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.
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.
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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
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Miller, K.E. (2004, February 1)…