Sexually Transmitted Diseases:
Female Prisoners’ Preferences of Collection Methods for Testing for Chlamydia trachomatis and Neisseria gonorrhoeae Infection
NEWMAN, SARA B. DrPH, MCP*; NELSON, MICHAEL B. DO†; GAYDOS, CHARLOTTE A. DrPH, MS‡; FRIEDMAN, HEIDI B. PhD*
*Department of Preventive Medicine and Biometrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland; †Health Services Division, Federal Bureau of Prisons, Washington, DC; and ‡Chlamydia Laboratory, The Johns Hopkins University, Baltimore, Maryland
This study was supported by grants from the Centers for Disease Control and Prevention, the Federal Bureau of Prisons, and the Uniformed Services University of the Health Sciences. Becton Dickinson donated Probetec assay kits for this study.
Dr. Newman is currently with the United States Public Health Service in the Division of Immigration Health Services.
Reprint requests: Sara B. Newman, DrPH, MCP, Epidemiologist, United States Public Health Service, Division of Immigration Health Services, 1220 L Street, NW, Washington, DC 20005.
Received June 14, 2002,
revised October 16, 2002, and accepted October 21, 2002.
Background: There is an increasing reliance on noninvasive techniques to collect specimens for the detection of sexually transmitted infections. The acceptability of these methods among the general population has been explored, but little is known about their acceptability among women confined in prison.
Goal: The goal was to compare female prisoners’ preferences for collection of specimens (self-collected vaginal swab specimens, urine collection, or pelvic examination) for detection of Chlamydia trachomatis and Neisseria gonorrhoeae.
Study Design: A cross-section of inmates in a large federal prison provided urine samples and self-collected vaginal swab specimens. Women then completed a questionnaire regarding the ease of each method and their preferences for future specimen collection.
Results: A total of 535 women between the ages of 18 and 52 years (median = 33) participated in the study. More than half of the participants (57%) reported no difference between urine and swab in terms of ease of collection. Approximately 30% of participants said they would prefer to give a swab specimen in the future rather than collect urine (21%), but nearly half of the women expressed no preference for one method over the other. Most participants (60%) expressed a preference for providing a self-collected swab specimen rather than having a pelvic examination (23%), but nearly 17% expressed a preference for one over the other.
Conclusion: The study population of female federal prisoners expressed no aversion to the self-collection of either vaginal swab or urine specimens for STD testing. A majority of participants expressed a preference for noninvasive techniques rather than a pelvic examination.
NEW, HIGHLY SENSITIVE nucleic acid amplification tests (NAATs) provide opportunities for using noninvasive techniques such as self-collection of urine or swab specimens for widespread and cost-effective screening for sexually transmitted infections. While there is mounting evidence in the literature on the effectiveness of these collection methods, 1–9 few peer-reviewed studies have evaluated preferences of women for noninvasive techniques. 10,11 Most studies explore preferences of adolescent girls and reveal a strong preference for noninvasive techniques over pelvic examination. 12–14 A recent study involving adult women showed that half had no preference for self-collection of swab specimens versus urine collection, and those investigators concluded that the acceptability of these methods suggests they are suitable for widespread screening. 10
Prisoners might be good candidates for noninvasive collection methods. Mistrust of health care workers, loss of privacy, and the discomfort of pelvic examinations may deter prisoners from consenting to standard testing. Although females account for only 7% of the total federal prison population, their number increased from 3825 in 1990 to more than 11,000 in 2002. 15 This rapid growth has strained the limited resources and time of prison health staff. Noninvasive techniques may provide an effective alternative that reduces the demands on highly skilled clinicians. Self-collection of swab specimens is an especially appealing method because it is easy to perform and, compared with collected urine, can be more easily stored and transported and requires less laboratory processing time.
Limited research has been conducted among federal prisoners, yet our study suggests that the prevalence of Chlamydia trachomatis among female inmates exceeds 8% in the youngest subgroup (18–22 years). 16 To our knowledge, there has been no research among prisoners to determine preferences for use of noninvasive techniques, which may provide a less costly, more acceptable alternative to specimen collection by a clinician.
Women aged 18 to 45 years incarcerated in one of the five main federal prisons for women were eligible for an institutional review board–approved study of Chlamydia trachomatis and Neisseria gonorrhoeae prevalence and risk factors. The study was carried out over 4 days in October 2001. All eligible women were requested to attend a “call out” to learn about the study. A “call out” is a routinely used system for gathering inmates together in groups, in this case 30 at a time. Volunteers from these groups provided informed consent, completed a self-administered questionnaire on risk factors for infection, and provided urine and self-collected vaginal swab specimens. Specific methods and results of this microbiologic testing and risk factor assessment are reported elsewhere. 16
Immediately following specimen collection, a trained interviewer administered a short survey asking participants for their opinions concerning the self-collection techniques. For example, women were asked whether they found it easier to provide the swab or the urine sample and whether they would prefer one method, the other, or pelvic examination in the future. We also asked women whether they were currently menstruating, to determine if this might influence their choices and attitudes. Questions on preferences were open-ended and later coded into categories for quantitative analysis. To assess the relation between demographic factors and preferences of the women for collection methods, chi-square tests were used and prevalence ratios (PRs) were calculated. Analyses were conducted with SPSS (version 10.1; SPSS, Chicago).
Of the approximately 800 female inmates eligible to participate, a total of 748 (94%) came to the health center to learn about the study. Of these, a total of 614 (82%) provided a specimen. Women who did not participate were either confined in a secure housing unit (5%), sick, unable to participate because of work conflicts, or declined participation. All women who provided specimens also volunteered to participate in the preferences survey; however, because of time constraints, the survey was not administered to 79 volunteers. Consequently, 535 (87%) of the 614 women who provided a specimen also completed a survey and were included in the present analysis. The age (median, 33 years) and racial and ethnic background of study participants did not differ significantly from those of the population of eligible inmates. Approximately 25% of study participants were black, 20% were white, and 40% were Latina. The remaining 15% of study participants included Asians, Native Americans, blacks from Africa and the Caribbean, and other ethnic groups.
Nearly all participants (97%) provided both a urine specimen and a swab specimen. In terms of ease of the two methods, 57% (299/521) found no difference between them. Approximately 23% (118/521) reported that urine collection was easier, and 21% (108/521) reported that swabbing was easier. Of the eight women who chose to provide only a swab specimen, two said they did so because they did not have to urinate. Of the 10 who declined to give a swab sample, six explained they were afraid it would be uncomfortable. An additional three women said that they would not like or were afraid to insert something inside their vagina.
Asked which of the noninvasive methods of collection they would prefer in the future, nearly half of the women (48% [256/535]) said that it made no difference to them, 31% (164/535) said they would prefer the swabbing, and 21% (110/535) said they would prefer the urine collection (Fig. 1). Of the women who preferred the swabbing, 41% said it is easier to do and cleaner than giving a urine specimen (Table 1). Nearly 20% of women said they preferred to provide a swab specimen because they cannot always urinate on demand. Of women who preferred urine collection to swab collection, approximately half (45%) said that urine collection was easier or that the swabbing was too difficult. Seventeen percent of women who preferred providing urine said they do not like to insert something inside themselves. Thirteen percent of women said they found the swab method to be uncomfortable, and five women said they were afraid they were not doing the swabbing correctly.
When asked whether they would prefer undergoing a pelvic examination or providing a self-collected vaginal swab in the future to test for infection, most women (60% [314/535]) reported that they would prefer to collect the vaginal swab specimen themselves, 23% (122/535) said they preferred a pelvic examination, and 17% (87/535) said that it did not matter to them (Fig. 2). Many of the women for whom the method did not matter indicated that they would prefer to use whichever of the two methods provides a more accurate medium for detecting infection. Approximately 20 women also commented that they preferred the pelvic examination because the doctor could look for other health problems. Nearly 40 women also expressed preference for the pelvic examination because they were not confident about their ability to perform correctly the self-collection of the swab specimen.
Differences Among Subgroups of Women
Nineteen percent of participants (103/535) were menstruating at the time of the study. A significantly greater proportion of menstruating versus nonmenstruating women expressed a preference for the noninvasive methods (P < 0.05) (Fig. 3).
We also explored differences between racial and ethnic groups. As with the general study population, we learned that more than half (56%) of the Latinas found no difference between swabbing and urine collection in terms of ease of the method. Latinas did, however, express a slight preference for the latter. There were no significant differences among other races in terms of ease of use or preferences for the future.
Participants’ age influenced preferences. Young participants (aged 18–22 years) were more than twice as likely as all other women to report that self-swabbing was an easier method and to express a preference for using that method rather than urine collection in the future (Fig. 4;P < 0.05). This age group differed only slightly from older women with regard to preferences for pelvic examination or self-collection of swab specimens in the future.
Until recently, optimal screening for bacterial sexually transmitted infections in women required performance of pelvic examination and endocervical specimen collection. With the advent of NAATs, alternative clinical specimens such as voided urine and self-collected swabs perform as well as clinician-obtained specimens for STD diagnosis. They also provide noninvasive options that have been shown in previous studies to be preferred to pelvic examination. 6,12,13 Yet, because most studies exploring preferences and acceptability of noninvasive techniques have generally included adolescent females, this study contributes to our knowledge about adult women's opinions.
Although women in this study could choose to provide a urine specimen, a swab specimen, or both, the fact that 97% of participants agreed to provide both specimens suggests that there was no strong aversion to either method. The results of this study suggest that female federal prisoners would generally favor noninvasive collection methods to invasive collection techniques. Half of the study population expressed no preference for urine or swab collection, finding both to be easy to perform. Inmates did not express aversion to urine collection, despite our concerns that they might suspect drug testing. In fact, a few women said that they preferred urine collection because they are so accustomed to it and they consider it a routine or “normal” procedure.
To our knowledge, whether menstruation influences a woman's preference concerning collection method has not been explored in other studies. We found that menstruating women prefer noninvasive collection to pelvic examination. Latinas were not as comfortable with the self-swabbing as other participants. This is consistent with the findings of focus group studies in which Latinas expressed greater discomfort with the swab self-collection procedure than did their non-Latina counterparts. 17 Young participants (18–22 years old) showed an overall greater preference than in older populations for self-collected swab versus urine specimen collection or pelvic examination. This preference by younger women is consistent with findings in other studies, in which youths expressed a preference for noninvasive techniques, and may reflect a cohort difference in one age group over the other. 12,13
An important limitation of this study is that data were collected from women in only one of the five main federal women's prisons. Therefore, the study results may not be generalizable to the entire women's federal prison population. Another limitation derives from the fact that nearly 80 of the women who gave specimens were required to return to their cells before completing the preferences survey. Fortunately, there were no significant demographic differences between these women and the women included in the study.
This study contributes to our understanding of women's preferences for STD specimen collection, particularly among women incarcerated in long-term facilities. The study found that one in four women preferred the pelvic examination to self-collection techniques. This differs from the findings of studies of adolescent girls in which more than 90% expressed a preference for self-collection techniques over pelvic examination. This difference may be explained by age and experience. Whereas in our study population more than 75% of women reported having had a pelvic examination at least 12 months before incarceration, many young girls (nearly half) have never had a pelvic examination, and fear of the examination may make the noninvasive techniques more appealing. 13,18
In our study, women's concerns about the noninvasive techniques seemed to center around access to a more comprehensive examination and a lack of confidence about self-collection methods. Although women prisoners would not have input on the specimen collection techniques used, knowing that they do not have strong preferences for or aversions to certain collection methods may assist prison health planners to implement changes on the basis of cost and staffing.
Increasing evidence of the effectiveness of these noninvasive methods may result in greater reliance upon them in future testing for a number of sexually transmitted infections. 19–22 If prison health planners consider using noninvasive techniques in the future, findings from this study provide evidence that female prisoners find them acceptable. While these techniques may provide an important opportunity to reduce the heavy demand on highly skilled clinicians, spare women from the discomfort of a pelvic examination, and provide a private, less invasive technique for finding infections, these techniques should not replace or undermine the delivery of quality health care attention by skilled practitioners to female inmates. The benefits of relying on patient-collected specimens must be carefully weighed against the risks of foregoing a pelvic examination in which other treatable conditions might be detected.
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