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
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Abstract |
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Key words: Chlamydia trachomatis/health education/sexually transmitted disease
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Introduction |
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Current sexual practices favouring transmission of Chlamydia include early age at first intercourse (UK Family Planning Research Network, 1988; Wellings et al., 1994
), poor condom use (DeBuono et al., 1990
; Wellings et al., 1994
), and an overall increase in the number of lifetime sexual partners (UK Family Planning Research Network, 1988
; Wellings et al., 1994
). Generally, the public do not perceive themselves to be at great risk (DeBuono et al., 1990
; Wellings et al., 1994
), 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., 1996). 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., 1994
; Wellings et al., 1994
; Boyer et al., 1997
).
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.
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Materials and methods |
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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.
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Results |
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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 I shows the demographic characteristics of the women. The median age was 24 years (range 1356), 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 II
.
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Table III 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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Discussion |
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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, 1996) 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., 1992
), Australia (Wright et al., 1991), and the USA (Baynham et al., 1996
). This contrasts with Sweden where awareness of Chlamydia is very high (Tydén et al., 1991a
,b
; Persson and Jalbro, 1992
; Andersson-Ellström et al., 1996
).
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., 1987). 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, 1989; Clarke et al., 1990
; Shiloh et al., 1990
; Wright et al., 1991; Biro et al., 1994
; Boyer et al., 1997
) 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 1
). 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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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, 1994; Editorial, 1994
) and Sweden (Persson and Jalbro, 1992
; Persson, 1993
). 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, 1994
) and teenage Chlamydia prevalence from 20% to <5% (Persson, 1993
).
The Chief Medical Officer's Expert Advisory Group on Chlamydia (Expert Advisory Group, 1998) 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.
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Acknowledgments |
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Notes |
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References |
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Baynham, S.A., Katner, H.P., Flowers, M.B. and Loftin, S. (1996) An analysis of knowledge of sexually transmitted diseases among Georgia high school seniors. J. Med. Assoc. Georgia, 85, 159161.[Medline]
Biro, F.M., Rosenthal, S.L. and Stanberry, L.R. (1994) Knowledge of gonorrhoea in adolescent females with a history of STD. Clin. Pediat., 33, 601605.[ISI][Medline]
Boyer, C.B., Shafer, M. and Tschann, J.M. (1997) Evaluation of a knowledge and cognitive behavioral skills-building intervention to prevent STDs and HIV infection in high school students. Adolescence, 32, 2542.[ISI][Medline]
Burns, C.M., Richman, R. and Caterson, I.D. (1987) Nutrition knowledge in the obese and overweight. Int. J. Obesity, 11, 485492.[ISI][Medline]
Cates, W. Jr, and Wasserheit, J.N. (1991) Genital chlamydial infections: epidemiology and reproductive sequelae. Am. J. Obstet. Gynecol., 164, 17711781.[ISI][Medline]
Clarke, J., Abram, R. and Monteiro, E.F. (1990) The sexual behaviour and knowledge about AIDS in a group of young adolescent girls in Leeds. Genitourin. Med., 66, 189192.[ISI][Medline]
Coste, J., Laumon, B., Bremond, A. et al. (1994) Sexually transmitted diseases as major causes of ectopic pregnancy: results from a large case control study in France. Fertil. Steril., 62, 289295.[ISI][Medline]
Dean, M. (1994) Muddle over sex education. Lancet, 343, 1149.[Medline]
DeBuono, B.A., Zinner, S.H., Daamen, M.D. and McCormack, W.H. (1990) Sexual behaviour of college women in 1975, 1986, and 1989. New Engl. J. Med., 322, 821824.[Abstract]
Editorial (1994) Sex education in schools: peers to the rescue? Lancet, 344, 899900.[ISI][Medline]
Expert Advisory Group (1998) Chlamydia trachomatis Summary and Conclusions of Chief Medical Officer's Group. Department of Health, London, pp. 122.
Goldsmith, M. (1996) Health education to prevent pelvic infection. In Templeton, A. (ed.), Prevention of Pelvic Infection. Royal College of Obstetricians and Gynaecologists, London, pp. 229240.
Goodman, E. and Cohall, A.T. (1989) Acquired immunodeficiency syndrome and adolescents: knowledge, attitudes, beliefs, and behaviors in a New York adolescent minority population. Pediatrics, 84, 3642.[Abstract]
Henry-Suchet, J., Utzmann, C., DeBrux, J. et al. (1987) Microbiologic study of chronic inflammation associated with tubal factor infertility. Fertil. Steril., 47, 274277.[ISI][Medline]
Holtzman, D., Lowry, R., Kann, L. et al. (1994) Changes in HIV-related information sources, instruction, knowledge, and behaviours among US high school students, 1989 and 1990. Am. J. Publ. Health, 84, 388393.[Abstract]
Mellanby, A., Phelps, F., Lawrence, C. and Tripp, J.H. (1992) Teenagers and the risks of sexually transmitted diseases: a need for the provision of balanced information. Genitourin. Med., 68, 241244.[ISI][Medline]
Paavonen, J. (1992) Genital chlamydia trachomatis infections in the female. J. Infection, 25, 3945.[ISI][Medline]
Persson, E. (1993) The sexual behaviour of young people. Br. J. Obstet. Gynaecol., 100, 10741076.[ISI][Medline]
Persson, E. and Jalbro, G. (1992) Sexual behavior among youth clinic visitors in Sweden: knowledge and experiences in an HIV perspective. Genitourin. Med., 68, 2631.[ISI][Medline]
Scholes, D., Stergachis, A., Heidrich, F.E. et al. (1996) Prevention of pelvic inflamatory disease by screening for cervical chlamydial infection. New Engl. J. Med., 334, 13621366.
Shiloh, S., St. James, P. and Waisbren, S. (1990) The development of a patient knowledge test on maternal phenylketonuria. Patient Educ. Counsell., 16, 139146.
Simms, I., Catchpole, M., Brugha, R. et al. (1997) Epidemiology of genital Chlamydia in England and Wales. Genitourin. Med., 73, 122126.[ISI][Medline]
Svensson, L., Mardh, P.A. and Westrom, L. (1983) Infertility after acute salpingitis with special reference to chlamydia trachomatis. Fertil. Steril., 40, 322329.[ISI][Medline]
Taylor-Robertson, D. (1994) Chlamydia trachomatis and sexually transmitted disease. Br. Med. J., 308, 150151.
Tydén, T., Björkelund, C. and Olsson, S.-O. (1991a) Sexual behaviour and sexually transmitted diseases among Swedish university students. Acta Obstet. Gynecol. Scand., 70, 219224.[Medline]
Tydén, T., Norden, L. and Ruusuvaara, L. (1991b) Swedish adolescents' knowledge of sexually transmitted diseases and their attitudes to the condom. Midwifery, 7, 30.
UK Family Planning Research Network (1988) Patterns of sexual behaviour among sexually experienced women attending family planning clinics in England, Scotland and Wales. Br. J. Fam. Plan., 14, 7482.
Wellings, K., Field, J., Johnson, A.M and Wadsworth, J. (1994) Sexual Behaviour in Britain. The National Survey of Sexual Attitudes and Lifestyles. Penguin, London.
Submitted on September 30, 1998; accepted on January 6, 1999.