Teenagers are dramatically affected by sexually transmitted infections (STIs).1,2 The early practice of sexual relations and the teenargers’ reluctance to use condoms could explain the rise of STIs.3,4 Many of these teenagers have heard of HIV and AIDS, but very few of them are aware of other infections such as chlamydia or the human papillomavirus3 despite having received STIs training.5,6 Education and training on STIs to decrease the risk of contracting these infections needs to improve.5,7,8

The Delphi method is a structured technique with a multistage process designed to turn the opinions of a surveyed group into a consensus.9,10 It is often used in social sciences and health, including dermatology, for data mining purposes, especially if there is little documentation on the issue at stake.11

The Coordinator of the Andalusian Plan against HIV/AIDS and other STIs collaborated in this project.

After a structured literature review, we did not find any validated tools to evaluate the knowledge, habits, and attitudes of teenagers and young adults on STIs. Therefore, we deemed necessary to elaborate and validate an updated STIs questionnaire for contemporary teenagers and young adults to come up with the proper training tools (supplementary data I).

The categories of the questionnaire were established following the Delphi method. We considered three sections: knowledge, habits, and attitude. Also, the items proposed by the expert panel were clustered under different domains suggested in the relevant literature available.

An anonymous expert panel was selected. A critical evaluation of the domains was conducted by each panelist during the first half of July 2019. Each domain was scored from 1 to 9. Only the domains that scored between 6 and 9 were accepted. Both the median scores and strict disagreement (when, at least, 1 of the scores fell within the range from 1 to 3 and, at least, 1 of the scores fell within the range from 7 to 9) were assessed in each dimension and item. It was determined whether the item was adequate (if the median range went from 7 to 9 and there was no disagreement), inappropriate (if the median range went from 1 to 3 without disagreement), and equivocal (if the median range went from 4 to 6, therefore with disagreement on item adequacy). Finally, only items without strict disagreement were accepted. A limit of 50 items per expert was established. A comprehensive list of items, with closed-ended questions was submitted by the expert panel and received during the second half of July 2019. Redundant items were streamlined and a preliminary synthesis report including 104 items with new domains was elaborated. This preliminary synthesis was submitted to the experts for critical analysis (to be scored between 1 and 9) from August through September 2019. Back in October 2019, a new synthesis report was drafted, with a limit of 50 items to avoid weariness. A qualified Spanish linguist reviewed the correct drafting of each item and domain and their accurate addition into each section: knowledge, habits, or attitudes.

A total of 11 panelists were initially contacted, 1 of whom refused to participate and 2 who did not actively contribute and, therefore, were not taken in consideration. Finally, 8 experts made up the panel (supplementary data II). After the 1st round, a total of 11 domains and 104 items were considered (Table 1). At the end of the 2nd round, we had a total 7 domains for knowledge, 4 for behavior, and 6 for attitudes (Table 1). The median score for accepted domains and items was ≥8, finally leading to a questionnaire of 14 domains and 40 items (Table 2). All items but 4 have 5 options available per answer (Table 2).

As far as we know, this is the first questionnaire designed to specifically study the knowledge, habits and attitudes of teenagers and young adults on STIs, while considering that they are particularly vulnerable to these infections.1,2 There are questionnaires of knowledge limited to particular groups such as HIV infected individuals,13 Hispanic men in the United States,4 or college students.6 However, we have not found any surveys aimed at teenagers alone.

The items of our questionnaire illustrate the most important points outlined by the panelists. We took into account recent changes in sexual behavior such as early initiation of sexual relations and the teenagers’ reluctance to use condoms,3 but also the rising sexual practices of oral and anal sex. Sexual relations between young people with same-sex partners is also on the rise.14 All the above calls for a new approach to the terms homo- or hetero-sexual, avoiding any categorizations to make conversations on this issue more fluid and comfortable,8 especially when dealing with self-administered questionnaires.

The main method to control STIs is sexual education.15 In Spain, the ratio of new HIV infections is above average in Europe, and the diagnoses of syphilis, gonorrhea, venereal lymphogranuloma, and genital herpes have increased significantly over the past decade.16 Therefore, promoting healthy sexual habits in early adolescence is an important strategy to prevent STIs.16 Most STIs prevention campaigns have been focused on HIV despite the increase of other curable STIs.15 Although STIs prevention programs have been widely implemented, they have a limited effectiveness on teenagers because they focus on adult problems.17 Therefore, the design of these programs must be improved, adapting them to the addressed age range. For this reason, our questionnaire explores the knowledge, habits, and attitudes associated with all STIs, not just HIV in contemporary teenagers.

An increasing use of consensus methods, such as “Brainstorming” or the “Delphi method”, among others, has been observed in the medical literature reviewed. They are useful for making decisions in contradictory cases or when information is lacking.

In our study we have eight experts, a number similar to that seen in other questionnaires on STIs development.13 Cases where panelists disagreed in their views were associated with more and better solutions than in more homogeneous groups.10 To select the members of our panel, we considered people with extensive knowledge on the subject, while looking for a multidisciplinary representation of health professionals who remain in close contact with teenagers. These professionals included dermatologists, internists, epidemiologists, gynecologists, general practitioners, and high school teachers. We maintained anonymity among the panelists to keep impartiality and avoid biases when evaluating the items depending on who had generated them. The benefit of impartiality and anonymity among the panelists has been reported in previous studies.9 The answers from each round were summarized and submitted to the panel to reach a consensus similar to that described in the medical literature available.9 Initially, 31 of the 137 reviewed studies were selected to be submitted to the experts as examples of current knowledge on STIs in teenagers in full compliance with the Delphi method,9 and following the method of another developed questionnaire on STIs knowledge.13 The responses of the panelists were arranged by score, which is similar to the routine clinical practice18 by placing them in descending order depending on the score. Feedback between rounds broadened perspectives, and created new ideas.10 Although some authors considered 4 rounds as optimal, recent studies have considered that 2 or 3 rounds are more appropriate because of the need for “knowing when to stop” and “avoiding weariness”, being necessary to balance time, costs, and possible participant fatigue.10 We agree with this, and accordingly our study was designed in two steps. There is no established rate to define consensus as threshold varies in the medical literature available from 51% to 70%, or even >80%.9 In our case, we reached consensus for items and domains of >80%, which led to a 40-item survey. The number of items is similar to that of other questionnaires on STIs from similar studies [80 items,4 27 items,13 50 items12]. The limitations of this type of study are the subjectivity involved when selecting the experts, the number of “rounds” involved, or the percentage retained for “consensus”.9 Similarly, the representation of a wide range of health professionals resulted in different preferences for the items to be evaluated according to the different professions. However, this was compensated by the high median score selected for domains and items.

This is the very first questionnaire to analyze the knowledge, habits, and attitudes of contemporary teenagers and young adults on STIs (supplementary data III) using the Delphi method for validation. This questionnaire was built to be used as a training tool on STIs. The Delphi method is based on questions asked by a panel of professionals from different fields of medicine and teaching. All the panelists are in close contact with the young population. The interest of this work is to devise effective information and training programs for the prevention of STIs in teenagers and young adults, specifically addressed to the actual shortcomings of this vulnerable sector of the population with continuously changing sexual habits.

We think it is absolutely necessary to have a validated questionnaire on STIs in teenagers and young adults to elaborate suitable educational tools to prevent surges of STIs and unwanted pregnancies in this range of population.

The authors declare that they have no conflict of interest.