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College students engage in risky sexual behaviors, resulting in unintended pregnancies, early marriages, abortion, and having multiple relationships which expose them to sexually transmitted diseases (STDs) including HIV/AIDS. Having lived through years of civil war and the Ebola crisis, Sierra Leonean youth are at a high risk of risky behaviors including STDs and HIV. The prolonged exposure to adverse childhood experiences can have detrimental psychological effects resulting from exposure to trauma. In Sierrra Leone, adolescents ages 15-19, for example, report having children or being currently pregnant compared to only 2% in the U.S. About 39% of Sierra Leonean youth marry before the age 18 and 13% before the age 15. Despite their knowledge of career development and success, college students may lack sexual health knowledge and STD prevention skills. The purpose of this study, therefore, was to test a pathway model of the associations between adverse childhood experiences (ACEs), mental health, sexual risk behavior; and to examine whether STIs/HIV health literacy moderated the relationship between mental health and sexual risk behaviors among college students in Sierra Leone.
Methods
A cross-sectional design tested a hypothetical model of STIs among a sample of 338 college students in Sierra Leone. The primary predictive variable in this model was ACEs, which was assessed using the World Health Organization’s ACEs Questionnaire. The mediating variables on the relationship between ACEs and STIs/HIV diagnosis were mental health and sexual risk behavior. Mental health was operationalized using depression and anxiety, the PHQ-9 and GAD-7 scale, respectively. Another mediator was sexual risk behavior, which was a latent variable of sex while using alcohol or drugs and multiple sex partners. The endogenous variable was STI/HIV diagnosis and moderating variable was STI/HIV health literacy. Structural Equation Modeling (SEM), using Mplus version 7.4, was the primary analytical method used to test the measurement and structural models. Since the moderator was a latent variable, the Mplus model fit indices do not provide chi-square, CFI, TLI, or RMSEA. The loglikelihood was -4010.34.
Results
The findings partially supported our hypotheses. The results showed that ACEs significantly predicted sexual risk behavior, and that sexual risk behavior was significantly associated with STI/HIV among college students. In addition, STI/HIV health literacy significantly moderated the relationship between sexual risk behavior and STI/HIV diagnosis. For college students with lower STI/HIV health literacy knowledge, the impact of sexual risk behavior on STI/HIV diagnosis was greater than for those with higher health literacy. However, while ACE was positively associated with mental health (depression and anxiety) in the model, mental health was not significantly associated with sexual risk behavior.
Conclusions and Implications
Students with greater exposure to ACEs have disproportionately high levels of engaging in risky sexual behavior that could expose them to HIV/AIDS. Because health literacy moderated the relationship between sexual risk behavior and STI/HIV diagnosis, health literacy-informed interventions for these populations are warranted.