Socio-demographic and structural barriers to being tested for chlamydia in general practice

Screening for chlamydia and/or gonorrhea in primary health care: systematic reviews on effectiveness and patient preferences

BACKGROUND

We conducted systematic reviews on the benefits and harms of screening compared with no screening or alternative screening approaches for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) in non-pregnant sexually active individuals, and on the relative importance patients' place on the relevant outcomes. Findings will inform recommendations by the Canadian Task Force on Preventive Health Care.

METHODS

We searched five databases (to January 24, 2020), trial registries, conference proceedings, and reference lists for English and French literature published since 1996. Screening, study selection, and risk of bias assessments were independently undertaken by two reviewers, with consensus for final decisions. Data extraction was conducted by one reviewer and checked by another for accuracy and completeness. Meta-analysis was conducted where appropriate. We used the GRADE approach to rate the certainty of the evidence. The Task Force and content experts provided input on determining thresholds for important effect sizes and on interpretation of findings.

RESULTS

Of 41 included studies, 17 and 11 reported on benefits and harms of screening, respectively, and 14 reported on patient preferences. Universal screening for CT in general populations 16 to 29 years of age, using population-based or opportunistic approaches achieving low screening rates, may make little-to-no difference for a female's risk of pelvic inflammatory disease (PID) (2 RCTs, n=141,362; 0.3 more in 1000 [7.6 fewer to 11 more]) or ectopic pregnancy (1 RCT, n=15,459; 0.20 more per 1000 [2.2 fewer to 3.9 more]). It may also not make a difference for CT transmission (3 RCTs, n=41,709; 3 fewer per 1000 [11.5 fewer to 6.9 more]). However, benefits may be achieved for reducing PID if screening rates are increased (2 trials, n=30,652; 5.7 fewer per 1000 [10.8 fewer to 1.1 more]), and for reducing CT and NG transmission when intensely screening high-prevalence female populations (2 trials, n=6127; 34.3 fewer per 1000 [4 to 58 fewer]; NNS 29 [17 to 250]). Evidence on infertility in females from CT screening and on transmission of NG in males and both sexes from screening for CT and NG is very uncertain. No evidence was found for cervicitis, chronic pelvic pain, or infertility in males from CT screening, or on any clinical outcomes from NG screening. Undergoing screening, or having a diagnosis of CT, may cause a small-to-moderate number of people to experience some degree of harm, mainly due to feelings of stigmatization and anxiety about future infertility risk. The number of individuals affected in the entire screening-eligible population is likely smaller. Screening may make little-to-no difference for general anxiety, self-esteem, or relationship break-up. Evidence on transmission from studies comparing home versus clinic screening is very uncertain. Four studies on patient preferences found that although utility values for the different consequences of CT and NG infections are probably quite similar, when considering the duration of the health state experiences, infertility and chronic pelvic pain are probably valued much more than PID, ectopic pregnancy, and cervicitis. How patients weigh the potential benefits versus harms of screening is very uncertain (1 survey, 10 qualitative studies); risks to reproductive health and transmission appear to be more important than the (often transient) psychosocial harms.

DISCUSSION

Most of the evidence on screening for CT and/or NG offers low or very low certainty about the benefits and harms. Indirectness from use of comparison groups receiving some screening, incomplete outcome ascertainment, and use of outreach settings was a major contributor to uncertainty. Patient preferences indicate that the potential benefits from screening appear to outweigh the possible harms. Direct evidence about which screening strategies and intervals to use, which age to start and stop screening, and whether screening males in addition to females is necessary to prevent clinical outcomes is scarce, and further research in these areas would be informative. Apart from the evidence in this review, information on factors related to equity, acceptability, implementation, cost/resources, and feasibility will support recommendations made by the Task Force.

SYSTEMATIC REVIEW REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO), registration number CRD42018100733 .

Barriers to accessing healthcare among women in Ghana: a multilevel modelling

BACKGROUND

Women's health remains a global public health concern, as enshrined in the Sustainable Development Goals. This study, therefore, sought to assess the individual and contextual factors associated with barriers to accessing healthcare among women in Ghana.

METHODS

The study was conducted among 9370 women aged 15-49, using data from the 2014 Ghana Demographic and Health Survey. Barrier to healthcare, derived from four questions- whether a woman faced problems in getting money, distance, companionship, and permission to see a doctor-was the outcome variable. Descriptive and multilevel logistic regression analyses were carried out. The fixed effect results of the multilevel logistic regression analyses were reported using adjusted odds ratios at a 95% confidence interval.

RESULTS

More than half (51%) of the women reported to have at least one form of barrier to accessing healthcare. Women aged 45-49 (AOR = 0.65, CI: 0.49-0.86), married women (AOR = 0.71, CI:0.58-0.87), those with a higher level of education (AOR = 0.51, CI: 0.37-0.69), those engaged in clerical or sales occupation (AOR = 0.855, CI: 0.74-0.99), and those who were covered by health insurance (AOR = 0.59, CI: 0.53-0.66) had lower odds of facing barriers in accessing healthcare. Similarly, those who listened to radio at least once in a week (AOR =0.77, CI: 0.66-0.90), those who watched television at least once a week (AOR = 0.75, CI: 0.64-0.87), and women in the richest wealth quintile (AOR = 0.47, CI: 0.35-0.63) had lower odds of facing barriers in accessing healthcare. However, women who were widowed (AOR = 1.47, CI: 1.03-2.10), those in the Volta Region (AOR 2.20, CI: I.38-3.53), and those in the Upper West Region (AOR =2.22, CI: 1.32-3.74) had the highest odds of facing barriers to healthcare accessibility.

CONCLUSION

This study shows that individual and contextual factors are significant in predicting barriers in healthcare access in Ghana. The factors identified include age, marital status, employment, health insurance coverage, frequency of listening to radio, frequency of watching television, wealth status, and region of residence. These findings highlight the need to pay critical attention to these factors in order to achieve the Sustainable Development Goals 3.1, 3.7, and 3.8. It is equally important to strengthen existing strategies to mitigate barriers to accessing healthcare among women in Ghana.

Individual and contextual factors associated with barriers to accessing healthcare among women in Papua New Guinea: insights from a nationwide demographic and health survey

BACKGROUND

This study sought to assess the individual and contextual factors associated with barriers to accessing healthcare among women in Papua New Guinea.

METHODS

The study was conducted among 14 653 women aged 15-49 y using data from the 2016-2018 Papua New Guinea Demographic and Health Survey. The outcome variable was barriers to accessing healthcare. Descriptive and multilevel logistic regression analyses were conducted. Statistical significance was declared at P < 0.05.

RESULTS

Women aged 15-19 y were more likely to experience at least one barrier compared with those aged 40-49 y (adjusted OR [AOR]=1.48; 95% CI 1.18 to 1.86). Women with secondary/higher education (AOR=0.68; 95% CI 0.57 to 0.81), women in the richest wealth quintile (AOR=0.36; 95% CI 0.28 to 0.46) and those in the least disadvantaged socioeconomic status (AOR=0.46; 95% CI 0.33 to 0.64) had lower odds of having challenges with at least one barrier to healthcare. However, living in rural areas increased the odds of facing at least one barrier to healthcare (AOR=1.87; 95% CI 1.27 to 2.77).

CONCLUSIONS

This study has demonstrated that both individual and contextual factors are associated with barriers to healthcare accessibility among women in Papua New Guinea. To enhance the achievement of the Sustainable Development Goals 3.1, 3.7 and 3.8, it is critical to deem these factors necessary and reinforce prevailing policies to tackle barriers to accessing healthcare among women in Papua New Guinea.

Mixed effects analysis of factors associated with barriers to accessing healthcare among women in sub-Saharan Africa: Insights from demographic and health surveys

Background

Access to healthcare is one of the key global concerns as treasured in the Sustainable Development Goals. This study, therefore, sought to assess the individual and contextual factors associated with barriers to accessing healthcare among women in sub-Saharan Africa (SSA).

Materials and methods

Data for this study were obtained from the latest Demographic and Health Surveys (DHS) conducted between January 2010 and December 2018 across 24 countries in SSA. The sample comprised 307,611 women aged 15–49. Data were analysed with STATA version 14.2 using both descriptive and multilevel logistic regression modelling. Statistical significance was set at p<0.05.

Results

It was found that 61.5% of women in SSA face barriers in accessing healthcare. The predominant barriers were getting money needed for treatment (50.1%) and distance to health facility (37.3%). Women aged 35–39 (AOR = 0.945, CI: 0.911–0.980), married women (AOR = 0.694, CI: 0.658–0.732), richest women (AOR = 0.457, CI:0.443–0.472), and those who read newspaper or magazine at least once a week (AOR = 0.893, CI:0.811–0.983) had lower odds of facing barriers in accessing healthcare. However, those with no formal education (AOR = 1.803, CI:1.718–1.891), those in manual occupations (AOR = 1.551, CI: 1.424–1.689), those with parity 4 or more (AOR = 1.211, CI: 1.169–1.255), those who were not covered by health insurance (AOR = 1.284, CI: 1.248–1.322), and those in rural areas (AOR = 1.235, CI:1.209–1.26) had higher odds of facing barriers to healthcare access.

Conclusion

Both individual and contextual factors are associated with barriers to healthcare accessibility in SSA. Particularly, age, marital status, employment, parity, health insurance coverage, exposure to mass media, wealth status and place of residence are associated with barriers to healthcare accessibility. These factors ought to be considered at the various countries in SSA to strengthen existing strategies and develop new interventions to help mitigate the barriers. Some of the SSA African countries can adopt successful programs in other parts of SSA to suit their context such as the National Health Insurance Scheme (NHIS) and the Community-based Health Planning and Services concepts in Ghana.

The Association between the Australian Alcopops Tax and National Chlamydia Rates among Young People-an Interrupted Time Series Analysis

A national tax increase, which became known as the "alcopops tax", was introduced in Australia on the 27th April 2008 on ready-to-drink alcoholic beverages, which are consumed predominantly by young people. The affordability of alcohol has been identified as the strongest environmental driver of alcohol consumption, and alcohol consumption is a well-known risk factor in the spread of sexually transmitted infections via its association with sexual risk-taking. We conducted a study to investigate whether there was any association between the introduction of the tax and changes in national chlamydia rates: (i) notification rates (diagnoses per 100,000 population; primary outcome and standard approach in alcohol taxation studies), and (ii) test positivity rates (diagnoses per 100 tests; secondary outcome) among 15-24 and 25-34-year-olds, using interrupted time series analysis. Gender- and age-specific chlamydia trends among those 35 and older were applied as internal control series and gender- and age-specific consumer price index-adjusted per capita income trends were controlled for as independent variables. We hypothesised that the expected negative association between the tax and chlamydia notification rates might be masked due to increasing chlamydia test counts over the observation period (2000 to 2016). We hypothesised that the association between the tax and chlamydia test positivity rates would occur as an immediate level decrease, as a result of a decrease in alcohol consumption, which, in turn, would lead to a decrease in risky sexual behaviour and, hence, chlamydia transmission. None of the gender and age-specific population-based rates indicated a significant immediate or lagged association with the tax. However, we found an immediate decrease in test positivity rates for 25-34-year-old males (27% reduction-equivalent to 11,891 cases prevented post-tax) that remained detectable up to a lag of six months and a decrease at a lag of six months for 15-24-year-old males (31% reduction-equivalent to 16,615 cases prevented) following the tax. For no other gender or age combination did the change in test positivity rates reach significance. This study adds to the evidence base supporting the use of alcohol taxation to reduce health-related harms experienced by young people and offers a novel method for calculating sexually transmitted infection rates for policy evaluation.

Testing for chlamydial infection: are we meeting clinical guidelines? Evidence from a state-level laboratory data linkage analysis for 15- to 29-year-olds

Background Clinical guidelines recommend annual chlamydia tests for all sexually active people aged 15-29 years. This study measured adherence to these guidelines and compared testing rates to the projected levels required to reduce chlamydia prevalence.

METHODS

All chlamydia tests conducted in Tasmania during 2012-13, for residents aged 15-29 years, were linked. Data linkage allowed individuals who had multiple tests across different healthcare settings to be counted only once each year in analyses. Rates of testing and test positivity by age, sex, rebate status and socioeconomic indicators were measured.

RESULTS

There were 31899 eligible tests conducted in 24830 individuals. Testing coverage was higher in females (21%, 19404/92685) than males (6%, 5426/98123). Positivity was higher in males (16%, 862/5426) than females (10%, 1854/19404). Most tests (81%, 25803/31899) were eligible for a rebate. Positivity was higher in females with non-rebatable tests (12%, 388/3116 compared with those eligible for a rebate (9%, 1466/16285). More testing occurred in areas of middle disadvantage (10%, 9688/93678) compared with least (8%, 1680/21670) and most (10%, 7284/75460) (both P<0.001) disadvantaged areas. Higher test positivity was found in areas of most-disadvantage (11%, 822/7284) compared with middle- (10%, 983/9688) and least- (8%, 139/1680) disadvantaged areas.

CONCLUSIONS

Chlamydia testing rates are lower than recommended levels. Sustaining the current testing rates in females aged 20-24 years may reduce population prevalence within 10 years. This study meets key priorities of national strategies for chlamydia control by providing a method of monitoring testing coverage and evidence to evaluate prevention programs.

Exploring psychosocial predictors of STI testing in University students

Background

To explore university students’ Sexually Transmitted Infection (STI) testing knowledge, psychosocial and demographic predictors of past STI testing behaviour, intentions to have an STI test, and high risk sexual behaviour, to inform interventions promoting STI testing in this population.

Methods

A cross-sectional, quantitative online survey was conducted in March 2016, recruiting university students from North East Scotland via an all-student email. The anonymous questionnaire assessed student demographics (e.g. sex, ethnicity, age), STI testing behaviours, sexual risk behaviours, knowledge and five psychological constructs thought to be predictive of STI testing from theory and past research: attitudes, perceived susceptibility to STIs, social norms, social fear and self-efficacy.

Results

The sample contained 1294 sexually active students (response rate 10%) aged 18–63, mean age = 23.61 (SD 6.39), 888 (69%) were female. Amongst participants, knowledge of STIs and testing was relatively high, and students held generally favourable attitudes. 52% reported ever having an STI test, 13% intended to have one in the next month; 16% reported unprotected sex with more than one ‘casual’ partner in the last six months. Being female, older, a postgraduate, longer UK residence, STI knowledge, perceived susceptibility, subjective norms, attitudes and self-efficacy all positively predicted past STI testing behaviour (p < 0.01). Perceived susceptibility to STIs and social norms positively predicted intentions to have an STI test in the next month (p  < 0.05); perceived susceptibility also predicted past high-risk sexual behaviour (p < 0.01).

Conclusions

Several psychosocial predictors of past STI testing, of high-risk sexual behaviour and future STI intentions were identified. Health promotion STI testing interventions could focus on male students and target knowledge, attitude change, and increasing perceived susceptibility to STIs, social norms and self-efficacy towards STI-testing.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5587-2) contains supplementary material, which is available to authorized users.

Correlates of sexually transmissible infection testing among a sample of at-risk young Australians

Annual chlamydia testing is recommended for all sexually active Australians aged 15-29 years; however, the testing rate is below recommended levels. Three surveys at a Melbourne music festival were conducted over 2012-14 to identify correlates of sexually transmissible infection (STI) testing among young people at risk of STIs. In total, 3588 participants were recruited; 72% reported having sex in the past year. Based on sexual behaviours, 38% of sexually active participants were classified as at risk of contracting STIs. In the past year, at-risk participants had significantly higher odds of reporting a STI test (37%) than participants classified as not at risk (24%) (OR=1.9; CI=1.6-2.3). Among at-risk participants, correlates of STI testing in the past year included being aged 20-24 years, visiting a GP, higher knowledge levels, earlier sexual debut and reporting more than five lifetime partners. Testing rates in our sample did not meet levels required to reduce chlamydia prevalence. However, the testing rate was higher in at-risk participants than participants who were not at risk. Future programs aiming to increase chlamydia testing should improve knowledge and promote the importance of testing after risk exposure, particularly among 16- to 19-year-olds.