Attitudes and Perceptions Regarding Sexual Health History Taking; A Cross-Sectional Study Among Undergraduate Medical Students of College of Medicine and Health Sciences, Oman

Background: Sexual health has been recognised as an essential dimension of health. Therefore, sexual health training of health care providers assumes a significant role. The present study was conducted to assess the attitudes and perceptions of final-year medical students regarding sexual health history taking at a medical college in Oman. Methods: The present cross-sectional survey was conducted among 81 final-year medical students. Demographic characteristics, attitudes and perceptions of the participants regarding sexual health history taking were collected using a self-administered questionnaire after obtaining informed consent. Prior approval was obtained from the institutional research and ethics committee. Statistical analysis was conducted using SPSS 20.0 Results: The mean age of the participants was 24.19 ± 1.03 years. Most of the participants (97.6%) opined that it was important for doctors to know how to elicit a sexual health history. Most of the participants were aware of their limitations in eliciting sexual health history and recognizing gender and cultural differences (67.9%) as barriers while communicating sexual health problems with the patients. About 50%of the participants responded that they had satisfactory understanding of sexual health (50.7%); a similar number had an adequate understanding of sexual health problems (53.1%). Majority (65.4 %) of the participants were interested in learning about sexual health. Conclusion: The present study revealed that medical students recognised the importance of sexual health history taking and their strengths and limitations regarding the same. The study revealed the barriers to effective communication between students and patients in matters of sexual health, which pave the way to improve teaching-learning programs and ultimately contribute to providing effective holistic health care.

Sexual health is an integral aspect of general health and quality of life, constituting a fundamental component of holistic health care delivery 1 . The World Health Organization (WHO) has defined sexual health as "a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity…" 2 .Human sexuality is a complex and multidimensional phenomenon influenced by various factorsbiological, social, behavioural and environmental.. Health professionals usually focus on the biological factors (contraception and sexually transmitted diseases) and usually neglect the significance of the other factors 1 . Underestimation of the sexual concerns of the patients by health professionals is because of various reasons like inadequate training in communication, personal factors such as conservative sexual beliefs, attitudes and perceptions regarding sexual health which make them uncomfortable. It has been widely reported that doctors find it uncomfortable to discuss the subject of sex and to probe into the patients' sexual practices 3 . A key measure to overcome the barriers of doctor-patient communications in matters of sexual health would be to ensure appropriate training in medical education programs, taking into consideration the personal factors of the students.
An understanding of the students' attitudes and perceptions regarding sexual health history taking and training received would be the starting point in fostering positive attitudes, which ultimately would contribute to delivering quality health care. The present study aimed to assess the students' perceptions and attitudes regarding sexual health history taking and training received in the same area.

METHODS
The present cross-sectional study was conducted among the final year medical students of Oman Medical College (Currently referred to as College of Medicine and Health Sciences under the National University of Science and Technology), Oman.
A questionnaire was developed based on the scientific literature review of published articles 4,13 . The questionnaire was modified after conducting a pilot study. The questionnaire included items to assess the study participants' demographic characteristics, attitudes and perceptions regarding sexual health history taking, including their medical education received about sexual health history taking.
The study was conducted after obtaining approval from the Institutional Research and Ethics committee. Data collection began in 2017. All the final-year (7th year) MD medical undergraduate students were invited to participate in the study.
(n=96) The students were approached during their clinical rotation in batches (10 -15 students per batch). The objectives and the need for the study and details regarding the questionnaire items were explained to the students. The questionnaire was distributed to the students after receiving informed consent. The questionnaire was self-administered. A total of 81 students (sample size) consented and responded to the study. The completed questionnaires were collected, data were entered in Microsoft Excel and analysed using descriptive statistics of SPSS (statistical package for the social sciences) version 20.0. The data were primarily expressed in terms of numbers and percentages.

RESULTS
A total of 96 students were approached, and 81 students participated in the study (Response rate was 84 %). The demographic characteristics of the study participants are highlighted in Table1. The average age of the study participants was 24.19 ± 1.03 years. Females accounted for 91.4 % of the study population. Most (84.4%) of the participants hailed from urban areas. Table 2 reflects the participants' attitudes and perceptions regarding sexual health history   taking. Most of the participants (97.6%) opined that it was important for doctors to know how to elicit a sexual health history. However, only 29.6 % of the participants were comfortable discussing sexual health problems with patients. The percentage was further reduced to 21% for comfort levels in eliciting history of sexual health problems with patients of the opposite gender. Most (82.7%) participants were aware of their limitations in taking sexual health history and recognised gender (54.3%) and cultural differences (68.8%) as barriers to discussing sexual health problems with their patients. Most of the participants disagreed with the idea that patients should be the first to initiate the discussion on sexual health problems, while 32.1 % were neutral on this question. 74.1 % of the participants agreed that being non-judgemental was important while eliciting sexual health history. A majority (65.4 %) of the participants were interested in learning about sexual health. Table 3 shows the participants' perceptions regarding their skill and training regarding sexual health history taking. Almost half of the participants (50.6%) responded that they had an adequate understanding of sexual health, while a similar number (53.1%) expressed an adequate understanding of sexual health problems. Further, 29.6 % were neutral, and 18.5% agreed on the adequacy of the training received on sexual health history taking at their medical school.

DISCUSSION
In the present cross-sectional study, the majority of the study participants were females, which was a reflection of the overall female student majority representation in the medical institution throughout all the years of the MD program.
The study revealed that a majority (97.6%) placed a high level of importance on sexual health history taking. This finding is also consistent with findings in a study conducted by Ariffin et al 4 wherein (95%) of students were of a similar opinion. The study however, revealed that 28 % of the students were not comfortable and 42 % were neutral about conversing regarding sexual health problems with patients, which was also reflected in a similar study conducted by Khanam et al 5 which showed that 20 % of the students were uncomfortable and 60% were neutral. The comfort level further decreased when students were faced with a proposition of understanding and eliciting history of sexual health problems with patients of the opposite gender. The above findings might be attributed to the prevailing socio-cultural factors. It was also observed that most (82.7%) medical students were aware of their limitations in taking the sexual health history of patients. The limitations were mostly due to gender and cultural differences which were significant barriers to communication and was also observed in a study conducted by Temple Smith M et al 6 on barriers to sexual health history taking. Medical students might not be able to effectively communicate during sexual health history taking, which could have physical, mental and social implications for the patients. It has been reported that providers should be empowered with effective communication skills to interact with their patients effectively by being honest, confidential, respectful and providing optimal sexual health care 7 . Students would also require learning communication skills like active listening and using appropriate and sensitive language.
It was encouraging to note that 44 % students believed they should be the first to initiate the conversation on sexual health issues with their patients. In addition, patient confidentiality was an important priority for the students pertaining to sexual health history taking which was comparable to a study conducted by Ariffin et al 4 and also in line with the principles of sexual health history taking as emphasised by Jones R and Barton 8 . Furthermore, it was also reassuring to note that majority of students believed that being non-judgemental was one of the most important prerequisites for effective sexual health history taking as has also been highlighted by Jones R et al 8 John T 9 in their studies.
Considering the students' perceptions regarding the training received in matters of sexual health, just about half the students felt they had an adequate understanding of sexual health and sexual health problems which was comparable to a study conducted among Malaysian medical students 4 .The need for adequate training in sexual history taking and sexual medicine assessment and treatment is also echoed by Sharon J et al 10 and by CJ Ng et al 11 in their studies. A study conducted by Warner C et al 12 in the United States of America noted that medical students were under-prepared to address essential sexual health issues. These findings imply a need for improvement in curricula to improve training in sexual health. Various strategies can be employed to overcome these barriers and improve training in sexual health. These include cross cultural training, cultural competency training and using bio-psycho-social interprofessional approaches. Vertical integration of sexual health topics across the various years and courses of medical school starting with early exposure for example from embryology/ anatomy extending all the way to the clinical years would help build confidence and develop adequate skills necessary to assess and manage sexual health issues.

CONCLUSIONS
The study revealed that medical students recognised the importance of sexual health history taking and also identified their strengths and limitations regarding the same. The study revealed the barriers to effective communication between students and patients in matters of sexual health. This paves the way to improve teaching-learning programs in matters of sexual health and ultimately contribute to providing effective holistic health care.