Ignorance about Chlamydia among sexually active women—a two centre study

Susan Macmillan1,3, Rob Walker2, Emeka Oloto2, Ann Fitzmaurice1 and Allan Templeton1

1 Department of Obstetrics and Gynaecology, University of Aberdeen, Aberdeen AB25 2ZD, and 2 Academic Department of Obstetrics and Gynaecology, Level 09, Gledhow Wing,St. James's University Hospital, Leeds LS9 7TF, UK


    Abstract
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
Chlamydia trachomatis is the micro-organism causing the most common sexually transmitted disease in the UK and Europe. The majority of female infections are asymptomatic and recognized sequelae include pelvic inflammatory disease, infertility, and ectopic pregnancy. Over 1200 sexually active women from two urban centres in the UK were questioned about awareness and knowledge of Chlamydia genito-urinary infection. Awareness was poor, as half of the study population had never heard of Chlamydia. Overall, less than one-quarter demonstrated adequate knowledge regarding transmission, immunity, symptoms, and sequelae. Better knowledge was found in women over the age of 25 years, in those cohabiting, in those with a professional/management occupation, and in those attending family planning clinics. The Chief Medical Officer's Expert Advisory Group on Chlamydia (1998) has recommended opportunistic screening of asymptomatic sexually active women in the UK. This study gives insight into the considerable task facing the Department of Health, as only an informed public will take up the offer of screening. Research is urgently needed to assess the impact of different approaches to education regarding sexually transmitted infection.

Key words: Chlamydia trachomatis/health education/sexually transmitted disease


    Introduction
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
Chlamydia trachomatis is the micro-organism causing the most common sexually transmitted disease (STD) in the UK and Europe. Women bear the brunt through the recognized consequences of pelvic inflammatory disease (Cates and Wasserheit, 1991Go; Paavonen, 1992Go), tubal infertility (Svensson et al., 1983Go; Henry-Suchet et al., 1987Go), and ectopic pregnancy (Coste et al., 1994Go). Notwithstanding human costs, the healthcare costs of this infection are estimated at £50 million per year in the UK alone (Taylor-Robertson, 1994Go).

Current sexual practices favouring transmission of Chlamydia include early age at first intercourse (UK Family Planning Research Network, 1988Go; Wellings et al., 1994Go), poor condom use (DeBuono et al., 1990Go; Wellings et al., 1994Go), and an overall increase in the number of lifetime sexual partners (UK Family Planning Research Network, 1988Go; Wellings et al., 1994Go). Generally, the public do not perceive themselves to be at great risk (DeBuono et al., 1990Go; Wellings et al., 1994Go), probably due to the asymptomatic nature of the infection.

Primary prevention aims to decrease the prevalence and morbidity of Chlamydia through the adoption of healthier lifestyle choices. The benefits of secondary prevention have been recently illustrated by a randomized control trial which found that targeted Chlamydia screening could reduce the incidence of pelvic inflammatory disease by 56% (Scholes et al., 1996Go). To achieve both primary and secondary prevention goals, the public requires accurate knowledge, which can then be translated into appropriate decision-making (Holtzman et al., 1994Go; Wellings et al., 1994Go; Boyer et al., 1997Go).

The aim of this study was to assess knowledge of genito-urinary chlamydial infection in a large group of sexually active women. The extent of public awareness of this infection has not been investigated widely.


    Materials and methods
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
Consecutive women, attending either an abortion or family planning clinic in Aberdeen and Leeds, were invited to participate in the study by means of an information sheet given by either the clinic receptionist or staff. There were no exclusion criteria and patients agreed to participate by verbal consent.

A tick-style questionnaire was devised with the first section requesting demographic details and the second exploring the participant's knowledge regarding genito-urinary chlamydial infection in females.

If the participant had never heard of Chlamydia, she was instructed not to attempt any further questions. If she had, five stem questions sought her knowledge regarding the following: type of infection, transmission, immunity, symptoms, and sequelae. In two questions, regarding transmission and sequelae, the participants were given more than one option to tick; `don't know' and `other' provided alternative options, where applicable.

On completion, the participant was given a health education handout leaflet about Chlamydia. This described what Chlamydia is, how it is and is not transmitted, symptoms in men and women, how testing is performed, treatment, risk of recurrence, sequelae, prevention, and where to seek advice.

The questionnaire was pilot tested on 25 women from the abortion clinic in Aberdeen, with changes made, where appropriate. It revealed that those who participated and had never heard of the infection wished information about it, while those who had heard wished feedback regarding the correct answers to the questions asked. This was requested in written form, hence the introduction of the health education handout leaflet. Any further questions were directed to the clinic staff.

A knowledge score was devised from the data collected. A correct response was given a value of +1, `don't know' a value of 0, and an incorrect response a value of –1. A score could therefore range from –9 to +9. Those who had not heard of Chlamydia scored zero. Those who scored +5 or higher were felt to have adequate knowledge of chlamydial infection. A measure of alpha reliability was calculated to assess the internal consistency of the questionnaire as a knowledge test. Adequate knowledge (equivalent to scoring 5 or higher) was the dependent variable used to examine the association between knowledge and a number of demographic characteristics using univariate and multivariate logistic regression.

Data were stored in a personal computer and the results analysed using the Statistical Package for Social Sciences (SPSS, Inc., Chicago, IL, USA). Ethical approval was received prior to commencement of the study from the Aberdeen and Leeds' Ethical Committees.


    Results
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
In all, 1378 consecutive women were recruited from abortion and family planning clinics in Aberdeen from February to August 1997 and in Leeds from September to November 1997 and in July 1998. A total of 131 questionnaires (10%) was invalid, leaving 1247 that could be analysed.

In Aberdeen, 503 (40%) women were recruited. Of these, 235 (47%) came from abortion clinics and 268 (53%) from the family planning clinic. Seven hundred and forty-four (60%) women were recruited from Leeds, 443 (60%) from abortion clinics and 301 (40%) from family planning clinics.

Table IGo shows the demographic characteristics of the women. The median age was 24 years (range 13–56), and 655 (53%) were <25 years of age. In total, 622 (50%) of the study population had not heard of Chlamydia. Out of the women who had, the proportion that correctly answered each knowledge question is shown in Table IIGo.


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Table I. Demographic characteristics of the study population (n = 1247)
 

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Table II. Correct answers to knowledge questions among those women who had heard of Chlamydia (n = 625)
 
A Cronbach alpha reliability of 0.9292 was calculated for the knowledge score. The median score for the study population was 0 (range –1 to 9) with a median score of 4 for those who had heard of Chlamydia. A total of 303 women, which was 49% of those who had heard of Chlamydia or 24% of the total population, demonstrated adequate knowledge by scoring >=5.

Table IIIGo shows the association between adequate knowledge (equivalent to a score of >=5) and demographic characteristics by univariate and multivariate logistic regression. Univariate analysis indicated that those >25 years old, those who were cohabiting, those in a professional/managerial occupation, and those attending the family planning clinic had better knowledge. Parity and country (i.e. whether the women resided in Scotland or England) were not significantly associated with knowledge. Multivariate analysis produced the same results when each factor was adjusted for the effect of the other demographic factors.


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Table III. Association between demographic characteristics and knowledge score by univariate and multivariate analysis
 
Those >25 years old were 2.02 times (confidence interval 1.44–2.83) more likely than younger women to have adequate knowledge. Those who were married or single were less likely to have adequate knowledge when compared with cohabiting women. Those from skilled, semi-skilled, unskilled occupations, students, housewives, and the unemployed were all less likely to have adequate knowledge when compared with those in professional/management occupations. Those attending family planning clinics were 1.49 times (confidence interval 1.13–1.97) more likely than those from the abortion clinics to have adequate knowledge.


    Discussion
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
This study identifies a clear lack of knowledge among sexually active women about the most common STD in the UK. Many studies have assessed awareness/knowledge of STD as a whole, but none, to our knowledge, has specifically examined chlamydial infection. Lack of knowledge means that an individual is unable to assess her personal risk and develop skills to promote healthier behaviour. Given that half the women were unaware of Chlamydia, it is not surprising that the current sexual climate promotes the transmission of this infection.

The number who refused to participate was not recorded. The proportion volunteering to take part, however, was high, reflecting the questionnaire's style and limited length. Due to the fact that large numbers were recruited during a short time period and that no statistical difference was found in analyses between the two units, we believe that the study population is representative of women attending abortion and family planning clinics.

Only half of our population had even heard of Chlamydia. The Health Education Authority (Goldsmith, 1996Go) found poorer results in 1994 (7%), 1995 (25%), and 1996 (<30%). These, however, are not directly comparable as they were conducted using home interview surveys of men and women of various ages, and covered sexual behaviour/attitudes as well as knowledge of STD. Findings similar to ours have come from questionnaire studies concerning knowledge about all STDs from England (Mellanby et al., 1992Go), Australia (Wright et al., 1991), and the USA (Baynham et al., 1996Go). This contrasts with Sweden where awareness of Chlamydia is very high (Tydén et al., 1991aGo,bGo; Persson and Jalbro, 1992Go; Andersson-Ellström et al., 1996Go).

The tick questionnaire could be criticized as acting as an aide memoir. Certainly, poorer results have been found in interview settings, where the participant is asked to name known STDs. This questionnaire, though designed to explore factual knowledge, was intended to be answered easily and quickly. By this we hoped to avoid random ticking. The inclusion of `other' and/or `don't know' were included to prevent guessing.

Cronbach's alpha is one of the most commonly used measures of reliability, relating to the internal consistency of a test. A value near 1.0 indicates reliability. Though usually applied in the context of psychological and mental health tests, it has been used in cases where knowledge of a subject is being assessed (Burns et al., 1987Go). We felt it appropriate to use, as it was expected that a response(s) in one stem would correlate with that from another, as well as with the total score. The high value calculated confirmed this to be true.

A knowledge score has been used in other studies (Goodman and Cohall, 1989Go; Clarke et al., 1990Go; Shiloh et al., 1990Go; Wright et al., 1991; Biro et al., 1994Go; Boyer et al., 1997Go) to assess comprehension of a subject in detail. Most score `1' for a correct answer and `0' for `don't know' or an incorrect answer. We appointed `–1' to incorrect answers as it was felt that the tick design did offer some memory advantage. A score of >=5 was deemed to reflect adequate knowledge, as the scores of those who had heard of Chlamydia closely followed a normal distribution (Figure 1Go). As the majority of those who had heard of Chlamydia recognized it as a sexual infection caught by sex (99% and 96% respectively), this left only 0.3% (2/625) who faired no better than those who had never heard of Chlamydia, by failing to answer any other questions correctly. The remainder had some accurate knowledge. It is of great concern, however, that less than half of those who had heard of Chlamydia, and less than one-quarter of the total study population, managed to answer a further three out of seven possible correct responses to achieve an adequate score of five.



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Figure 1. Distribution of knowledge scores in those who had heard of Chlamydia (n = 625).

 
There was no difference in knowledge between the English and Scottish study populations, but greater awareness was found in the family planning group, in those cohabiting, in those in a professional/management occupation, and in those >25 years of age. The former may be related to the presence of health education leaflets in the waiting areas. The association with cohabitation is less obvious, but may reflect a more modern and therefore informed approach to sexual relationships. The association with occupation probably reflects type and length of education, while older age represents a longer influence of education, media information, peer discussion, and possible personal experience of Chlamydia. However, as those <25 years of age are at highest risk of contracting Chlamydia (Simms et al., 1997Go), this is a concern.

The results of this study are not entirely amenable to generalization because of the population chosen. We recruited only women on the grounds that they bear the brunt of sequelae to Chlamydia infection and are easier to target than men. Recruiting only those attending family planning and abortion clinics biased the population to sexually active women, with some displaying the effects of unprotected sex. It was a group, however, at risk of contacting Chlamydia and therefore needing to know about the infection.

Our results suggest that although knowledge may be increasing, Chlamydia is still a relatively unknown infection. This research does, however, support the health education efforts presently provided by family planning clinics and the receptivity of its clientele. The public should be educated from an early age, before a pattern of risky sexual behaviour has evolved. To this end, the UK must look to examples in Holland (Dean, 1994Go; Editorial, 1994Go) and Sweden (Persson and Jalbro, 1992Go; Persson, 1993Go). Their synchronized approach to sex education, based on policies of openness and knowledge, have cut teenage pregnancies to 1/7 of the rate in UK (Dean, 1994Go) and teenage Chlamydia prevalence from 20% to <5% (Persson, 1993Go).

The Chief Medical Officer's Expert Advisory Group on Chlamydia (Expert Advisory Group, 1998Go) has recommended opportunistic screening of asymptomatic, sexually active women. This study gives insight into the considerable task facing the Department of Health. Concerted educational initiatives will be required to disseminate the facts about Chlamydia, as only an informed general public will come forward for screening.

We therefore have two conclusions: (i) this study identifies a clear lack of knowledge about the most common STD in UK, among women attending family planning and abortion clinics; (ii) further research is needed to assess the impact of different approaches to education regarding sexually transmitted infection in terms of provision of balanced information, knowledge attainment, and behaviour modification.


    Acknowledgments
 
We wish to thank the women from Aberdeen and Leeds who responded to the survey. We acknowledge the assistance of Sisters Valerie Peddie, Lisa Lawrie and Hazel McBain from Aberdeen in the distribution of the questionnaires. We also thank Dr Wendy Graham (Director of the Duguld Baird Research Centre on Women's Health) for her advice regarding questionnaire design and data analysis and Dr Siladitya Bhattacharya for his critique of the first draft.


    Notes
 
3 To whom correspondence should be addressed Back


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 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
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Submitted on September 30, 1998; accepted on January 6, 1999.