidemic crisis facing health care in the US. Half of all STI's and STD's are being contracted by those who are between the ages of 15-24 and the current education available is failing to address this crisis. This study was aimed at improving sexual education among college aged students 18-24 with the use of Media Aware, a technology-based application focused on sexual health and knowledge. This was meant to be a prospective randomized analytical experimental study with a control and intervention group to compare differences in knowledge after utilization of Media Aware. Participants were asked to complete three surveys (Pre, Post, 6-week Post) based on intervention (completion of Media Aware program and surveys) or control (completion of surveys only) status. The recidivism rate of participants in follow up of the project made it difficult to ascertain statistical significance between the intervention and control groups. Descriptive statistics related to 10 participants (intervention group) who only completed surveys one and two were evaluated, but each Likert type question failed to reject the Null hypothesis that knowledge was improved with the Media Aware program. This finding was repeated with the five participants (intervention group) who completed all three surveys. The sample size of the groups made statistical significance inconsequential. Positive trends in data related to the survey questions were promising and indicated that some knowledge was being obtained after using the Media Aware program. Further research with this program would be beneficial to other providers in this milieu. Education with the use of technology and a classroom setting may prove more beneficial to this age group. More studies should be aimed at the creation of teaching modalities that college age students between the ages of 18-24 are willing to utilize and/or seek out.

STI’S/STD’S, UNWANTED PREGNANCY, AND SEXUAL ASSAULT An Evidence-Based Educational Intervention Utilizing Technology to Provide Sexual Education to College Aged Students 18-24 William John Self Director of DNP Program: Ronda Lucey, DNP Project Chair: Julie Balk, DNP Content Experts: April Greener, DNP Westminster College of Nursing In Partial Fulfillment of the Requirements for the Doctor of Nursing Practice 1 STI’S/STD’S, UNWANTED PREGNANCY, AND SEXUAL ASSAULT Abstract 2 Sexually transmitted infections (STI’s) and sexually transmitted diseases are at their highest levels ever in the United States (US) with annual increases for the past six years. The Department of Human Health and Services (HHS) and the Centers for Disease Control are considering the rise in these levels the next epidemic crisis facing health care in the US. Half of all STI’s and STD’s are being contracted by those who are between the ages of 15-24 and the current education available is failing to address this crisis. This study was aimed at improving sexual education among college aged students 18-24 with the use of Media Aware, a technology-based application focused on sexual health and knowledge. This was meant to be a prospective randomized analytical experimental study with a control and intervention group to compare differences in knowledge after utilization of Media Aware. Participants were asked to complete three surveys (Pre, Post, 6-week Post) based on intervention (completion of Media Aware program and surveys) or control (completion of surveys only) status. The recidivism rate of participants in follow up of the project made it difficult to ascertain statistical significance between the intervention and control groups. Descriptive statistics related to 10 participants (intervention group) who only completed surveys one and two were evaluated, but each Likert type question failed to reject the Null hypothesis that knowledge was improved with the Media Aware program. This finding was repeated with the five participants (intervention group) who completed all three surveys. The sample size of the groups made statistical significance inconsequential. Positive trends in data related to the survey questions were promising and indicated that some knowledge was being obtained after using the STI’S/STD’S, UNWANTED PREGNANCY, AND SEXUAL ASSAULT 3 Media Aware program. Further research with this program would be beneficial to other providers in this milieu. Education with the use of technology and a classroom setting may prove more beneficial to this age group. More studies should be aimed at the creation of teaching modalities that college age students between the ages of 18-24 are willing to utilize and/or seek out. Keywords: sexually transmitted infections, sexually transmitted disease, education, knowledge, technology, prevention STI’S/STD’S, UNWANTED PREGNANCY, AND SEXUAL ASSAULT 4 An Evidence-Based Educational Intervention to Provide Sexual Education to College Aged Students 18-24 with Technology Sexually transmitted infections (STI’s) and sexually transmitted diseases (STD’s) have often been used synonymously, however, it is important to understand that STI’s are based on an infection state (lacking disease), some infections are asymptomatic, and STD’s have progressed to a disease state (causing damage to the body). There are many types of STI’s & STD’s that have been around for many centuries. Some accounts mention them in the Old Testament of the bible. These diseases have most likely been around since the beginning of mankind, but the way they are perceived, diagnosed, and treated has drastically changed. Some of the most common STI’s and STD’s include syphilis, gonorrhea, chlamydia, human papilloma virus, trichomoniasis, and human immunodeficiency virus (HIV) coupled with acquired immune deficiency syndrome (AIDS). This list is not inclusive but serves as a foundation for some of the most common sexually transmitted infections and diseases. “The World Health Organization (WHO) estimated there were 376 million infections of the 4 curable STIs—chlamydia, gonorrhea, trichomoniasis, and syphilis—in 2016, accounting for more than 1 million infections per day worldwide” (Adamson, et al. 2020, p. 1344). The largest concern at this point is how much these STI’s continue to proliferate over time instead of having an expected reduction in incidents. Clearly, we are failing at providing a knowledge base to help all humans, but specifically college age students between the ages of 18-24. The increase in rates are staggering, gonorrhea has increased by 63%, a 19% increase in chlamydia, and an extremely concerning level of 71% with syphilis, as determined in 2014 (Adamson, et al. 2020). Half of all the human immunodeficiency virus (HIV) infections occurring in the world today are to those aged 15-24, this young age reflects the stakeholders in this project (Mason- STI’S/STD’S, UNWANTED PREGNANCY, AND SEXUAL ASSAULT Jones, et al., 2016). Certain populations continue to have unusually high levels of HIV in 5 comparison, this includes racial and ethnic minorities, as well as men who are homosexual and/or bisexual (HIV.GOV, 2020). “The latest estimates indicate that effective HIV prevention and treatment are not adequately reaching those who could most benefit from them…” (HIV.GOV, 2020, para. 6). Again, we are not educating people, specifically those aged 18-24, and the US is at risk for seeing these levels rise when prior to the pandemic we were seeing a decrease in HIV levels. The estimated costs related to STI’s and STD’s is about $16 Billion in medical costs and the numbers for people with STI’s is around 1 in 5 people (CDC, 2021). This is the 6th year in a row with record levels of STI’s and STD’s (CDC, 2021). The Human Health and Services has declared STI’s and STD’s an epidemic that it is taking a toll on the quality of health in the US and increasing costs of healthcare to an already fractured system (US Department of Human Health and Service, 2021). The concern is that college aged patients between 18-24 are at an elevated risk for being infected with an STD’s/STI’s. The current educational resources appear to have compounded this problem and we must find a better way to educate this vulnerable population. Problem Statement College aged students from ages 18-24 are contracting STI’s and STD’s at an increased rate locally, nationally, and globally. The burden of sexually transmitted diseases (STDs) among people aged 15–24 years accounts for nearly half of all STDs reported in the U.S. (CDC, 2020). The numbers for Utah in 2019 are as follows: 11,071 Chlamydia, 2,883 Gonorrhea, and 428 Syphilis (2019 HIV and STD prevention and surveillance update, 2019). “This is the highest number of sexually transmitted diseases (STDs) ever reported in Utah” (Utah Department of STI’S/STD’S, UNWANTED PREGNANCY, AND SEXUAL ASSAULT Health, 2019, p. 1). The rates of HIV indicate that the state of Utah had 134 new cases in 2019. 6 The level relates to about 4.2 cases per 100,000 and according to the Utah Health Department, this level is “slightly higher than the 5-year average” (Utah Department of Health, 2019, p. 1). On a local perspective Utah is in desperate need of new ideas and legislation. The need for creativity and the utilization of technology cannot be overelaborate. Inconsistent education and the lack of federally mandated comprehensive sexual education are contributing factor to this problem, and the use of abstinence only education (AOE) does not address the problem. Most states in the US are teaching AOE and many of them are only briefly covering sexual education. Likewise, socioeconomic status related to environment, stigma, race, etc. are also contributing factors. New technological tools could increase the knowledge of college age students 18-24. Most students are accessing inappropriate methods of sexual education and failing to protect themselves against STI’s and STD’s. Review of Literature Inconsistent Sexual Education Previous attempts to address the growing rates of STI’s and STD’s have been ineffective. The inconsistent approach to sexual education and abstinence only education is not adequately reducing STI or STD rates. The more that society denies the problem the more our children are suffering from unnecessary infections and diseases. According to Brayboy et al. (2018) students in elementary, middle, and high school are only receiving limited exposure to sexual health education, including about seven hours in elementary school, 16 hours in middle school, and 20 hours in high school. Brayboy et al. (2018) notes that most states are not concerned with medically accurate information; only 13 states require this with their sexual education. STI’S/STD’S, UNWANTED PREGNANCY, AND SEXUAL ASSAULT The Guttmacher Institute has compelling evidence indicating that there are some states 7 that do not require any type of sexual education (Sex and HIV education, 2021). Moreover, about 26 states focus on teaching abstinence only, while another 18 states only focus on sexual education when one is married (Adolescent sexual and reproductive health in the United States, 2019). With the understanding that there are only about 12 states requiring some sort of discussion related to sexual education, the responsibility of education falls on the shoulders of the college environment. Sadly, the education in these 12 states does not appear to be heavily regulated and ground is being lost with sexual education (Adolescent sexual and reproductive health in the United States, 2019). Again, this should be seen as an opportunity for colleges to increase healthy sexual education. Some school districts allow exclusion of sexual education programs, some 80.4% of middle schools and 74.5% of high schools (Brayboy et al., 2018). Report after report indicated with empirical evidence that AOE does not reduce pregnancy, abortion, or even the initiation of sexual activities (Chevrette & Abenhaim, 2015). Further research clarified that abstinence only education continues to be the method of choice due to vast amounts of grant money being provided (Rabbitte & Enriquez, 2019). That fact that scientific evidence shows that AOE is not beneficial and is compounded by the fact that in 2008, “$177 million was allocated in the federal budget for AOE grants to states, with no funding for CSE [comprehensive sexual education] programs” clearly defines the problem (Rabbitte & Enriquez, 2019, p. 35). Furthermore, an increase of STI rates was apparent in states that adopted abstinence policies (Carr & Packham, 2017) and current sexual education had virtually no impact on teen birth rates and thus STI’s and STD’s (Chevrette & Abenaim, 2015). Policy does not appear to correlate with the opinions of the STI’S/STD’S, UNWANTED PREGNANCY, AND SEXUAL ASSAULT public, the public wants comprehensive education, they also want education on contraceptives 8 and condoms (Bleakley, et al., 2006). Social Determinates There are many reasons that the rates of STI’s and STD’s are on the rise. Consequently, it is important to note that there several social determinates that contribute to our health. In this case, health care providers must recognize that multiple factors contribute to this epidemic. Some of the contributors include urbanicity (unstable housing), drug use, poverty, stigma, race, decreased condom use (individual factor), and “[c]uts to sexually transmitted disease programs at the state and local level” (Tapp & Hudson, 2020, p.288). The final determinant is reflective of political involvement determining how education should proceed without regards to evidencebased research. The information is mirrored in by the CDC which concurs that interventions to curb the rise in STD’s and STI’s focus on social determinates (Tapp & Hudson, 2020). Education/Interventions Malcolm Knowles is known for his seminal working on how adults learn best. Henry (2011) explained that Knowles focus in 1975 was on the belief that adult learners are at their best when they are self-directed. According to Knowles as cited by Henry, (2011) self-directed learners are recognizing that they are adults when they realize, “psychologically” that they must learn independently within themselves (p.85). With this thought in mind the project would focus on the cohort’s ability to be self-directed. Considering that this age group of 18-24 has just entered into adulthood, this researcher wanted to put the ability of learning in the hands of the learner. By giving the control of self-directed teaching, the hope was that there would be more incentive to complete the Media Aware sexual health application. The hope was that this would improve each person’s self-identity. STI’S/STD’S, UNWANTED PREGNANCY, AND SEXUAL ASSAULT Of important note, one other study completed by Scull et al. (2018) among 18 and 19- 9 year-old community college students was completed with solid evidence on the efficacy of the Media Aware program for college students. However, the Media Aware program has been upgraded since this report and the intention of this research was to validate similar results in a similar population. However, the age was expanded from 18-24-year-old participants. Some of the questions are similar, but they have been simplified to encourage more participation Technology based teaching methods based on using computer, smart phones, and texting may be an effective method for improving outcomes for our adolescents and college aged students (Brayboy et al., 2018). This technology provides the option of reaching more people with less cost, more privacy, and the ability to personalize information if needed. Brayboy et al. (2018) further implies that using Media Aware type education (mHealth) with young women of color has been effective with teaching healthy sexual information and they have noticed that the use of applications “…have positive effects especially when targeted and tailored toward specific populations” (p.308). Understanding 95% of teens in the United States utilize “smartphones” on a regular a basis, whether this includes owning them or being able to utilize one at any given time, makes a persuasive argument for the use of technology to provide healthy sexual education (Brayboy et al., 2018). The current material viewed by adolescents and college aged students appears to be related to sexual functions, pornography, and inappropriate material that “reinforce sex stereotypes” and makes it extremely difficult to educate with healthy sexual information (Brayboy et al., 2018). If our nation took the time to utilize appropriate healthy sexual information in an application format, the hope would be to decrease the elevation in STI’s and STD’s. STI’S/STD’S, UNWANTED PREGNANCY, AND SEXUAL ASSAULT The state of Utah has seen increases in STI’s and STD’s (Utah Department of Health, 10 2020) and data from a small Student Health Services clinic at a liberal arts college noted a 2-3fold increase in STI’s and STD’s as well. The increased rate for STI’s and STD’s in the college age individuals created an opportunity to intervene and make healthy sexual education available in a format that the college age students 18-24 would utilize. One way of improving education is to utilize Media Aware software available on cell phones, laptops, and/or other operating systems that this age level is accustomed to using. Media literacy programs like Media Aware can help “promote healthier sexual attitudes, normative beliefs and behaviors” and can be “an important strategy to provide sexual education to larger number of youth, who are traditionally hard to reach” (Scull et al., 2018, p. 175). Research in other age groups and similar age groups has proven to be beneficial and can be utilized as an excellent means of comprehensive sexual education if educators, providers, and parents are willing to allow students access to this program. At this time, the specific college identified for the intervention of this project offered a sexual violence computer-based teaching program, but this did not focus on comprehensive sexual education specifically related to STI’s and STD’s. Purpose of the Project The purpose of this project included assessing current knowledge of STI’s and STD’s, providing a technologically based computer training program to increase knowledge on STI’s and STD’s, the end result being an increase in sexual educational knowledge to reduce the number of STI’s and STD’s college aged students 18-24 are experiencing. Project goals included using a technological based program that is simplistic, easily accessible, anonymous and educational. This coupled with the hope that this knowledge will help to reduce the amount of STI’S/STD’S, UNWANTED PREGNANCY, AND SEXUAL ASSAULT STI’s, and STD’s experienced by this age group. The long-term goal was to implement a tech- 11 based program that is available to all incoming college freshman. Theoretical Framework Margaret Neuman’s theory of the Unitary-Transformative paradigm (1991) and Rosswurm and Larrabee’s model of evidence-based practice (1999) gave inspiration for the education of college aged students from ages 18-24 in hopes to increase knowledge in regard to STI’s and STD’s. Neuman’s theory was focused on attention to the patient being a part of the team and helping in a mutuality to solve patient centered issues. The relationship was part of the present and required a mutual process to overcome issues. George (2002) in defining Neuman’s paradigm gives rise to the following: “The professional enters into partnership with the client. The situation that brings the client to the attention of the nurse is often one of chaos and, at the minimum involves circumstances [STI’s & STD’s] that the client does not know how to handle. The client is at a choice point and is seeking a partner to participate in an authentic relationship. The nurse and client trust that through the process of the unfolding of the relationship, both will emerge at a higher level of consciousness. The nurse [APRN] is with the client throughout the process” (p. 527). So much of Neuman’s paradigm encourages others to realize that they are a part of something larger than themselves and this author felt compelled to use this approach with the realization that this cohort should realize that life is more than one’s self. Utilization of A Model for Evidence-Based Practice from Rosswurm and Larrabee (1999) melding nicely with the direction of this project. The model relies on 6 primary steps to work STI’S/STD’S, UNWANTED PREGNANCY, AND SEXUAL ASSAULT toward a change when a problem or concern has been identified. These six steps include 12 assessing the problem of increased STI and STD rates; linking the problem with interventions which included increasing education, synthesizing best evidence which included utilizing the Media Aware education. The change intervention included completion of the technology-based education Media Aware intervention and statistical analysis evaluated the intervention. (Rosswurm & Larrabee 1999). The final step of the model, integration and maintenance were outside the scope of this project. Objectives of the Project Three specific objectives were created to help with maintaining direction and timelines, see Appendix A. The first goal was to Identify Current Sexual Knowledge related to STI & STD’s among college age students 18-24. The second objective was to provide up to 50 students Media Aware Application (intervention). This was a projection in an effort to have robust data for analysis. Finally, an evaluation of the effectiveness of healthy sexual education training with the use of pre and post surveys was completed. The project lead researcher created pre and post assessments based on a Likert type scale for the presentation of descriptive statistics after the conclusion of the study. The pre & post surveys were reviewed with both a DNP, Advanced Practice Registered Nurse and a PhD prepared individual as well as an Epidemiologist to validate relevance for data analysis. The data were compared to determine if the Media Aware program showed an increase in knowledge after completion of the program. Each of these objectives were completed throughout the specific periods outlined on the IRB proposal. Implementation of the Project This quality improvement intervention was implemented at a small college in Salt Lake City, Utah with a community population of roughly 2800 students, faculty, and staff. The clinic STI’S/STD’S, UNWANTED PREGNANCY, AND SEXUAL ASSAULT 13 is open in correlation with the semesters and May term which equates to about 9 months out of the year. This clinic has roughly 1200 students visit annually. Participants were approached for participation in the study though the student health clinic at a local college. This ensured that all subjects were eligible for inclusion. Participants were given information regarding the project and then completed the informed consent for participation. Randomization to the control or intervention group was completed via a coin flip. The cohorts were offered questionnaires, pre and post, and Media Aware (computer based sexual education software) was offered only to the intervention group. The goal was to have cohorts of 50 participants in both the control and intervention groups. Media Aware utilizes a college-based program with the ability of the users to login and complete four location modules with two and three lessons in each section (Media Aware, 2017). The average amount of time to complete the training is roughly two hours. The program provides comprehensive sexual education on STI’s & STD’s. Additionally, information is included about contraception, sexual violence, communication, and the use of recreational drugs/EtOH coupled with sexual outcomes (Media Aware, 2017). The idea of the program is to break the barriers of avoiding comprehensive sexual knowledge and encouraging healthy sexual communication. The program did not include all the intended teaching aspects that would benefit college age students, but it served as a valuable starting point. All participants in the intervention group were given a QR code and/or an email to log into the Media Aware website and additional information video was created for convenience purposes of participants (https://sites.Google.com/moffatfarm.com/healthysexed/home). Each aspect of the project was addressed in the video and provided specific details and in-depth information to complete the project. STI’S/STD’S, UNWANTED PREGNANCY, AND SEXUAL ASSAULT 14 Participants were asked to complete a pre- and post-questionnaire, at enrollment, a week later, and then approximately six weeks later to assess current and retained knowledge. These surveys were conveniently located on the website and were created using Google forms. The intervention group was offered Media Aware, a technological based teaching program (application for phone, laptop, or desktop). This was offered as a free application to the intervention group with the intention that they would be willing to complete the two-hour teaching program. Intervention participants were given 1 week to complete the 2-hour computer program with the benefit of retaining the program for a full year. A follow up survey was sent out approximately 6 weeks after to determine retention of information. The intended outcome was to show the significance of providing comprehensive sexual education with a technologically based platform to college aged students ages 18-24. This research also intended to give statistically significant evidence for the use of technological programs in an effort to reduce STI’s and STD’s among college ages students between 18-24 years. The research required approval from the Westminster College institutional review board (IRB). The IRB application was submitted, processed and approved prior to implementation of this project, see Appendix B. The students were incentivized with t-shirts and gift cards for the completion of all three surveys outlined in the project however, there was no cash exchange or funding accepted for this study. Funding for the study (Media Aware access) was completed with private funds. Participation in this study was completely voluntary and collected data from surveys were de-identified and results were reported in aggregate form only. There were no identified safety concerns for participants before or during this quality improvement project. STI’S/STD’S, UNWANTED PREGNANCY, AND SEXUAL ASSAULT Random identifiers were required for data input to protect all the subjects who 15 participated in the project. This was completed using the last four digits of phone numbers coupled with middle initials. This gave anonymity and privacy of personal health information to all participants of the control and intervention groups. Results Participants were recruited over a one and half month period between March and April of 2021. This effort was completed so that the final survey could be sent out to all participants 4-6 weeks after completion of the second survey. The final email correspondence was sent in May 2020, which gave ample time for all students to complete the first and second survey with the intervention group having time to complete the Media Aware program. The data indicated that the control group had 20 people complete the first survey and the intervention group only had 10 people complete the first survey. Additionally, 40 Media Aware programs were sent to participants, 13 people completed the program but only 10 completed the surveys. Seven people started but did not finish the program and 20 people never opened the Media Aware program. Data was studied, formatted, and finalized during May and June of 2020. The recruitment process resulted in a rapid uptake of participants within the first week. Within about three weeks there were 70 confirmed participants, which met the need for validity of the control and intervention groups, (see Table 1). The goal of 35 participants in each group was a sample size powered to obtain statistical significance. The first survey was completed by 30 of the previously mentioned participants (see Table 1). This number was the result after removing two duplicate surveys. There were 10 participants in the intervention group and 20 participants in the control group that completed the first survey. Only one participant in the control group completed the second survey. Therefore, no data was STI’S/STD’S, UNWANTED PREGNANCY, AND SEXUAL ASSAULT available to compare because the control participants did not complete the second or third 16 surveys. Lack of data from the control group made it impossible to run a comparison study in difference of change between the control group and the intervention group using T-tests. Data may have been compared with the first survey accounting for no difference in change for the control vs. the difference in change for the intervention, but this data did not seem appropriate while attempting to compare equal samples. Table 1 Survey Participants (Person to Person Consult And Coin Flip) 70 Students - Verbal agreement to particpate ↓ (Access to Video with Informed Consent) ↓ (Email/Text Correspondence) 30 Students - Complete First Survey ↓ → → → 1 Student Completes (Control) Second Survey 19 Students Did not Complete Second or Third surveys ↓ (Email/Text Correspondence) 11 Students -Complete → Second Survey (Intervention) 1 Student in Control ↵ ↓ ↓ (Email/Text Correspondence) 6 Students -Complete → Third Survey (Intervention) ↓ 1 Student- Did Not follow directions 10 Students= Prinary focus of Data 5 Students- Not enough for T-Test or Wilcoxin Rank Sum Test Furthermore, the participants in the intervention group were reduced tremendously while following the timeline for the project. Of the 10 participants in the intervention group, outlined in table one, only five completed the first, second, and third surveys (one of the participants STI’S/STD’S, UNWANTED PREGNANCY, AND SEXUAL ASSAULT completed two of the second survey and was removed from the sample). This made a 17 comparison study of the change in control and intervention groups difficult realizing that robust data comes from a sample size of at least 30 participants. Given the small sample size the Wilcoxon rank Sum test was utilized to determine if the 10 participants who completed the first and second surveys had a change in educational awareness of sexual health There was an insufficient number of participants that completed all three survey to utilize the non-parametric Wilcoxon rank Sum to determine if there was statistical change in knowledge education with the use of Media Aware. The Man-Whitney U test was utilized for the group of five participants, but each Likert type question failed to reject the Null hypothesis indicating no difference in the improvement of knowledge. The samples were too small, and the changes were extremely minor, however, the results were trending in a positive manner indicating some change in knowledge but not enough for statistical significance. The final pre & posttest surveys had 12 and 15 questions respectively, visually presented in Appendix C & D. Five of the questions were Likert type questions intended to be used for a comparison study between the control and intervention groups. These five questions were the same on each survey but were numbered differently from survey one to survey two. Qualitative data was obtained in Survey one as shown in Appendix E, Figure E1. This data included information on current knowledge, fulfilling objective number one. The data indicates that of the first 30 participants surveyed, 31% of students obtained sexual knowledge from friends and 31% from family. Of the same sample 43.8% believed they had healthy sexual education where 34.4% said they did not. Interestingly only 3% of participants admitted to having an STI or STD in the past month. With the last three questions of the first survey the rates STI’S/STD’S, UNWANTED PREGNANCY, AND SEXUAL ASSAULT of discussing sexual health with their physicians and partners was above 60% where only 46% 18 had discussed this with their parents. The following data on the second and third surveys, as depicted in Appendix E, Figure E2, had a sample size of 20 surveys (5 people that completed the survey twice). This indicates that a total of 15 people completed the first and second surveys. The information obtained demonstrated that 75% of the sample believed they had received healthy sexual education. This was a trend in a positive direction for the participants understanding that Media Aware was a form of healthy education. Additionally, 100% of this sample denied having an STI and/or STD in the past month. This may indicate that the participants understand the benefit of healthy sexual education. The number of participants that had discussed sexual health with their parents, doctor, or partner was greater than 75% reinforcing the importance of discussing sexual health with others. This increased by nearly 30% from the first survey. The most interesting information obtained in in survey two and three was in regard to the two questions related to the Media Aware program. The graph in Appendix E, Figure E2, demonstrates that 100% of the participants found the Media aware program to be helpful in their knowledge of healthy sexual education and convenient when learning about healthy sexual education. This supported objective three indicating improved knowledge with sexual education using the Media Aware application. Qualitative statistics were used to evaluate effective learning environments and results supported that students learn best with electronic education (45%) and classroom education (40%). This indicates that the use of technology coupled with classroom learning for healthy sexual education may be beneficial. STI’S/STD’S, UNWANTED PREGNANCY, AND SEXUAL ASSAULT In an effort to distinguish statistical significance between the surveys after participants 19 completed the Media Aware program, non-parametric Wilcoxon rank Sum test was utilized and the results are depicted in Appendix F & G. The preidentified alpha value for this project was a p-value of 0.05. Each of the Likert type questions showed a p-value > 0.05 with scores of 0.38, 0.5, 0.4399, and 0.5 respectively (see Appendix F & G). Therefore, the results failed to reject N0 in each question indicating no improvement of knowledge with the use of the Media Aware educational program. Fortunately, the trending of all data indicated a positive deflection supporting that a larger sample size may have shown improvement in educational knowledge. The trends depicted in Appendices H & I are promising for future research and with better participation from the sample audience, expectantly, evidence would support the use of the Media Aware as a method for increasing healthy sexual education among college aged students ages 18-24. Discussion Summary Of the 70 subjects that agreed to complete the project, five of them followed the directions on the video and completed all three of the surveys as outlined by the project. Due to the project only having five participants, the project was inadequately powered to make any statistical inferences. These results led to an attempt to determine if there was an increase in knowledge with the 10 students that completed just the first and second surveys. Utilizing the Wilcoxon rank sum test showed no statistical improvement, likely due to a small sample size. Although statistical significance could not be obtained the trending data on the survey questions indicated that those students who participated in the project appeared to improve their knowledge in relationship to STI’s and STD’s. This trending data gives promise to utilizing STI’S/STD’S, UNWANTED PREGNANCY, AND SEXUAL ASSAULT technology to improve the knowledge of 18-24-year olds. The qualitive data from questions 20 indicated that students were pleased when using the Media Aware program. All of the participants found some type of value in utilizing the program and felt that it was helpful for their knowledge. Media Aware appears to have the potential to be a successful means of education for college aged students. The students who accessed the program seemed satisfied with the information. Factors influencing the participants failure to complete the Media Aware program would be extremely beneficial information to further evaluate the effectiveness interventions such as this study utilized. This may be an area of study to explore with future projects. There also may be value in developing a method for incoming college freshman to participate in the Media Aware program as a requirement or as a supplemental course. Discussion In early 2020 the world was experiencing the Covid-19 pandemic and to control transmission schools and businesses were shut down. Despite this lock down, there continued to be an increase in the number of students seeking sexually transmitted infection and sexually transmitted disease (STI/STD) testing. The restriction placed on students appears to have made them seek out covert relationships possibly attributing to an increase the levels of STI’s/STD’s. This increase coupled with past experience over the last two years related to STI’/STD’s created the inspiration for this project. The rates are clearly higher given the timeline of this study. With the pandemic there is a good possibility that the rates of STI’s and STD’s may be even higher given the lack of ability and desire to make appointments with primary care providers. Students showed valuable interest while being recruited and seemed excited to start the program. Incentives were offered to students with completion of the project; however, this was STI’S/STD’S, UNWANTED PREGNANCY, AND SEXUAL ASSAULT 21 not enough to encourage completion. The pandemic led to the majority of classes being held in online format that led to students being required to complete all communication via internet. It is possible that this contributed to a high recidivism rate within the project. Another potential barrier to successful program completion could be that many of the students at the college were inundated with electronic correspondence making it difficult to find the project emails. Additionally, it is also possible that some of the participants did not check their college emails which was the format for project communications. Many students have multiple email accounts and this project focused primarily on the college emails. An additional consideration is that students of this age may be reluctant to participate in sexual education when it is possible that they came to college to engage in sexual relations without reparations. According to King et al. (2020) 45% of the students they surveyed did not take a human sexuality course because they already knew enough about human sexuality. It is possible that addressing comprehensive sexual health at an earlier age could support healthy sexual education in 18 to 24-year olds. Limitations The project was created with the intention of determining the sexual knowledge of college aged students; however, limitations must include that the project was implemented during a pandemic. The pandemic contributed to the lack of starting the project and perhaps to the lack of follow up with directions. College students were extremely concerned with protecting themselves, but they were also inundated with mandatory computer work occupying most of their days in online classes and studies. The addition of one more computer project to their schedules may have been overwhelming. STI’S/STD’S, UNWANTED PREGNANCY, AND SEXUAL ASSAULT It is possible that being in-person and providing Power Point type instruction on the 22 project could have been helpful. The presentation and directions being available in video format may have confused some of the participants and/or made it easier to avoid follow up. In discussions with other researchers related to this topic, the project may have had better attendance and follow through if it was presented with an oral presentation with visual instruction. Presenting the data in a classroom setting starting with the immediate completion of the first survey. There was a healthy number (40%) of subjects that indicated classroom instruction being of benefit. However, given the current situation with a pandemic, this option did not seem appropriate given the CDC recommendations for meeting in groups at the stage of the pandemic that the study was completed in. The time during the academic school year may have contributed to the lack of follow up as well. Students were completing finals during the timeline for the final survey to be completed. Therefore, implementing this project during the first semester of college, coming off a summer break, could have yielded better outcomes for the project. The students were finishing their final semester prior to a summer break and the education format was completely modified from the inperson education to an all online format. This project had the groundwork for success given the simplicity of the directions and expectations for completion; however, the results from this project disagreed with this hopeful expectation. Descriptive statistics were unable to give evidence of improved knowledge related to using the Media Aware program to increase health sexual education. There was an extreme amount of interest among students during the recruitment phase of the project. Unfortunately, this would prove to be a misrepresentation of reality for the project. Some of the participants failed to follow directions in regard to the control and intervention groups which could be due to STI’S/STD’S, UNWANTED PREGNANCY, AND SEXUAL ASSAULT design error. Utilization of email correspondence and text messaging proved to be futile in 23 garnering participation in the project. This may be in part to the time of year or the amount of time the program required to complete the training with Media Aware. Expecting students to participate in a two-hour project may have been too overwhelming. Conclusions STI’s and STD’s are on the rise and the CDC and HHS are declaring these rates as epidemic. These numbers reflect ineffective educational programs directed at reducing numbers. Programs such as AOE have not been effective at reducing prevalence rates therefore a gap in educational modalities for STI’s and STD’s exists. The lack of awareness to evidence-based research on the part of federal, state, and local officials is disconcerting. Reluctance and/or refusal to acknowledge the current data reflecting a six-year increase in levels will only harm society and increase the expense in health care. However, providers working with college age students between the ages of 18-24 need to recognize the importance of comprehensive sexual education, possibly through the use of Media Aware type programs. Based on the research in this project, Media aware, and/or other technological type teaching modalities, may be beneficial for this need. Based on the research completed Media Aware and other technological type programs may or may not be useful for teaching college aged students. However, the more research that is taking place to educate college aged students about healthy sexual education the greater the benefit for this population. Each similarly focused project has the ability to present evidence that is compelling to stakeholders for making changes to the current education system. Research indicates that students utilize technology frequently throughout the day; however, they are using it for the things they want to view. Clinicians, politicians, parents, and computer scientists need STI’S/STD’S, UNWANTED PREGNANCY, AND SEXUAL ASSAULT 24 to work together to create a comprehensive sexual education program that students will want to utilize. Some of the trending data indicated a positive change in attitudes toward healthy sexual education. Many of the participants who finished mentioned that the program was helpful and increased their knowledge. The data indicated that of those who completed the Media Aware program, more of them were willing to talk with their primary care providers, partners, and parents. The data also indicated that of those who completed the Media Aware program, none of them admitting having an STI or STD over the past month. These are promising results that may be compounded with further studies utilizing the Media Aware program with a larger cohort. Future implications indicate a need for new ideas and more creative thinking to combat the rise in STI’s and STD’s among college aged student ages 18-24. Media Aware may be a starting point for this education, but a variety of stakeholders such as providers, parents, politicians, and students must be engaged to support effective changes to reduce these increasing numbers of STI’s and STD’s. The utilization of new types of technology with the support of students, educators, and health providers may be a valuable team approach to creating beneficial sexual education programs in the future. STI’S/STD’S, UNWANTED PREGNANCY, AND SEXUAL ASSAULT References 25 Adamson, P. C., Loeffelholz, M. J., & Klausner, J. D. (2020). Point-of-care testing for sexually transmitted infections: A review of recent developments. Archives of Pathology & Laboratory Medicine, 144(11), 1344–1351. https://doi- org.ezproxy.westminstercollge.edu/10.5858/arpa.2020-0118-RA. Adolescent sexual and reproductive health in the United States. (2019, September). Retrieved from Guttmacher Institue: https://www.guttmacher.org/fact-sheet/americanteens-sexual-and-reproductive-health# Bleakley A, Hennessy M, & Fishbein M. (2006). Public opinion on sex education in US schools. Archives of Pediatrics & Adolescent Medicine, 160(11), 1151–1156. https://doiorg.ezproxy.westminstercollege.edu/10.1001/archpedi.160.11.1151 Brayboy LM, McCoy K, Thamotharan S, Zhu E, Gil G, Houck C. (2018) The use of technology in the sexual health education especially among minority adolescent girls in the United States. Current Opinion Obstetrics Gynecololgy, 30(5):305-309. doi: 10.1097/GCO.0000000000000485. Carr, J.B., Packham, A. (2017) The effects of state-mandated abstinence-based sex education on teen health outcomes. Health Economics. 26(4):403-420. doi: 10.1002/hec.3315. Chevrette, M., Abenhaim, H.A. (2015). Do state-based policies have an impact on teen birth rates and teen abortion rates in the United States? Journal of Pediatric Adolescent Gynecology, 28(5):354-61. doi: 10.1016/j.jpag.2014.10.006. Data and trends: US statistics. (2020, November 13). Retrieved from HIV.Gov: https://www.hiv.gov/hiv-basics/overview/data-and-trends/statistics STI’S/STD’S, UNWANTED PREGNANCY, AND SEXUAL ASSAULT George, J. B. (2002). Health as expanding consciousness Margaret Newman. In M. 26 Conner& B.A. Romph (Eds.), Nursing theories: The base for professional nursing practice (5th Ed) (pp. 519-538). Pearson Education, Inc. Henry, G. (2011). Malcolm Shepherd Knowles: A History of His Thought. Nova Science Publishers, Inc. King, B.M., Scott, A.E., Van Doorn, E.M., Abele, E.E., & McDevitt, M.E. (2020). Reasons students as a US University do or do not enroll in a human sexuality course. Sex Education: Sexuality, Society and Learning, 20(1), 101-109. Mason‐Jones, A.J., Sinclair, D., Mathews, C., Kagee, A., Hillman, A., & Lombard, C. (2016). School‐based interventions for preventing HIV, sexually transmitted infections, and pregnancy in adolescents. Cochrane Database of Systematic Reviews, 1-73, https://doi- org.ezproxy.westminstercollege.edu/10.1002/14651858.CD006417.pub3. Media Aware. (2017). Knowledge is power: prevent sexual assault and promote sexual health in college with Media Aware. http://mediaawarecollegeprograms.com Rabbitte, M., Enriquez, M. (2019). The role of policy on sexual health education in schools: Review. Journal of School Nursing, 35(1):27-38. doi: 10.1177/1059840518789240. Rosswurm, A., & Larrabee, J. H. (1999). A model for change to evidence-based practice. Image: Journal of Nursing Scholarship, 31(4), 317-322 Scull, T. M., Kupersmidt, J. B., Malik, C. V., & Keefe, E. M. (2018). Examining the efficacy of an mHealth media literacy education program for sexual health promotion in older adolescents attending community college. Journal of American College Health, 66(3), 165–177. https://doi- STI’S/STD’S, UNWANTED PREGNANCY, AND SEXUAL ASSAULT 27 org.ezproxy.westminstercollege.edu/10.1080/07448481.2017.1393822 Self, W.J. (2020, May 17). Sexually Transmitted Infections and Sexually transmitted diseases in college age students aged 18-24. Healthysexed. https://sites.Google.com/moffatfarm.com/healthysexed/home Sex and HIV education. (2021, January 23). Retrieved from Guttmacher Institue: https://www.guttmacher.org/state-policy/explore/sex-and-hiv-education Sexually transmitted diseases; adolescents and young adults. (2020, November 31). Retrieved from Centers For Disease Control: https://www.cdc.gov/std/life-stages- populations/adolescents-youngadults.htm Sexually transmitted infections prevalence, incidence, and cost estimates in the United States. (2021, May 16). Retrieved from Centers For Disease Control: https://www.cdc.gov/std/statistics/prevalence-incidence-cost-2020.htm STI national strategic plan overview. (2021, July 2). Retrieved from US Department of Health and Human Services: https://www.hhs.gov/programs/topic-sites/sexuallytransmitted-infections/plan-overview/index.html Tapp, J., & Hudson, T. (2020). Sexually transmitted infections prevalence in the United States and the relationship to social determinants of health. Nursing Clinics of North America, 55(3), 283–293. https://doi- org.ezproxy.westminstercollege.edu/10.1016/j.cnur.2020.05.001 Utah Department of Health. (2020, June 9). HIV and STD’s in Utah: 2019 surveillance update. https://ptc.health.utah.gov/wp-content/uploads/2020/09/2019_HIV-and-STDPrevention-and-Surveillance-Program_Surveillance-Update.pdf STI’S/STD’S, UNWANTED PREGNANCY, AND SEXUAL ASSAULT 28 APPENDIX A Objectives and Goals Objectives Implementation Evaluation 1. Identify Current Sexual Knowledge related to STI & STD’s among college age students 18-24 Provide questionnaire with qualitative and quantitative questions. Surveys are completed and data analyzed. 2. Offer up to 50 students Media Aware Application (intervention) Random Selection of up to 50 participants with flip of a coin, download application on device Receive confirmation of Media Aware training. Give out T-Shirt for completion. Analyze data. 3 Evaluate the effectiveness of Healthy Sexual Education training with follow-up Questionnaire. Evaluate for improved knowledge of STI’s STDs with Media Aware. Determine when students have completed Media Aware training. Follow up with questionnaire in 6 weeks. This will be modified to address technological education and effectiveness. Review quantitative and qualitative data with descriptive statistic and determine efficacy of technological sex education. Discuss positive or negative findings. STI’S/STD’S, UNWANTED PREGNANCY, AND SEXUAL ASSAULT APPENDIX B 29 STI’S/STD’S, UNWANTED PREGNANCY, AND SEXUAL ASSAULT 30 APPENDIX C DNP PROJECT Pre-QUESTIONAIRE STI’S AND STD’S AMONGST COLLEGE AGE STUDENTS AGED 18-24 WESTMINSTER COLLEGE 1. Where did you get your sexual knowledge? Family (home) School Friends Other: _____________________ 2. Have you ever received healthy sexual education? YES NO Unknown 3. How Knowledgeable do you think you are in sexual health related to STI’s & STD’s? Not at All Knowledgeable knowledgeable Somewhat Knowledgeable Extremely 4. How likely are you to use protection during sexual activity or intercourse? Not likely Somewhat likely Most likely Very Likely 5. How frequently do you have unprotected intercourse? Never Sometimes Most Times Every-time 6. How likely are you to have intercourse while drinking? Never Sometimes Most Times Every-time 7. How likely are you to have group sex (2 or more partners)? Never Sometimes Most Times Every-time 8. Did you learn about STD’s and STI’s in K-12 education? YES NO 9. Have you had an STD/STI in the past month? YES NO 10. Have you discussed your sexual health with your parents? YES NO 11. Have you discussed your sexual health with your Health Care Provider? YES NO 12. Have you discussed your sexual health with your Partner? YES NO STI’S/STD’S, UNWANTED PREGNANCY, AND SEXUAL ASSAULT 31 APPENDIX D 1. 2. 3. DNP PROJECT POST-QUESTIONAIRE STI’S AND STD’S AMONGST COLLEGE AGE STUDENTS AGED 18-24 WESTMINSTER COLLEGE Have you ever received healthy sexual education? YES NO Unknown Did you Finish the Media Aware Healthy Sexual Education Teaching? YES NO Unknown How Knowledgeable do you think you are in sexual health related to STI’s & STD’s? Not at All Knowledgeable Somewhat Knowledgeable Extremely knowledgeable 4. How do you think people in your age range would learn best regarding healthy sexual education? 6. How convenient was the Media Aware program for healthy sexual education? Not Helpful Somewhat Helpful Helpful Extremely Helpful 5. 7. 8. 9. Do you Think the Media Aware Program was helpful with Sexual Education? Not Helpful Somewhat Helpful Helpful Extremely Helpful How likely are you to recommend the Media Aware program to others when discussing sex? Never Sometimes Most Times Every-time How likely are you to use protection during sexual activity or intercourse? Not likely Somewhat likely Most likely Very Likely How frequently do you have unprotected intercourse? Never Sometimes Most Times 10. How likely are you to have intercourse while drinking? Never Sometimes Most Times 11. How likely are you to have group sex (2 or more partners)? Never Sometimes Most Times 12. Have you had an STD/STI in the past month? YES NO 13. Have you discussed your sexual health with your parents? YES NO Every-time Every-time Every-time 14. Have you discussed your sexual health with your Health Care Provider? YES NO 15. Have you discussed your sexual health with your partner? YES NO STI’S/STD’S, UNWANTED PREGNANCY, AND SEXUAL ASSAULT APPENDIX E Figure E1. Graph survey # 1 (qualitative summary) Figure E2. Graph survey #2 & #3 (qualitative summary) 32 STI’S/STD’S, UNWANTED PREGNANCY, AND SEXUAL ASSAULT 33 APPENDIX F Figure F1. Wilcoxon rank Sum (Question #3 for both Surveys) Survey Question #3 for Both Surveys Survey #1 (Pre) Survey #2 (Post) Surveys Rating Rank 2 3 First Survey 2 3 4 First Survey 3 3 3 First Survey 3 2 3 First Survey 2 4 3 First Survey 4 4 2 First Survey 4 2 4 First Survey 2 2 4 First Survey 2 4 3 First Survey 4 2 3 First Survey 3 Second Survey 3 Second Survey 4 Second Survey 3 Second Survey 3 Second Survey 3 Second Survey 2 Second Survey 4 Second Survey 4 Second Survey 3 Second Survey 3 3 10 10 3 17.5 17.5 3 3 17.5 10 10 17.5 10 10 10 3 17.5 17.5 10 10 𝑁0 Knowledge was not improved (Did Rankings increase or stay equal with survey 1) with Media Aware Education= Fail to RejectH0 > 0 Knowledge was improved (Did rankings decrease with survey 2) with Media Aware Education= Reject the Null hypothesis Ha < 0 𝑁𝐴 Rank Sum First Survey Second Survey 94.5 115.5 First Survey Count Second Survey Count 𝜇𝑤 Mean- 105 SD- 𝜎𝑤 z 10 10 n1 (n1+n2+1)/2 13.22876 ⬚ -0.79373 z= p-value 0.213678 Alpha 0.05 Fail to reject null 𝑛1 𝑛2 𝑛1 + 𝑛2 + 1 12 𝑥−𝜇 𝜎 Lower Tailed Test 𝑁0 Median 1 -Median 2 > 0 𝑁𝑎 Median 1 -Median 2 < 0 Figure F2. Wilcoxon rank Sum (Question #5 from survey one; Question #8 from survey two) Survey Questions #5 (Survey One) Question #8 (Survey two) Survey #1 (Pre) Survey #2 (Post) Surveys Rating Rank 2 4 First Survey 2 4 4 First Survey 4 4 3 First Survey 4 4 4 First Survey 4 3 4 First Survey 3 2 4 First Survey 2 4 4 First Survey 4 4 2 First Survey 4 3 4 First Survey 3 4 2 First Survey 4 Second Survey 4 Second Survey 4 Second Survey 3 Second Survey 4 Second Survey 4 Second Survey 4 Second Survey 4 Second Survey 2 Second Survey 4 Second Survey 2 𝑁0 2.5 14 14 14 6 2.5 14 14 6 14 14 14 6 14 14 14 14 2.5 14 2.5 Knowledge was not improved (Did Rankings increase or stay equal with survey 1) with Media Aware Education= Fail to RejectH0 > 0 Knowledge was improved (Did rankings decrease with survey 2) with Media Aware Education= Reject the Null hypothesis Ha < 0 𝑁𝐴 Rank Sum First Survey Second Survey 101 109 First Survey Count Second Survey Coun 𝜇𝑤 z 10 10 Mean- 105 SD- 𝜎𝑤 n1 (n1+n2+1)/2 13.22876 ⬚ -0.30237 p-value Alpha 0.381184 0.05 Fail to reject null 𝑛1 𝑛2 𝑛1 + 𝑛2 + 1 12 z= 𝑥 − 𝜇 𝜎 Lower Tailed Test 𝑁0 Median 1 -Median 2 > 0 𝑁𝑎 Median 1 -Median 2 < 0 Figure F3. Wilcoxon rank Sum (Question #6 from survey one; Question #9 from survey two) Survey Questions #6 (Survey One) Question #9 (Survey two) Survey #1 (Pre) Survey #2 (Post) Surveys Rating Rank 3 4 First Survey 3 3 4 First Survey 3 4 3 First Survey 4 4 3 First Survey 4 3 4 First Survey 3 2 4 First Survey 2 4 4 First Survey 4 4 2 First Survey 4 4 3 First Survey 4 2 2 First Survey 2 7.5 7.5 15.5 15.5 7.5 2.5 15.5 15.5 15.5 2.5 Second Survey 4 15.5 Second Survey 4 15.5 Second Survey 3 Second Survey 3 7.5 7.5 Second Survey 4 Second Survey 4 Second Survey 4 Second Survey 2 Second Survey 3 Second Survey 2 15.5 15.5 15.5 2.5 7.5 2.5 𝑁0 𝑁𝐴 Knowledge was not improved (Did Rankings increase or stay equal with survey 1) with Media Aware Education= Fail to RejectH0 > 0 Knowledge was improved (Did rankings decrease with survey 2) with Media Aware Education= Reject the Null hypothesis Ha < 0 Rank Sum First Survey Second Survey 105 105 First Survey Count Second Survey Count 𝜇𝑤 𝜎𝑤 z p-value Alpha MeanSD- 10 10 105 13.22876 0 0.5 0.05 Fail to reject null n1 (n1+n2+1)/2 ⬚ 𝑛1 𝑛2 𝑛1 + 𝑛2 + 1 12 z= 𝑥 − 𝜇 𝜎 Lower Tailed Test 𝑁0 Median 1 -Median 2 > 0 𝑁𝑎 Median 1 -Median 2 < 0 STI’S/STD’S, UNWANTED PREGNANCY, AND SEXUAL ASSAULT 34 APPENDIX G Figure G1. Wilcoxon rank Sum (Question #7 from survey one; Question #10 from survey two) Survey Questions #7 (Survey One) Question #10 (Survey two) Survey #1 (Pre) Survey #2 (Post) Surveys Rating Rank 3 4 First Survey 3 4 4 First Survey 4 4 3 First Survey 4 4 4 First Survey 4 2 4 First Survey 2 2 2 First Survey 2 3 4 First Survey 3 4 2 First Survey 4 4 4 First Survey 4 4 2 First Survey 4 Second Survey 4 Second Survey 4 7 14.5 14.5 14.5 3 3 7 14.5 14.5 14.5 14.5 14.5 Second Survey 3 7 Second Survey 4 14.5 Second Survey 4 Second Survey 2 Second Survey 4 Second Survey 2 Second Survey 4 Second Survey 2 14.5 3 14.5 3 14.5 3 𝑁0 𝑁𝐴 Knowledge was not improved (Did Rankings increase or stay equal with survey 1) with Media Aware Education= Fail to RejectH0 > 0 Knowledge was improved (Did rankings decrease with survey 2) with Media Aware Education= Reject the Null hypothesis Ha < 0 Rank Sum First Survey Second Survey 107 103 First Survey Count Second Survey Coun 𝜇𝑤 𝜎𝑤 10 10 Mean- 105 SD- n1 (n1+n2+1)/2 13.22876 ⬚ z -0.15119 p-value 0.439915 Alpha 0.05 Fail to reject null z= 𝑛1𝑛2 𝑛1 + 𝑛2 + 1 12 𝑥−𝜇 𝜎 Lower Tailed Test 𝑁0 Median 1 -Median 2 > 0 𝑁𝑎 Median 1 -Median 2 < 0 Figure G2. Wilcoxon rank Sum (Question #8 from survey one; Question #11 from survey two) Survey Questions #8 (Survey One) Question #11 (Survey two) Survey #1 (Pre) Survey #2 (Post) Surveys Rating Rank 4 4 First Survey 4 4 4 First Survey 4 4 4 First Survey 4 4 4 First Survey 4 4 4 First Survey 4 4 4 First Survey 4 4 4 First Survey 4 4 4 First Survey 4 4 4 First Survey 4 4 4 First Survey 4 Second Survey 4 Second Survey 4 Second Survey 4 Second Survey 4 Second Survey 4 Second Survey 4 Second Survey 4 Second Survey 4 Second Survey 4 Second Survey 4 10.5 10.5 10.5 10.5 10.5 10.5 10.5 10.5 10.5 10.5 10.5 10.5 10.5 10.5 10.5 10.5 10.5 10.5 10.5 10.5 𝑁0 𝑁𝐴 Knowledge was not improved (Did Rankings increase or stay equal with survey 1) with Media Aware Education= Fail to RejectH0 > 0 Knowledge was improved (Did rankings decrease with survey 2) with Media Aware Education= Reject the Null hypothesis Ha < 0 Rank Sum First Survey Second Survey 105 105 First Survey Count Second Survey Count 10 10 𝜇𝑤 z 𝜎𝑤 MeanSD- 105 13.22876 0 n1 (n1+n2+1)/2 ⬚ z= p-value Alpha 0.5 0.05 Fail to reject null 𝑛1𝑛2 𝑛1 + 𝑛2 + 1 12 𝑥−𝜇 𝜎 Lower Tailed Test 𝑁0 Median 1 -Median 2 > 0 𝑁𝑎 Median 1 -Median 2 < 0 3 3 2 4 4 2 2 4 2 0743N 7168J 0551T 6889A 2255S 4957M 0724D 2990D Not At All knowledgeable- 1 Somewhat Knowledgeable-2 Knowledgeable-3 Extremely Knowledgeable-4 2 3197D Survey #1 0828C DEIDENTIFIED STUDENTS (10) Question #3: (Both Surveys) How knowledgeable do you Please enter your Study ID [last 4 digits of your think you are in sexual health phone number + Your Middle Name Initial]. related to STI’s & STD’s? Example: 1416A * (Students Sampled) (Sexually Transmitted Infections & Sexually Transmitted Diseases) Survey #2 3 3 4 4 2 3 3 3 4 3 Not Likely-1 Somewhat likely-2 Most likely-3 Very Likely-4 Survey #1 4 3 4 4 2 3 4 4 4 2 Question #5(Survey 1) Question #8 (Survey 2): How likely are you to use protection during sexual activity or intercourse? (Condoms, birth control, etc.) Survey #2 2 4 2 4 4 4 4 3 4 4 Never-4 Sometimes-3 Most times-2 Every time-1 Survey #1 Question #6 (Survey 1) and Question #9 (Survey 2) How frequently do you have unprotected sex? 2 4 4 4 2 3 4 4 3 3 Survey #2 2 3 2 4 4 4 3 3 4 4 Never-4 Sometimes-3 Most times-2 Every time-1 Survey #1 Question #7(Survey 1) Question #10 (Survey 2): Have you engaged in intercourse or sexual activities while under the influence of Alcohol, Marijuana, or other recreation drugs? 4 4 4 3 2 2 4 4 4 3 Survey #2 DATA FOR SURVEY ONE AND TWO FOR 10 STUDENTS THAT COMPLETED (Likert Type Questions) 2 4 2 4 2 4 4 3 4 4 Never-4 Sometimes-3 Most times-2 Every time-1 Survey #1 4 4 4 4 4 4 4 4 4 4 Question #8 (Survey 1) Question #11 (Survey 2): How likely are you to have group sex (2 or more partners)? Survey #2 4 4 4 4 4 4 4 4 4 4 STI’S/STD’S, UNWANTED PREGNANCY, AND SEXUAL ASSAULT APPENDIX H 35 N/A N/A Yes Unknown Yes No No Yes No Yes What is Healthy Sexual Education? Yes No 7168J 3197D 0828C 6889A 4957M 2990D 0551T 2255S 0724D N/A N/A N/A Yes Yes Yes Unknown NO NO NO NO YES NO NO NO NO NO NO NO NO NO NO NO NO NO NO Survey 2 N/A N/A N/A N/A N/A NO NO NO NO NO Survey 3 NO YES NO NO NO YES YES YES YES YES Survey 1 Question #10: Have you discussed your sexual health with your parents? YES YES YES YES NO NO YES YES YES YES Survey 2 N/A N/A N/A N/A N/A NO YES YES NO YES Survey 3 NO YES YES NO YES YES NO YES YES NO Survey 1 Question #11: Have you discussed your sexual health with your Health Care Provider? NO YES YES YES YES YES YES YES YES YES Survey 2 N/A N/A N/A N/A N/A YES YES YES YES YES Survey 3 YES YES NO YES YES NO NO n/a n/a n/a Survey 1 Question #12:. Have you discussed your sexual health with your partner? YES YES YES YES YES YES NO NO YES YES Survey 2 N/A N/A N/A N/A N/A YES NO YES YES YES Survey 3 APPENDIX I No Yes Yes Yes Yes Yes Unknown No NO Yes 0743N Yes Survey 1 Survey 3 Survey 1 Participant Survey 2 Question #9: Have you had an STD/STI in the past month? Please enter your Study ID [last 4 digits of your phone Question #2: Have you number + Your ever received Healthy Middle Name Sexual Education? Initial]. Example: 1416A * Yes & No Questions for STI/STD RESEARCH STI’S/STD’S, UNWANTED PREGNANCY, AND SEXUAL ASSAULT 36 APPROVAL of a thesis/project submitted by Author(s): Bill Self School Department: DNP Title of Thesis: An Evidence-Based Educational Intervention Utilizing Technology to Provide Sexual Education to College Aged Students 18-24 The above named master's thesis/project has been read by each member of the supervisory committee and has been found to be satisfactory regarding content, English usage, format, citations, bibliographic style, and consistency, and is ready to be deposited and displayed in the Westminster College—Institutional Repository. Chairperson, Supervisory Committee: Ronda Lucey, DNP Approved On 2/15/2023 5:59:14 PM Dean, School: Sheryl Steadman Ph.D Approved On 2/17/2023 8:21:26 AM STATEMENT OF PERMISSION TO DEPOSIT & DISPLAY THESIS IN THE INSTITUTIONAL REPOSITORY Name of Author(s): Bill Self School Department: DNP Title of Thesis: An Evidence-Based Educational Intervention Utilizing Technology to Provide Sexual Education to College Aged Students 18-24 With permission from the author(s), the staff of the Giovale Library of Westminster College has the right to deposit and display an electronic copy of the above named thesis in its Institutional Repository for educational purposes only. I hereby give my permission to the staff of the Giovale Library of Westminster College to deposit and display as described the above named thesis. I retain ownership rights to my work, including the right to use it in future works such as articles or a book. Submitted by the Author(s) on 8/7/2021 4:03:18 PM The above duplication and deposit rights may be terminated by the author(s) at any time by notifying the Director of the Giovale Library in writing that permission is withdrawn.