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Are Women With Chlamydia Infection Who Self-Refer to Genitourinary Medicine Clinics Different?

Posted on: Saturday, 29 October 2005, 03:01 CDT

By Huengsberg, M; Ahmed-Jushuf, I; Rogstad, K E; Jeyasingh, N; Et al

Summary: The objective of this study was to explore whether patients with Chamydia trachomatis infection who self-refer to genitourinary medicine clinics have different demographic characteristics to those who initially attend other agencies. This study took place in three genitourinary medicine clinics from Birmingham, Nottingham and Sheffield. Demographic and post-code data were collected from female patients diagnosed with genital chlamydia infection in 2000. Townsend scores, as an index of socioeconomic status, were derived from post-codes from a subset of the cohort (from Birmingham). Comparison was made between those who were diagnosed by genitourinary medicine clinics and those diagnosed in the community and referred to genitourinary medicine clinics for further management. Data were collected from 1047 genitourinary medicine and 816 non-genitourinary medicine women, of whom 686 (84.1%) attended genitourinary medicine clinics following referral. After excluding those with incomplete data, 1614 (987 genitourinary medicine and 627 non-genitourinary medicine) patients were included in the study. Using logistic regression analysis, we were unable to demonstrate any significant differences in age or Townsend scores between genitourinary medicine and non-genitourinary medicine patients. However, significantly more Black Caribbean (odds ratio [OR] = 2.72, 95% confidence interval [CI]: 2.22, 3.20) and single women (OR = 1.97, 95% CI: 1.64, 2.29) self-referred to genitourinary medicine clinics compared with other health-care settings. This trend was consistent between Birmingham and Nottingham. In Sheffield, there was no difference in marital status. Ethnicity was not a factor as there were no Black Caribbean patients in the Sheffield cohort. Women who were diagnosed with genital chlamydia infection in genitourinary medicine clinics have some different demographic characteristics to those who were diagnosed in the community.

Keywords: chlamydia testing, community setting, sexual health, GU medicine

Introduction

Chlamydia trachomatis infection is a common sexually transmitted infection (STI).1 In the UK, genitourinary (GU) medicine clinics specialize in the diagnosis and treatment of STIs, as well as contact tracing and sexual health education. Genitourinary medicine clinics are open access and patients can self-refer. However, a significant proportion of chlamydia infection are diagnosed in settings outside genitourinary medicine clinics, for example, obstetrics and gynaecology services, family planing and pregnancy termination clinics, general practitioners (GPs) and outreach clinics.2-4 Some local services including the study centres have joined forces, and STIs diagnosed in these settings are referred to the local genitourinary medicine clinics for follow-up and contact tracing.

It is, however, not clear what factors influence the patients' choice of health services. There is evidence that certain service attributes and patients' attitude towards genitourinary medicine clinics can partially, but not fully explain patients' choice.5 Patient factors cited include knowledge of health system and psychological factors such as embarrassment,6'7 and perceived stigma of attending a genitourinary medicine clinic.8 The 1990 UK population-based national survey of sexual attitude and lifestyle (Natsal) suggests that certain demographic variables are associated with self-reported attendance of genitourinary medicine clinics.9 Natsal 2000 showed that willingness of being tested for chlamydia during the survey varied significantly by area of residence, socioeconomic status and ethnicity.2

This study intends to explore whether patients whose genital chlamydia infection was diagnosed at a genitourinary medicine clinic have different demographic characteristics to those whose chlamydia was diagnosed elsewhere, who were subsequently referred to and attended genitourinary medicine clinics.

Method

The study took place in three urban genitourinary medicine clinics in Birmingham, Nottingham and Sheffield. Demographic data were collected from two groups of female patients diagnosed with genital C. trachomatis infection in 2000. These include those diagnosed by genitourinary medicine clinics, and those diagnosed outside the genitourinary medicine setting, but referred to genitourinary medicine clinics for further management. In Birmingham and Nottingham, genitourinary medicine clinics receive referrals via the microbiology laboratories of all positive STI diagnosis from family planning clinics and gynaecological services in their catchment areas. In Sheffield, locally agreed clinical care pathways recommended that the medical practitioners refer all patients with positive chlamydia to genitourinary medicine clinic. However, the degree of adherence to this protocol, and hence the proportion of women referred compared with those diagnosed are not known. In the three genitourinary medicine clinics, chlamydia screening was done in all patients. There is no information available on the indications for chlamydia testing for non-genitourinary medicine services, but most likely for diagnostic rather than screening purposes, as none of the three cities had systematic chlamydia screening outside genitourinary medicine settings at the time of the study.

We collected data on age, marital status and self-reported ethnic groups on all patients. For the subset of Birmingham cohort, we have also collected the six-digit post-code information of patients' home addresses, from which Townsend Score was derived. The Townsend Score is a fourcomponent index designed to measure material deprivation, especially suitable for reflecting socioeconomic index in urban populations. These components include percentage of residents in working age range who are unemployed, percentage households who do not have a car, not owner occupied and with more than one person per room. It is based on variables extracted from UK 1991 Census. The higher the Townsend Score, the more deprived an area: those with a negative score are less deprived than 'average'; those with a positive score are more deprived. In addition, we also calculated the distance from patients' home address to the genitourinary medicine clinic (Whittall Street Clinic) in Birmingham, using Maplnfo Professional 6.0 (a computer geographical mapping programme).

Pearson's χ^sup 2^ test was used for univariate analysis of categorical variables, independent samples t-test used to compare means of continuous variables, logistic regression was used for multivariate analysis (SPSS version 10.0). Each city cohort was analysed separately. For Nottingham and Sheffield, the variables adjusted for include age, marital status and ethnic groups. For Birmingham, Townsend scores were also included. The Townsend scores were entered as a continuous variable, while the others as categorical variables. The age was dichotomized at 25, marital status divided into two groups: single (including separated or divorced) and not-single (i.e. married or co-habitating). The ethnic groups were divided into four groups as: White, Black Caribbean, Black other (which also included Black African or mixed Black race) and other races (which included Asian, Chinese and other races). Odds ratio (OR) and 95% confidence intervals (CI) were calculated, and the level of significance was set as P < 0.05.

Results

There were 1047 women who had chlamydia infection diagnosed in the three genitourinary medicine clinics in 2000 (genitourinary medicine group), and a further 816 women were referred from non- genitourinary medicine sources. Of these, 686 (84.1%) have attended the genitourinary medicine clinics. Those patients with incomplete data were excluded from the demographic analysis, leaving 998 in the genitourinary medicine and 633 in the non-genitourinary medicine groups suitable for analysis. Of the latter, 257 (40.6%) were referred from GP, 258 (40.8%) from gynaecology, 101 (16.0%) from family planning and 17 (2.7%) from other services. Table 1 shows patient details from each centres.

Townsend score was available in a total of 355 genitourinary medicine patients, and 145 nongenitourinary medicine patients, all from the Birmingham cohort.

On univariate analysis between the genitourinary medicine and non- genitourinary medicine patients for each centre and collectively, there was no significant difference in mean age (22.86.3 versus 25.35.0) or age groupings in all cities (Table 1). However, there were significant difference in marital status in the Birmingham and Nottingham cohort, with those attending genitourinary medicine more likely to be single. This difference persists with multivariate analysis (Table 2). However, there was no difference in marital status in the Sheffield cohort.

Table 1 Demographic factors of women with genital chlamydia diagnosed in GU medicine versus non-GU medicine settings

Table 2 Demographics factors predicting likelihood of women self- referring to GU medicine clinics

On univariate analysis of ethnicity, Birmingham cohort showed highly and Nottingham borderline significant difference between genitourinary medicine and non-genitourinary medicine groups. On multivariate analysis (Table 2), this difference in ethnicity was entirely due to the Black Caribbea\n patients being significantly more likely to present to genitourinary medicine than other settings in both Birmingham (OR 2.50, 95% CI 1.85, 3.15) and Nottingham (OR 3.45, 95% CI 2.27, 4.63). There were no cases from Black Caribbean groups in the Sheffield cohort, which may explain the lack of any difference in ethnicity in that city.

The Townsend score in the Birmingham cohort was not significant in the regression analysis (Table 2). Analysis of distance from home to genitourinary medicine clinic in Birmingham showed no difference in mean distance between the genitourinary medicine (6.27km) and nongenitourinary medicine (6.32km) samples, neither was there any difference from home to genitourinary medicine clinic between the Black Caribbean and white women (6.28 and 6.31 km, respectively).

For those patients whose chlamydia was diagnosed outside and attended genitourinary medicine clinics following referral, we have also collected data on co-infection with gonorrhoea when additional full STI screening were carried out in genitourinary medicine clinics. In Birmingham, 289 women were referred to genitourinary medicine, and 199 attended (68.9%). A total of 15 women had gonorrhoea diagnosed (7.5%), seven (out of 90 women) were from GP, the rest from gynaecology services. In contrast, the gonorrhoea co- infection rate of women whose chlamydia was diagnosed in Birmingham genitourinary medicine clinic was significantly higher at 15.3% (77/ 502) (P = 0.01).

The attendance rate following referral of women with chlamydia to a genitourinary medicine clinic in Nottingham was 96% (290/301), and 87% (196/ 225) in Sheffield. The gonorrhoea co-infection rate was 8.6% (25/290) in Nottingham nongenitourinary medicine and 10.7% (38/ 354) in genitourinary medicine groups (P = 0.66), and 3.0% (6/196) in Sheffield non-genitourinary medicine and 5.7% (11/193) in genitourinary medicine groups (P = 0.22).

Discussion

This study is, to our knowledge, the first to explore demographic differences in women with chlamydia infection, comparing women who are diagnosed outside and referred to genitourinary medicine with women who are self-referred to genitourinary medicine clinics. It shows that women with chlamydia infection who attend genitourinary medicine clinics appear to have similar age and socioeconomic characteristics to those who were diagnosed in the community, but there can be a difference in marital status and ethnicity.

Our finding on ethnic differences between the two groups is unexpected and not fully explained. There was a preponderance of women from Black Caribbean ethnic group accessing the genitourinary medicine service, but not other Black ethnic community including the Black Africans (Table 2). This finding is consistent between Birmingham and Nottingham. In Sheffield, there were no patients from this ethnic group, most likely reflecting the local population make- up (only 1% of the population in Sheffield is of Black Caribbean origin). This phenomenon of ethnic predilection is difficult to explain, principally because we do not have any data on the indication for chlamydia testing outside genitourinary medicine settings. The denominators of populations tested for chlamydia within and outside genitourinary medicine are likely to be different. Those diagnosed in the community may be more likely to be symptomatic, where chlamydia testing were done for diagnosis rather than screening. We do not know, for example, whether Afro-Caribbean women are less likely to be symptomatic from their infection, and hence less likely to be diagnosed outside genitourinary medicine settings, although there is no evidence to suggest this being the case. An alternative explanation is that Afro-Caribbean women perceive themselves to be more at risk for infection, and more likely to choose genitourinary medicine setting for infection screening. There may also be differences in health-seeking behaviour between different ethnic groups as has been reported from the United States10 and the UK.11 A further factor, that of geographical accessibility of genitourinary medicine clinics to Black Caribbean groups, or difficulty of access to other health services due to factors such as pressure on inner city GP surgeries, is less likely since women who come to genitourinary medicine, regardless of ethnic background, do not live closer to the genitourinary medicine clinic compared with those presenting to other health-care settings. Whatever the reason for this ethnic difference, prevalence studies of STIs based on KC60 coding from genitourinary medicine clinics would tend to over-estimate the population impact of disease on certain ethnic groups.

The finding of that in Nottingham and Birmingham, although not in Sheffield, single, non-married women have a predilection for genitourinary medicine clinics is of interest but not explained. In addition to the possible explanations discussed above, single women feel less stigmatized regarding attending genitourinary medicine clinics. In support of this hypothesis, being single is a predictor favouring genitourinary medicine attendance independent of either age or socioeconomic status as determined by the Townsend score. The difference between the cities is unexplained.

Gonorrhoea co-infection rate in women whose chlamydia were diagnosed outside genitourinary medicine settings shows marked differences among the cities (8% in Nottingham and 3% in Sheffield) and was approximately half that of corresponding genitourinary medicine clinics. Since we do not have data on antibiotics prescribed by the primary clinician who initially diagnosed the chlamydia infection before the patients were referred to the genitourinary medicine clinics for further STI screening, our results could underestimate the true gonorrhoea co-infection rate in this population. If we assume that women outside genitourinary medicine settings were tested because of symptomatic disease, these prevalence rates cannot be used to predict co-infection rates in asymptomatic women screened in the community. However, there may be a significant gonorrhoea co-infection rate in the community, which could be missed if full STI screening is not carried out, particularly in areas of high gonorrhoea prevalence.

Acknowledgements: The authors would like to thank Sarah Deakin, statistician from Birmingham Health Authority for performing the Townsend Score analysis.

References

1 Simms I, Catchpole M, Brugha R, et al. Epidemiology of genital Clilamydia traclioinatis in England and Wales. Genitonrin Med 1997;73:122-6

2 Fenton KA, Jorovessis C, Johnson AM, et al. Sexual behaviour in Britain: reported sexually transmitted infections and prevalent genital Chlamydia trachomatis infection. Lancet 2001:358:1851-4

3 Shahmanesh M, Gayed S, Ashcroft M, et al. Geomapping of chlamydia and gonorrohea in Birmingham, UK. Sex Transm Infect 2000;76:268-72

4 Pimenta JM, Catchpole M, Rogers PA, et al. Opportunistic screening for genital chlamydial infection II: Prevalence among health care attenders, outcome and evaluation of positive cases. Sex Tmism infect 2003;79:22-7

5 Leenaars PE, Rombouts R, Kok G. Service attributes and the choice for STD health services in persons seeking a medical examination for an STD. Soc Sci Med 1994;38:363-71

6 Dixon-Woods M, Stokes T, Young B, et al. Choosing and using services for sexual health: a qualitative study of women' views. Sex Transm Infect 2001;77:335-9

7 Scoular A, Duncan B, Hart G. That sort of place...where filthy men go...': a qualitative study of women's perceptions of genitourinary medicine services. Sex Transm Inject 2001:77:340-3

8 Fortenberry JD, McFarkanc MM. The relationship of stigma to sexually transmitted diseases (STD)-related care-seeking among adolescents. J Adolesc Health 2000;26:97

9 Johnson AM, Wadsworth J, Welling K, Field J. Who goes to sexually transmitted disease clinics? Results from a national population survey. Cenitoiirin Med 1996;72: 197-202

10 Reitmeijer CA, Bull SS, Oritz CG, Leroux T, Douglas Jr JM. Patterns of general health care and STD services use among high- risk youth in Denver participating in community-based urine chlamydia screening. Sex Transm Dis 1988;25: 457-63

11 Gillam SJ, Jarman B, White P, Law R. Ethnic differences in consultation rates in urban general practices. BMJ 1989;299:930-1

(Accepted W August 2004)

M Huengsberg FRCOG MD1, I Ahmed-Jushuf FRCP MBA2, K E Rogstad FRCP3, N Jeyasingh MBBS1, G Paul MBBS1, S Singh MBBS1, B Tan MBBS2, S Lackenby MBChB3 and M Shahmanesh FRCP MD1

1 Department of Genitourinary Medicine, Whittall Street Clinic, Birmingham, UK; 2 Department of Genitourinary Medicine, City Hospital, Nottingham, UK; 3 Department of Genitourinary Medicine, Royal Hallamshire Hospital, Sheffield, UK

Correspondence to: Dr Mia Huengsberg

Email: mia.huengsberg@hobtpct.nhs.uk

Copyright Royal Society of Medicine Press Ltd. Oct 2005

Source: International Journal of STD & AIDS

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