what can health educators do to decrease the prevalence of stds among college students?

Abstract

Applying life course theory, this study examined the straight and indirect effects of agin babyhood experiences (ACEs) on the risk of contracting sexually transmitted diseases (STDs), mediated by early sex (beginning sexual experience before age 15), number of lifetime sex partners, and mental health bug. The link between ACEs and mental health on college students' sexual take chances is still understudied. Using cantankerous-sectional data from a sample of 327 college students in Sierra Leone, this study tested the hypothesized mediation model using structural equation modeling analysis. The results showed that ACEs significantly increased sexual risks. Specifically, ACEs increased the chance of early initiation of sexual activity and the number of lifetime sex partners, which in plough increased the chance of STDs. Furthermore, ACEs significantly predicted negative mental health and were significantly associated with an increased hazard of STDs. Effective future intervention strategies should include health education programs to address the lifelong furnishings of ACEs and mental wellness treatment.

Introduction

Adolescents and young adults appoint in risky behaviors such as unprotected sexual activeness, sexting and problematic and risky cyberspace use, use of illegal substance, and unsafe driving than any other age grouping (Centers for Disease Control and Prevention [CDC], 2018). The 2019 Sierra Leone Demographic and Wellness Survey (SLDHS) indicated high-risk sexual behaviors such as having multiple sexual partners, unprotected sex, and transactional sexual practice among adolescents. In the U.s., for case, despite educational efforts to provide teens with information most risky behavior, adolescents ages fifteen–24 business relationship for half the 20 meg new sexually transmitted diseases (STDs) annually, with incidences of gonorrhea, chlamydia, and syphilis exceeding 1.5 one thousand thousand among college students (Within Higher Didactics 2016).

Extant enquiry is silent on why STD cases are loftier among college students (CDC 2016), a growing torso of brain enquiry, however, reveals that boyhood is a stage of neurodevelopment affecting decision making (Steinberg 2008). These neurodevelopmental changes occur around the time of puberty, to affect the lateral prefrontal cortex (PFC) responsible for emotional maturity, self-regulation, and reward-seeking (Chambers et al. 2003). Other biological factors that may facilitate STD transmission among young women include the underdeveloped cervical cells. For case, cervical ectopy is associated with chlamydia trachomatis infection and HIV in young women (Kleppa et al. 2015). Adverse childhood experiences (ACEs) such as a history of conflicts and war, as is the instance for Sierra Leone, or witnessing violence among household members may These neurodevelopmental changes occur around the time of puberty, to affect the lateral prefrontal cortex (PFC) responsible for emotional maturity, self-regulation and reward-seeking also affect sexual behaviors (Betancourt et al. (2011). Today'southward new media platforms create an data commitment pipeline of problematic and risky internet use that could facilitate sexual activities (Collins et al. 2011). Branley and Covey (2017) found a stiff linkage between social media content and associated offline individual risky behaviors.

The touch of the surround on risky sexual behaviors has also been studied (DiClemente et al. 2005). Living in environments where abuse and trauma are prevalent (Jones et al. 2013; Littleton et al. 2007), substance misuse (Mandavia et al. 2016; Schäfera et al. 2017), or with individuals with untreated mental illnesses (Bahk et al. 2016; Dubé et al. 2016) may too heighten problem behaviors including risky sexual behaviors. Examined less often in the ecological systems literature is how time (or, in Bronfenbrenner'due south terms, "the chronosystem") impacts the association among the factors. In add-on, life-course theory examines the longitudinal processes of man development, organized effectually iv disquisitional focal points: (1) historical time and place, given the thought that the social context of people's lives influences their opportunities as well equally their challenges; (2) linked or interdependent experiences, based on the interconnected nature of individual lives and how social networks present both risk and resilience factors; (3) timing of life events, as information technology is assumed that the time when pregnant events occur in ane's life will touch on one's developmental trajectories; and (4) developmental run a risk and protection, equally i life consequence or transition impacts subsequent events and transitions, and either may put it at run a risk or protect the life-course trajectory (Elder 1998; Elder et al. 2003; Giele and Elder 1998; Hutchison 2019). The life grade theory has been applied to studies examining individuals' experiences with early initiation of sexual activities (EISA) (e.one thousand., Haydon et al. 2014), multiple sexual partners (e.thousand., Rapp 2018), psychological damage (e.g., Thomeer et al. 2016), and sexually transmitted diseases (eastward.1000., Lucke et al. 2013), which impact health trajectories.

Adolescents living in Sierra Leone face up unique challenges. The civil war (1991–2002) and the Ebola crisis (2014–2016) are historical risky factors that take embroiled Sierra Leone. Exposure to arduousness and disharmonize may be associated with higher odds of engagement in risky behaviors, including sexual risk behaviors (Jessor and Jessor 1977). Among individuals with a history of ACEs, riskysexual behaviors may stand for their attempts to accomplish intimate interpersonal relationships (CDC 2019; Noll et al. 2009). Further, the furnishings of war, conflicts, and poverty on Sierra Leone's health infrastructure cannot be underestimated. More than 60% of the population of Sierra Leone alive below the United Nations' poverty line of Usa$1 per day. A lack of acceptable shelter, food, and other basic needs at minimum consumption levels unduly impact young people in Sierra Leone or sub-Saharan Africa (SSA) increasing disease risk. For example, about 14,000 people are infected with HIV, and eleven,000 die from AIDS-related illnesses daily in SSA. To put this into context, approximately 6313 COVID-xix related deaths occurred worldwide on September 4, 2020 (Worldmeter 2020).

There are several reasons for examining college students and risk-taking in this context. First, although at greater vulnerability for STD infection, this population is assumed to exist educated and knowledgeable most STDs (Subbarao and Akhilesh 2017). Second, despite the realities of the biological and cultural factors mentioned above, college students are assumed to be educated, resilient, and unaffected by the touch of ACEs (Kelifa et al. 2020). Tertiary, Sierra Leone is a less developed country (LDC) that struggles to maintain a steady STD prevention and treatment campaign due to budget constraints. For example, in 2017, the AIDS Healthcare Foundation (AHF) gave Sierra Leone $5 meg to help the government step up its HIV and STD prevention efforts (AHF 2017). By comparison, the U.S. spends $fifteen.vi billion a year on adolescent sexual wellness programs (CDC 2018). Such scarcity of resource may be associated with a high STD brunt in Sierra Leone and other SSA countries.

Very niggling research has examined interactions between multiple social-ecological factors concerning college students' sexual beliefs, such as booze apply and misuse, risky sexual behaviors, peer influence, and other macrolevel factors such equally advertising and marketing (Sudhinaraset et al. 2016). Such research is needed to sympathize the mechanisms of sexual risk to inform intervention outcomes. The current study utilizes Bronfenbrenner's ecological systems perspective (1979) and life class perspective (Elder et al. 2003; Giele and Elder 1998) to assess ACEs' related sexual risks among college students in Sierra Leone.

Sexually Transmitted Diseases Amid Students In Sierra Leone

Results from the 2019 Sierra Leone Demographic and Health Survey (SLDHS) found that young females and males ages 15–24 who were never married have engaged in multiple sexual relationships in the previous 12 months. Among those surveyed, 80% of the females and 71% of the males reported having sexual relationships with people other than their partners. Teen pregnancy was high, at 65%, during the 2016 Ebola crunch (CDC 2018). By comparing, the Section of Health's (2019) National Antenatal Sentinel HIV and Syphilis Prevalence Surveys of South Africa showed that 7% of young women ages 15–24 in South Africa were pregnant in 2017 (Department of Health [South Africa] 2019). According to the Globe Bank, Sierra Leone had the 13th highest rate of teenage pregnancy globally in 2017, with 113 births per 1000 adolescents, more than 10 times the rate in Europe (Peyton 2019). The high pregnancy rates in Sierra Leone are driven by low instruction, poverty, and abuse (Peyton 2019).

Adverse Childhood Experiences, Mental Health, and Sexually Transmitted Diseases

ACEs, including child abuse and trauma, accept been implicated as predictors of sexual risk behaviors and related lifelong consequences (Senn and Carey 2010; Wilson et al. 2012). They are associated with high-hazard sexual behavior, including early initiation of sexual activity (EISA), unprotected intercourse without a male or female condom, having multiple sex partners, or having a loftier-risk partner (1 who has multiple sex partners or other risk factors; Bensley et al. 2000). Furthermore, childhood abuse interrupts a kid's developmental stages, affecting learning, intimacy skills, dating, and developing one'due south identity or autonomy (Connolly and McIsaac 2009; Steinberg 2008). Toxic stress from ACEs can interfere with encephalon development, and people with increased exposure to ACEs may have associated pain-related psychological trauma, depressive episodes, and psychosocial impairment (Ege et al. 2015).

Electric current Written report

Consistent with life form theory, which suggests that the times when significant life events occur touch on 1'southward developmental trajectories, nosotros theorize that students exposed to babyhood abuse or trauma take a college likelihood of engaging in sexual risk behaviors compared with those who have not been exposed, controlling for other factors such equally parenting manner, gender, and habitation environs (Lucke et al. 2013; Haydon et al. 2014; Rapp 2018; Thomeer et al. 2016). The current written report applies the concepts of life class theory to examine the relationship between ACEs and sexual gamble. Therefore, we tested the post-obit hypotheses: [H1] ACEs volition be significantly associated with increases in risk of contracting STDs; [H2] ACEs will exist significantly associated with early initiation of sexual practice (EISA), number of lifetime sexual practice partners (NLSPs), and mental health issues (i.eastward., depression and feet); [H3] EISA, NLSPs, and mental health will be significantly associated with increases in risk of contracting STDs; [H4] EISA will mediate the association between ACEs and STDs; [H5] NLSPs will mediate the association between ACEs and STDs; [H6] Mental wellness will mediate the association between ACEs and STDs; [H7] NLSPs will mediate the clan between ACEs and STDs via EISA; [H8] Mental health will mediate the association between ACEs and STDs via NLSP; [H9] Mental health will mediate the clan between ACEs and STDs via EISA and NLSPs.

Methods

Study Pattern and Sample

This cross-sectional study involved a sample of 327 university students attention two colleges located in the southern and northern province of Sierra Leone between May and June of 2017. Approval of the study was granted by the first author's University Institutional Review Board and the Sierra Leone Part of Ideals and Scientific Review Committee in August of 2016 and May of 2017, respectively. A convenience sampling method was used to select the ii universities based on proximity to the pb author and diversity in geography (southern and northern regions).

Students were recruited from a biological science class and a liberal arts class in the respective regions. Students' instructors informed the students about the study prior to the commencement of the class. The purpose of the study, potential benefits, and risks were explained in detail past the lead author before admistering the survey, and all participants were subsequently provided with an informed consent form. Participation in the study was voluntary and anonymous, and refusal to participate did non affect the students' course grades. Participation was granted if the student was xviii years or older, enrolled at one of the 2 institutions, and could read and write in English. The atomic number 82 author administered the survey during a normal class period. The survey took betwixt twoscore and 60 min to consummate. Incentives to participate were provided in the form of a lottery draw, in which the winning ticket was selected from a range of numbers between 0–100. A winning ticket had a number in the course of a smiley face, with a sticker that indicated, "You are the winner of a USB stick." A not-winning number came with the post-obit message: "Sorry, you were not lucky this time." Participants were informed that if they experienced any discomfort while answering the questions, they could cease and exit the room without consequences. Contact data for psychological help was besides provided if always needed.

Measures

Exogenous Variable

The Adverse Childhood Experiences International Questionnaire (ACE-IQ; WHO 2016) was used to measure out respondents' feel of kid corruption during the start xviii years of life. Equally shown in Table 1, the calibration consists of xiii domains and 28 questions including 3 questions on neglect, two questions on protection, two questions on physical abuse, two questions on emotional abuse, four questions on sexual abuse, 3 questions on domestic violence, ane question on booze abuse by a household member, one question on the incarceration of a household member, 1 question on mental illness in the household, 1 question on whether parents are dead or divorced, one question on bullying, three questions on customs violence, and iv questions on collective violence. The measurement uses a five-bespeak Likert calibration ranging from 1 (never) to 5 (always). Of 13 domains, eight domains accept two items or more. Composite variables were created for these domains. Each composite score was divided past the number of items, and the mean of the composite score was used as an indicator for the analysisAs shown in Table one, the Cronbach'due south alpha coefficients for these viii domains with two or more items ranged from 0.57 to 0.xc. The Cronbach'south alpha coefficient for the whole scale was 0.90, indicating strong internal consistency reliability.

Table 1 Questions in ACE-IQ domains

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Endogenous Variable

Data about STDs was obtained by respondents answering aye to the following question nigh STD: "Have you ever been diagnosed with or had whatsoever of the following STDs?" The response categories were none, Chlamydia, Gonorrhea, Syphilis, Herpes, HPV/Warts, HIV/AIDS, Hepatitis B, Hepatitis C, or other. We changed this categorical variable to a dichotomous variable (no = 0, yes = 1) for whatsoever of the listed STD.

Mediating Variables and Control Variable

Iii mediating variables were included in this study: (a) early initiation of sex activity, (b) the number of lifetime sexual partners, and (c) mental health. Start, early initiation of sex activity was assessed every bit a continuous variable that measured the age when the respondent had sexual intercourse for the commencement fourth dimension. For this report, we changed from the continuous variable to a dichotomous variable using the cut off age of fifteen years old based on the written report conducted past Chocolate-brown and colleagues (2017). Having sexual intercourse before 15 years old was categorized as 1 and having sexual intercourse after 15 years sometime was categorized equally 0. 2nd, the number of lifetime sex partners was assessed every bit a count variable that measured the number of people the individual had e'er had sex with. Lastly, mental health was conceptualized every bit anxiety and depression. Nosotros assessed participants' mental health problems past utilizing the Patient Wellness Questionnaire nine (PHQ-9) and the Generalised Anxiety Disorder (GAD-seven) questionnaire. The ultimate mental health variable was comprised of these ii variables. The PHQ-9 was developed past Kroenke et al. (2001); information technology is a 9-detail self-administered questionnaire for the assessment of the severity of symptoms of depression for patients undergoing clinical treatment. A sample question is, "In the concluding ii weeks, how often accept you been bothered past any of the following problems?" Respondents indicated the degree to which each statement was true on a 4-signal Likert scale, ranging from 0 (not at all) to 3 (nearly every solar day). PHQ-9 independent statements such as "lilliputian interest or pleasance in doing things" and "trouble falling or staying asleep, or sleeping too much." Scores have been organized on a calibration of increasing severity of depression, ranging from 0 to 4. For this research, the mean of the PHQ-9 became central to the analysis (run into Table three), having a Cronbach's alpha coefficient of 0.lxx. The GAD-7 scale was used to measure anxiety. This 7-item scale, adult by Spitzer and colleagues (2006), is a cocky-administered questionnaire for the assessment of how frequently anxiety symptoms appear for patients receiving clinical treatment or participating in clinical research. The GAD-7 measurements range over a four-betoken Likert scale from 0 (not at all) to 3 (well-nigh every day). A multi-role sample question is, "In the last ii weeks, how often have you been bothered by the following bug: (1) not being able to stop or control worrying, and (2) feeling agape as if something atrocious might happen." In this research, the analysis was undertaken using the hateful for the GAD-7 (run into Table 3). The Cronbach alpha for the GAD-7 was 0.82, which indicates strong relibility. Age was a control variable in this study.

Data Analysis

For the central analysis, Mplus vii.four (Muthén and Muthén 2015) was used to conduct structural equation modeling (SEM), comprised of a measurement model and a structural path model. Westland (2010) suggests ten per indicator in a path model as the minimum preferred sample size to use SEM to accomplish statistical stability. For this report, the sample size of 327 was adequate to examination the SEM model with ix indicators in the path model.

Confirmatory factor analysis (CFA) was used to test the measurement model before testing the structural path model. The measurement model was tested to determine whether the observed items employed for measuring the two latent variables (adverse childhood experience and mental health) operated equally valid indicators for the constructs. The structural path model then underwent testing to appraise the hypothesized conceptual model. The structural path model offers a clarification of how all the variables for the projected model are interrelated. This model also displays the directly and indirect effects of specific variables on certain other variables in the model. This research looks at the direct and indirect paths from adverse childhood experiences to STD infections through the mediators of early initiation of sexual practice, number of lifetime sex partners, and mental health.

Results

Descriptive Information

Table 2 includes the descriptive information of the sample. The sample of college students identified as 41.9% female and 58.1% male. The average age of the respondents was 24.33, with a range of xviii to 56 years. 61.2% were from the southern university, and 38.8% from the northern region. The majority of the sample (84.1%) were college freshmen, followed past college juniors (6.4%), seniors (4.6%), sophomore (3.1%), and master's students (1.eight%). Because of the country context, sophomore satus may not have any association with age since it is not unusual for individuals to start college at an older age. More than than 90% of the sample reported their family'due south income as lower than boilerplate or similar to the boilerplate family.

Table 2 Descriptive sample statistics (Due north = 327)

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With respect to early on initiation of sex, 7.6% of the respondents reported they first had sex before historic period xv. The average number of lifetime sex partners among respondents was 3.24 people, ranging from 1 to 6 people. Approximately one-third of the respondents reported they had experience with sexually transmitted infections. Table 3 describes the means and standard deviations of the variables in the SEM model.

Table 3 Description of the variables (N = 327)

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Measurement Model—CFA Results

As shown in Tabular array 4, the initial original model fit was inadequate. When estimating the factor loadings, v items (i.e., neglect, protection, incarceration of a house fellow member, mental illness of a house member, and bullying) had a factor loading lower than 0.5. In contrast, all other indicators had a factor loading greater than 0.5 (see Table five). According to Truong and Mccoll (2011), factor loadings should be greater than 0.5 for better results. Therefore, the five items for ACEs were not included in the mail service hoc model. The reduced number of items based on the information of factor loadings and the incorporation of the error covariance resulted in an improvement in the model fit, as seen on Tabular array 4. The TLI and CFI values were above 0.98, suggesting an first-class fit of the data model. The RMSEA value of 0.05 met the criteria for a good model. Furthermore, the AIC values decreased from xiv,623.46 to 6368 in the desired direction. The concluding model fit of the measurement model was also improved by allowing several items to co-vary based on the information from the modified model fit indices (see Fig. 1). Likewise, the reliabilities of ACEs and mental health were assessed with composite reliability (CR). If the value of CR is college than 0.seven, information technology is considered adequate. CR is calculated using the post-obit formula: CR = (∑Қ)²/[(∑Қ)^two + (∑i − Қ²)]) (Қ = cistron loading of every particular; Fornell and Larcker 1981). Overall, the composite reliability of each latent construct was greater than 0.7 (ACEs = 0.84, mental health = 0.75).

Table iv CFA model fit indices

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Table 5 CFA results

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Fig. 1

Path results. Note 1. * < .05, ** < .01, *** < .001; ACEs = adverse babyhood experiences, PA = concrete abuse, EA = emotional abuse, SA = sexual abuse, DV = domestic violence, AAH = alcohol abuse of a business firm fellow member PDD = Parents dead or divorced, CV-ii = collective violence_2, EISA = early on initiation of sex activity (1st sexual practice < 15), NISP = number of lifetime sexual activity partners, STDs = sexually transmitted diseases, D = depression, A = anxiety, 2. Age was a command variable

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Structural Model—Path Results

To explore the direct and indirect effects of ACEs on STDs through the mediators of early initiation of sexual activity, the number of lifetime sex partners, and mental wellness, we tested the path model using SEM. The path results are shown in Fig. i. The structural path model had skilful model fit [χ² (52) = 89.64, p< 0.001, CFI = 0.97, TLI = 0.95, RMSEA = 0.05] every bit described in Fig. 1. The post-obit direct and indirect path results partially supported our hypotheses.

Direct Effects

10 direct paths were estimated, and the results showed that 7 out of x direct paths in the model were statistically significant (see Table 6). ACEs was significantly associated with early initiation of sexual practice (β = 0.159, p< 0.01), the number of lifetime sexual activity partners (β = 0.179, p< 0.01), and mental health (β = 0.331, p< 0.001). However, ACEs was non directly associated with STDs. Moreover, early initiation of sexual activity significantly increased the number of lifetime sex partners (β = 0.229, p < 0.001) and increased the run a risk of STDs (β = 0.120, p < 0.05), but information technology was not directly associated with mental health. Likewise, the number of lifetime sex partners increased the hazard of STDs (β = 0.192, p < 0.001), simply it was not significantly associated with mental health. In addition, mental health significantly increased the adventure of STDs (β = 0.150, p < 0.05), like early initiation of sexual activity and the number of lifetime sex activity partners.

Table vi Direct and indirect effects

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Indirect Furnishings

The path results showed three meaning mediating effects out of seven (see Table 6): (a) the number of lifetime sex partners significantly mediated the relationship between ACEs and STDs (β = 0.022, p < 0.05); (b) mental wellness significantly mediated the relationship between ACEs and STDs (β = 0.032, p < 0.05); and (c) early initiation of sexual practice too as the number of lifetime sex partners significantly mediated the relationship between ACEs and STDs (β = 0.077, p < 0.01). To be specific, the results demonstrated that ACEs significantly predicted the increased number of lifetime sex partners, which in plow led to an increased risk of STDs. Similarly, ACEs significantly predicted negative mental health, and and then it was significantly associated with an increased gamble of STDs. Lastly, ACEs increased the gamble of early initiation of sex activity and the number of lifetime sex partners, which in turn significantly increased the take a chance of STDs. However, the results did non support the hypothesis regarding the indirect mediating effects of early on initiation of sex activity, the number of lifetime sex partners, and mental health on the relationship betwixt ACEs and STDs.

Word

STDs are one of the earth'south most common diseases. Our results showed that one-third of our respondents (32%) have had an STD, with an average of three sexual partners. Although U.Southward. college students report having ever had, on boilerplate, more than 10 sexual partners (CollegeStats, due north.d.), which exceeds our sample's self-study, sub-Saharan Africa carries a disproportionate burden of STDs, peculiarly HIV, which accounts for more than 70% of the global burden of infection. Nosotros likewise found that about 8% of the respondents reported engaging in sexual activity when they were younger than historic period 15. This prevalence is like to the charge per unit of other countries in Africa. For example, Mavhandu-Mudzusi and Asgedom (2016) establish that near 6% of college students in Ethiopia began having sex before age 15. Enquiry shows that adolsecnets who have a sexual debut before age xv are less probable to use contracetion, including condoms that those who debut in the normative late historic period (CDC 2018). They may besides develop cervical ectopy which is associated with STDs and HIV (Kleppa et al. 2015).

Our study extends the literature on boyish risky sexual behaviors by examining straight and indirect furnishings of adverse childhood experiences (ACEs) on STD diagnosis through early initiation of sexual activity, number of sexual partners, and mental health bug. Our directly effects results are consistent with findings from previous studies that involved not-African higher students, every bit well as in African settings (e.1000., Ashenhurst et al. 2017; Hill et al. 2017). Early initiation of sex, number of sexual partners, and mental health problems that involve anxiety and depression positively predicted STD diagnosis. The findings carry important implications for STD intervention research among college students, particularly those in Sierra Leone.

Kickoff, sexual education is disquisitional in informing young people about responsible choices in sexual relationships. However, information technology is not uncommon for college students to appoint in sexual activity (e.g., Kebede et al. 2018). In our written report, ix-in-10 individuals in the sample, consisting of more than than lxxx% of freshmen, engaged in sex activity. Other risks reported by our respondents reported early sexual debut (nether 15 years), (vii.half dozen%), have had STDs (31.v%), and having sex with more than iii.24 sexual partners (44.iii%). Sexual education that teaches abstinence, postponing sexual intercourse, resisting unwanted and early sexual intercourse, and using contraception and practicing safer sex when adolescents become sexually agile, is what universities can implement (Henok et al. 2015).

Communicating with the youth about the negative consequences of unprotected sex and providing them with health data that is basic and authentic will give them skills to protect themselves and others from HIV infection, other STDs, and pregnancy (Ashenhurst et al. 2017). We found that individual ACEs are associated with early-historic period sexual initiation, which likewise increased STD risk. The affect of ACEs, including concrete, emotional, or sexual abuse, exact humiliation that occurs while growing up with an abusive family fellow member, can negatively affect neurobiology (Steinberg 2008). 1 style to bargain with some effects from ACEs is to larn to build one'southward self-efficacy past seeking the right kinds of relationships. For example, finding people who are supportive and provide positive interactions with others, which tin forge stiff social ties that build confidence. Without positive reinforcement, individuals may not take the confidence to refuse unprotected or unwanted sex. In a study with a sample of college students in Ghana (Asante et al. 2016), students with higher self-efficacy levels for condom use were likely to use condoms. In helping female person students develop self-efficacy, programs should consider gender-ability inequality issues because Sierra Leone's Gender Inequality Index ranked 150 out of 189 in 2017 (Un Development Plan 2018).

In improver, based on our finding that the path from mental health problems to diagnosis of STDs is significant, screening for mental wellness issues, such equally anxiety and low, should be integrated into the assessment and handling of STDs. It is of import that students care for their mental wellness issues while screening for and treating STDs. Accordingly, information technology is recommended that grooming programs for healthcare professionals include mental health screening tools and resources for referral of STD students with mental wellness bug. Importantly, service providers demand to empathize that these students are probable to experience fear, shame, and stigma nigh STDs that may affect advisable screening and handling (Fortenberry et al. 2002).

Our written report highlights that the associations between ACEs and diagnoses of STDs were significantly mediated by early on initiation of sex activity, number of sexual partners, and mental health problems. These findings are consequent with several previous studies' findings that compared with individuals who have no ACEs, individuals with ACEs are at increased gamble of mental health bug, such as depression and anxiety (Hughes et al. 2017; Kim 2017; Merrick et al. 2017; Rehan et al. 2017). In addition, exposure to ACEs, including emotional abuse, concrete corruption, sexual abuse, and parental incarceration, is associated with risky sexual outcomes including multiple sexual partners and contracting STDs (London et al. 2017). Service providers should carefully consider how early ACEs may exacerbate the risk of risky sexual behaviors and mental health problems, which are, in plow, associated with diagnoses of STDs. It is important to sympathise that exposure to ACEs has a lasting impact on risky sexual behaviors, mental and physical health. Notably, ACE screening and intervention, along with early education for sexual practice and screening for mental health bug, may exist useful in addressing STDs amid college students. For case, young men in Tanzania are less likely to utilise condoms if they have mental health issues such every bit depression and anxiety (Colina et al. 2017). It is of import to notation that exposure to the decade-long civil state of war in Sierra Leone negatively affected individual mental health. Although our students may not have experienced war themselves outset hand, most reported post childhood adversity through ACEs. Admission to mental wellness care providers is a big challenge considering of a dramatic shortage in such health care professionals (WHO northward.d.). In a country where physician density (per m) is 0.024, (WHO north.d.). having adequate mental wellness care is near inconceivable. Mental health trainings for various levels of service providers (east.g., social workers, community health workers, and nurses) could assist accost this mental health care provider shartages (WHO n.d.).

This study should be interpreted within several limitations. First, no causal relationships tin can be determined considering of the cross-sectional study design. For example, the link betwixt mental wellness bug and diagnosis of STDs can exist reversed. In other words, college students can feel depressed or anxious later getting an STD. However, as mentioned higher up, nosotros found more than testify of the path from ACEs to mental health problems, and the path from mental health problems to the conquering of STDs. Second, recall bias tin exist in the measures, such as ACEs, as the events happened during childhood. Third, underreporting tin can exist considering both ACEs and sexual action are sensitive subjects. College students tend to underreport their ACEs, onset age of sexual practice, number of sexual partners, and diagnoses of STDs. Fourth, the ACE-IQ, PHQ-9, and GAD-7 measures in this study have non been validated with higher students in the sub-Saharan Africa. When conducting future enquiry, it may be helpful to use measures that tin can exist validated with African college students. Fifth, the data do not include some important information such as self-efficacy and use of sure contraceptive methods, still, students were asked whether they used condoms every bit away to protect themselves against STDs. Lastly, we used convenience sampling to collect information from simply two colleges in Sierra Leon. Thus, the results are not generalizable to students in other colleges, or those individuals who are not attending a college in the state. These study limitations link to implications for future research. Futurity studies should utilize a longitudinal report blueprint for causality, recruit other college students and higher-aged individuals who are not attending a higher using probability sampling for generalizability, and exam additional predictors of diagnoses of STDs, such every bit self-efficacy and use of contraceptive methods, to strengthen our theoretical model. A nother possible limition of the study is social desirability, especially given that the survey was completed in form around peers. They could have been less likely to disclose certain data given the nature of the topic.

Regardless of any limitations, this study strengthens the ecological model past providing evidence on the chronosystem of the ecological model. Dissimilar previous studies, our report uniquely examined the mediating roles of early on initiation of sex, number of sexual partners, and mental health issues on the link between ACEs and STDs in a sample of college students in Sierra Leon. As mentioned, more than than 30% of our written report respondents reported experiencing an STD. It is important to empathize the direct and indirect associations between ACEs and STDs and their joint associations with mental wellness problems and risky sexual behaviors among higher students in Sierra Leon. It is likewise important to back up continued efforts to design more constructive intervention and wellness education programs for college students with STDs past addressing the lifelong effects of ACEs on risky sexual behaviors and mental health problems.

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1. Schoolhouse of Social Work, Academy of Texas, Arlington, 211 S. Cooper St., Bldg. A, Arlington, TX, 76019, United states of america

   Eusebius Small

2. School of Social Work, Louisiana State Academy, 207 Huey P. Long Field Firm, Baton Rouge, LA, 70803, USA

   Youn Kyoung Kim

3. School of Social Piece of work, Department of Public Health, University of Missouri, 720 Clark Hall, Columbia, MO, 65211, Usa

   Mansoo Yu

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Correspondence to Eusebius Small.

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Small, E., Kim, Y.K. & Yu, G. Sexually Transmitted Diseases Among Higher Students in Sierra Leone: A Life Course Ecological Analysis. Sexuality & Civilization 25, 884–903 (2021). https://doi.org/10.1007/s12119-020-09799-1

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• Accepted: 05 December 2020

• Published: 08 January 2021

• Outcome Engagement: June 2021

• DOI : https://doi.org/10.1007/s12119-020-09799-one

Keywords

• Agin childhood experience
• Sexually transmitted illness
• Early sexual practice
• Number of lifetime sex partners
• Mental wellness

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