SEXUALLY TRANSMITTED DISEASES (STDs) are among the most common causes of illness in the world, affecting health and social well-being, especially of those in the reproductive and economically most productive age groups 1; they are considered a major public health problem because they can result in serious complications, 2 they can facilitate the spread of HIV, 3–6 and they are associated with particular types of cancer in adult males and females. 1,7,8
No data worthy of consideration were available in Italy until 1991, when a national Sentinelle Surveillance System was established to improve the epidemiologic reliability of reports on STDs, collecting data on incident cases of certain infections reported by 47 STD clinics throughout the country. 9 Notifications from 1991-1996 revealed that patients’ mean age was 33.6 ± 11.4 years, and that 63% were males. More than 50% had a primary school degree (8 y of full-time education), 36% had a secondary school degree, and 7% had a college degree. The most frequent diagnoses were genital warts (29.4%), nonspecific vaginitis (18%), and male nonspecific urethritis (12.3%) followed by latent syphilis (8.9%) and genital herpes (7.7%). Considering the number of notifications, classic STDs such as gonococcal urethritis and primary and secondary syphilis held the 7th and the 9th positions, respectively. Canchroid, granuloma inguinale, and lymphogranuloma venereum almost disappeared in the Italian population because notified cases were mainly the result of foreigners coming from endemic areas (Table 1). Annual reports revealed no significant change in the number and type of STDs. 10,11 An updated report, including the infections diagnosed from 1997-1999, was published in 2001. According to Suligoi et al., 60,724 notifications were made to the Sentinelle System from 1991-1999; no differences could be found comparing the prevalence of each STD with those published in the previous report, apart from latent syphilis and pediculosis. In fact, the latest report showed a significant drop in the notifications of such infections. 12
The importance of STDs as a public health problem and the need for privacy in the management of these causes of illness persuaded us to find a new and alternative solution to deliver information, an STD hotline. Telephone crisis intervention services, known as hotlines, have been widely used to provide information concerning many different medical topics such as substance abuse, suicide, pregnancy, and abortion. 13 The so-called “Operation Venus,” begun in Philadelphia in 1970, was the first toll-free hotline specific for STDs; since then, more hotlines were developed both in the United States and Europe to provide information concerning infections transmitted through sexual intercourse and AIDS. 14 According to Williams and Douds, 15 the success of hotlines as a channel to deliver health information is the result of several reasons: 1) the caller has more control over the situation deciding when to initiate and stop the conversation; 2) remaining anonymous, the caller can more easily talk about sensitive issues than in face-to-face settings; 3) hotlines break geographic barriers, therefore, even people living far from facilities can receive help through the telephone; and 4) the caller can imagine the operator as the type of person with whom he or she is more comfortable because the healthcare provider also remains anonymous. Operators do not use medical jargon, and they respond to callers in a sensitive manner so that information can be more easily understood. In addition, interviews are perceived as more confidential and less intimidating than standard interviews. 14,16,17
In Italy a toll-free hotline was established in 1987 to provide confidential health information and counseling about HIV infection and AIDS, 18 but until 1997 there was no service informing Italians about STD assistance available throughout the country. Establishing a national hotline, we wanted to increase the accessibility of qualified information concerning STDs to enable callers to express their uneasiness, to clarify all their concerns, and to refer them to local sources of information and assistance.
The national STD hotline, which operates Monday through Friday from 3:00 pm to 6:00 pm, is staffed by 9 gynecologists working at Modena Policlinico Hospital, University of Modena and Reggio Emilia. The operators, trained in communication skills, respond to callers’ questions, deliver prevention messages, refer callers to the best clinical and diagnostic centers in the country, and provide telephone counseling. There are no volunteer information specialists. Although the national STD hotline originally operated with volunteer staff to answer telephone calls, now it uses only paid staff to maintain consistent information delivery. Only one call can be handled at a time. An answering machine, working during off-hours, reminds callers when the telephone service is available. Calls are periodically recorded and monitored by supervisors for quality control. The hotline, which was activated on February 1997, is accessible through 800-0-17913 to all parts of the country.
To make the public aware of this telephone service, a press release was sent to some Italian newspapers; moreover, television and radio networks were notified. The hotline telephone number is periodically included in articles concerning female health published in Italian magazines, and it can also be found on a few web sites concerning STDs. Pamphlets and posters are other important ways to promote the national STD hotline only in the city of Modena and its surroundings. In fact, the hotline staff in family planning centers and chemistries periodically distribute these media.
Hotline operators used a standard questionnaire to create a detailed profile of the callers. No personal identifying information was collected. Callers were advised that they could refuse to answer any or all questions; however, only those surveys with responses to all questions were included in this study. The hotline information specialists asked the questions at the end of the telephone calls, after addressing the callers’ concerns. The recorded data included the following: the actual disease concern, the perception of the individual as being certainly infected or exposed to an STD, date and day of the call, the sex and the age of the caller, the area from which the call originated, how the caller learned of the hotline service, the level of the caller's education, and whether a referral to a medical facility was made. Almost no resistance was encountered from callers in answering these questions. At no time did hotline operators attempt to make a diagnosis according to the symptoms the caller referred or suggested a specific treatment for the symptoms the caller reported.
A few criteria were observed for making referrals. When callers asked for the location of the STD clinic nearest to them, referrals were made. When callers stated that they had been exposed or that they had been involved in at-risk sexual behaviors, operators offered to make a referral. When callers described abnormal signs or symptoms in the genital region (discharge ± foul odor, pain, burning, itching, erythema, ulcers, and so on), operators strongly emphasized that only an accurate physical examination could determine the cause.
Two different types of referral were made: a “general referral” when an examination performed by a qualified medical practitioner and/or a specific panel of tests were necessary; and a “specific referral” when the caller asked for the STD clinic nearest to him or her, how to contact a specific STD clinic, or at which STD clinic a particular test such as HPV testing was available. For this purpose, a list of the major public STD clinics was made available.
Information was collected using checkoff-style paper information forms. The hotline operators could check the response given by the caller among a series of options following each question. In case the response given was not one of the listed options, “others” was checked and the specific response was recorded. A specially designed computer program processed all the data collected.
From February 19, 1997, to December 12, 1999, the operators of the Italian STD hotline received a total of 4055 calls. A total of 3577 (88.2%) calls were included in this study, whereas 478 (11.8%) phone calls were excluded from the analysis as a result of missing or incomplete data elements.
Statistical analysis was performed using chi-squared test and Student t-test by SPSS version 6.1 (SPSS Inc, Milan, Italy).
Of the 3577 calls studied, 1794 (50.2%) were from men and 1783 (49.8%) were from women (Table 2). The men's mean age was nearly 2 years older than women's, being 36.2 ± 12.2 (mean ± standard deviation) and 34.3 ± 11.8 years, respectively (P = 0.289). Table 2 compares the geographic distribution of the calls taken by the national hotline; 1714 (47.9%) were from northern Italy, 761 (21.3%) were from central Italy, and 1102 (30.8%) were from southern Italy. * A total of 757 callers (21.2%) had a primary school degree, 2375 (66.4%) had a secondary school degree, whereas 445 (12.4%) were university students or graduates from a university.
Table 2 shows the data collected on the respondents’ concerns. A total of 1573 (44%) callers were diagnosed by a qualified medical practitioner as being infected by an STD at the time of the call. Their questions mainly addressed the type of treatment they were prescribed; if the type of drug and the duration of the administration were proper for that disease, which could be the possible side effects, if new treatments were available. This interest in medications was the result of both lack of information and incomplete understanding of the information provided by physicians. Moreover, because the telephone call was toll-free, callers also asked hotline operators for another specialist's opinion on the treatment they had been prescribed. Hotline callers also requested information on when they could have come into contact with the infective agent and for how long they could be a source of infection for their partners. A total of 501 (14%) suspected that they were infected by an STD at the time of the call because they presented abnormal symptoms in the genital region. Inquiries concerned the consistency with an STD infection of the symptoms they reported, the kind of infection that could cause such symptoms, and the possible timing of contracting the infection. A total of 679 (19%) callers with at-risk sexual behaviors asked information about the type of infections they could be exposed to and what diagnostic tests should have performed to assess any possible infection. A total of 214 callers (6%) had been recently informed of their partner being infected by an STD. They mainly inquired about the possibility of transmission of the disease from their partner, what kind of diagnostic tests they should be subjected to, and if preventive measures were still available. If the caller did not belong to any of the previous risk categories, the call was coded as “general.” Because hotline operators are gynecologists, women who wanted information not strictly related to STDs but to common gynecologic topics were also included in the “general” category. The most frequently asked questions concerned the meaning of colposcopic terminology and Bethesda System terminology, hormonal replacement therapy, and contraception. A total of 610 calls (17%) classified as “general” were answered by the hotline operators.
Two pregnant women called the national STD hotline with questions regarding the effects on the fetus of a specific drug (ampicillin and doxicillin, respectively) they had been prescribed. Interestingly, 47 physicians, mainly general practitioners, referred to the national STD hotline the most common inquiries concerned the medications to use for a specific STD and the location of STD clinics. These physicians’ telephone calls were not enclosed in the data analysis.
As shown in Table 2, no significant differences were detected between men and women on the categories “certain infection” and “suspect infection” (P = 0.384 and P = 0.400, respectively); at-risk sexual behaviors were more frequently reported by male callers (P <0.001), whereas the number of callers whose partner was infected with an STD and the number of “general” calls were higher among women (P <0.001).
Callers’ Disease Interests
Hotline operators routinely elicited information about the specific disease interest expressed by the callers; these data are presented in Table 3. The demand for information about HIV and AIDS was greater than for any other STD. Although there is a toll-free national AIDS hotline, 30% of the hotline callers were concerned about HIV infection and its consequences, but only 24 of 1075 admitted being HIV-positive. Hotline operators answered basic questions and referred callers to the Italian AIDS hotline in case more accurate and updated information was required. Specific questions regarding genital herpes were asked by 19.3% of the callers, HPV and genital warts accounted for 16.7% of the questions, whereas 13.1% of the inquiries were about mycosis. Information concerning hepatitis B virus (HBV) and hepatitis C virus (HCV) comprised 7.4% of the answers provided by hotline operators. Bacterial or protozoan infections were mentioned by only 10% of the hotline callers, gonorrhea and syphilis being the 2 least frequent disease concerns. Table 3 shows that inquiries on HIV, HBV/HCV, nonspecific urethritis, and gonorrhea were more common among male callers (P <0.001), whereas questions about HSV, HPV/genital warts, genital mycosis, and nonspecific vaginitis were more frequently asked by female callers (P <0.001). No significant differences were observed between men and women on the inquiries concerning Chlamydia trachomatis and syphilis (P = 0.039 and P = 0.233, respectively).
Although the number of immigrants residing in Italy has greatly increased in recent years, only 4 foreign women called the national STD hotline. They were all from eastern Europe, 2 of them reported dyspareunia, 1 of foul-smelling vaginal discharges, and one asked information about oral contraceptives.
Referral to public health facilities occurred in 1355 (37.9%) calls, 1210 (89.3%) being “general referrals” and 145 (10.7%) “specific referrals.” Men received both general and specific referrals more frequently than women, accounting for 759 (62.7%) and 86 (59.3%), respectively, of the cases referred (P <0.001).
Callers’ Source of Information
Hotline operators queried callers on how they found out about the service; answers are shown in Table 4. Magazines and newspapers accounted for 67.3% of the sources, TV and radio programs for 19.2%, whereas word of mouth was reported as the manner in which 13.5% of callers learned about the STD hotline. Women more frequently reported magazines and newspapers to be the source of the hotline telephone number (P <0.001), whereas men more frequently learned of the STD hotline through TV and radio programs (P = 0.001).
The first goal of this study was to determine the profile of callers to the national STD hotline. Although women were underrepresented in the STD clinic client population, they called the hotline service almost as often as men for STD information, accounting for 37% of the STD clinic attendees and 49.8% of the hotline callers, respectively. Women probably tended to consider confidentiality and fear of humiliation as barriers to seeking medical assistance, even more than men did. Thus, they felt more comfortable talking about sensitive issues when remaining anonymous rather than in face-to-face settings. No statistically significant differences were observed between female and male callers’ mean age, being 34.3 ± 11.8 years and 36.2 ± 12.2 years, respectively (P = 0.289). Hotline callers’ mean age was slightly higher than STD clinic clients’, which was 33.6 ± 11.4 years.
The number of hotline service callers with secondary school and university education was higher than that of STD clinic attendees. Calls about STDs were received from the entire nation, although almost half of them were from the north of Italy. This regional prevalence was probably the result of the location of the hotline seat, which is in the north of Italy, and to a wider promotion of the hotline service in that area through television and press among the general population and through medical journals and congresses among physicians. Moreover, a better organization of screening programs for breast and cervical cancer and a more articulate health system has made people living in the north more sensitive to and more involved in health-promoting initiatives.
The second aim of the survey was to assess the concerns of the hotline callers. As also reported by Newmann et al. about the Centers for Disease Control and Prevention's National Sexually Transmitted Disease Hotline, 19 although the intended users of the hotline were the general public, the majority of effective users were persons infected with or exposed to STDs. The different risk categories that male and female callers belonged to could at least in part account for the different diseases inquired about by hotline callers. Table 3 shows that questions concerning HIV were more frequently asked by men (P <0.001). This fact could be the result of the perception of HIV as the most threatening STD and to the higher number of male callers reporting at-risk sexual behaviors (P <0.001). In fact, approximately one third of the STD-related information provided by hotline operators addressed HIV and AIDS. Additionally, inquiries about HBV and HCV were more often made by men (P <0.001) because such infections were typically considered consequences of unprotected sexual intercourse and at-risk sexual behaviors were more common among men (P <0.001). Because the hotline information specialists were gynecologists, questions on nonspecific vaginitis, trichomonas vaginalis, and genital mycosis were more frequently asked by women (P <0.001) who considered these diseases common genital infections requiring a gynecologic referral. The attention placed on HPV and genital warts by women was significantly higher than by men (P <0.001). In fact, gynecologists had played an important role in raising the issue of HPV among women. Thanks to the recent introduction of organized cervical cancer screening programs, women have been sensitized to the importance of prevention in lower genital tract malignancies through Pap smear, colposcopy, and vulvoscopy, as well as the relationship between such neoplasms and HPV. Women (P <0.001) more frequently asked questions about HSV Over the last few years, gynecologists have more systematically provided information about HSV through pamphlets, posters, and during office visits, also emphasizing the serious consequences of herpetic infection on the management of the delivery and on the fetus.
The most frequently asked questions on the hotline were related to HIV, although a specific telephone service had been activated in 1987. Different factors seem to account for this finding. As previously mentioned, men were inclined to consider HIV a consequence of at-risk sexual behaviors; therefore, they referred to a service providing information on diseases transmitted through sexual intercourse. Because the STD hotline operators were gynecologists, and because in Italy gynecologists usually address women's questions concerning STDs, the frequent use of the hotline service by women asking about HIV was not surprising. Moreover, the STD hotline telephone number was also provided in articles concerning female health and HIV infection in magazines targeted to women. Finally, an effective campaign of information contributed to the popularity of this telephone service.
Other than in a few categories, sharp differences were observed when comparing the distribution of disease-specific interests expressed by hotline callers and the diagnoses made at sentinel clinics. These findings seem to be the result of 2 factors: 1) data collected from the STD hotline did not simply reflect the epidemiology of STDs in Italy, but they expressed how people referring to the telephone service perceived STDs; and 2) hotline callers were not statistically representative of the whole Italian population.
The top 4 disease-specific interests expressed by hotline callers were HIV, genital herpes, HPV/genital warts, and genital mycosis whereas, according to Suligoi et al., 12 the top 4 diagnoses made at sentinel clinics were genital warts, nonspecific vaginitis, nonspecific urethritis, and genital herpes. As previously mentioned, concerns about HIV and AIDS were the most frequent inquiries among hotline callers, but such disease categories were not considered among the diagnoses made in sentinel clinics. Genital herpes and HPV/genital warts were the second and third diseases most frequently mentioned by hotline callers and were among the top 4 diagnoses made at sentinel clinics. This demand for information was probably the result of the epidemiologic distribution of such infections. In other words, people used to ask hotline operators about such diseases because they were considered common. Nonspecific vaginitis and nonspecific urethritis were the diseases most frequently diagnosed at STD clinics after genital warts but represented the 8th most prevalent disease concern expressed by hotline callers. Because such infections were often silent or presented with nonspecific symptoms, they were considered common intercurrent discomforts rather than STDs, although they could have serious consequences on the reproductive tract. The same perception was observed for C. trachomatis. Gonococcal urethritis and syphilis were among the least common diseases asked about by hotline callers, probably as a result of the decline in the incidence of such diseases 9,20,21 as established by the Italian Sentinel System.
The third goal of the study was to identify the callers’ sources for the hotline telephone number. Despite the relatively high utilization of the different sources, this service needed and still needs to be promoted more widely, especially in central and southern Italy. Women mentioned newspapers and magazines as sources of information about the hotline more frequently than men, probably because these sources were targeted to women or included columns addressing women's issues. These media were mainly cited by callers following the publication of articles concerning the hotline service or providing the hotline telephone number. The distribution of pamphlets and posters to general practitioners, family planning centers, and chemistries would make the hotline telephone number more accessible for interested people, improving the knowledge of this service.
Today, nearly 3% of the Italian population is made up of immigrants, but only 4 of 3577 hotline callers were foreign residents. This low representation is probably the result of the poor access that immigrants have to health and social facilities. Fears concerning their illegal status, when applicable, the absence of personnel speaking their native languages, and the difficulty of access to health and social facilities could have hindered the provision of health care among immigrants. The hotline service needed and still needs to be publicized more widely among foreigners, also because the frequency of diseases such as gonococcal urethritis and syphilis was, respectively, 3 times as great and twice as great as it was detected among Italians, revealing that the immigrant population comprises a considerable source of infection. 22,23
In conclusion, the national STD hotline has proved to be a consistent source of information and an effective way to allay fears on STDs for anonymous callers. The opportunity for callers to ask questions in a layperson's context helped to eliminate embarrassment. Moreover, the use of nonstrict medical language by hotline operators made delivery of information clear and easily comprehensible. Callers were encouraged to seek medical attention and were provided with referrals to medical facilities in their local areas. In the near future, we hope the hotline service could be able to provide callers with printed materials concerning STDs, to extend the time of operation, and to increase the number of operators to raise the level of public awareness about STDs. Because STDs are strictly related to HIV and a great number of questions asked of STD hotline operators concerned HIV, it would be desirable to improve information delivery by combining the Italian STD and the Italian AIDS hotlines. Unfortunately, this solution does not seem to be plausible in the near future. Perhaps these 2 sources might at least collaborate to ensure that the same basic information on the topics of HIV and STDs is provided by both telephone services.
*Northern Italy includes the following regions: Valle d'Aosta, Piemonte, Liguria, Lombardia, Emilia Romagna, Trentino, Veneto, and Friuli; central Italy includes Toscana, Marche, Umbria, Lazio, Abruzzo, and Molise; southern Italy and islands are Campania, Puglia, Basilicata, Calabria, Sicilia, and Sardegna. Cited Here...