Group 2: Provider Education for Chlamydia Prevention

Assignment 1

Group 2: Provider Education for Chlamydia Prevention

Thien Nguyen – Community Level

Hannah Nichols – Individual Level

Angelica Ramirez – Interpersonal Level

Lynsie Ranker – Institutional and Culture/Society/Policy Level

Nature and Scope of the Health Outcome

Chlamydia, a common sexually transmitted infection (STI), is a major public health concern in the United States. The disease, caused by Chlamydia trachomatis, can infect both males and females and can be contracted through vaginal, oral, or anal sex (CDC, 2013). Individuals can become infected more than once, putting persons at risk for a cycle of re-infection(CDC, 2013). As the most commonly reported STI in the United States, Chlamydia is estimated to infect 2.8 million people annually(CDC, 2013). The disease is most common among young people, with an estimated 1 in 15 sexually active females aged 14 to 19 years in the United States being infected, according to data reported by the Centers for Disease Control (CDC)(CDC, 2013).

Individuals contract Chlamydia by having sex with someone who is infected (CDC, 2013). Having sex includes vaginal, anal and/or oral sex. Chlamydia can still be transmitted without the passage of semen (CDC, 2013).Thus, sexually active individuals are at risk for contracting Chlamydia. An increase in the number of sexual partners increases a person’s risk for contracting the STI (CDC, 2013). Also, practicingsex without a condom puts individuals at higher risk (CDC, 2013). Sexually active adolescent females are at a higher riskfor contracting Chlamydia since their cervix is not fully matured, making it easier for transmission to occur (CDC, 2013). Men who have sex with men (MSM) are also at risk for Chlamydial infection since the STI can be transmitted through oral or anal sex (CDC, 2013).Chlamydia can also be spread from an infected woman to her baby during childbirth (CDC, 2013).

While Chlamydia infection can easily be treated with antibiotics, it is frequently left untreated,as infection is often asymptomatic. The lack of symptoms is one reason for the high infection and re-infection rates for Chlamydia, as many asymptomatic individuals may unknowingly spread the infection to others(CDC, 2013).If left untreated, Chlamydiahas been shown to increase a person’s risk of acquiring and/or transmitting HIV, cause pelvic inflammatory disease (PID) in females, and can lead to pelvic pain, abdominal pain, and burning sensation when urinating(CDC, 2013).For males, painful urination accompanied with burning or itching around the penis may occur. In addition, there may pain or swelling in one or both testicles, also called epididymitis(CDC, 2013).When left untreated, Chlamydiacan cause many painful and detrimental health consequences that may take years to uncover. Therefore, it is vital to screen and counsel youth in order to prevent the more harmful consequences from occurring.

Theoften-asymptomatic nature of the infection makesChlamydia a “silent STI.” This “silent” quality of Chlamydiacauses grave concerns for the spread of the infection. If individuals have the infection unknowingly they may continue to have unprotected sex and transmit the disease to more partners. Both screening and proper use of male condoms can help to reduce the spread of Chlamydia by first informing individuals of their status and preventing further transmission. Condom use is also an important method to prevent transmission because even if individuals are unaware of their Chlamydial status, proper use of condoms will eliminate the risk of transmission.Interventions for reducing Chlamydiashould be tailored with the asymptomatic nature of the infection in mind.

Target Group

In 2011, Chlamydia was the most common STI in Boston with 4,805 reported cases (BPHC, 2011). This figure represents an increase in number of new cases of 18.1% since 2008 (BPHC, 2011). The rate in Boston was 2.18 times the national rate for Chlamydia (BPHC, 2011).

While Chlamydia can effect individuals of all demographics, Chlamydia rates differ by gender, race/ethnicity, age, and neighborhood of residence in Boston(BPHC, 2011). Statistics show a gender disparity in infection rates.While the female population is 52% of Boston’s total population, they account for 66% of the reported cases of Chlamydia in 2011, while only 34% of the reported cases were males (BPHC, 2011). Racial and ethnic disparities exist as well. Black Boston residents had the highest rates of Chlamydia in 2011, with an incidence rate of 1,373 cases per 100,000 persons(BPHC, 2011). The case rates among Blacks were nine times higher than that of Whites. Additionally, Latinos had the second highest number of cases, with an incidence rate four times that of White residents( BPHC, 2011). Further, Black females had the highest rate of any group when stratified by race and gender, with 1,674 cases per 100,000 persons ( BPHC, 2011). Black males in Boston had the highest incidence rate (1,011 per 100,000 persons) when compared to Latinos (403 per 100,000) and Whites (132 per 100,000) (BPHC, 2011). When looking at the cases by age, the majority of the cases reported in 2011 in Boston occurred in those who were between the ages of 15 and 24 (BPHC, 2011). This age group makes up 67% of the total cases in Boston (3,242 cases). Within this age group, females ages 15 to 19 make up 70% of the cases (4,083 per 100,000). This was 2.8 times that of males in the same age group. Additionally Black males and females between the ages of 15 and 24 had the highest incidence rate when compared to Latino and White males and females (16.25 and 16.21, respectively) (BPHC, 2011).

There are also geographic differences in the distribution of Chlamydia infection within the city of Boston.When comparing the different neighborhoods in Boston, Roxbury (1,566.4 per 100,000), North Dorchester (1,493.0 per 100,000), Mattapan (1,251.1 per 100,000), and South Dorchester (1196.1 per 100,000) had the highest incidence rates of Chlamydia in 2010 (“Health of Boston 2011,” 2011).These incidence rates are well above the incidence rate of Boston (751.8 new cases per 100,000 person) (“Health of Boston 2011,” 2011). Additionally Roxbury had the highest population of males and females between the ages of 15 and 19 (10.5%) when compared to North Dorchester (7.7%), Mattapan (7.9%), and South Dorchester (7.6%) (Boston Redevelopment Authority, 2011). Since Roxbury has the highest population of adolescents between the ages of 15 and 19 and the highest rate of Chlamydia, efforts will be made to address the high Chlamydia rates and the associated disparities in Roxbury.

Health Behavior to be Changed

Chlamydia is a complex health issue. Many behaviors influence the continuing spread of this infection within Boston communities. Individual behaviors, such as lack of consistent and correct condom use and having multiple sexual partners, have been shown to increase the risk of infection (CDC, 2013; Navarro, Jolly, Nair, & Chen, 2002). Studies suggest that much of the higher prevalence seen among adolescents is due to these difference in sexual behaviors, as adolescents are more likely to have multiple, non-regular partners and report lower use of condoms during sexual encounters than their adult counterparts (Navarro et al., 2002). While some evidence suggests interventions may be able to delay sexual debut, results from such efforts vary with regards to ability to reduce infection risk among youth (Navarro et al., 2002).

Chlamydia has been linked to determinants beyond the level of the individual such as socioeconomic status (SES) and race (Navarro et al., 2002). Individuals of low SES have been shown to be less likely to seek medical care than those of higher SES (VanDevanter et al., 2005). As Chlamydia is often asymptomatic, those of higher SES may be more likely to have consistent access to screening and treatment for Chlamydia (Navarro et al., 2002). Studies consistently show a higher burden of STIs in communities that are predominately African American (Navarro et al., 2002; Newman & Berman, 2008). Although SES and health behaviors appear to contribute to the higher rates seen among African Americans, sexual networks and other population-level determinants appear to play a critical role in the racial disparities seen.

It is also important to consider the unique challenges facing adolescents that may inhibit proper prevention as well as reduce the likelihood of seeking screening and treatment when infected. Literature reviews have found that at-risk teens do not engage in conversations with their providers about this topic because they are often too embarrassed (Blake, 2003). Concerns around confidentiality, particularly the fear that the provider may inform their parent that they are sexually active, may deter adolescents from talking openly with their providers (Carlisle, Shickle, Cork, & McDonagh, 2006). This may mean that the responsibility for initiating the conversation falls on the provider, to assure the youth that this is a safe environment to talk openly regarding sexuality and health.

There have been missed opportunities to discuss sexual health during adolescent health visits. One study found that, among at-risk youth who had a annual physical in the past year, only 42% of females and 26% of males had discussed STIs or pregnancy prevention with their provider (Burstein, Lowry, Klein, & Santelli, 2003). Providers often do not feel adequately trained to discuss this topic with youth, and therefore do not initiate the conversation in order to avoid offending their patients (Haley et. al, 1999). Other barriers include lack of comfort and knowledge regarding sexual health education, personal provider biases regarding sexual health topics, fear of offending patients, and limited time to talk with patients during the typical visit (Ferrara et al., 2003). Although there have been an increased in training medical students in sexual health counseling and to discuss sexual health histories in the recent decades, many students continue to graduate feeling unprepared to deliver sexual health counseling to adolescent patients (Ferrara et al., 2003). This suggests an opportunity to engage physicians to address a possible gap in their medical education, specifically how to address sexual health with their adolescent patients.

As aforementioned, adolescents are less likely to practice safe sex, such as use of barrier methods during intercourse, and may not acknowledge the risks of sexual behavior (Navarro et al., 2002). Due to these risk factors, and the subsequent lack of conversation between patients and providers, universal screening for youth (regardless of risk) along with sexual health education from providers may be a strong method for primary prevention of Chlamydia among youth (Navarro et al., 2002). By opening up the channel of communication between providers and youth, an opportunity for screening and treatment as well as counseling regarding Chlamydia risk reduction may be more likely to occur. Having a conversation about a sensitive health topic such as drugs, sex, and mental health has been shown to have a positive impact on youth perceptions of care; leading to youth taking a more active role in treatment (Brown and Wissow, 1999). It is thought that this more active role in treatment exhibited by youth that have engaged in conversations about sensitive health topics with their provider can lead to increased adoption of preventative practices among youth, particularly youth considered high risk, and greater compliance in treatment for Chlamydia among those who screen positive (Ham & Allen, 2012). Screening may be one method by which providers can easily initiate conversation regarding the sensitive topic of Chlamydia (Navarro et al., 2002). Taking the first step to ask for an exam has proven a daunting task for many young adults, which further adds to the importance of having the physician proactively raise the topic (Blake et al, 2003). Through screening, delivery of treatment, and counseling on risk reduction, decreases in transmission and infection rates may occur. By having the provider feel adequately prepared for a conversation regarding sexual health, this very important sexual health conversation can occur.

Although there are a host of health behaviors that could be targeted for change, focusing on the interpersonal relationship between youth and their physicians may be a powerful tool for influencing youth behavior and subsequently reducing Chlamydia rates within Roxbury. In addition to the support for this behavior change within the literature, the health agency has expressed interest in provider education as a method for better communicating sexual health to youth. For this reason, our behavior change is to increase communication, more important quality of communication, about Chlamydia between youth of color ages 15-19 and their providers in the Roxbury area of Boston, Massachusetts during yearly check-ups or sexual health related visits.

Introduction of Public Health Agency

Glitter Alliances League (GALs) is an independent public health agency located in Boston, Massachusetts. With an annual budget of over $100 million and a workforce of one thousand employees, GALs provides a variety of programs and services (BPHC, 2013). Their mission is to ensure and improve the health of all city residents, particularly those residents who may be most vulnerable or disenfranchised (BPHC, 2013).

To support this mission, GALs offers programming and support for residents over a wide range of public health areas, including adolescent health and infectious disease (BPHC, 2013). While GALs has many priorities, a major five-year goal is to reduce Chlamydia rates among Boston youth and reduce the racial gap seen in infection rates (BPHC, 2013). This goal is a result of growing concern within the agency regarding the high Chlamydia rates within the city of Boston (BPHC, 2013). The youth division sees the city’s health providers as a valuable resource to address this pressing health issue. For this reason, GALs has reached out for consultation in developing an intervention to support providers in improving provider-patient conversations with youth surrounding this pressing health issue.

GALs is uniquely positioned to oversee an intervention surrounding physician behavior change. The agency has a strong history of providing support and training for providers and working to help them better serve their communities(BPHC, 2013). The Infectious Disease Bureau of GALs has already begun to engage physicians regarding the high STI rates in Boston. They have developed a Healthcare Providers Toolkit website which contains information for physicians regarding STI rates in Boston, CDC guidelines surrounding treatment, as well as details surrounding new legislation such as Expedited Partner Therapy (EPT) for Chlamydia(BPHC, 2013). GAL’s Infectious Disease Bureau has also developed Medical Education Course focused on Chlamydia, which providers can attend for Continuing Medical Education (CME) credit(BPHC, 2013). This course was specifically designed for community health care providers who work with youth(BPHC, 2013). Course content includes information regarding Chlamydia rates in the city’s youth as well as a discussion of some of the barriers providers face in the prevention and treatment of Chlamydia in Boston(BPHC, 2013). The goal is to not only educate providers, but to help them identify potential changes they can make in their own practice to address this major health issue facing their communities.

For piloting the intervention, GALs will partner with Roxbury Comprehensive Health Center (RoxComp). GALs has a long-standing relationship, not only with providers in this community, but also with RoxComp. Roxcomp representatives attend GAL sponsored Health of Roxbury Community Meeting(BPHC, 2013). In addition, RoxComp’s guiding mission is in line with many of the overarching goals of GALs. Since its founding in 1969, RoxComp’s mission is to “provide culturally, ethnically, and linguistically competent primary health care and social services to people of all ages, regardless of ability topay,”(RoxComp, 2013).Located in Warren Street in Roxbury, RoxComp provides a wide range of services to Roxbury residents and residents from surrounding communities (RoxComp, 2013). RoxComp’s Pediatric/Adolescent Department offers services such as The Kids Heart and Sole Program which works with adolescent patients with high BMI to encourage physical activity and other lifestyle behaviors to improve their health (RoxComp, 2013).RoxComp has a consistent commitment to youth health and wellness, as well as offering preventative services in addition to treatment (RoxComp, 2013). The prior partnership and the shared missions of RoxComp and GALs lead to the potential for a strong, positive partnership to help reduce Chlamydia rates in a community that is overburdened.

Social-Ecological Model

Literature has shown that there is a great need to improve the communication barriers between patients and providers(Towle, Godolphin, & Staalduinen, 2006; Brown & Wissow, 2009).If the quality of the patient-provider communication can be improved, patients may feel more comfortable with sharing accurate information with providers.Further, providers would be more comfortable raising concerns regarding sensitive topics such as STI or sexual behaviors to their patients. In order to find the best approach, all the levels (individual, interpersonal, community, institutional, and cultural) of the social-ecological model are examined to find evidence-based interventions concerning Chlamydia prevention and communications programs.

Individual Level

At the individual level, there have been many different approaches to reducing Chlamydia and other sexually transmitted infections(STIs) among youth. After searching through PubMed and Google Scholar articles under various search terms including but not limited to:Chlamydia screening program, STI prevention program, STI intervention among youth, STI among youth, and adolescent STI prevention,several types of interventions were found to be effective. Interventions aim to address a combination of knowledge, attitudes, beliefs, skills, self-efficacy, and outcome expectations. Programs are implemented in schools, clinics, social media platforms,and community-based organizations. The place and context of implementation may impact the effectiveness of programs; therefore implementing programs in the correct context is vital for improvement (Schaalma et al., 2004). This section provides an overview of individual level interventions to reduce STIs among youth. The section does not provide a description of every intervention conducted and evaluated, but instead offers a broad overview of the various methods and settings for STI reduction.