Chlamydia Screening Focus Groups of Healthcare Providers
My research focus is the study of Chlamydia trachomatis. I am interested in Chlamydia because it is the most prevalent bacterial sexually transmitted disease in the United States. Young adults have the highest rates of chlamydial infection and are at the highest risk for infection among all age groups. Yet, as a group, they do not use Chlamydia screening services. Why? Early diagnosis of Chlamydia is important, not only to minimize disease spread but also to prevent sequelae, including epididymitis, pelvic inflammatory, disease, ectopic pregnancy, infertility and chronic pelvic pain. Traditional Chlamydia testing procedures have served as another obstacle to early detection because collection of endocervical and urethral specimens is uncomfortable at best. Fortunately, the introduction of several nucleic acid amplification tests (NAATs) now makes it possible to detect Chlamydia noninvasively from male and female using a simple urine sample. My interest in increasing the participation of the gatekeepers, the medical profession in offering these screening programs to this age group by having focus groups address concerns and dispel misconceptions, and provide more information about Chlamydia to this population that is the highest risk.
REVIEW OF THE LITERATURE
Chlamydia is one of the most common sexually transmitted diseases in modern Western society. In the United States alone, there are about four million chlamydia infections annually. However, a disturbing amount of those infected with Chlamydia — as many as fifty percent of the men infected, and three-quarters of the women infected — are asymptomatic and do not know that they have this disease. (Dedius et al., 2005) Lack of symptoms, however, does not imply harmlessness. Complications range from infertility to blindness, and it is therefore vital that steps be taken to reduce the number of Chlamydia infections that remain undetected.
Among women infected with Chlamydia, about fifty percent of them will develop pelvic inflammatory disease; Chlamydia causes between 250,000 to 500,000 cases of pelvic inflammatory disease every year in the United States alone. (Dedius et al., 2005) Pelvic inflammatory disease, or PID, is something of a catch-all phrase referring to an infection of the uterus, fallopian tubes, or ovaries. Up to ten percent of the total cases of PID are complications of Chlamydia, and PID itself is identifies as the leading cause of infertility. Thirteen percent of women that experience pelvic inflammatory disease will become infertile, and multiple infections increase this percentage. (Icarus et al., 2005) Sometimes, PID does not show any symptoms, however some of the common symptoms are fever, tenderness of the cervix, abdominal pain, abnormal vaginal discharge, pain during intercourse, and irregular menstrual bleeding. Even without the presence of these symptoms, PID may still cause permanent damage, including scarring of the reproductive tissues, which may cause problems such as chronic pelvic pain, ectopic pregnancy, or other reproductive problems.
Women face a particular danger if they are infected with Chlamydia during pregnancy, or if they become pregnant while infected. It is estimated that half of all infants born to mothers with this disease will be affected by it. Chlamydia can cause spontaneous abortion (or miscarriage), premature birth, blindness, and pneumonia in the child. Avoiding vaginal birth can significantly reduce the risk of transmission during birth, however the child may still be affected.
While men do not (and cannot) suffer from PID, other diseases may be caused by Chlamydia that can also cause sterility and other long-term problems. One such disease is epididymitis, which is an inflammation of the epididymis, which is likely to occur if Chlamydia spreads to the testicles. Another condition which is particularly problematic for young men infected with Chlamydia is Reiter’s Syndrome. Reiter’s syndrome is identified by three symptoms: inflammatory arthritis of large joints, inflammation of the eyes, and arthritis. Chlamydia is among the most common bacterial infections that will cause Reiter’s syndrome. (YurikBot et al., 2005) Fifty percent or more of men with Reiter’s syndrome will develop eye problems and/or blindness, and up to forty percent of men will develop penile lesions. Additionally, the Chlamydia bacteria will cause Trachoma, an eye disease which causes ulceration and scarring of the cornea. This is the leading cause of blindness worldwide and afflicts as many as 400 million people, although it is rare in the United States. (Arcadian et al., 2005)
With or without the presence of pelvic inflammatory disease or other secondary diseases, Chlamydia may be with or without noticeable symptoms. If symptoms do occur, they may include, in women, vaginal discharge of an abnormal color or with an unusual smell, pain in the abdomen and reproductive regions, painful urination, and/or the urge to urinate more often than usual. In men, if symptoms do occur, chlamydia may cause painful or burning urination, unusual discharge from the penis, swollen or tender testicles, and/or fever. (Dedius et al., 2005)
The Chlamydia infection is caused by bacteria. The Chlamydia trachomatis is a species of the chlamydiae, a group of obligately intracellular bacteria. This bacteria replicates within cells, then bursts out of the cell membrane to spread the infection to other cells. This is one of the smallest bacteria, as tiny as 500nm wide. (Grosse et al., 2005) Additionally, they cannot be cultured outside of host cells because of the intracellular nature. Due to these factors regarding the Chlamydia trachomatis bacteria, research has faced many challenges.
Fortunately, this very common sexually transmitted disease can be effectively treated and cured with simple antibiotics, which is not the case with some common STDs. Unfortunately, large numbers of infected patients do not realize they have Chlamydia, and screening for this disease is lacking in many ways. People do not realize how important it is to get tested for Chlamydia, and there are a vast array of misconceptions and misunderstandings about this infection. Doctors are limited by patient concerns, financial issues, lack of education, and many other unfortunate factors. Education, screening, and proper treatment are vital in curbing the occurrences of Chlamydia.
According to the U.S. Preventitive Services Task Force (USPSTF), sexually active women up to twenty-five years of age should be routinely screened for Chlamydia trachomatis. The American Family Physician article “Recommendations on screening for Chlamydia” (Morantz, 2003), rates of infection vary greatly among different communities and populations. Infection is the most common among females under twenty-one years of age, however it is also extremely prevalent among women up to twenty-five years of age. Women over the age of twenty-five are also at risk, however some sources such as this one recommend screening only if particular risk factors occur, such as not using condoms all of the time, having new or many sexual partners, or a history of sexually transmitted diseases. Screening pregnant women is also necessary, because of the danger posed to the unborn child. This article reveals that the optimal timing for screening pregnant women is not known, and that early screening may help improve outcomes such as low birth weight and premature delivery, while screening in the third trimester may be more effective in preventing the transmission of the infection to the child during childbirth. Additionally, this article reveals that the ideal time between screenings (which have negative results) is not known, and that risk factors such as age and sexual behavior should be taken into consideration. This article is clear that screening is recommended and that Chlamydia is a threat, however in this source several of the problematic attitudes which may be interfering with proper screening practices. Automatic screening for Chlamydia is not recommended by the USPSTF, but rather many risk factors are recommended for consideration before deciding to screen for the infection. Additionally, if there are benefits to both early and late screening during pregnancy, it would be logical to recommend screening twice during pregnancy as an automatic part of prenatal care.
According to the British Medical Journal article “Screening for genital chlamydial infection – Evidence-Based Health Policy Report” (Pimenta, 2000), there are serious consequences for an inadequate sexual and reproductive health care system. The United Kingdom developed an integrated strategy on sexual health in response to these concerns. This report found that in the 1990’s, there was a significant rise in the occurrence of Chlamydia infections among females between sixteen and nineteen years of age, and among males between twenty and twenty-four years of age. Women attending clinics to have an abortion were also found to have higher rates of infection than samples from the general public. Professional awareness of the disease is rising, however it is not sufficient to curb the danger, and vast quantities of infected individuals remain untreated. This article additionally addresses the questions of whether screening itself is effective, and how to determine the costs and benefits of different screening procedures. A study conducted in Wisconsin from 1986 to 1990 confirmed that screening for Chlamydia lowered the incidents of pelvic inflammatory disease. (Pimenta, 2000) The proposal discussed in this article suggested a focus on opportunistic screening, such as screening females only when they are attending certain types of clinics. Again, the concern of keeping cost low is suggesting severe limitations on screening of women, and even stricter limitations on screening men. This proposed program does suggest the use of less invasive tests, as well as providing continued education and support for patients. Some doctors involved in this pilot study expressed concerns that STD testing may affect insurance premiums, and while most health insurance companies will omit specific questions about STDs, this concern is relevant; various insurance-related complications are a significant obstacle to screening and treating Chlamydia. (Pimenta, 2000)
According to the Morbidity and Mortality Weekly Report article “Chlamydia screening among sexually active young female enrollees of health plans — United States, 1999-2001” (Shih, 2004), there is further evidence that screening is beneficial, but that screening methods currently in use are not effective enough. Up to fourteen percent of young women who are routinely screened for Chlamydia are found to be infected, which proves the need for further screening to be done. Many groups, including the CDC and the U.S. Preventive Services Task Force, as well as many clinical organizations, have recommended routine screening for Chlamydia for young sexually active women, as well as all pregnant women. Studies found that despite these recommendations, as well as an increase in coverage by commercial and Medicaid health insurance plans, data from this two-year period found Chlamydia screening rates remained very low. “Increased screening by healthcare providers and coverage of screening by health plans will be necessary to reduce substantially the burden of chlamydial infection in the United States.” (Shih, 2004)
Health care alone is not enough to prevent Chlamydia infection if screening specifically for the disease is not done. According to the Perspectives on Sexual and Reproductive Health article “Gonorrhea and chlamydia infection among women visiting family planning clinics: racial variation in prevalence and predictors” (Einwalter, 2005), the prevalence of Chlamydia infection in different populations must be taken into consideration in order to ensure that the most at-risk patients consistently receive screening. Considering patient populations that attend STD clinics alone is not sufficient; at-risk populations in all clinical settings must be screened. Previous studies did not provide information regarding ethnicity as a determining factor of risk, however this study revealed that rates of Chlamydia infection are higher among African-American populations and other minorities. This study, however, did not provide evidence from a broad enough sampling, and the reasons for higher rates among the Black population were not clear. White women seemed most at-risk when having contact with a new sexual partner, while among Black women, being under twenty-one years of age appeared to be the cause of the most risk. (Einwalter, 2005) This data is not conclusive, and race certainly should not be used to exclude patients from screening because of an assumption that they are not “at-risk.” However, using this preliminary data to ensure that groups which may be at the most risk are screened thoroughly and provided with information.
Screening is not a simple subject to broach with at-risk groups. “Improving Chlamydia Screening Programs” from the American Family Physician (Miller, 2004) identifies some of the obstacles that prevent the most at-risk group — teenagers and young adults — from getting screened. “These obstacles include lack of health insurance and a regular health care source, fear of the traditional chlamydia testing methods and results of tests for sexually transmitted diseases (STDs), and concern that others might discover that they were tested.” (Miller, 2004) This study interviewed people from fifteen to twenty-four years of age, which revealed a lot of misinformation. Participants recommended that educational material be more easily accessible, make testing simple and less invasive, and to make the entire process more confidential. “Limitations of screening tests for asymptomatic Chlamydia” (Miller, 2005) identifies the importance of finding the least invasive testing methods. Nucleic acid amplification tests can detect the bacteria on secretions and urine samples, however there were different levels of effectiveness found among nine different tests available for screening. Combining testing methods improved accuracy, and the accuracy levels of different tests must be taken into consideration.
There are many psychosocial implications to keep in mind when implementing screening for Chlamydia. In the British Medical Journal article “Qualitative analysis of psychosocial impact of diagnosis of Chlamydia trachomatis: implications for screening” (Duncan, 2001) Interviews with women recently diagnosed with chlamydia revealed many of the same concerns that others have expressed regarding screening. “Three themes were identified: perceptions of stigma associated with sexually transmitted infection, uncertainty about reproductive health after diagnosis, and anxieties regarding partner’s reaction to diagnosis.” (Duncan, 2001) These women revealed that stereotypes about who is “at-risk” for Chlamydia prevented them from finding information about STDs to be personally relevant. This is one reason that only screening women who appear to be at-risk is a dangerous way to approach screening methods. Because these women believed that only “other” sorts of women got STDs, they feared a negative reaction from others. Education should focus on the prevalence of this disease among people of all classes, races, and groups of people, and help “normalize” getting STDs so that there will be less anxiety.
Additionally, screening for Chlamydia in men must be combined with education that normalizes STDs for men. There is a tendency to associate certain STDs, such as Chlamydia, with women only. “Sexuality and health: the hidden costs of screening for Chlamydia trachomatis” from the British Medical Journal (Duncan, 1999) identifies that screening women for chlamydia, but not men, minimizes men’s responsibility for sexual and reproductive health. “Women have feelings of “contamination” reduced attractiveness, and sexual dysfunction and that a positive test result is associated with promiscuity.” (Duncan, 1999) Furthering gender inequalities, social divisions, and misconceptions about sexually transmitted diseases is an unfortunate consequence of the way in which most screening programs are approached. In fact, many physicians simply do not screen for Chlamydia because they are “worried about backlash in the community.” (Many HMO Docs, 2000) Self-reporting screening criteria is simply not effective.
In order to reduce many of the stressing factors of Chlamydia screening, anonymous home-testing was done with a sample of teenagers in a report found in the British Medical Journal. (Ostergaard, 1998) Responses to this way of testing were very positive, because the home tests were far less invasive than a vaginal swab or other testing method done in the office.
While many health care workers are failing at providing adequate education, screening, and treatment for Chlamydia, some are already putting forth excellent effort. For example, the Kaiser Permanente medical group has worked closely with the CDC to improve screening and treatment. (PRNewswire, 2005) “When we thought about changes in how we do this screening at Kaiser Permanente, we decided to keep it straightforward. For instance, the clinical assistants in our OB/GYN department now set out a chlamydia test along with any Pap test, so it’s effortless for our physicians.” (PRNewswire, 2005) Kaiser Permanente also provides training for health care workers. Due to their increased standards, there was a very significant increase in the number of screenings — forty-two percent in the OB/GYN departments — , and there has been a ten percent increase in the number of diagnoses. Health care costs attributed to chlamydia exceeds $3.5 billion per year in the United States, however proper screening and treatment will actually reduce these costs, not increase them, because it is easy and inexpensive to treat the disease with antibiotics if it is caught early. However, many health care workers are not aware of current screening methods, treatment methods, or the benefits of proper care.
RESEARCH QUESTIONS
It is apparent that screening for Chlamydia is the key to preventing high rates of morbidity from this infection. However, screening is not widespread or common enough, and health care workers seem to not have access to the latest information on screening methods. The proposed study will attempt to answer the following questions:
1. Can we increase the diagnosis and treatment of chlamydia with the new urine-based tests?
2. Why don’t healthcare providers use these tests or offer these tests more often?
RESEARCH DESIGN AND RATIONALE
This research will be conducted with a wide focus group, so as to achieve the most accurate results.
Use focus groups of high medium and low testers. Include high, middle and lower income clinic healthcare professionals.
WORKS CITED
Arcadian, et al. (2005, September 4) Trachoma. Wikipedia. http://en.wikipedia.org/wiki/Trachoma
Decius, et al. (2005, October 2) Chlamydia. Wikipedia. http://en.wikipedia.org/wiki/Chlamydia
Duncan, B. (2001, January 27) Qualitative analysis of psychosocial impact of diagnosis of Chlamydia trachomatis: implications for screening. British Medical Journal. http://findarticles.com/p/articles/mi_m0999/is_7280_322/ai_70634425/print
Duncan, B. (1999, April 3) Sexuality and health: the hidden costs of screening for Chlamydia trachomatis. British Medical Journal. http://findarticles.com/p/articles/mi_m0999/is_7188_318/ai_54514754/print
Einwalter, L.A. (2005, September) Gonorrhea and chlamydia infection among women visiting family planning clinics: racial variation in prevalence and predictors. Perspectives on Sexual and Reproductive Health. http://findarticles.com/p/articles/mi_m0NNR/is_3_37/ai_n15623617/print
Grosse, J., et al. (2005, September 29) Chlamydia trachomatis. Wikipedia. http://en.wikipedia.org/wiki/Chlamydia_trachomatis
Icarus3, et al. (2005, July 9) Pelvic inflammatory disease. Wikipedia. http://en.wikipedia.org/wiki/Pelvic_inflammatory_disease
“Many HMO Docs Ignore Chlamydia Guidelines.” (2000, April 1) OB/GYN News. http://findarticles.com/p/articles/mi_m0CYD/is_7_35/ai_62024944/print
Miller, K.E. (2004, February 1) Improving chlamydia screening programs. American Family Physician. http://findarticles.com/p/articles/mi_m3225/is_3_69/ai_112915130/print
Miller, K.E. (2005, January 1) Limitations of screening tests for asymptomatic chlamydia. American Family Physician. http://findarticles.com/p/articles/mi_m3225/is_1_71/ai_n8704721/print
Morantz, C. (2003, July 15) Recommendations on screeding for Chlamydia. American Family Physician. http://findarticles.com/p/articles/mi_m3225/is_2_68/ai_105645312/print
Ostergaard, L. (1998, July 4) Efficacy of home sampling for screening of Chlamydia trachomatis: randomised study. British Medical Journal. http://findarticles.com/p/articles/mi_m0999/is_7150_317/ai_53499986/print
Pimenta, J. (2000, September 9) Screening for genital chlamydial infection. British Medical Journal. http://findarticles.com/p/articles/mi_m0999/is_7261_321/ai_65772551/print
PRNewswire. (2005, July 29) Simple Screening Prevents Disease, Improves the Health of Young Women and Unborn Children. PR Newswire. http://findarticles.com/p/articles/mi_m4PRN/is_2005_July_29/ai_n14837422/print
Shih, S. (2004, October 29) Chlamydia screening among sexually active young female enrollees of health plans — United States, 1999-2001. Morbidity and Mortality Weekly Report. http://findarticles.com/p/articles/mi_m0906/is_42_53/ai_n7070286/print
YurikBot, et al. (2005, October 4) Reiters Syndrome. Wikipedia. http://en.wikipedia.org/wiki/Reiters_Syndrome
Zoler, M.L. (2004, July 1) New guidelines may alter practice: many gyns. fail to offer Chlamydia screening. OB/GYN News. http://findarticles.com/p/articles/mi_m0999/is_7150_317/ai_53499986/print
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