Sexual Health Survey

Abstract

The Sexual Health Survey (SHS), developed by Heather Eastman-Mueller, Deborah Carr, and Steve Osterlind at the University of Missouri, Columbia, is an empirically validated multidimensional psychometric instrument designed to evaluate the tripartite matrix of sexual health among emerging adults enrolled in higher education institutions. Grounded in holistic models of health psychology and behavioral medicine, the instrument assesses three core domains: Sexual Health Knowledge (SHK), Sexual Health Attitudes (SHA), and Sexual Health Behaviors (SHB). The initial 200-item experimental pool was derived from rigorous construct explication, focus groups, and expert content validity indexing across five priority domains: contraception, pregnancy prevention, sexual health communication, sexual behavior, and sexually transmitted infections (STIs) alongside institutional barriers to diagnostic testing.

Following pilot administration among a randomized cohort of N = 600 undergraduate and graduate university students, psychometric item analysis refined the instrument to a 127-item comprehensive assessment battery. Subsequent dimensionality investigations via principal axis factoring (PAF) with orthogonal varimax rotation isolated a robust five-factor psychometric core comprising 17 high-loading items that account for 71.46% of total construct variance. These latent dimensions encompass: (1) Perceived Sexual Readiness (α = .88), (2) Comfort Sexual Communication (α = .91), (3) Comfort with Barrier Methods (α = .79), (4) Latex Barrier Effectiveness (α = .79), and (5) Belief in Rape Myths (α = .74), yielding an overall structural internal consistency coefficient of α = .79. The SHS provides student health professionals, epidemiologists, and university administrators with an empirically grounded diagnostic tool capable of informing targeted health promotion interventions, identifying sexual violence risk perceptions, and quantifying safer-sex behavioral practices across diverse collegiate demographics.

Keywords

Sexual Health Survey, collegiate sexual health, sexual health knowledge, sexual health attitudes, sexual health behavior, barrier contraception, STI prevention, condom negotiation, rape myth acceptance, psychometrics, emerging adulthood, higher education health promotion.

Authors

The Sexual Health Survey was conceptualized, psychometrically developed, and standardized by a multidisciplinary team of scholars and clinical health promotion specialists at the University of Missouri, Columbia:

• Heather Eastman-Mueller, PhD, CHES — Health Promotion Department, Student Health Center, University of Missouri, Columbia, MO. Primary investigator specializing in collegiate human sexuality, sexual violence prevention, and LGBTQ+ health equity. (Correspondence: [email protected]).
• Deborah Carr, PhD — University of Missouri, Columbia. Clinical researcher and public health specialist focusing on reproductive healthcare access, barrier method adherence, and health literacy among young adults.
• Steve Osterlind, PhD — Department of Educational, School, and Counseling Psychology, University of Missouri, Columbia. Renowned psychometrician and measurement theorist specializing in test construction, modern psychometric theory, differential item functioning, and exploratory factor analysis.

Purpose

Emerging adulthood represents a developmental epoch characterized by identity exploration, shifts in interpersonal autonomy, and escalating sexual experimentation. Within collegiate environments, students encounter unique interpersonal dynamics, peer norms, and environmental factors that elevate vulnerability to unintended pregnancies, human immunodeficiency virus (HIV), and other sexually transmitted infections such as chlamydia, gonorrhea, and human papillomavirus (HPV). Despite the availability of medical resources, pervasive informational deficits, communication apprehension, and normative rape myth endorsements persistently undermine proactive sexual safety. The Sexual Health Survey (SHS) was engineered to furnish a methodologically rigorous, multi-tiered diagnostic instrument specifically calibrated to the cognitive, affective, and behavioral characteristics of university students.

The programmatic purpose of the SHS is threefold:

• Comprehensive Needs Assessment: To provide university health centers and student affairs divisions with empirical epidemiological baselines concerning biological knowledge gaps, preventative misconception rates, and prevalent sexual behaviors (including alcohol-involved intercourse and barrier non-compliance).
• Structural Diagnostic Profiling: To assess nuanced affective barriers that mediate preventative practices—specifically assessing whether behavioral deficits stem from objective factual ignorance (knowledge deficits), communicative anxiety regarding partner negotiation (attitudinal barriers), or physical discomfort with barrier method procurement.
• Intervention Evaluation: To serve as a standardized, sensitive pre- and post-intervention outcome measure for university-wide sexual health curricula, peer education programs, consent workshops, and sexual assault risk reduction campaigns.

By measuring knowledge, attitudes, and concrete behaviors within a unified instrument, the SHS enables researchers to model complex causal pathways and structural relationships. Rather than treating sexual safety as a unidimensional construct, the survey disentangles subjective readiness, partner-level communication efficacy, mechanical barrier competence, and socio-cultural belief systems surrounding sexual violence.

Psychological Construct

The SHS conceptualizes collegiate sexual wellbeing through an integrated tri-component behavioral health paradigm spanning cognitive, affective/normative, and action-oriented behavioral domains:

1. Sexual Health Knowledge (SHK)

This cognitive dimension operationalizes an individual's objective retention of biological facts and empirical risk probabilities across 24 specific items. It assesses knowledge concerning:

• Mechanisms of biological conception (e.g., probability of conception occurring during initial intercourse).
• Modes of viral and bacterial STI transmission, with specific focus on oral-genital transmission vectors.
• Efficacy profiles of diverse barrier technologies, such as comparing standard latex condoms, spermicide-treated prophylactics, and dental dams.
• Systemic pharmacological interactions, such as the compounding impact of alcohol intoxication on physiological judgment and preventative compliance.

2. Sexual Health Attitudes (SHA)

Spanning 48 items, the affective domain evaluates emotional valences, self-efficacy beliefs, socio-normative standards, and perceived barriers. Rather than indexing mere theoretical approval of safe sex, it interrogates interpersonal friction points, including:

• Perceived Sexual Readiness: Normative frameworks regarding timing of sexual onset, ranging from conservative/abstinence endorsements (reserving intercourse exclusively for formal marital unions) to situational permissiveness within early dating stages.
• Partner Communication Self-Efficacy: Psychological comfort and apprehension when initiating transparent verbal discussions with romantic or casual partners regarding sexual history, diagnostic STI status, and recent HIV testing.
• Somatic and Social Procurement Discomfort: Evaluative anxiety tied to publicly purchasing barrier products (condoms, dental dams) or introducing them into intimate encounters.
• Rape Myth Endorsement: Sociocognitive acceptance of victim-blaming stereotypes surrounding sexual violence, coercive relationship roles, and erroneous causal attributions between partner count and assault vulnerability.

3. Sexual Health Behaviors (SHB)

Comprising 17 multiple-choice items and 16 dichotomous indicators (33 items total), this domain measures concrete, self-reported behavioral epidemiology. Assessed parameters include age at sexual debut, lifetime partner counts, 30-day behavioral frequencies (oral, anal, and vaginal sex), systematic barrier non-compliance etiologies (e.g., substance intoxication, spontaneous encounters, lack of barrier availability), clinical testing histories, and experiences with nonconsensual sexual contact.

Theoretical Framework

The structural architecture of the Sexual Health Survey synthesizes three prominent theoretical frameworks in health psychology and behavioral science:

The Information-Motivation-Behavioral Skills (IMB) Model

Formulated by Fisher, Fisher, and colleagues (1992, 2002), the Information-Motivation-Behavioral Skills Model asserts that sexual risk-reduction behavior is directly determined by behavioral skills, which are in turn jointly determined and enacted via relevant sexual health information and motivation. The SHS operationalizes this tripartite paradigm directly:

• Information: Operationalized through the 24-item Sexual Health Knowledge (SHK) module, capturing accurate heuristic heuristics and preventative mechanics.
• Motivation: Captured via the Sexual Health Attitudes (SHA) subscales, measuring personal attitudes toward safer-sex practices, social norm perceptions, and the affective appraisal of sexual readiness.
• Behavioral Skills: Evaluated through interpersonal communication comfort subscales (negotiating condom use, inquiring about HIV/STI status) and concrete barrier procurement self-efficacy.

The Theory of Planned Behavior (TPB)

Under Ajzen's Theory of Planned Behavior (1991), intentional human action is governed by attitudes toward the behavior, subjective normative beliefs, and perceived behavioral control. Within the SHS, items measuring comfort in requesting condom usage or querying past sexual partners represent subjective operationalizations of perceived behavioral control within emotionally charged, sexually intimate scenarios.

Bandura's Social Cognitive Theory

Albert Bandura's construct of self-efficacy underpins the communicative dimensions of the survey. Bandura posited that individuals must possess not only knowledge of what actions to take, but the conviction that they can successfully execute those actions in the face of psychosocial obstacles. The SHS explicitly separates abstract knowledge (e.g., knowing condoms prevent disease) from communicative self-efficacy (e.g., comfort demanding condom adherence when a partner objects).

Validity

The psychometric integrity of the SHS was established through an extensive multi-phase validation methodology meeting modern educational and psychological testing standards:

Content Validity

Initial item generation originated from comprehensive bibliographic literature reviews paired with qualitative focus groups that performed construct explication on collegiate sexual priority areas. The preliminary 200-item pool was submitted to a structured expert panel of five specialists selected for broad interdisciplinary representation:

• A licensed counseling psychologist specializing in collegiate developmental transitions.
• A clinical registered nurse experienced in reproductive healthcare and STI epidemiology.
• A research psychometrician and statistician specializing in measurement error and item bias.
• An academic scholar in human sexuality and reproductive health education.
• An expert in sexual violence prevention, LGBTQ+ identity dynamics, and gender-affirming care.

The panel reviewed every candidate item for clinical accuracy, item clarity, cultural competency, and gender sensitivity, eliminating ambiguous, coercive, or heteronormative phrasings.

Construct and Factorial Validity

Empirical construct validation was executed using an online pilot administration across a randomized sample of N = 600 university students. Classical item analysis evaluated item-total correlations, item endorsement rates, and discrimination indices, paring the instrument from 200 to 127 items. The structural dimensionality of the refined instrument was examined via principal axis factoring. Sampling adequacy was verified by a Kaiser-Meyer-Olkin (KMO) index of .784 and a statistically significant Bartlett's Test of Sphericity (χ², p < .001). The five-factor solution extracted accounted for 71.46% of the cumulative variance, with all retained item loadings exceeding the .30 threshold (ranging from .60 to .96).

Convergent and Discriminant Validity

The subscales exhibited strong patterns of theoretical divergence and convergence. Factor 2 (Comfort Sexual Communication) converged substantially with Factor 3 (Comfort with Barrier Methods), demonstrating that interpersonal communicative self-efficacy tracks physical barrier assertiveness. Conversely, Factor 5 (Belief in Rape Myths) demonstrated discriminant divergence from technical barrier efficacy (Factor 4), confirming that adherence to gender-role myths operates as an independent socio-cognitive schema distinct from mechanical health literacy.

Reliability

Internal consistency for the SHS subscales and overall structural model was assessed using Cronbach's alpha (α) along with corrected item-total correlation coefficients across the validation sample (N = 600):

• Factor 1: Perceived Sexual Readiness (k = 5 items): Exhibited high internal consistency with α = .88. All corrected item-total correlations exceeded .63, reflecting exceptional item homogeneity regarding normative timelines for sexual debut within relationships.
• Factor 2: Comfort Sexual Communication (k = 3 items): Demonstrated exemplary internal consistency with α = .91. Corrected item-total correlations were all .71 and above, underscoring high internal congruence in assessing conversational disclosure regarding HIV and STI diagnostic histories.
• Factor 3: Comfort with Barrier Methods (k = 3 items): Achieved solid reliability with α = .79, with corrected item-total correlations of .58 and above.
• Factor 4: Latex Barrier Effectiveness (k = 3 items): Yielded an internal consistency of α = .79, with corrected item-total correlations remaining at .56 and above.
• Factor 5: Belief in Rape Myths (k = 3 items): Demonstrated acceptable internal consistency with α = .74, capturing victim-blaming stereotypes and relational vulnerability assumptions.
• Composite Structural Model (k = 17 items): Across all 17 items spanning the five extracted factors, the instrument demonstrated an overall internal consistency of α = .79, with corrected item-total correlations ranging between .23 and .54.

Factor Analysis

To detect underlying structural dimensions and determine the latent architecture of the instrument, Eastman-Mueller and colleagues conducted Exploratory Factor Analysis utilizing Principal Axis Factoring (PAF). Given that inter-variable correlations among the items largely fell below .32 (as recommended by Tabachnick & Fidell, 2001), an orthogonal Varimax rotation was executed to maximize factor interpretability and facilitate distinct conceptual separation.

The mathematical extraction yielded five primary factors possessing initial eigenvalues exceeding 1.0 (Kaiser's criterion), which cumulatively accounted for 71.46% of the total variance. Because relying solely on Kaiser's criterion can occasionally over-extract or under-extract factors, Cattell's scree test was inspected as a confirmatory criterion; the scree plot break unambiguously supported the five-factor structural solution.

Instrument / Measurement Tool

• Instrument Designation: Sexual Health Survey (SHS).
• Administration Format: Self-administered paper-and-pencil questionnaire or secure web-based online survey platform.
• Target Population: Undergraduate and graduate students enrolled in institutes of higher education (typically aged 18 to 25+).
• Completion Duration: Approximately 20 minutes for the full battery.
• Full Instrument Composition (127 items total):
  • Sexual Health Knowledge (SHK): 24 items rated on a 6-point Likert-type scale (0 = Strongly Disagree / Very Ineffective to 5 = Strongly Agree / Very Effective).
  • Sexual Health Attitudes (SHA): 48 items rated on a 6-point Likert-type scale (0 = Very Uncomfortable / Very Unconcerned / Strongly Agree to 5 = Very Comfortable / Very Concerned / Strongly Disagree).
  • Sexual Health Behaviors (SHB): 33 items comprising 17 multiple-choice indicators and 16 dichotomous (Yes/No) questions capturing debut age, 30-day sexual acts, partner numbers, alcohol use, and nonconsensual assault histories.
  • Sociodemographic Variables: Age, academic standing (class year), biological sex, gender identity (including transgender identities), sexual orientation, relationship status, living arrangements (Greek housing, residence halls, off-campus), and Greek life affiliation.
• Validated 5-Factor Solution (17 items):
  • Factor 1: Perceived Sexual Readiness (5 items).
  • Factor 2: Comfort Sexual Communication (3 items).
  • Factor 3: Comfort with Barrier Methods (3 items).
  • Factor 4: Latex Barrier Effectiveness (3 items).
  • Factor 5: Belief in Rape Myths (3 items).
• Scoring Protocols:
  • Construct-Level Knowledge Scoring: Sum all 24 knowledge items (Items K1–K24) for a total Knowledge score ranging from 0 to 120. Higher scores denote superior biological and prophylactic literacy.
  • Construct-Level Attitude Scoring: Sum Items A1 through A10, A17 through A19, A21, A25, and A27 (16 items total) for a maximum score of 80.
  • Factor-Level Scoring: Sum item ratings within each respective factor. For Factors 1, 2, 3, and 5, higher scores represent more favorable attitudes toward safer-sex/abstinence, heightened comfort with communication, elevated comfort procuring barrier methods, and elevated belief in rape myths, respectively. For Factor 4, lower scores indicate deficits in objective knowledge regarding latex barrier effectiveness.

Permissions & Fee and Test Year

The Sexual Health Survey instrument was officially copyrighted in February 2006 by Dr. Heather Eastman-Mueller, Dr. Deborah Carr, and Dr. Steve Osterlind at the University of Missouri, Columbia. All proprietary rights reside with the primary authors.

The instrument is made accessible for academic, clinical, and non-profit collegiate research applications under written authorization. Commercial applications, widespread institutional deployments, or alterations to scale items require formal licensing. Inquiries regarding permissions, complete full-length survey modules (including behavioral indices), or scoring code should be addressed to the primary developer:

Heather Eastman-Mueller, PhD, CHES
Health Promotion Department, Student Health Center
University of Missouri, Columbia
1101 Hospital Drive, Columbia, MO 65212
E-mail: [email protected]

References

• Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50(2), 179–211. https://doi.org/10.1016/0749-5978(91)90020-T
• Eastman-Mueller, H., Carr, D., & Osterlind, S. (2006). Sexual Health Survey: Development and psychometric evaluation of a multidimensional sexual health assessment for university students. Student Health Center Publications, University of Missouri, Columbia.
• Fisher, J. D., & Fisher, W. A. (1992). Changing AIDS-risk behavior. Psychological Bulletin, 111(3), 455–474. https://doi.org/10.1037/0033-2909.111.3.455
• Fisher, W. A., Fisher, J. D., & Harman, J. (2002). The Information-Motivation-Behavioral Skills Model: A general social psychological approach to understanding and promoting health behavior. In J. Suls & K. A. Wallston (Eds.), Social psychological foundations of health and illness (pp. 82–106). Blackwell Publishing. https://doi.org/10.1002/9780470753552.ch4
• Heck, R. H. (2000). Factor analysis: Exploratory and confirmatory approaches. Lawrence Erlbaum Associates.
• Tabachnick, B. G., & Fidell, L. S. (2001). Using multivariate statistics (4th ed.). Allyn & Bacon.

13. Items of the Scale (Questionnaire)