Johnson K, Akpan I, Kinard A, Reeves J, Griner S. Self-sampling methods for STI screening among college women: a qualitative to identify opinion leaders. HPHR. 2023;52. https://doi.org/10.54111/0001/ZZ8
Nearly half of new sexually transmitted infections (STIs) occur in young adults, however, less than half of young adult women receive STI screening annually. Novel screening strategies could aid in reducing screening barriers and improving screening rates. Self-sampling methods (sample collection at home) could be an innovative solution to improve screening rates among young adult women: however, there is little research exploring how knowledge of self-sampling methods is shared with this population. Thus, the purpose of this study was to investigate the influence of opinion leaders on self-sampling methods for STI screening among college women.
Participants (n=24) were sexually active, young adult (18-24), college women who attended a university in the southeastern United States. The interview guide was based on the opinion leaders construct from the Diffusion of Innovation theory. Two coders independently coded 10% of interviews with a Cohen’s Kappa of .84, and subsequent interviews were thematically coded by a singular coder.
Opinion leaders fell into two categories: internal and external, with internal including resident assistants, student government leaders, coaches and captains, and sorority leaders. These campus leaders were discussed as opinion leaders because they influence decision-making and are seen as role models and trustworthy. External opinion leaders included celebrities or artists who were open about health issues or sexual topics and politically involved celebrities, who may have larger platforms to discuss self-sampling methods.
New, innovative strategies for STI screening, such as self-sampling methods, could be a solution to overcome the barriers hindering annual STI screening among college women. Opinion leaders may play an important role in shaping the perception and dissemination of knowledge regarding self-sampling methods for STI screening among this demographic.
Opinion leaders can be used as conduits for health information on self-sampling methods within the college community and in the social system at a broader level.
Chlamydia and gonococcal infections are highly prevalent sexually transmitted infections (STIs) in the United States (U.S.), particularly among individuals under 25, with two-thirds of chlamydia cases occurring in those aged 15-24.1 These infections can lead to severe health complications for women including pelvic inflammatory disease, ectopic pregnancy, and infertility.1 Given their often asymptomatic nature, annual screening is recommended for sexually active women under 25 for early detection and to reduce these long-term consequences.2
STI screening barriers exist for adolescents, young adults, and college students aged 18–24 including privacy concerns, cost, limited access, and underutilization of healthcare services.3 Self-sampling methods (collecting a sample at home and mailing it in for testing) for STI screening offer a solution to these barriers, being cost-effective, efficacious, and convenient.4-6 Previous studies have shown that college women find vaginal swab self-sampling methods to be acceptable and easy, yet concerns persist, including the novelty of self-collection and limited awareness of this option.7,8
Increasing awareness of self-sampling methods is essential to promote self-sampling as a viable STI screening alternative. Utilizing opinion leaders (also known socially as influencers) who influence the opinions, attitudes, beliefs, motivations, and behaviors of others can be an effective approach.9 Opinion leaders, rooted in the Diffusion of Innovation (DOI) theory,10 possess knowledge and communication skills to initiate behavior change.11 DOI is a theoretical model that guides understanding of how a new innovation is spread and adopted through society. It consists of six elements: form and informal communication within the social system, the social system, time, characteristics of the innovation, individual categories, and the innovation.10 Opinion leaders are key features of the social system, reflecting its norms and informally influencing individuals’ attitudes or behaviors.10
Among college women, targeted opinion leaders could assuage concerns and positively influence attitudes about self-sampling methods for STI screening among young adults. These opinion leaders can be internal to the social system, utilizing interpersonal communication approaches, and those external to the social system, such as celebrities using mass media channels.10 While research has explored opinion leader influence in clinical settings, limited work has focused on college social environments.12,13 Thus, the purpose of this study was to explore the influential opinion leaders among college women, providing valuable insights into potential communicators and disseminators of self-sampling information for STI screening promotion.
Note: ‘Our World in Data’ produced the original image based on the data from the United Nations-Population Division published in 2022.
The inclusion criteria for interviews were: 1) identified as a woman; 2) was currently enrolled as a student at the participating university 3) reported sexual activity in the past 12 months; and 4) was 18-24 years old. Participants were recruited from a large university in the southeastern U.S. through flyers, emails, and social media. Invitations to participate were shared with student organization members through a student organization e-portal, posted on social media accounts of student organizations and sororities, and flyers were posted across the university with a link to participate. The invitations and flyers were linked to a screening survey which verified the inclusion criteria of the participants, and participants provided information about their perceptions of self-sampling methods for STI screening and identified which characteristics, such as the methods being low cost, available in a convenient location, and avoiding interactions with a healthcare provider, were most salient and influential to adopting the method.4 Participants were asked to leave their contact information if they were willing to participate in an interview, and those willing were contacted in order of survey completion. Those who did not respond after the third attempt (n=7) were not contacted further and the next participant was contacted. Interviews were conducted in person at a centrally located space in the university, lasted for approximately 45 minutes, and were audio recorded and transcribed. Participants were given an overview of a self-sampling method “kit”, based on the EveKit, prior to the interview to familiarize themselves. Interview participants were given $20 for their time following completion. Ultimately, 24 women were interviewed. This study was approved by the University’s Institutional Review Board (IRB).
The interview guide was focused on STI-related intervention development and guided by DOI, particularly constructs within the social system domain. This paper reports on the results from two items assessing opinion leaders: Who would influence your decision to use this kit [a self-sampling method for STI screening]? Who could be a potential role model to promote [self-sampling methods or at home STI testing]? While opinion leaders are typically part of the social system or network of the participants, we allowed participants to respond broadly and identify potential opinion leaders inside and outside of their networks.11
Transcripts were checked for accuracy compared to the audio files, and were then uploaded into MaxQDA, a qualitative data analysis software. Interviews were analyzed thematically using a priori codes for internal and external opinion leaders. Interrater reliability was calculated between two coders through independent coding of 10% of the transcripts (three interviews). Based on this, Cohen’s Kappa was .84, which indicated high coding agreement.14 One coder completed the coding of the remaining interviews due to the high level of coding agreement.
Interview participants (n=24) were all undergraduate students, with a mean age of 19.5 (standard deviation (SD)=1.1) and an average number of 2.7 sex partners (SD=2.4). Half of the participants (50%) were heterosexual, the remaining half were bisexual (33%), lesbian (4%), or identified as another sexual orientation (13%). Most of the participants were white (75%), non-Hispanic (83%), and enrolled in health-related degree programs (54%). Results are separated into subgroups of opinion leaders within the college/university community and those external to the college/university community. The most salient subthemes are presented for each subgroup.
Women participating in this study identified student leaders, including resident assistants, captains of sports teams, sorority presidents, those in student government, and university orientation leaders as the most influential people in their lives, particularly related to health issues (n=9, 38%). These individuals represented something to strive toward, and participants were receptive to women students in leadership positions, especially those who they perceived to be similar to themselves and viewed as trustworthy. One participant described her thoughts about student leaders and their role in communicating about innovative methods of STI screening as follows:
“Leaders of student organizations. I thought of our Panhellenic president. She is in a sorority but she’s very professional and forward-thinking and she wants to make a difference in the community. Someone who is you but better. So, like someone a year older than you, someone who’s in the same club as you but a little higher up. Someone you trust and they’re just like you, but they’re not. They’re you but they have it all together.”
– Participant S8
“For some reason, there’s a weird trust thing with student government people. I have friends on there and I feel a lot of them are very trustworthy. And a lot of them would be really willing to [talk about self-sampling methods for STI screening].”
– Participant NS4
Resident Assistants. Resident Assistants (RAs) were commonly viewed as opinion leaders for a variety of health behaviors, and specifically for STI screening and promotion of self-sampling methods. Participants in this sample described an RA’s role of ensuring their well-being and discussed that RAs often held meetings about health-related topics and shared health information. Because of this, many participants felt that a discussion involving self-sampling methods of STI screening fit naturally within their role. Participants also described that their respect and trust for RAs and also for their orientation leaders continued, even after they had moved from the dorms or moved on from orientation. Many participants described forming relationships with their RAs and orientation leaders and valuing their input on self-sampling methods due to their leadership position, but also because of their informal role. Again, participants reported they valued RAs and orientation leaders as a resource, as these opinion leaders are viewed as responsible in their lives:
“There’s presidents of sororities and you have an RA in the dorms. The RA would have to have meetings every so often. During the meetings they were like, “Okay, guys step out for a second, okay girls, this is the thing, this is an option, it’s okay,” I feel like that will be a valuable resource. Because when I was a freshman, the RA was a junior, and she seemed like she had everything together. So if she talked about that [self-sampling methods], then it would be a little easier to do. Having someone that’s kind of in a position of authority but not like the president of the school, having someone more in an informal setting saying it’s [using self-sampling methods] okay, I think that would help.”
– Participant NS9
“Just hearing [about self-sampling method] from the RAs on campus, because a lot of people I’ve spoken to, they respect them. They’re like, “That was my orientation leader. That was my RA.” They’ll look back on that with good and positive vibes.”
– Participant NS3
Sorority Leaders. Greek life overall was viewed as a connection that might influence the use of self-sampling methods. Those in sororities positively described the presidents of their sororities as opinion leaders, good role models, and trustworthy. Within sororities, those in roles as “big sisters” or “bigs” who mentor incoming students were viewed as influential in sexual health.
“Honestly, I feel like, if you could get the Greeks on campus involved in it [promoting self-sampling methods], it would be really good for their reputations. Because with Greek culture comes a certain amount of rape culture. And so, pushing this to the Greeks especially would one, boost their image, but it would also boost your product as well.”
– Participant NS1
Coaches and Captains. Similar to RAs and those in student leadership positions, participants who were involved in sports clubs or on teams mentioned their captains or presidents who were women as opinion leaders. Information about self-sampling methods for STI screening was viewed as similar to other health-related information provided by student coaches regularly. Captains and coaches were also described as important in individual maturation and decision-making regarding health and overall well-being.
“My color guard coach is all about self-maturation and you taking care of yourself, and figuring out yourself, basically. If she were to say, “You can do this [self-sampling] and it’s normal, and I’ve done it,” especially if the person says “I have physically done it, and I trust it.””
– Participant NS4
“I’m in a sport club, and I feel like if one of the captains there or the president mentioned it [self-sampling methods] like, “Oh hey, like there’s this option,” I wouldn’t really blink twice. We’re expected to hear about stuff from them anyways.”
– Participant NS9
Participants also considered many external groups of people as opinion leaders for self-sampling methods for STI screening. They commonly included performers and musicians who were open about their own health, artists who discussed sexual content in their art or were open about sexuality, and those who were politically involved or activists (n=14, 58%).
Performers Who are Open about Health Issues. Although a wide range of celebrities were mentioned, many people who had publicly been through a health-related issue were considered as opinion leaders for self-sampling methods. One example was Demi Lovato and participants discussed their drug use and recent relapse.15 While this was not related to sexual health, participants viewed their open discussion of their addiction as an honest and positive trait. Similarly, celebrities such as Miley Cyrus and Kesha were mentioned as being open about health and sexuality. Miley Cyrus was viewed as a sexual woman, given her performances, videos, and photographs,16 while Kesha recently went through a lawsuit due to her experiences of sexual assault and was open regarding her experiences.17 Another example mentioned was named Doja Cat, who was viewed as influential toward young adult culture but also casual about sexual behaviors.18
“She’s [Doja Cat] very open about everything and she’s really open about her sexuality. A lot of her songs, she references stuff like that. People seeing her would be like, “Hey, there’s this thing [self-sampling methods] I feel like you should do,” or like, “It [self-sampling methods] looks like it’s really convenient, so like you should get tested because you don’t want to be unhealthy.” Like someone very casual and very lax about the sexual aspect of things. And also someone that tends to be involved with a lot of like young adult culture.”
– Participant S11
“Demi Lovato or Taylor Swift…if they advocated for it [self-sampling methods], people would use it. Like if Taylor Swift said it, they’d be like “Yeah, she had, like, a hundred boyfriends. That seems fair.” If Demi Lovato did it, like “Oh, yeah [they] had a eating disorder, [they] self harmed, [they] probably know how to take care of [themself] now.”
– Participant NS7
“Demi Lovato is going through drug stuff so I think [they’re] opening the stigma around going to rehab and relapsing. I think after that settles, if [they] were to talk about sex or sexual education, I think that will be beneficial.”
Artists who are Vocal about Sexual Topics. Many women artists who focused specifically on sexual behaviors in their art, such as Amber Rose, were mentioned positively as opinion leaders for self-sampling methods. Amber Rose is a former sex worker who speaks out against slut-shaming, and given her advocacy related to sexual health topics, participants felt she would be a trustworthy source for self-sampling information.19 Other artists and actresses who were mentioned as opinion leaders because of their discussions of sexual behaviors included Issa Rae, an actress who often advocates for women’s health,20,21 and Cardi B, a musician who is vocal about sexuality in her music.22 These women were mentioned as people who included who sexual undertones in their performances, writing, and music, and therefore were viewed as knowledgeable when considering new methods of STI screening.
“Amber Rose is a big one. She’s had the slut walk. She’s just really big on female sexual empowerment just because she was a dancer. Just because she’s sexual, that doesn’t define her. And even because she is sexual, she’s still a good woman.”
– Participant NS6
“People like Amber Rose, because Amber Rose is big on not slut shaming people. She does the Slut Walk every year. Basically, saying that people should not judge, because women like to have sex. Cardi B as well because she’s always talking about sexual things. People, especially people who have sexual content. Especially people who’ve had history with sexual infections and that kind of thing, getting them to push it [this method] might probably be a good option.”
– Participant NS1
Politically-Involved Celebrities. Participants also described opinion leaders as being other celebrities who were involved in politics. Participants mentioned specific people they viewed as political, such as Beyonce, Olivia Wilde, Rashida Jones, Miley Cyrus, and Selena Gomez. In addition to, and sometimes linked with political involvement, participants described opinion leaders as women who were viewed as empowered, and participants also described feminism as a value of importance in opinion leaders. Participants mentioned artists who described feminism in their songs as potential opinion leaders and also described celebrities that were viewed as role models or “good people” such as Nicki Minaj and Carrie Underwood.
“Maybe someone who’s like more informed. Maybe a celebrity that speaks out …politically. Who actually has a voice. You don’t just see them. You actually associate them with some type of movement. Kind of like Olivia Wilde, or Rashida Jones or something.”
– Participant S1
“Maybe Miley Cyrus or Kesha could be. Miley has some type of clothing line that she sells that all the proceeds go to LGBT teen groups or something. So clearly she’s very active already. I feel like they’ve both gone through a lot, so they have that strong woman thing that people could look up to.”
– Participant NS11
This study offers insights into opinion leaders among college women, particularly related to communication about self-sampling methods for STI screening. Overall, opinion leaders were delineated into two spheres: those within the college community context (e.g., student leaders, resident assistants, and coaches) and those external to it (e.g., celebrities, artists). Participants identified opinion leaders as people who are concerned about others’ well-being and who possess platforms for information dissemination, whether small or large scale.
Campus leaders were identified as influential figures who serve as role models, earning trust due to their perceived knowledge and exposure to health topics, including self-sampling methods. By strategically targeting these campus leaders, they can become advocates for self-sampling methods, by raising awareness and motivating their peers to adopt this STI screening method. Additionally, studies suggest that training opinion leaders, like peer educators, can effectively disseminate innovations, including self-sampling methods, within the college context.23-25 Given the campus context, internal opinion leaders and on-campus health centers may have an opportunity to collaborate by equipping campus leaders with the appropriate training, communication skills, and resources to be effective peer educators or disseminators of self-sampling method information to promote STI screening.
Participants also valued the opinions of certain celebrities, especially those vocal about sexuality and sexual health. Celebrities’ vast platforms and respect among their followers make them potential allies in promoting self-sampling methods.26-29 Collaborations with such celebrities can enhance awareness and build trust among college women hesitant to discuss their sex lives with healthcare providers.8 However, it is important to acknowledge that celebrities, while influential, can also spread misinformation that impacts health decisions negatively.29 Collaborations should involve providing celebrities with accurate information about sexual health topics.9 One of the most effective approaches to reach a young adult audience is to be active on social media, and opinion leaders, such as celebrities, who are active on social media and share information about their personal opinions and experiences can influence the decisions of their followers.30-32 Prior to exploring these approaches, celebrities must be given appropriate information to be well informed about these sexual health topics or there is potential for inaccurate health information to be spread.9
Despite the rich data this study provided, there are still limitations. This study utilized a convenience sample of sexually active college-age women who may have been more comfortable with sexual health topics, potentially introducing bias. The small sample size limits generalizability of these findings to all college women or other institution and may represent a limited scope of perspectives due to participants being of similar background. Nonetheless, the goal of this study was to garner a deeper understanding of this intricate subject. Discussing matters related to sexual health can introduce response bias into the interviews, as participants may be inclined to answer in a way they believe aligns with the researcher’s expectations. In-depth interviewing and data triangulation ensured that responses were as truthful as possible, which contributed valuable insights into influential individuals related in the context of stigmatized sexual health topics.
Overall, this study investigated that opinion leaders who can be used as conduits for health information on self-sampling methods for STI screening, both internally to the college community and externally in the broader social system. Future studies should focus on the role of opinion leaders in the dissemination of health information and if college women will be receptive to the content. This information about the relevance of opinion leaders can be used to inform future evidence-based communication interventions to increase STI screening among college women.
This study was funded in part through the Doug Kirby Adolescent Sexual Health Research Grant from the Rural Center for AIDS/STD Prevention at Indiana University. This study was also funded through University of South Florida, College of Public Health.
The author(s) have no relevant financial disclosures or conflicts of interest.
Kaeli Johnson is a doctoral student in the School of Public Health at the University of North Texas Health Science Center. Her research focuses on maternal and child health and reproductive health, particularly among racial and gender minority populations.
Idara Akpan is a doctoral student of Health Behavior Research at the University of North Texas Health Science Center, School of Public Health. Her research interests center around women’s health, with a focus on human papillomavirus (HPV) vaccination, sexual and reproductive health needs.
Ashlyn Kinard is a fourth-year medical student at the Texas College of Osteopathic Medicine at The University of North Texas Health Science Center. She is pursuing a career in obstetrics and gynecology and has been heavily involved in research, with specific interests in sexual and reproductive health.
Dr. Jaquetta Reeves is an Assistant Professor in the College of Nursing and Health Innovation at The University of Texas at Arlington. Her research focuses on addressing sexual health inequities and increasing access to STI/HIV testing and care among minority adolescent and young adult populations.
Dr. Stacey Griner is an assistant professor in the School of Public Health at the University of North Texas Health Science Center. Her research focuses on sexually transmitted infection screening, prevention, and control. She uses implementation science and patient-centered approaches to translate public health research into clinical practice