Behavioral intervention to increase condom use among high-risk female adolescents

Prevention of gonorrhea and Chlamydia through behavioral intervention: results of a two-year controlled randomized trial in minority women

BACKGROUND

Sexually transmitted disease (STD), including AIDS, disproportionately affects African-American and Hispanic women.

GOAL

To evaluate efficacy of standard and enhanced (addition of optional support groups) gender- and culture-specific, small-group behavioral interventions, compared to interactive STD counseling, in high risk minority women for two years.

METHODS

Women with a non-viral STD were treated and enrolled in a randomized trial. Follow-up screens and interviews occurred at 6 months, 1 year, 18 months (short interview, optional exam) and 2 years. The primary outcome was subsequent infection with chlamydia and/or gonorrhea. Secondary outcomes included risky sexual behaviors. We employed logistic regression based on intention-to-treat.

RESULTS

Data from 775 women were included; the retention rate was 91%. Adjusted infection rates were higher in the controls in Year 1 (26.8%), Year 2 (23.1%), and cumulatively (39.8%) than in the enhanced (15.4%, P = 0.004; 14.8%, P < 0.03; 23.7%, P < 0.001, respectively) and standard (15.7%, P = 0.006; 14.7%, P = 0.03; 26.2%, P < 0.008, respectively) intervention arms at these time points. Enhanced-intervention women who opted to attend support groups (attendees) had the lowest adjusted infection rates in Year 1 (12.0%) and cumulatively (21.8%). Intervention women in general, but particularly attendees, were significantly less likely than controls to have repeat infections. Multiple partners and unprotected sex with an untreated or incompletely treated partner helped explain group differences in infection.

CONCLUSIONS

Risk-reduction interventions significantly decreased both single and multiple infective episodes with chlamydia and/or gonorrhea and risky sexual behaviors in the two-year study period. Support-group attendance appeared to contribute additional risk reduction in Year 1.

Chlamydia and gonorrhea screening in asymptomatic young women

BACKGROUND

Adolescent and young adult minority women are at high risk for chlamydia (CT) and gonorrhea (NGC) cervical infections, which are significant causes of pelvic inflammatory disease, impaired fertility, ectopic pregnancy and chronic pain. The purpose of this article is to review among young women in the United States: (1) the epidemiology of CT and NGC cervical infection and their medical complications; (2) current public health recommendations to promote asymptomatic CT and NGC screening; (3) current screening practices and challenges of implementing public health recommendations; (4) testing and cost issues; and (5) future directions in promoting asymptomatic CT and NGC screening.

METHODS

We conducted a MEDLINE search for articles published over the last two decades relating to CT and NGC screening in young women and then systematically reviewed all relevant articles.

RESULTS

The data indicate that CT and NGC infection are geographically widespread in the U.S. and asymptomatic infection is highly prevalent among economically disadvantaged young females. Public health recommendations promoting CT and NGC screening in asymptomatic young women are directed to both health care providers and clients. However, strategies to promote screening efforts have been primarily directed toward health care providers; there are no published studies on client-initiated screening strategies. Challenges of implementing public health recommendations and future directions for CT and NGC screening are discussed.

CONCLUSIONS

Young sexually active women continue to be at high risk for CT and NGC infection. The data indicate that implementation of health provider-based and client-initiated screening in private and public health care settings is a challenge. However, there is a great need to develop strategies to understand and promote client-initiated screening.

Prevalence and High Rate of Asymptomatic Infection of Chlamydia trachomatis in Male College Reserve Officer Training Corps Cadets

BACKGROUND

Prevalence of Chlamydia trachomatis and risk factors for infection are not well described in male college students enrolled in the Reserved Officer Training Corps (ROTC).

GOAL

The goal was to determine prevalence of C. trachomatis infection, percentage of asymptomatic infections, and risk factors for infection in a population of male college ROTC students.

STUDY DESIGN

We conducted a prevalence survey of C. trachomatis infection and risk factors using urine ligase chain reaction and questionnaire. Participants were 1443 ROTC male college cadets at Ft. Lewis, Washington, from June to July 2001.

RESULTS

Prevalence of C. trachomatis infection was 31 of 1252 (2.48%); 93.6% of the infections were asymptomatic. Black race, exposure to a partner with a prior sexually transmitted disease, and self-reported symptoms were significant risk factors.

CONCLUSIONS

The prominence of asymptomatic infection in a male population with comparatively low prevalence suggests that risk factor rather than clinically based screening could be beneficial in this population.

The next generation of HIV prevention for adolescent females in the United States: linking behavioral and epidemiologic sciences to reduce incidence of HIV

Given the increasing numbers of new HIV infections among adolescent females and limitations of the current generation of HIV interventions, a new generation of interventions is needed to prevent HIV and other infections in this population. Interventions available today are limited by their focus on single behaviors that have little epidemiologic significance, such as condom use, and their failure to be tested among the highest risk females. Recent advances in epidemiologic sciences suggest that the next generation of interventions should focus on parenting and parenting skills, sexual risk networks in which drug use and other high-risk behaviors are prevalent, and neighborhoods where these networks exist. Future research should include formative and observational studies to inform new intervention trials that reach the highest risk female youth.

Methodological challenges in research on sexual risk behavior: I. Item content, scaling, and data analytical options

Investigation of sexual behavior involves many challenges, including how to assess sexual behavior and how to analyze the resulting data. Sexual behavior can be assessed using absolute frequency measures (also known as counts) or with relative frequency measures (e.g., rating scales that range from never to always). We discuss these 2 assessment approaches in the context of research on HIV risk behavior. We conclude that these 2 approaches yield nonredundant information and, more important, that only data yielding information about the absolute frequency of risk behavior have the potential to serve as valid indicators of HIV contraction risk. However, analyses of count data may be challenging because of non-normal distributions with many outliers. Therefore, we identify new and powerful data analytical solutions that have been developed recently to analyze count data and discuss limitations of a commonly applied method (viz., analysis of covariance using baseline scores as covariates).

Prevention opportunities in health care settings

Psychologists have an opportunity to offer their expertise at a time when health care settings are beginning to recognize the importance of behaviorally based interventions for improving health and health care. The authors review the changing patterns of health and illness that have led to an increased interest in the role of patient and provider behavior and discuss the many advantages of using health care settings as prevention sites. Examples of successful behaviorally based prevention programs are presented, along with the evidence supporting the cost-effectiveness of such programs. Challenges presented by working in health care settings are described. Throughout, the authors emphasize the multiple opportunities for psychologists' involvement across a wide variety of health care delivery sites.

HIV sexual risk-reduction interventions for youth: a review and methodological critique of randomized controlled trials

The authors review and provide a methodological critique of randomized controlled studies of HIV risk reduction interventions that measured sexual risk behavior outcomes with adolescents. Studies conducted in school, community, and health care settings were reviewed. Overall, 13 of 23 interventions (57%) were effective in reducing sexual risk behavior. Methodological strengths of extant studies included an emphasis on a theoretical framework, evaluation of both individualized and group-intervention formats, use of multiple assessments of risk behavior (including biological outcomes), and inclusion of efficacy and effectiveness trials. Methodological limitations included limited evaluation of theoretical mediators of risk reduction, failure to report effect sizes, and lack of sustained findings. Inconsistencies were found in data analytic procedures and reporting, including how nested designs, skewed data, and attrition were addressed. Recommendations for designing methodologically rigorous interventions are provided.

Screening and counseling for adolescent alcohol use among primary care physicians in the United States

OBJECTIVE

To examine the prevalence and quality of alcohol prevention services delivered to adolescents in the United States.

METHODS

A national, stratified random sample of pediatricians and family practitioners was drawn from the American Medical Association Masterfile. The response rate was 63%, and the final sample size was 1842 physicians. Quality of services delivered was assessed by 2 scales: quality of screening (percentage of patients screened and depth of screening questions used) and quality of education (level of effectiveness of educational methods used and frequency of use).

RESULTS

Although most physicians reported providing some degree of alcohol prevention services, their efforts were typically inconsistent, not in enough depth, and they failed to incorporate the most effective educational methods. Reported rates of universal screening and counseling were low, and younger adolescents were less likely to receive services. Physicians' beliefs about their alcohol management skills and perceptions of resource availability were the most consistent correlates of higher quality service.

CONCLUSIONS

Prospective studies that elucidate the conditions under which individual physicians do and do not screen, as well as future efforts to educate physicians about the most effective brief intervention approaches, seem warranted.

Association of adolescents' history of sexually transmitted disease (STD) and their current high-risk behavior and STD status: a case for intensifying clinic-based prevention efforts

BACKGROUND

Adolescents are at high risk of sexually transmitted disease (STD)/HIV infection, and one vulnerable subgroup is African American females. The association between adolescents' previous experience of STD and recent sexual risk behaviors has been ill-defined.

GOAL

The goal was to examine the associations between adolescents' self-reported history of STD diagnosis and current sexual risk behaviors, prevention knowledge and attitudes, and STD infection status.

STUDY DESIGN

This was a cross-sectional survey. Recruitment sites were in low-income neighborhoods of Birmingham, Alabama, characterized by high rates of unemployment, substance abuse, violence, and STDs. Participants were sexually active adolescent females (N = 522) 14 to 18 years of age. Information on STD history and current sexual behaviors (within the 30 days before assessment) was collected in face-to-face interviews. Less sensitive topics, such as STD prevention knowledge, attitudes about condom use, and perceived barriers to condom use, were addressed via self-administered survey. DNA amplification of vaginal swab specimens provided by the adolescents was performed to determine current STD status. Outcomes associated with past STD diagnosis were determined by means of logistic regression to calculate adjusted odds ratios (AORs) in the presence of observed covariates.

RESULTS

Twenty-six percent of adolescents reported ever having an STD diagnosed. Although past STD diagnosis was associated with increased STD prevention knowledge, it was not associated with increased motivation to use condoms. Compared with adolescents who had never had an STD, adolescents with a history of diagnosed STD were more likely to report not using a condom at most recent intercourse (AOR = 2.54; 95% CI = 1.64-3.93; = 0.0001), recent unprotected vaginal intercourse (AOR = 1.79; 95% CI = 1.15-2.79; = 0.010), inconsistent condom use (AOR = 2.27; 95% CI = 1.46-3.51; < .0001), sexual intercourse while drinking alcohol (AOR = 2.09; 95% CI = 1.33-3.28; = 0.001), and unprotected intercourse with multiple partners (AOR = 3.29; 95% CI = 1.09-9.89; = 0.034). Past STD diagnosis was associated with increased risk for current biologically confirmed gonorrhea and trichomoniasis (AOR = 2.48; 95% CI = 1.09-5.23; = 0.030; and AOR = 2.05; 95% CI = 1.18-3.59; = 0.011, respectively). Past STD diagnosis was not significantly associated with increased risk of current biologically confirmed chlamydia (AOR = 0.78; 95% CI = 0.45-1.37; = 0.38).

CONCLUSION

Among this sample of female adolescents, past STD diagnosis was an indicator of current high-risk sexual activity and increased risk for two common STDs: gonorrhea and trichomoniasis. Although adolescents may gain factual knowledge from the experience of having an STD diagnosed, they are not applying that knowledge to their current sexual behaviors. Thus, these adolescents remain at risk for subsequent STD infection. Therefore, the findings suggest that there is a need to intensify clinic-based prevention efforts directed toward adolescents with a history of STDs, as a strategy for reducing STD-associated risk behaviors and, consequently, the likelihood of new STD infections.

Pregnant African-American teens are less likely than their nonpregnant peers to use condoms

OBJECTIVE

The aim of this study was to prospectively compare pregnant and nonpregnant adolescents' recent condom use and sexually transmitted disease (STD) acquisition.

METHODS

Sexually active African-American females (N = 522), ages 14-18, were recruited from clinics and schools. Adolescents completed baseline interviews and provided vaginal swabs for STD testing, and urine for pregnancy testing. Assessments were repeated 6 and 12 months post baseline assessment. Analyses compared adolescents who became pregnant between baseline and the 6-month assessment with their peers who had negative pregnancy tests. Condom use between the 6- and 12-month assessments and incidence of STDs at the 12-month assessment served as outcomes. Adolescents who did not report sexual activity between the 6- and 12-month assessments were excluded.

RESULTS

Ten percent of the adolescents became pregnant and continued sexual activity. Pregnant adolescents reported less overall condom use (P < 0.0001), more infrequent condom use (adjusted odds ratio [AOR] = 4.5, P < 0.001), and more unprotected vaginal sex (AOR = 4.7, P < 0.003). Pregnant adolescents were equally likely to test positive for STDs (31% vs 26%) and to self-report having STDs at the 12-month follow-up period (30% vs 23%).

CONCLUSIONS

Findings suggest that pregnant adolescents may be less likely to use condoms than their nonpregnant peers and that STD incidence among pregnant adolescents may be high. Condom use promotion may be important during adolescents' prenatal care.

Using sexually transmitted disease incidence as a surrogate marker for HIV incidence in prevention trials: a modeling study

BACKGROUND

Because many of the sexual behaviors that place individuals at risk of acquiring HIV are the same as those that place them at risk for other sexually transmitted diseases (STDs), researchers and policymakers have called for the use of non-HIV STDs as surrogate markers for HIV infection.

GOALS

This study examined the epidemiologic conditions under which changes in STD incidence are associated with changes in HIV incidence.

STUDY DESIGN

A mathematical model of HIV/STD transmission was applied to empirical data from a large HIV prevention intervention. The association between participants' HIV infection risk reduction scores and their STD risk reduction scores was measured with use of the Pearson product-moment correlation. The authors examined how the strength of association varied across different epidemiologic parameters and heterosexual behaviors.

RESULTS

Moderate to strong associations were noted when the infectivity of the STD was similar to the infectivity of HIV. The association was attenuated for larger STD infectivity values. The prevalence of STD infection was a less important determinant of the strength of association. Stronger associations were obtained when the number of sex partners was large or the number of sex acts was small.

CONCLUSIONS

Easily transmitted STDs, such as gonorrhea, are unsuitable for general use as surrogate markers for HIV infection. Hepatitis B, syphilis, and chlamydial infection have more promising epidemiologic profiles. Careful studies of STD infectivity are needed to aid in the identification of potential marker STDs.

Older partners not associated with recurrence among female teenagers infected with Chlamydia trachomatis

BACKGROUND

Chlamydia trachomatis-infected female teenagers with older partners may be less likely to discuss the infection with their partner(s) and to use condoms and therefore may be more likely to get reinfected.

GOAL

To determine if C trachomatis-infected female teenagers with older partners were more likely to be reinfected than those with same-aged partners.

STUDY DESIGN

Females aged 14 years to 18 years who had uncomplicated chlamydial infection, were nonpregnant, attended clinics in five United States cities from June 1995 to May 1997, completed treatment, and resumed sexual activity were observed at 1 and 4 months for interim history and retesting.

RESULTS

Of 225 women studied, 73.3% were black, 34.5% had at least one partner who was 3 or more years older during follow-up, 51.6% reported using a condom at the last sex act with all partners, 13.8% had a recurrent infection, and 47.4% reported they were certain that all of their baseline partners were treated. Partner age was not associated with condom use, certainty of partners' taking medication, or recurrent infections after adjustment for visit.

CONCLUSIONS

Older partners, accounting for approximately one third of all partners, did not increase the risk of reinfection. Given the high risk for recurrence, follow-up testing and enhanced efforts to ensure partner treatment are appropriate for all young women with chlamydial infections.

Effective approaches to reducing adolescent unprotected sex, pregnancy, and childbearing

In the United States, there exist a multitude of different approaches to reducing adolescent sexual risk-taking, unintended pregnancy, childbearing, and sexually transmitted disease, including HIV. While many of these approaches have some positive effects upon some outcomes (such as greater knowledge), only some of these programs actually delay the initiation of sex, increase condom or contraceptive use, and reduce unprotected sex among youth. This article summarizes a review of 73 studies and their respective programs, and describes four groups of programs which have reasonably strong evidence that they delay sex, increase condom or contraceptive use, or reduce teen pregnancy or childbearing. These four groups of programs include (a) sex and HIV education curricula with specified characteristics, (b) one-on-one clinician-patient protocols in health settings with some common qualities, (c) service learning programs, and (d) a particular intensive youth development program with multiple components.

Clinic-based service programs for increasing responsible sexual behavior

Three general classes of clinic-based programs to increase responsible sexual behavior are considered: (a) clinic-based educational/counseling programs, (b) school clinic-based condom distribution programs, and (c) clinic-based STD/HIV screening programs. Consistent condom use may double in response to clinic-based counseling. However, consistent use seldom exceeds 50% of coital exposures. Extensive and personalized counseling interventions reduce incident sexually transmitted infections by 5% to 10%. Increases in responsible sexual behavior following school-based condom distribution programs is reported in some but not in all studies. Screening programs for sexually transmitted infections are associated with decreases in rates of some infections. STD/HIV screening should be considered an important aspect of healthy sexuality and an adjunct to other counseling efforts.

Tailoring clinical management practices to meet the special needs of adolescents: sexually transmitted infections

Sexually transmitted infections are a major health risk to all sexually active adolescents and improving clinical management for this age group is of major importance. Currently, adolescents are managed in the same way as adults. This paper summarizes recommendations by the World Health Organization that services be more responsive to adolescent concerns about confidentiality, risk assessment be more attuned to their sexual behavioral patterns, and services be tailored to give more time for counseling, assessment of stage of maturity and continuity of reproductive health care.

Determinants of persistent and recurrent Chlamydia trachomatis infection in young women: results of a multicenter cohort study

BACKGROUND

Sequelae of genital Chlamydia trachomatis infection in women are more strongly linked to repeat infections than to initial ones, and persistent or subsequent infections foster continued transmission.

OBJECTIVE

To identify factors associated with persistent and recurrent chlamydial infection in young women that might influence prevention strategies.

METHODS

Teenage and young adult women with uncomplicated C trachomatis infection attending reproductive health, sexually transmitted disease, and adolescent medicine clinics in five US cities were recruited to a cohort study. Persistent or recurrent chlamydial infection was detected by ligase chain reaction (LCR) testing of urine 1 month and 4 months after treatment.

RESULTS

Among 1,194 women treated for chlamydial infection, 792 (66.4%) returned for the first follow-up visit, 50 (6.3 %) of whom had positive LCR results. At that visit, women who resumed sex since treatment were more likely to have chlamydial infection (relative risk [RR], 2.0; 95% CI, 1.03-3.9), as were those who did not complete treatment (RR, 3.4; 95% CI, 1.6-7.3). Among women who tested negative for C trachomatis at the first follow-up visit, 36 (7.1%) of 505 had positive results by LCR at the second follow-up visit. Reinfection at this visit was not clearly associated with having a new sex partner or other sexual behavior risks; new infection was likely due to resumption of sex with untreated partners. Overall, 13.4% of women had persistent infection or became reinfected after a median of 4.3 months, a rate of 33 infections per 1,000 person months.

CONCLUSIONS

Persistent or recurrent infection is very common in young women with chlamydial infection. Improved strategies are needed to assure treatment of women's male sex partners. Rescreening, or retesting of women for chlamydial infection a few months after treatment, also is recommended as a routine chlamydia prevention strategy.

Incidence and prevalence of chlamydia, herpes, and viral hepatitis in a homeless adolescent population

BACKGROUND

High rates of unprotected intercourse and illegal drug use have been reported among homeless adolescents. As a transient population with the potential to act as disease vectors from one location to another, incidence and prevalence of sexually transmitted infections in this population are of particular concern.

GOAL

To assess a homeless adolescent population for incidence and prevalence of Chlamydia trachomatis, herpes simplex virus type 2, hepatitis B virus, hepatitis C virus, HIV, and psychosocial correlates of the acquisition of sexually transmitted infections.

STUDY DESIGN

Longitudinal with assessments at baseline, 3 months, and 6 months (n = 536; 319 males and 217 females).

RESULTS

Baseline prevalence of C trachomatis was 4.17% for males and 6.30% for females. Prevalence of herpes simplex virus type 2 was 5.73% for males and 12.50% for females. Hepatitis B virus and hepatitis C virus prevalences were 3.60% and 5.0%, respectively. HIV seroprevalence was 0.3%. The incidence of sexually transmitted infections was significantly higher among females than among males (16.7% versus 9.8%) and was associated with inconsistent condom use and, for females, number of partners and sex with older partners. Incident hepatitis B virus and hepatitis C virus infection rates were 3.44% and 6.61%, respectively; both were associated with injection drug use.

CONCLUSIONS

Among females, the incidence of herpes simplex virus type 2 (> 25%) and C trachomatis (12%) was relatively high. Inconsistent condom use was the primary factor associated with a significantly greater risk of incident sexually transmitted infections. This was especially true for females with multiple partners. Homeless adolescents also are at high risk for hepatitis B virus and hepatitis C virus infection, primarily associated with self-reported injection drug use.

An appraisal of screening for maternal type-specific herpes simplex virus antibodies to prevent neonatal herpes

Almost all neonatal herpes simplex virus infections occur as a result of first-episode maternal infection during late pregnancy when delivery occurs before the development of protective maternal antibodies. Screening of pregnant women for the presence of type-specific herpes simplex virus antibodies has therefore been suggested as a means of identifying women vulnerable to herpes simplex virus acquisition and subsequent transmission of herpes simplex virus to their neonates. Couples in whom herpes simplex virus serotype discordance is identified could be counseled regarding sexual behavior modification to avoid maternal herpes simplex virus infection. However, the ramifications of routine screening for herpes simplex virus susceptibility during pregnancy could be profound in terms of costs, prenatal care delivery, and even social duress. The recent US Food and Drug Administration approval of type-specific herpes simplex virus antibody assays for clinical use lends temporal urgency to the need for a critical examination of the relevant data. After we performed such an evaluation and created a decision analysis model to assess the potential cost-effectiveness of herpes simplex virus antibody screening, we concluded that screening for maternal type-specific herpes simplex virus antibodies cannot be recommended to prevent neonatal herpes.

Prevention of cervix cancer

Cervix carcinoma is an important health problem world-wide, being the second most common cancer among women, ranking first in many developing countries. A number of important epidemiological risk factors have been identified as contributing to the development of CIN and invasive cervix carcinoma. Of key importance is infection with human papillomavirus (HPV), which is the primary risk factor. There are evolving primary and secondary preventive strategies that could further reduce the burden from cervical carcinoma. The possible primary preventive strategies include risk reduction, diet or dietary supplements, HPV vaccines, and other chemopreventive agents. The possible advances in secondary preventive strategies include new technologies for Pap smears, HPV typing triage, and other adjuvant screening procedures. The impact of these strategies will depend upon evidence to support their use along with the characteristics of the population and environment in which they are used.

Interventions for encouraging sexual lifestyles and behaviours intended to prevent cervical cancer

BACKGROUND

Cervical cancer is one of the most common cancers affecting women world-wide. Prevention falls into two main categories - primary and secondary. Primary prevention is characterised by health promotion to promote lifestyles and behaviours minimising risk of cervical cancer. Interventions to promote the use of condoms for sexual intercourse (especially early intercourse amongst young women), sexual partner reduction, and negotiated safer sex strategies has been recommended as one approach to limit the spread of Human Papilloma Virus (HPV), one of the major risk factors for cervical cancer.

OBJECTIVES

To determine the effectiveness of health education interventions to promote sexual risk reduction behaviours amongst women in order to reduce transmission of HPV.

SEARCH STRATEGY

Electronic searching of EMBASE, ERIC, MEDLINE, PsycLIT, Social Science Citation Index and the CCTR were undertaken using a highly sensitive search strategy. Hand-searching took place of selected journals and reference lists.

SELECTION CRITERIA

Studies were included if they evaluated educational interventions targeting women only, and measured the impact on : either a behavioural outcome such as condom use for sexual intercourse, partner reduction, or abstinence; or a clinical outcome such as incidence of a sexually transmitted disease (STD).

DATA COLLECTION AND ANALYSIS

Data were extracted and methodological quality was assessed independently by two reviewers and any discrepancies were resolved between them. Ten per cent of the total number of studies were reviewed additionally by a third reviewer as a quality check and differences in judgement were resolved accordingly.

MAIN RESULTS

Thirty trials met the inclusion criteria for the review. All of them had the primary aim of preventing HIV and other STDs rather than cervical cancer. Four core methodological qualities were present in 10 of the 30 studies and constitute the subset from which potentially reliable conclusions may be drawn. Each of the 10 studies showed a statistically significant positive effect on sexual risk reduction, typically with increased use of condoms for vaginal intercourse. This positive effect was generally sustained up to three months after intervention.

REVIEWER'S CONCLUSIONS

Educational interventions targeting socially and economically disadvantaged women in which information provision is complemented by sexual negotiation skill development can encourage at least short-term sexual risk reduction behaviour. This has the potential to reduce the transmission of HPV, thus possibly reduce the incidence of cervical carcinoma.

Knowledge of Chlamydia trachomatis infection in genitourinary medicine clinic attenders

OBJECTIVES

To determine the level of awareness of genital chlamydial infection, and level of knowledge related to this infection, in genitourinary medicine (GUM) clinic attenders.

METHODS

500 consecutive patients attending a GUM clinic for the first time during a 3 month study period were invited to complete an anonymous self administered questionnaire on aspects of chlamydial infection.

RESULTS

482 (96.4%) questionnaires were available for analysis (57% female). 289 (60%) respondents had heard of Chlamydia trachomatis compared with 472 (98%) for thrush, 467 (97%) for HIV/AIDS, and 434 (90%) for gonorrhoea. Subjective knowledge of chlamydia, relative to the other infections, was poor. Overall, the mean chlamydial knowledge score was 0.38 (range 0.0-1.0). Females scored significantly higher than males (0.45 v 0.26; p < 0.00001) and younger females scored significantly higher than older females (p = 0.001). More females had experienced genital chlamydial infection than males (22.4% v 12.1%, p = 0.004). Those with prior exposure to C trachomatis had higher mean knowledge scores than those without (males 0.55 v 0.25, p < 0.00001; females 0.68 v 0.37, p < 0.00001).

CONCLUSION

Even for a population considered as "high risk" by their attendance at a GUM clinic, there was poor awareness of genital chlamydial infection, and mean knowledge scores were low. Whether increased knowledge was due to successful health education at the time of diagnosis in those with previous infection remains to be determined. In the future, one would hope for increased knowledge scores in those at risk before the acquisition of infection, which may be achieved by national health education programmes for C trachomatis.

A randomized, controlled trial of a behavioral intervention to prevent sexually transmitted disease among minority women

BACKGROUND

African-American and Hispanic women are disproportionately affected by sexually transmitted diseases, including the acquired immunodeficiency syndrome (AIDS). In the effort to reduce infection rates, it is important to create and evaluate behavioral interventions that are specific to the target populations.

METHODS

We enrolled women with nonviral sexually transmitted diseases in a randomized trial of a sex- and culture-specific behavioral intervention. The intervention consisted of three small-group sessions of three to four hours each designed to help women recognize personal susceptibility, commit to changing their behavior, and acquire necessary skills. The control group received standard counseling about sexually transmitted diseases. The design of the intervention was based on the AIDS Risk Reduction Model and ethnographic data on the study populations. Participants in both groups underwent screening, counseling, and an interview before randomization and at the 6- and 12-month follow-up visits. The principal outcome variable was subsequent chlamydial or gonorrheal infection, which was evaluated on an intention-to-treat basis by logistic-regression analysis.

RESULTS

A total of 424 Mexican-Americans and 193 African-American women were enrolled; 313 were assigned to the intervention group and 304 to the control group. The rate of participation in the intervention was 90 percent. The rates of retention in the sample were 82 and 89 percent at the 6- and 12-month visits, respectively. Rates of subsequent infection were significantly lower in the intervention group than in the control group during the first 6 months (11.3 vs. 17.2 percent, P=0.05), during the second 6 months (9.1 vs. 17.7 percent, P=0.008), and over the entire 12-month study period (16.8 vs. 26.9 percent, P=0.004).

CONCLUSIONS

A risk-reduction intervention consisting of three small-group sessions significantly decreased the rates of chlamydial and gonorrheal infection among Mexican-American and African-American women at high risk for sexually transmitted disease.

Tobacco cessation and youth: the feasibility of brief office interventions for adolescents

BACKGROUND

The prevalence of tobacco use among adolescents remains high and the great majority of adult smokers begin smoking prior to the age of 18. While there have been a number of primary prevention projects in communities and schools, less attention has been given to smoking cessation for adolescents. This paper reviews the literature on the theory and practice of cessation as applicable to adolescents.

METHODS

The relevant literature was culled from a MEDLINE search and supplemented with secondary searches from those articles.

RESULTS

There have been few studies on brief interventions for adolescent smoking cessation in health care settings. However, there are several models for smoking cessation that are either applicable to or designed for adolescents. Pharmacologic treatments are also beginning to be used.

CONCLUSIONS

There is a great need for the development and evaluation of models for adolescent smoking cessation in health care settings. Recent developments, however, give cause for optimism in helping adolescent smokers in tobacco cessation.

Social and behavioral correlates of pelvic inflammatory disease

OBJECTIVES

To review the social and behavioral correlates of pelvic inflammatory disease (PID) in the light of the renewed interest in the transmission dynamics of communicable diseases, the new emphasis on health care seeking and health service provision, and increased attention to contextual and population level factors affecting morbidity.

METHODS

Social and behavioral correlates of PID are reviewed using a conceptual scheme that matrixes the differences among risk factors for exposure, acquisition, and development of sequelae with the differences between individual-level risk factors and population-level determinants.

RESULTS

Two major factors contribute to the development of PID: recurrent (or persistent) chlamydial infection of the cervix, which are geographically concentrated and associated with contextual variables, and critical delays in detection and treatment of cervical infection, which are amenable to interventions.

CONCLUSIONS

Widespread screening for cervical infection followed by timely and appropriate treatment is key for prevention of PID. Health care seeking, provider training, and availability of detection technologies and drugs need to be improved.

Evaluation of a randomized controlled trial of HIV and sexually transmitted disease prevention in a genitourinary medicine clinic setting

OBJECTIVE

To evaluate outcomes of a sexual health promotion intervention to prevent transmission of sexually transmitted diseases (STD) including HIV among genitourinary medicine clinic attenders.

DESIGN

A randomized controlled trial using pre-test and post-test measurements after 4 months, with clinical follow-up at 18 months.

SETTING

A genitourinary medicine clinic in Nottingham, UK.

PATIENTS

A total of 492 patients were randomly assigned either to an individually focused counselling and skills training intervention, including written materials (n = 148), to receive written materials only (n = 162), or to usual clinic procedure (n = 182).

INTERVENTION

Social learning theory provided the theoretical framework for the intervention, which was informed by previous research in this setting, and aimed to alter perception of risk for HIV infection, increase knowledge and attitudes to condoms, and increase condom use.

MAIN OUTCOME MEASURES

The main outcomes of interest were self-reported condom use and behaviour change. Other outcomes of interest were knowledge and attitudes to condoms, and re-attendance at the clinic with a diagnosis of STD.

RESULTS

Intervention subjects were significantly more likely than controls to report carrying condoms when anticipating sexual intercourse with a new sexual partner (P < or = 0.05), and were more likely to perceive themselves at risk of HIV infection (P < or = 0.001). There were no significant effects of the intervention on levels of knowledge about correct condom use, attitudes to condoms, self-reported condom use or incidence of STD.

CONCLUSIONS

The limited effectiveness of the intervention suggests that condom promotion should continue, but that additional investment in clinic-based health promotion is unlikely to result in consequent health gain.

Detection of Chlamydia trachomatis cervical infection by urine tests among adolescents clinics

PURPOSE

To compare urine ligase and polymerase chain reaction (LCR, PCR) tests for diagnosis of Chlamydia trachomatis cervical infection with PCR and nucleic acid probe (GPA) on cervical specimens in adolescents, as well as risk factors for C. trachomatis infection and prevalence of infection at enrollment.

METHODS

Urine and cervical specimens were collected from women aged 13-20 years attending adolescent clinics, and interviews were administered. Urine specimens were tested by PCR and LCR, and cervical specimens by GPA and PCR. Prevalence rates of C. trachomatis infection and gonorrhea were compared by demographic, behavioral, and clinical risk factors.

RESULTS

Of 415 women tested, 86 (20.7%) were infected with C. trachomatis as indicated by positive cervical PCR results. A higher prevalence of C. trachomatis infection was seen among adolescents who douched monthly or more frequently, or had gonorrhea; prevalence declined from 25.8% in the first 7 months to 16.3% in the last 14 months of the study (p = .017). A statistically significant protective effect for reported condom use was not observed. Sensitivity of urine PCR was 89.5% and specificity was 100% relative to cervical PCR, compared to 84.9% and 99.4% (urine LCR) and 65.4% and 98.0% (cervical GPA). Sensitivity of urine PCR was higher in women with discharge; urine LCR sensitivity was higher in women < 19 years of age.

CONCLUSIONS

Polymerase chain reaction and LCR assays on urine specimens were sensitive, specific, and noninvasive tests in this population of adolescents with high C. trachomatis infection prevalence. Chlamydia trachomatis infection was associated with douching monthly or more frequently. Prevalence of infection declined over the period during which the study was conducted.

The validity of self-reported condom use among adolescents

BACKGROUND

Research and public health interventions designed to reduce the risk of sexually transmitted diseases (STDs) often are based on self-reported condom use. Yet, validation of self-reported condom use, in particular with adolescents, has rarely been described in the literature.

METHODS

Baseline data were obtained from 540 adolescents, 13-21 years of age, enrolled in a 1-year longitudinal study of health beliefs, sexual behaviors, and STD acquisition. Of the 445 participants reporting to be sexually active, 404 (90.8%) agreed to a complete physical examination, including a genital examination, with STD screening after completing the self-administered written questionnaire. Participants' written self-report of condom use was compared to histories obtained by clinicians and laboratory diagnosis of acute STDs to assess validity of written self-report.

RESULTS

Complete data were available for 321 females and 77 males of whom 52 females and 5 males had laboratory evidence of 63 infections. Although three individuals who had STDs reported to be consistent users of condoms, a significant association (P < 0.05) was found between those who reported more frequent condom use with the last two partners and the absence of STDs.

CONCLUSION

In this group of adolescents, self-report of condom use with the last two partners was associated with the absence of an acute STD. This finding suggests that self-reported condom use is a valid indicator of risk for STDs, with implication for those working with adolescents clinically and in research contexts.