Objective
The purpose of this study was to determine predictors of the completion of free annual sexually transmitted infection screening among sexually active young women of ≤25 years old.
Study Design
We analyzed survey data from 2607 sexually active women who were enrolled in the Contraceptive CHOICE Project, a prospective cohort study. We evaluated demographic characteristics, sexual risk behaviors, relationship characteristics, and contraceptive methods. Receipt of a home- or clinic-based test kit within 56 days of the 12-month survey constituted a completed screen. A multivariable model to predict screening completion was created with the use of Poisson regression with robust error variance.
Results
Fifty-seven percent of the women completed the screening. Screening completion was associated most strongly with a college education or higher (adjusted relative risk, 1.2; 95% confidence interval, 1.1–1.3) and home-based testing (adjusted relative risk, 1.3; 95% confidence interval, 1.2–1.5).
Conclusion
Free and home-based testing increased screening rates among young women. To meet annual testing guidelines, the availability and use of home-based testing kits should increase.
Each year in the United States there are an estimated 2.8 million new cases of Chlamydia trachomatis infection and 718,000 new cases of Neisseria gonorrhoeae infection. The majority of both infections are reported among women ages 15-24 years. C trachomatis and N gonorrhoeae are referred to as “silent infections” because they are often asymptomatic. Untreated infections may spread to the fallopian tubes or uterus and cause pelvic inflammatory disease. Uterine and tubal damage can have long-term sequelae that include infertility, ectopic pregnancy, and chronic pelvic pain.
Although the Centers for Disease Control and Prevention recommends annual C trachomatis screening for all sexually active women who are ≤25 years old, the 2007 national annual screening rate among sexually active women who were 16-25 years old was only 41.6%. The low screening rate is most likely influenced by multiple factors that include a lack of access to health care, transportation, and financial limitations and concerns about confidentiality, waiting times, or the social consequences of a positive test result. Because of the asymptomatic nature of these infections women may not appreciate the importance of annual screening ; providers may fail to take a sexual history and perform the recommended C trachomatis screening.
The purpose of this analysis was to determine the factors that are associated with sexually transmitted infection (STI) screening behavior in young sexually active women who were offered free STI screening 12 months after enrollment in the Contraceptive CHOICE Project (CHOICE). We hypothesized that completion of STI screening at 12 months may be related to demographic characteristics, sexual risk behaviors, relationship characteristics, and the contraceptive method that was used. We were especially interested in whether the use of long-acting reversible contraceptive (LARC) methods (eg, levonorgestrel intrauterine system, copper intrauterine device, and etonorgestrel subdermal implant) is a significant predictor of the completion of annual STI screening. As LARC use increases, there may be concern that young women will not seek gynecologic care (including STI screening) on an annual basis because these contraceptive methods are effective for 3-10 years.
Materials and Methods
CHOICE is an on-going prospective cohort study of 9256 women from the St. Louis region that seeks to increase the use of LARC by removing financial barriers and decreasing the rates of unintended pregnancy. Participants are recruited from 2 abortion clinics, 8 community-based clinics, and university-affiliated medical clinics. Women are eligible to participate in CHOICE if they (1) are 14-45 years old, (2) are not currently using a contraceptive method or willing to start a new method of reversible contraception, (3) speak English or Spanish, (4) have not had a hysterectomy or tubal ligation, (5) do not desire pregnancy in the next year, and (6) are sexually active with a male partner or plan to become sexually active in the next 6 months. Informed consent is obtained from all participants. Approval was obtained from the Washington University School of Medicine Human Research Protection Office before participant recruitment. Each participant is provided with contraception of her choice at no cost for the 2-3 years that she is in the study. Follow-up interviews are conducted by telephone at 3 and 6 months and every 6 months thereafter. Questions are asked regarding demographic characteristics, pregnancy, sexual behaviors, STI history, contraceptive use and satisfaction, and experiences of depression, violence, and discrimination.
CHOICE offers C trachomatis and N gonorrhoeae screening and treatment at no cost to all participants at study enrollment and at the time of each annual telephone interview. During the in-person enrollment session, participants are instructed and complete a self-collected vaginal swab for C trachomatis and N gonorrhoeae screening with the use of the BDProbeTec ET instrument (Becton Dickinson, Sparks, MD). For annual screening, women undergo either clinic screening or home screening where the same collection kit that was used at enrollment is mailed to the participant. Detailed and illustrated instructions are included with the collection kit. Specimens are returned to the CHOICE office in a prepaid and preaddressed mailer. The same collection kits are used for women who complete screening at selected family planning clinics. CHOICE receives the completed test kits from the clinics within 5 days of collection and directly from participants by mail every day. All specimens are sent to an independent laboratory for testing.
Women who were included in this analysis were ≤25 years old at the time of study enrollment and reported vaginal or anal sex during the 12 months after enrollment. Because STI screening is offered on completion of the 12-month interview, women must have completed this interview to be included in the analysis. A specimen that is received from a home kit or clinic within 56 days after the 12-month interview is considered a complete annual test.
Some women in the sample were involved in substudies with respect to the testing site (home vs clinic; Figure ). Women who completed their 12-month interview from August-December 2008 were involved in an observational study and given a choice of home- vs clinic-based screening. Research assistants used a standard script to offer screening. From January 2009 through August 2009, women who used a LARC method at the 12-month interview and who agreed to be assigned randomly were assigned to home- vs clinic-based screening. Women who completed their 12-month interview during the remaining 16 months of this analysis were offered home-based screening. Women may decline annual screening altogether.
We analyzed data that were collected from the baseline, 3-, 6-, and 12-month interviews. We specifically examined demographic and reproductive characteristics, contraceptive methods, health-seeking behaviors, and relationship factors. Comparisons were made with χ 2 for categoric variables and with logistic regression for multivariate analyses. Poisson regression with robust error variance was used to determine predictors of completion of 12-month STI screening. This technique was used because the outcomes of interest occurred >10% of the time and because it provides a conservative estimate of the relative risk. Variables were included in the final multivariable model if they were significant on univariate analysis. LARC use was included in the model because we were interested particularly in its predictive value for the completion of STI screening. Multicollinearity was examined with the use of the variance inflation factor for all variables that were included in the models; all variables had a variance inflation factor of <10. Statistical analyses were performed with SAS software (version 9.2.; SAS Institute Inc, Cary, NC).
Results
Of the first 5087 women who were enrolled in CHOICE from August 2007 through December 2009, 51% of the women (n = 2607) met the inclusion criteria for this analysis ( Figure ). Baseline characteristics of young women who met the inclusion criteria for this analysis did not differ significantly from young women who were ≤25 years old who were enrolled in CHOICE. Of the 2480 women who were excluded, 73% of the women (n = 1799) were >25 years old, and 22% of the women did not complete their 12-month survey. Only 182 participants (7%) declined STI screening when it was offered during their 12-month interview. A participant was more likely to outright decline screening if she reported a pregnancy in the past year (adjusted relative risk [RR adj ], 0.86; 95% confidence interval [CI], 0.80–0.94).
Among the 2425 women who accepted STI screening, more than one-half of them (57%) completed the test. The demographic and behavioral characteristics of women who completed the screening compared with women who did not complete screening are shown in Table 1 . The 2 groups did not differ by age, current marital status, STI history, recent genitourinary symptoms, existence of a main partner, or recent Papanicolaou testing. Although all women used self-collection kits, women who did so at home were more likely to complete the test than were women who did so in the clinic (59.6% vs 45.0%).
| Characteristic | STI testing | P value | |||
|---|---|---|---|---|---|
| Completed (n = 1392) | Did not complete (n = 1033) | ||||
| n | % | n | % | ||
| Race | < .01 a | ||||
| Black | 612 | 54.5 | 511 | 45.5 | |
| White | 667 | 61.2 | 422 | 38.8 | |
| Other | 105 | 53.3 | 92 | 46.7 | |
| Age, y | .59 | ||||
| 14-17 | 90 | 58.8 | 63 | 41.2 | |
| 18-19 | 215 | 56.7 | 164 | 43.3 | |
| 20-22 | 505 | 55.9 | 399 | 44.1 | |
| 23-25 | 582 | 58.8 | 407 | 41.2 | |
| Marital status at time of 12-month survey | .21 | ||||
| Single | 966 | 58.3 | 692 | 41.7 | |
| Married/living with a partner | 425 | 55.6 | 340 | 44.4 | |
| Education level at time of 12-month survey | < .01 a | ||||
| ≤High school | 402 | 51.7 | 375 | 48.3 | |
| Some college | 634 | 56.2 | 495 | 43.8 | |
| College degree/graduate school | 355 | 68.7 | 162 | 31.3 | |
| Type of insurance at time of 12-month survey | < .01 a | ||||
| None | 498 | 56.8 | 378 | 43.2 | |
| Private/student/parent/military | 738 | 60.4 | 483 | 39.6 | |
| Medicare/Medicaid/disability | 149 | 47.3 | 166 | 52.7 | |
| Low socioeconomic status b at time of 12-month survey | < .01 a | ||||
| Yes | 645 | 54.2 | 546 | 45.8 | |
| No | 747 | 60.5 | 487 | 39.5 | |
| Age at first intercourse, y | < .01 a | ||||
| <14 | 123 | 53.5 | 107 | 46.5 | |
| 14-18 | 1089 | 56.7 | 833 | 43.3 | |
| ≥19 | 180 | 65.9 | 93 | 34.1 | |
| Main partner in past 30 days at time of 12-month survey | .28 | ||||
| Yes | 1200 | 57.0 | 905 | 43.0 | |
| No | 188 | 60.3 | 124 | 39.7 | |
| Other partners reported in the past year | < .05 a | ||||
| Yes | 224 | 63.5 | 129 | 36.5 | |
| No | 1168 | 56.4 | 904 | 43.6 | |
| New partners reported in the past year | < .01 a | ||||
| Yes | 558 | 61.1 | 356 | 38.9 | |
| No | 834 | 55.2 | 677 | 44.8 | |
| STI b diagnosis in lifetime | .65 | ||||
| Yes | 895 | 57.7 | 655 | 42.3 | |
| No | 497 | 56.8 | 378 | 43.2 | |
| STI symptoms c in past 7 days | .36 | ||||
| At least 1 | 327 | 59.3 | 224 | 40.7 | |
| None | 1036 | 57.1 | 777 | 42.9 | |
| Pregnant in past year | < .01 a | ||||
| Yes | 43 | 43.9 | 55 | 56.1 | |
| No | 1349 | 58.0 | 978 | 42.0 | |
| Papanicolaou smear test in past year | .43 | ||||
| Yes | 687 | 58.2 | 494 | 41.8 | |
| No | 696 | 56.6 | 534 | 43.4 | |
| Contraceptive method at time of 12-month survey | < .05 a | ||||
| Long-acting reversible contraceptive methods | 741 | 55.5 | 594 | 44.5 | |
| Non–long-acting reversible contraceptive methods | 651 | 59.7 | 439 | 40.3 | |
| Testing site | < .01 a | ||||
| Home | 1229 | 59.6 | 834 | 40.4 | |
| Clinic | 163 | 45.0 | 199 | 55.0 | |
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