Stealthing Intervention Report

Nicole Francine Celera BS, MPH(C), Valentina Chawdhury BS, MPH(C),

Jennifer Diaz BS, MPH(C), Cindy Mahoney BS, MPH(C), and Marwa Mohamed BS, MPH(C)

California State University of San Bernardino

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TABLE OF CONTENTS

1. Executive Summary…………………………………………………………...Page 2-3

2. Target Population ……………………………………………………………..Page 3-8

3. Program Description ………..………………………………………………....Page 8-10

4. Planning Information…………………...............................................................Page 10-13

5. Program Data.......................................................................................................Page 13-15

a. Section A……..………………………………………………………...Page 13-14

b. Section B………...……………………………………………………...Page 14-15

6. Reflection..……………………………………………………………………..Page 15-17

7. Reference……………………………………………………………………….Page 18

8. Appendix………………………………………………………………………..Page 19-25

Executive Summary
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Sexual decision making skills are determined by an individual’s education on safe sex

practice, socioeconomic background, social factors, and social settings. California State

University, San Bernardino students that are sexually active are at risk for unwanted pregnancies

and exposure to sexually transmitted diseases when not taking the necessary precaution. A great

number of students may not be aware of their resources or options when it comes to the crucial

need for contraceptives. This poses other issues such as the emerging trend called stealthing.

This act is when a male wearing a condom during sexual intercourse secretly removes the

condom without their partner’s consent. This can lead to stress, physical, and emotional harm.

Although individuals are committing this deed, they may not be aware of the consequences

involved. Their main focus is is receiving pleasure out of the act, but do not take in account the

long term effects that remain after. Without a mutual agreement when engaging in sexual

activity, it can escalate and be recognized as sexual assault. Change is imperative for the college

student population because of the new social environment they are exposed to. Due to this,

students are placed in social settings that increase their chances in risky behaviors. When

inebriated, students are at greater risk in taking part in such negative sexual behaviors. To

prevent students from making poor decisions on their sexual health, changes will be

implemented through the Safe Sex Program such as increasing the students’ knowledge and

emphasizing on self efficacy. The goal of this program is to decrease STDs and pregnancy rates

while focusing on maintaining students’ sexual safety.

Target Population
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California State University is one of the most diverse universities in the United States and

CSUSB reflects that diversity. Majority of CSUSB campus student population come from San

Bernardino and Riverside County (86%) ("Facts and Stats | CSUSB", 2018) . Predominantly, the

student population is female (61%) and 39% male ("Facts and Stats | CSUSB", 2018). The

student diversity population is majority Hispanics (61%) followed by 13% White, 7% non-

resident foreign students, 5% African American, and 5% Asian ("Facts and Stats | CSUSB",

2018). Majority of students who attend CSUSB campus are first generation college students

(81%) and more than half are considered low-income students (62%) ("Facts and Stats |

CSUSB", 2018). The population of this program for CSUSB students ages ranging 18-24. The

average age for undergraduate students is 22 years old ("Facts and Stats | CSUSB", 2018). We

are targeting this specific age group in order to reduce the number of positive STI screening

cases that are on a rise.

In addition to this data, the California State University San Bernardino Student Health,

provides data on the number of students testing positive to an STI screening.Therefore, our

intervention is focused on education of consent to prevent the act of stealthing to both genders in

order to prevent these high rates among the population. As shown on the chart below Syphilis is

on the rise. Syphilis is more prevalent among males in San Bernardino. For CSUSB students in

2017-Present time signify higher positive screening cases compared to previous years.

Syphilis
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CSUSB students have had a higher number of positive screening cases in 2017-Present
school year than in the past school years.
 5

Chlamydia has become more prevalent in females ages 18-24 compared to males

in San Bernardino (2015_Annual_Report.pdf, n.d.). CSUSB Student Health Center chart shows

2016-2017 school year with the highest number of positive screenings for Chlamydia with 88

cases. For the 2017-2018 CSUSB school year, an exceedingly high number of positive screening

cases for chlamydia resulted in 56 cases within only a one year span.

Gonorrhea is more common among the female population in San Bernardino. For

CSUSB students and for the city of San Bernardino, positive screening cases were highest in the

year 2013-2015 (2015_Annual_Report.pdf, n.d.). The number since then has steadily been

decreasing, but there are still a handful of individuals screening positive to present day. The

following chart displays the representation of Gonorrhea over the course of time along with its

steadily decreasing number of cases

Chlamydia
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Gonorrhea
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Program Description

California State University, San Bernardino students that are sexually active are at risk

for unwanted pregnancies and exposure to sexually transmitted diseases when not taking the

necessary precaution. This poses other issues such as the emerging trend called stealthing. A

survey questionnaire will be administered to Health Science 315 students in order to gather

information regarding student’s knowledge, attitude, and practice of consent and safe sex

practices. In order to spread awareness to this issue, a public service announcement (PSA) will

be launched in order to promote the matter. To prevent students from making poor decisions on

their sexual health, changes will be implemented through the Safe Sex Program such as

increasing the students’ knowledge and emphasizing on self-efficacy. This program is supported

through the Health Belief Model.

The Health Belief Model stresses preventative health behaviors while including

examples of health promoting options. This theory holds vital components such as, perceived
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susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action and self-

efficacy. After viewing the PSA, CSUSB students will learn their perceived susceptibility in

contracting STIs, HIV, or creating a pregnancy through their current sexual practices. As for

perceived severity, students will believe whether or not the consequences of creating a pregnancy

or getting STIs or HIV is a serious enough to avoid. The perceived benefits are that students will

believe that the recommended actions will prevent students from negative scenarios from

occurring and will be beneficial to protect themselves and preventing them from infecting others.

Perceived barriers from students can include condom usage, which will decrease sensation.

Students not being aware of their resources to receive contraceptives can also pose a barrier. The

program will enlighten students on how to increase sensation by putting lubricant inside the

condom and will direct students to the health center for the various contraceptives that they offer.

Because the program will provide training to students on their sexual health, students will obtain

self- efficacy after this by possessing confidence in using a condom correctly and being aware of

their resources they are provided with on campus.

The goal of this program is to decrease STDs and pregnancy rates while focusing on

maintaining students’ sexual safety. The public service announcement on safe sex practice is

significant to the CSUSB student population because they are at risk with this social issue. It will

help to promote the program with helping spread awareness. A survey with questionnaires will

indicate the level of knowledge these students obtained on the topic of sexual activity and what is

considered healthy, sexual behavior. With the program and PSA, providing training, guidance,

and information, student’s will possess the confidence to properly use a condom and will be able

to express positive behavior when engaging in sexual acts.

Planning Information
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When considering key elements for our stealthing project, it was necessary to assess the

level of information on the matter. Cindy Mahoney, Valentina Chawdhury, Marwa Mohamed,

Nicole Francine, and Jennifer Diaz were the group members who have identified related

information, as well as identifying a lack of research pertaining to this new public health issue.

The lack of accessibility to information expressed the need to educate individuals on the health

effects that stealthing may have. As mentioned, a large number of individuals who may

potentially fall into the issue are young adults, thus the group identified CSUSB students as our

priority population. San Bernardino overall has shown high rates of STI and STDs, making

stealthing a health education intervention program would benefit for CSUSB population. We

identified that unpractical sexual behaviors led to serious health effects, such as sexually

transmitted diseases, stress, and sexual abuse.

In our first group meeting, it was clearly agreed by all group members that a health

education intervention program should be in the works and that there was a need to polish old

information to a more current form of representation, thus modifying our video to better express

stealthing health information to our targeted audience. We agreed to modify our video to be best

aligned with our missions and goals in making it specific, which would be in increasing

knowledge on safer sex practices among CSUSB undergraduate students. Marwa added to our

group discussion that some of our major takeaways should be in reference to safer sex practices

through properly putting on a condom and students acknowledging that the Student Health

Center is a helpful resource. In identifying specific background information, all stealthing group

members were able to provide supported evidence that properly placing on a condom would be

beneficial in decreasing levels of sexually transmitted diseases and increase knowledge on

stealthing.
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It was also important to compare levels of sexually transmitted infections to a national

level. Group members looked at the health problem from a global perspective, in which it

showed that our community of students were already running the risk of health problems. Group

members identified in previous work that the city of San Bernardino ranked one of the highest

amongst other cities throughout the United States in increased cases on sexually transmitted

infections. Due to the high volume of cases in the community, group members knew that safer

sex practices needed to be met on school campus.

Throughout the creation of the intervention program, it was essential to identify members

who would become beneficial to our mission. Because our targeted audience was CSUSB

students, members viable to our mission would become the Student Health Center, CSUSB

students, campus organizations and clubs, thus involving our stakeholders, target audience, and

community. Because the program was recently new, having the option to use a public service

announcement (PSA) for intervention purposes would become beneficial in being able to spread

health education and promotion in producing beneficial health outcomes effectively and

efficiently by using useful resources and in being able to provide beneficial health outcomes.

As we continued to perfect a program that directs its attention to stealthing and its leading

health problems, group members had the opportunity to do a pilot test to a sample size of

CSUSB students in the HSCI 315 course. Given the opportunity, group members were now

focused on creating a pre and post questionnaire that would assess the level of information

gained from viewing the video. It was decided that the health belief model would be the theory

used for our program in order to keep goals going in the right direction. In addition, the health

belief model provided guidance in leaving no room for bias questions. Using the theory would

also help to support evidence-based practices by carefully planning out thoughtful and useful
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questions that could measure the performance of the program. Questions that would be included

for the measurement purposes would include topics on knowledge, practice, and attitude in

regard to students’ sexual safety practices.

After having corrected faults in the video and completed a pre and post evaluation, group

members asked their colleagues and close friends to look over the questionnaires for feedback

and editing purposes. After having received valuable feedback, it was time to pilot our

instrument to HSCI 315 students. Group members, Valentina Chawdhury and Nicole Francine

Celera presented the video, pre-evaluation, and post evaluations to the HSCI 315 students. They

introduced themselves to the HSCI 315 students, had them fill out the pre-evaluation, watch the

PSA, and then had them fill out the post evaluation questionnaire.

Acknowledging that there is minimum research on stealthing, the data received from

HSCI 315 may help serve as a baseline for future programming and implementation on consent

and safe sexual practices at CSUSB. With the HSCI 315 pilot surveys, group members will be

working on reviewing and measuring the results of the data. Considering that the program will

continue to undergo many phases of review, it is not to say that we will not continue to find

limitations in our work. It is important that we segment a national issue into a smaller group in

order to be able to promote health and wellness in this arena and be able to take the time in

analyzing the sample and creating the program to best fit the culture and level of education for

students to understand. Due to the freshness of the health topic, there is little competition in

marketing to people. Given the chance, we will continue to work with campus community

stakeholders in improving that students become aware of what stealthing is and its health

consequences.

Program Data
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Section A) The survey questions were developed as a collaborative effort. During one of our

initial meetings, each group member had a set of potential survey questions that we evaluated

each question together to determine which questions to use for our surveys. Collectively, we

selected questions we thought would be appropriate for the surveys and altered or created

additional questions to meet the number of questions required. There are a total of 25 questions

in our “Consent and Safe Sex Questionnaire”. There are 20 pre-test items and 5 post-test items.

These questions were qualitative and predominantly closed-ended questions, with the exception

of one post-test question that was open-ended. All questions in the pre- and post-surveys were

categorized.

The categories of questions included demographics, knowledge, attitudes, and practices.

The pre-test has a five-item 2-3-5 point Likert scale on demographics. This was developed to

understand the sex, age, race, education level, and relationship composition of the participants. A

five-item 2-3-5 point Likert scale was developed to assess the knowledge of consent and safe sex

practices. A five-item 2-5 point Likert scale was created to measure participants’ attitudes on the

subject. Two similar items were previously used in the Kaiser Family Foundation's A Series of

National Surveys of Teens about Sex: Safer Sex, Condoms and “the Pill” (2013). The last five-

item 2-3-5 point Likert scale in the pre-test aimed to assess current practices relating to consent

and safe sex practices.

Although in both surveys we aimed to measure knowledge, attitudes, and practices on

consent and safe sex practices and are similar in verbiage, they are organized differently and

presented at different times, hence allowing the data to be different. Pre-test items were

measured before the participants were introduced to our Public Service Announcement (PSA) on

consent and safe sex practices. The post-test questions were extracted from questions in the pre-
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test, however, featured questions inquiring participants’ knowledge, attitudes, and future

practices after watching our PSA. In the post-test, a two-item 2-5 point Likert scale aimed to

measure knowledge obtained from our PSA, an one-item 5-point Likert scale aimed to assess

attitude of sexual consent after watching our PSA, and an one-item 5-point Likert scale was

developed to assess possible future safe sex practices. Lastly, an open-ended item was included

in the post-test to observe what the most impactful information the participants derived from the

PSA. This was important in order to determine how effective the PSA is.

Section B): During the duration of our program’s development, we received feedback regarding

our program. Our HSCI 617 instructor, Dr. Mshigeni, brought concerns that our pre-surveys and

post-surveys on consent and safe sex practices were a surprise because our topic is on stealthing.

We explained our reasoning behind the surveys focusing on consent and safe practices as oppose

to stealthing is because we agreed on increasing knowledge on safer sex practices will lead to the

introduction to stealthing, since it is not a well-known topic as of yet. Another concern Dr.

Mshigeni brought up was that certain items in the surveys might alienate those who are not

sexually active and might make those who are not sexually active feel unable to answer certain

questions, which in turn will skew data results for our group. We altered those questions by

giving participants the option to answer “not applicable” to questions relating to sexual activity.

We received feedback of our surveys from friends and family members. They brought up

potential issues with unable to answer certain questions due to not knowing or understanding key

words or concepts as well as the suggestion of clearer instructions. We took those suggestions

into consideration, leading us to ensure instructions are very clear and giving participants the

option to declare “not sure” to questions they are not sure of. Also based on the results of the

data collected from the demographics in the pre-survey, females outnumber their male
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counterparts in HSCI 315. This may be a weakness since the results of this particular population

will lack efficient reflection and representation from males.

The strengths in our program based on feedback from the HSCI 315 students we pilot-

tested were that after viewing our PSA, many felt more confident in their ability to define sexual

consent and are now aware of the act of stealthing. Almost all the students in this class were

unfamiliar with the term and act of stealthing before our PSA, so it is a big strength for our

program to be able to educate more people about the topic. Some students felt that since our

program emphasized the importance of consent and being knowledgeable of resources, such as

the student health center, to obtain more information, are valuable remarks for CSUSB students

to be informed about.

Reflection

Stealthing is a subject few researchers have attempted to delve into, thus, making it a

prime area of fresh and new epidemiological study. We as researchers chose this heavy topic due

to our passion and drive to prevent the spread of sexually transmitted infections, unwanted

pregnancies and emotional distress from occurring among a particularly vulnerable population.

With the use of this intervention report, we hope further research can be performed on a larger

scale to implement positive change. To ensure the proper implementation of this study, such as

planning the study, conducting research and collecting data, we followed ethical guidelines and

principles. All researchers participating in this study were CITI certified.

The beginning steps involved in creating this intervention was the creation of a short

video/PSA. This video provided an educational background of safe sex practices, such as how to

define ‘consent’ and then segueing onto the topic of stealthing. We pilot tested the video among
 15

graduate students at California State University of San Bernardino (CSUSB) where we received

recommendations on how to improve it. This aided our progression towards mastering how to

improve our communication skills to relay information to diverse audiences. After the PSA was

improved to fit our target population, CSUSB undergraduate students, work began on the

creation of our instrument: surveys. Pre-surveys and post-surveys were created to measure the

level of understanding among undergraduate students about safe sex practices and their level of

confidence on how to define consent and stealthing before and after viewing the educational

video. We created, and pilot tested the epidemiologic surveys among the Health Science 315

class at CSUSB. Due to the sensitive nature of the video, a warning was placed within the

instructions of the pre-test to alert students who may feel uncomfortable and may not want to

participate.

Within this quasi-experimental study, we applied our knowledge of epidemiologic

principles and methods to make recommendations regarding the validity of epidemiological data.

In this case, we shed light on stealthing, an issue many are not aware exits. With the inclusion of

new data, from the pre- and post-surveys, a better understanding of the level of knowledge

among undergraduate students and stealthing was created. The new epidemiological data can be

used to elucidate level of awareness and knowledge, therefore, encouraging future researchers to

implement refined experiments on a broader scale and larger target population.

Although the intervention went as planned and we as researchers have mastered many

skills in epidemiology, there is one recommendation we suggest: to ensure a more accurate

representation of knowledge level on the subject matter, do not limit the target population to a

Health Science class. This might have skewed the results as some of the students have taken the
 16

Health Science 120 course where they learn about sexual and reproductive health. If given more

time and access, we would have liked to perform this experiment among classes in different

departments of the CSUSB campus to gather an accurate depiction of what we were attempting

to measure. Moving forward we would like to learn how to ultimately apply this intervention on

a larger scale to impact a larger audience.

References
Kaiser Family Foundation (2013). Sex Smarts Survey. Retrieved from
https://kaiserfamilyfoundation.files.wordpress.com/2013/01/sexsmarts-survey-safer-sex-
condoms-and-the-pill-toplines.pdf

Facts and Stats | CSUSB. (2018). Retrieved from https://www.csusb.edu/about-csusb/facts-and-

stats

2015_Annual_Report.pdf. (n.d.). Retrieved from

http://www.sbcounty.gov/uploads/dph/publichealth/documents/2015_Annual_Report.pdf
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Appendix

A. Meeting Minutes

a. First Meeting: October 02, 2018

i. Members Present: Nicole Francine Celera, Valentina Chawdhury, Jennifer

Diaz, Cindy Mahoney and Marwa Mohamed.

ii. Topic Addressed: Group members agreed that there was a need to polish

old information such as the video to fit the target audience.

1. Marwa added that some major takeaways should be in reference to

safer sex practices by highlighting condom usage.

2. Health Belief Model was chosen as the theory to edit and base the

video format on.

b. Second Meeting: October 09, 2018

i. Members Present: Nicole Francine Celera, Valentina Chawdhury, Jennifer

Diaz, Cindy Mahoney and Marwa Mohamed.

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ii. Topic Addressed: Group members created and edited survey questions

based on knowledge, attitude, practice and demographics.

1. Jennifer, Cindy and Nicole piloted the survey questions on

colleagues and friends to ensure content was appropriate and

organized.

c. Third Meeting: October 11, 2018

i. Members Present: Valentina Chawdhury and Marwa Mohamed.

ii. Topic Addressed: Valentina and Marwa worked on editing the video on

powtoons; updating content relevancy for target population.

d. Fourth Meeting: October 18, 2018

i. Members Present: Nicole Francine Celera and Valentina Chawdhury.

ii. Topic Addressed: Nicole and Valentina performed the pilot test of the

intervention among the students of HSCI 315.

1. After introducing the topic, the pre-survey was completed by the

HSCI 315 students to measure level of knowledge on content

matter.

2. Once the pre-survey was completed, the educational video was

shown.

3. After viewing the video, students completed the post-survey to

assess knowledge of content.

B. Health Education Program Video

a. https://www.powtoon.com/online-presentation/bIuqdHzskZB/consent-and-safe-

sex-practice/?mode=movie#/
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C. Pre-Survey Questions

Consent and Safe Sex Questionnaire Pre-Test

California State University, San Bernardino
Name: _________________________

INSTRUCTIONS:
Please read each question or statement carefully, circle and print responses legibly.

The purpose of this survey is to study the knowledge, attitude, and practice of consent and safe
sex practices. By filling out the questionnaire, you are voluntarily agreeing to participate. Be
aware that this survey requests the discussion of personal sexual practices and may be
uncomfortable. If for any reason you feel uncomfortable, please let the survey administrator
know and you will be excused without penalty.

This survey will take approximately 5 minutes to complete.

Please read each question carefully and print responses legibly.

1. What is your biological sex?

1. Male
2. Female

2. What is your age?

1. 18-24 years old
2. 25-29 years old
3. 30 years old and older

3. What is your race?

1. Latino/Hispanic
2. Asian/Pacific Islander
3. African American
4. Caucasian
5. Other: __________________

4. What year of schooling are you currently in?

1. First year
2. Second year
3. Third year
4. Fourth year
5. Fifth year +
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5. What is your relationship status?

1. Single
2. Married
3. In a relationship

6. How confident are you in your ability to define sexual consent?

1. Very confident
2. Fairly confident
3. Confident
4. Slightly confident
5. Not confident

7. Do you know what stealthing is?

1. Yes
2. No
3. Not sure

8. Can you identify two or more forms of contraceptive methods?

1. Yes
2. No

9. I am aware of the available resources on campus to receive STI testing,

free condoms, and/or contraceptives, etc.
1. Yes
2. No

10. I understand the emotional distress that results from stealthing.

1. Yes
2. No
3. Not sure

11. Is the way a person dresses, smiles, looks, or acts an indication of the desire to have
sex?
1. Yes
2. No

12. How important is it for both parties to understand sexual consent before any
sexual activity?
1. Very important
 21

2. Fairly important
3. Important
4. Slightly important
5. Not important

13. It is embarrassing to purchase condoms.

1. Yes
2. No

14. Having sex without a condom is not important.

1. Strongly agree
2. Fairly agree
3. Agree
4. Slightly agree
5. Do not agree

15. You do not need a condom if you do not have a lot of sexual partners.
1. True
2. False

16. I am fully confident on how to properly use a condom.

1. Very confident
2. Fairly confident
3. Confident
4. Slightly confident
5. Not confident

17. Do you always check the expiration date of a condom prior to usage?
1. Yes
2. No
3. Not applicable

18. During sexual activity I always use a condom.

1. Yes
2. No
3. Not applicable

19. Consent is always communicated between me and my sexual partner(s) prior

to any sexual activity.
 22

1. Yes
2. No

20. Have you ever been tested for a sexually transmitted infection?
D. Yes
E. No

D. Post-Survey Questions

Consent and Safe Sex Questionnaire Post-Test

California State University, San Bernardino

INSTRUCTIONS:
Please read each question or statement carefully, circle and print responses legibly.

1. After viewing the PSA, how confident are you in your ability to define sexual consent?
1. Very confident
2. Fairly confident
3. Confident
4. Slightly confident
5. Not confident

2. After watching the PSA, do you understand what stealthing is?

1. Yes
2. No

3. After watching the PSA, I understand the emotional distress that results from
stealthing.
1. Yes
2. No

4. After watching the PSA, how important is it for both parties to understand
sexual consent before any sexual activity?
1. Very important
2. Fairly important
3. Important
4. Slightly important
5. Not important

5. After watching the PSA, I am fully confident on how to properly use a condom.
1. Very confident
 23

2. Fairly confident
3. Confident
4. Slightly confident
5. Not confident

6. What were the most impactful takeaways from the PSA?

______________________________________________________________________________
___________________________________________________________
Thank you for your participation & have a great day!