Does Education Matter? Examining Racial Differences in the Association Between Education and STI Diagnosis Among Black and White Young Adult Females in the U.S.

With nearly 20 million cases occurring annually, sexually transmitted infections (STIs) continue to persist as a major public health issue in the United States. Half of these infections occur among adolescents and young adults aged 15 to 24 years, and of these, minority women are disproportionately affected.1 In 2007, three of the most common STIs—chlamydia, gonorrhea, and trichomoniasis—were significantly more prevalent among 20- to 24-year-old black females than among their counterparts of any other race/ethnicity. During this year, chlamydia rates among non-Hispanic black females were more than seven times that of white females, and rates for gonorrhea were nearly 15 times the rate of non-Hispanic white females of the same age, with rates for both infections on the rise from previous years. Although trend data for trichomoniasis are limited, data on initial physician visits suggest that rates may be on the decline.2 Despite these high rates of reported STIs, up to two times as many new infections are estimated to occur annually than are reported.2 As a result, many who suffer from STIs may do so for extended periods of time, enhancing the probability for other infections to occur. In fact, individuals who contract at least one STI are almost five times as likely to also contract human immunodeficiency virus (HIV). Additionally, STIs can have numerous lifelong health consequences, which can prove much more deleterious for women than for men.2–5 For STIs that go undetected, reproductive health effects for women can include infertility, cervical cancer, pelvic inflammatory disease, or possible STI transmission from mother to child during childbirth.3,6 The relationship between education and sexual risk has been studied extensively in the adolescent population;7–11 yet, the research on young adults often presumes education is a protective factor against risk outcomes or minimizes the role of key social determinants, such as education, on engagement in sexual risk behaviors and STI diagnosis. The transition to adulthood, however, is often accompanied by significant changes in social roles, environments, and individual achievement, making it an optimal time to understand how education influences STI risk. During this transition, social and economic trajectories often diverge.12 These divergent trajectories can result in a range of social environments that may be more or less “risky.” For example, although attending college may result in a college degree that leads to more optimal economic outcomes, it may also provide a social environment where young adults engage in risky health behaviors. 13–16 Moreover, studies suggest that the extent to which college students engage in risky behaviors may differ by race/ethnicity,17–19 suggesting the need to pursue research examining the social context that may predict or facilitate engagement in these behaviors and reasons for differences by race/ethnicity. Of the few studies that have been conducted with young adults to assess the relationship between educational factors and sexual risk, findings are inconsistent. This inconsistency may be due, in part, to the specialized populations sampled, the use of limited measures of sexual risk without direct assessment of STI diagnoses, and the use of less rigorous statistical techniques. For example, using the National Acquired Immunodeficiency Syndrome (AIDS) Behavioral Survey, Binson et al.20 found that white young adults (aged <25 years) who completed 12 or more years of education were more likely to have multiple sex partners than white young adults with fewer than 12 years of education. The authors found no association between education and the number of sexual partners among Hispanic and black individuals. In another study using a small clinic sample of black people who were currently or previously diagnosed with an STI in one metropolitan city, Irwin and colleagues21 found that symptomatic patients with at least a high school education were more likely to report “always” using condoms, compared with those with less than a high school education. A final example involved a sample of incarcerated women (aged ≥18 years) in Rhode Island.22 Findings revealed that women with more years of education were less likely to engage in risky sexual and nonsexual behaviors, such as having sex without a condom and sharing intravenous drug equipment, in the last three months, compared with those with less education. Additionally, extant research has not adequately explored the possibility that race may moderate the relationship between education and STI risk. Yet, a growing body of evidence documents that black people derive fewer economic and health benefits at equivalent levels of education and income than white people.23–25 For example, white college graduates' median net worth is more than three times the median net worth of black college graduates.24 Similarly, research has shown that income is unrelated to rates of overweight among black women, but is significantly associated with reductions of overweight among white women. Among women aged ≥20 years, the infant mortality rate of black college graduates is higher than it is for white people with less than a high school diploma.26 Thus, it is possible that education may also have a stronger association with STI diagnosis among white women than among black women. Given the significant processes occurring during the transition to adulthood, understanding the influence of education on STI risk is warranted. Thus, the purpose of our study was to (1) describe the association between education and STI diagnosis (self-reported and clinically assessed) among a national sample of black and white young adult females and (2) examine racial differences in this association.