Sexually Transmitted Diseases:
Access to Care Issues for African American Communities: Implications for STD Disparities
Parrish, Deidra D. MD, MPH&TM; Kent, Charlotte K. PhD, MPH
Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
Deidra D. Parrish is supported through a research appointment by the Oak Ridge Institute for Science and Education (ORISE).
The findings and conclusions in this report are those of the author(s) and do not necessarily represent the views of the Center for Disease Control and Prevention.
Correspondence: Deidra D. Parrish, MD, MPH&TM, Division of Infectious Diseases, Vanderbilt University School of Medicine, Suite A2200 MCN, 1161 21st Ave South, Nashville, TN 37232-2605. Email: email@example.com.
Received for publication April 23, 2008, and accepted September 25, 2008.
Reduced access to care is a major contributor to health disparities in black communities. This review discusses factors that serve to diminish access to care among blacks in the context of STD disparities and highlights strategies to improve access to STD care. At the individual level, structural factors such as poverty, lack of insurance, and lack of a regular source of care are known to decrease health service utilization and have been identified as barriers to STD care as well. Other individual level factors that influence access to care, particularly for STDs, include concerns about confidentiality and privacy, perceptions of discrimination, and perceptions of risk. At the health system level, availability of services, organizational inefficiencies, and staff perceptions affect access. Strategies to improve access to STD care include expanding services in high-risk nontraditional venues, developing multilevel partnerships, incorporating STD services into routine healthcare, integrating services with HIV, improving the quality of public STD clinic care, and ultimately addressing the broader underlying factors that contribute to health disparities.
DIFFERENTIAL ACCESS TO CARE between black and white populations has long been noted. Decreased access to health services among blacks contributes significantly to health disparities across a multitude of diseases and health outcomes.1 Sexually transmitted diseases are no exception, with reduced access contributing to higher rates of STDs in this population.2
The broad definition of access to care encompasses several dimensions, including utilization of services, barriers and facilitators to care, patient satisfaction, and quality of care.3,4 Others define it more narrowly as availability of care that is needed by a patient.5 In practical terms, access to care necessarily includes those factors that determine whether the patient-provider encounter occurs. Factors such as availability, utilization, health care seeking, and acceptability are closely intertwined and directly influence whether care is obtained.
STD care includes assessment of patients' health history and risk, clinical examination, lab testing, diagnosis, treatment, and health counseling, in addition to provision of broader public health services. These include identifying, locating, testing, and treating partners of patients who have STDs, screening targeted populations for certain diseases, and promoting changes in behavior that reduce the risk of acquiring an STD.6 Although these broader services are typically provided by publicly funded STD programs, most clinical visits for STDs are now performed in the private sector.7 Of the positive STD test results reported to the CDC in 2005, 77% of the chlamydia, 65% of the gonorrhea, and 71% of the syphilis came from health care providers outside of public STD clinics.8 Racial/ethnic differences influence where people get STD care. Blacks are more likely to get care at public clinics than are whites, and many public STD clinics are more likely to serve patients of minority races/ethnicities.7,9 Not surprisingly, a population-based survey of sexual behavior found that the percentage of patients who reported seeking STD care in the emergency department was as high as the percentage seeking care in public STD clinics.7 Use of the emergency department safety net for nonemergent illnesses such as STDs is indicative of problems accessing care in other settings. In several studies, emergency department patients have been found to have a high prevalence of STDs, reflecting the high-risk populations that rely on EDs for care.10,11
It is important to examine access to care issues for blacks as a whole due to the disparate STD rates across age and gender strata within the group.8 Yet, there are subpopulations of particular interest that shoulder the highest burden of STDs and that also have significant access to care issues. Adolescents consistently have the highest rates of STDs of any age group8 and are notoriously hard to reach, having low levels of health care utilization.12 Men and women in correctional facilities are another subgroup that has been shown consistently to have higher STD rates13,14 and inadequate access to care outside of correctional facilities.2
Individual Level Barriers to Access
There are many interconnected factors that contribute to reducing access to healthcare in general, and access to STD care specifically, among blacks. They can be categorized as structural and nonstructural factors acting at both the individual and health system levels. The most important individual level structural factor influencing access to care is poverty. Rust et al.15 found poverty to be a significant determinant in decreased health care utilization among blacks. Rates of poverty are higher among blacks than among white persons.16 Poverty acts as a barrier to access because of inability to pay for health services or to afford health insurance. Compounding the issue, poorer people are less likely to have jobs that provide health insurance.17 Additionally, poorer people may lack phones and means of transportation, resources that are often necessary to secure and meet appointments.18
In terms of accessing publicly funded STD services, poverty and insurance status are typically less of an issue because free services have frequently been available. However, in times of dwindling resources, some clinics have begun charging fees. The institution of a copayment at one public STD clinic resulted in significantly reduced clinic attendance and decreased numbers of diagnoses of chlamydia and gonorrhea.19 The investigators found that the drop in attendance was particularly pronounced among the poorest patients. Indeed, patients often cite cost as a barrier to accessing STD services.20,21
Lack of health insurance, independent of poverty, is a significant barrier to accessing health care.15 Most uninsured people have incomes up to 200% of the federal poverty level and members of racial/ethnic minority groups are disproportionately represented in this group.17 Many of these working poor or “near poor” are ineligible for Medicaid.15,18 Although blacks make up only about 12.3% of the US population, 17% of those without health insurance are black.17 The influence of insurance status on STD rates is demonstrated by data from a nationally representative survey of sexually active young adults, which found that having health insurance was associated with a lower risk of prevalent chlamydial infections.22
Another individual level structural factor found to contribute to reduced healthcare utilization among blacks is lack of a regular source of care.15 In general, a regular source of care is preferred by patients for addressing new problems, providing preventive care, and getting referrals.23 Regarding STD care, there is conflicting data about preference for a regular provider. Some anecdotal reports suggest that people would prefer not to see their regular provider for STD care due to stigma or shame. A survey of predominately black, mostly uninsured public STD clinic patients found that even if they had free choice of any source of care, two thirds indicated that they would still use the STD clinic.9 Reasons cited included confidentiality concerns related to keeping insurance companies from knowing about the STD visit. Another study of men attending an STD clinic found that 32% of them reported having a regular doctor.24 One would expect that studies of patients attending STD clinics would show a preference for STD clinic care. However, according to a national survey, the most common place chosen for STD treatment was a private physician's office.7 One study of low income women in Missouri, over one third of whom were black, found that most of them preferred to be tested for STDs by their own doctor.25 Furthermore, in a study of symptomatic, predominately black emergency department patients, a significantly higher number of patients testing negative for STDs were able to name their primary physician (47%) when compared to patients testing positive for STDs, of whom only 25% were able to name their doctor.11 Also, the same study of men with regular doctors attending STD clinics found that those men were significantly less likely to test positive for an STD than men without regular doctors.24 Finally, data from the nationally representative Add Health study of sexually active young adults found lower prevalent chlamydial infections in men who reported a primary care site versus an emergency room (adjusted OR 1.96) as their usual source of care.22 This compilation of findings supports the idea that lack of a regular care provider most likely decreases access to STD care, and contributes to STD disparities, for black communities.
Other interconnected factors that influence access to care at the individual level include acceptability of services and patients' perceptions and health care-seeking behaviors (explored more fully in this issue by Hogben and Leichliter26). Concerns about confidentiality, particularly among adolescents, may lead to decreased utilization of STD services.20 Privacy is another concern, especially in public STD clinics where patients have expressed anxiety about being seen in the waiting room by passers-by.27 Van Houtven et al28 found that patients' perceptions of discrimination and racism were associated with delays in filling prescriptions and with delaying tests or treatment. Some patients may falsely perceive that they are at low risk of acquiring STDs and thus fail to seek care or delay seeking care.10,29
Health System Barriers to Access
At the health system level, availability of providers influences access to care. Both rural areas and poor urban neighborhoods suffer from lack of healthcare providers.18,30 For STD services, patients report that distance to care is key; both adults and adolescents cite the importance of a facility that is close by and easy to get to by bus or walking.20,31 Organizational aspects of STD clinic sites can negatively affect access to care. The notorious inefficiency of public STD clinics coupled with the large volume of patients limits the actual number of patients that can be seen.2 Long wait times may cause patients to walk out without being seen by a health care provider.32 A facility's hours of operation may prohibit access to those who work full time, are in school, or who have child care concerns.18,20,31 Sometimes public clinics do not advertise their services because of fear of overloading an understaffed facility.18 Thus, patients are not even aware of the services that they can obtain. Bureaucracy related to enrolling in public or private healthcare systems can also be an obstacle.18 Lack of partner services is an issue, particularly for emergency departments and private sector clinics. Access to the full complement of STD services is effectively reduced in those settings not focused specifically on provision of STD care.33
Several nonstructural factors at the health system level have an effect on whether patients obtain care. Van Ryn and Burke found that physicians tended to rate blacks more negatively than whites, especially concerning compliance and risk behaviors.34 These types of perceptions can influence provider decision-making regarding appropriate care and turn away patients who sense the provider's bias. Mistreatment of patients by health system personnel and clinic staff can also turn away patients.18 Complaints by patients about 1 STD clinic included front desk staff giving them knowing looks, possibly laughing or joking at them, and treating them as dirty or promiscuous.27
Cultural competence, defined as the knowledge, skills, attitudes, and behavior required of a practitioner to provide optimal health care services to persons from a wide range of cultural and ethnic backgrounds,35 is often advocated to overcome some of these barriers,36 though no published findings address the affect of cultural competence on access to care. One factor shown to facilitate utilization of health services overall for blacks is having a provider of the same race.37 It is unclear whether this is also the case for STD care because there is limited STD-specific race concordance data. One small qualitative study of blacks in a southern city found that most of the respondents felt that race was not a factor in choosing an STD provider.38 In an STD/HIV prevention counseling intervention, race-matched counselors and clients were similar to nonrace-matched dyads in terms of clients completing the intervention and preventing acquisition of a new STD.39
Strategies to Improve Access to STD Care
Given that a multitude of factors contribute to STD disparities by reducing access to care in black communities, multiple approaches are required to address the challenges. Providing STD services in nontraditional venues is one approach. Educational settings are important venues for reaching segments of blacks at risk. Evaluation of a chlamydia screening program in California found high prevalence of disease in alternative high schools, facilities educating children who have been expelled from regular high school.40 Secondary school students tend to be amenable to receiving STD services in school settings20,41 but have expressed confidentiality concerns.31 Home STD testing may be another option, particularly for populations with confidentiality concerns. In one study, adolescent females preferred urine-based home testing for chlamydia and gonorrhea to clinic-based testing.42 For a home STD testing approach to be successful, however, there needs to be easy access to treatment and further evaluation. Providing STD services in correctional facilities is high yield in terms of finding and treating cases, among both adults and adolescents of both genders.14,41 Considering blacks' disproportionate incarceration rates in the context of social/sexual network dynamics, controlling STDs in populations in corrections has the potential to impact community rates of disease. Mobile community outreach has also had high acceptability in black communities.38
Utilizing new communications technologies to reach at-risk groups, particularly adolescents, has shown promise. An internet-based chlamydia screening project was able to reach higher risk females through mailed test kits containing vaginal swabs for self collection of specimens.43 Positives were referred to local clinics for treatment. This approach was well received by those visiting the website and yielded high treatment rates. Another intervention used phone text messaging to provide information and referrals for STD services, which was successful in reaching black adolescents.44 Notably, both of these interventions were designed with the input of the target populations,45 indicating the importance of community input in shaping acceptable, successful programs.
Other broad strategies to improve access to STD care are collaboration and service integration to enhance and expand STD service delivery. Partnerships between academia, public health departments, and community organizations for the purposes of rolling out interventions to target groups has worked in different settings.46,47 In the private sector, there are missed opportunities to provide comprehensive STD care that can and should be addressed, including screening high-risk patients for syphilis in primary care settings,48 increasing the low levels of prenatal syphilis screening,49,50 and assessing patients for risk of STDs during routine medical checkups.51 Because of the higher risk population served, the emergency department is also a site where more comprehensive STD services are warranted.11 One Institute of Medicine recommendation that should be further explored is integration of HIV and STD service delivery,2 which could incorporate testing for STDs in HIV clinical settings in addition to combining outreach activities, including awareness, education, training, and screening. Both CDC and the Infectious Diseases Society of America have developed guidelines for STD screening in HIV care settings.52,53
Though public STD clinics are seeing a smaller proportion of the STD burden each year, they are still important sources of STD care for large numbers of patients and are important entities for reducing STD disparities in black communities. Improving service delivery in these facilities will improve access to care. Very little attention or emphasis has been placed on quality of care in public STD clinics.2 Focusing on quality indicators and quality improvement in this setting can optimize care delivery and improve patient satisfaction.
Strategies such as these that address one or more of the individual level or health system level barriers to access are important short and intermediate term approaches. In the long term, the underlying structural determinants that are critical to health care accessibility in black communities, such as income, insurance status, and having a regular source of care, must be addressed. Individual strategies can only go so far when millions of Americans are uninsured and even more live in poverty. The fact that racial disparities exist across a plethora of acute and chronic conditions attests to the need for more substantial change in areas related to healthcare access.
1. Mayberry RM, Mili F, Ofili E. Racial and ethnic differences in access to medical care. Med Care Res Rev 2000; 57(suppl 1):108–145.
2. Eng TR, Butler WT, eds. The Hidden Epidemic: Confronting Sexually Transmitted Disease. Washington, DC: Institute of Medicine, National Academy Press, 1997.
3. Andersen RM, McCutcheon A, Aday LA, et al. Exploring dimensions of access to medical care. Health Serv Res 1983; 18:49–74.
4. Pathman DE, Fowler-Brown A, Corbie-Smith G. Differences in access to outpatient medical care for black and white adults in the rural South. Med Care 2006; 44:429–438.
6. Centers for Disease Control and Prevention. Program operations guidelines for STD prevention: community and individual behavior change interventions. Available at: http://www.cdc.gov/std/program/community.pdf
. Accessed May 6, 2007.
7. Brackbill RM, Sternberg MR, Fishbein M. Where do people go for treatment of sexually transmitted diseases? Fam Plann Perspect 1999; 31:10–15.
8. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2005. Atlanta, GA: US Department of Health and Human Services, 2006.
9. Celum CL, Bolan G, Krone M, et al. Patients attending STD clinics in an evolving health care environment: demographics, insurance coverage, preferences for STD services and STD morbidity. Sex Transm Dis 1997; 24:559–605.
10. Mehta SD, Shahan J, Zenilman JM. Ambulatory STD management in an inner-city emergency department: descriptive epidemiology, care utilization patterns, and patient perceptions of local public STD. Clinics Sex Transm Dis 2000; 27:154–158.
11. Bachman LH, Pigott D, Desmond R, et al. Prevalence and risk factors associated with gonorrhea and chlamydia infection in at-risk females presenting to an urban emergency department. Sex Transm Dis 2003; 30:335–339.
12. Fiscus LC, Ford CA, Miller WC. Infrequency of sexually transmitted disease screening among sexually experienced US female adolescents. Perspect Sex Reprod Health 2004; 36:233–238.
13. Silberstein G, Coles FB, Greenberg A, et al. Effectiveness and cost-benefit of enhancements to a syphilis screening and treatment program at a county jail. Sex Transm Dis 2000; 27:508–517.
14. Mertz KJ, Voigt R, Hutchins K, et al. Findings from STD screening of adolescents and adults entering corrections facilities: Implications for STD control strategies. Sex Transm Dis 2002; 29:834–839.
15. Rust G, Fryer GE Jr, Phillips RL Jr, et al. Modifiable determinants of healthcare utilization within the African-American population. J Natl Med Assoc 2004; 96:1169–1177.
16. DeNavas-Walt C, Proctor BD, Lee CH. Income, Poverty, and Health Insurance Coverage in the US, 2004. Washington, DC: US Government Printing Office, 2005. Current population reports P60-229. Available at: http://www.census.gov/prod/2005pubs/p60-229.pdf
. Accessed May 6, 2007.
17. Groman R, Ginsburg J. Racial and ethnic disparities in health care: A position paper of the American College of Physicians [abridged version]. Ann Intern Med 2004; 141:226–232.
18. Strickland J, Strickland DL. Barriers to preventive health services for minority households in the rural South. J Rural Health 1996; 12:206–217.
19. Rietmeijer CA, Alfonsi GA, Douglas JM, et al. Trends in clinic visits and diagnosed Chlamydia trachomatis
and Neisseria gonorrhoeae
infections after the introduction of a co-payment in a sexually transmitted infection clinic. Sex Transm Dis 2005; 32:243–246.
20. Tilson EC, Sanchez V, Ford CL, et al. Barriers to asymptomatic screening and other STD services for adolescents and young adults: Focus group discussions [serial online]. BMC Public Health 2004; 4:21.
21. Hogben M, Bloom F, McFarlane M, et al. Factors associated with sexually transmitted disease clinic attendance. Int J Nurs Stud 2004; 41:911–920.
22. Geisler WM, Chyu L, Kusunoki Y, et al. Health insurance coverage, health care seeking behaviors and genital chlamydia infection prevalence in sexually active young adults. Sex Transm Dis 2006; 33:389–396.
23. Hargraves JL, Cunningham PJ, Hughes RG. Racial and ethnic differences in access to medical care in managed care plans. Health Serv Res 2001; 36:853–868.
24. Sizemore JM, Sanders WM, Lackey PC, et al. Comparison of STD burden and risk among men with and without regular doctors attending a southern urban STD clinic. Sex Transm Dis 2003; 30:512–515.
25. Crosby RA, Yarber WL, Meyerson B. Perceived monogamy and type of clinic as barriers to seeking care for suspected STD or HIV infection: Results from a brief survey of low-income women attending WIC clinics in Missouri. Sex Transm Dis 1999; 26:399–403.
26. Hogben M, Leichliter JS. Social determinants and sexually transmitted disease disparities. Sex Transm Dis. In press.
27. Lichtenstein B, Bachmann LH. Staff affirmations and client criticisms: Staff and client perceptions of quality of care at sexually transmitted disease clinics. Sex Transm Dis 2005; 32:281–285.
28. Van Houtven CH, Voils CI, Oddone EZ, et al. Perceived discrimination and reported delay of pharmacy prescriptions and medical tests. J Gen Intern Med 2005; 20:578–583.
29. Brewer NT, Weinstein ND, Cuite CL, et al. Risk perceptions and their relationship to risk behaviors. Ann Behav Med 2004; 27:125–130.
30. Bach PB, Pham HH, Schrag D, et al. Primary care physicians who treat blacks and whites. N Engl J Med 2004;351:575–584.
31. Lane MA, McCright J, Garrett K, et al. Features of sexually transmitted disease services important to African American adolescents. Arch Pediatr Adolesc Med 1999; 153:829–833.
32. Phillips KA, Mayer ML, Aday LA. Barriers to care among racial/ethnic groups under managed care. Health Aff (Millwood) 2000; 19:65–75.
33. Chorba T, Scholes D, BlueSpruce J, et al. Sexually transmitted diseases and managed care: An inquiry and review of issues affecting service delivery. Am J Med Qual 2004; 19:145–156.
34. van Ryn M, Burke J. The effect of patient race and socio-economic status on physicians' perceptions of patients. Soc Sci Med 2000; 50:813–828.
35. Cohen JJ, Gabriel BA, Terrell C. The case for diversity in the health care workforce. Health Aff (Millwood) 2002; 21:90–102.
36. Horner RD, Salazar W, Geiger HJ, et al. Changing healthcare professionals' behaviors to eliminate disparities in healthcare: What do we know? How might we proceed? Am J Manag Care 2004; 10:SP12–SP19.
37. LaVeist TA, Nuru-Jeter A, Jones KE. The association of doctor-patient race concordance with health services utilization. J Public Health Policy 2003; 24:312–323.
38. Kahn RH, Moseley KE, Johnson G, et al. Potential for community-based screening, treatment and antibiotic prophylaxis for syphilis prevention. Sex Transm Dis 2000; 27:188–192.
39. Pealer LN, Peterman TA, Newman DR, et al. Are counselor demographics associated with successful HIV/STD prevention counseling? Sex Transm Dis 2004; 31:52–56.
40. Bauer HM, Chartier M, Kessell E, et al. Chlamydia screening of youth and young adults in non-clinical settings throughout California. Sex Transm Dis 2004; 31:409–414.
41. Coyne-Beasley T, Ford CA, Waller MW, et al. Sexually active students' willingness to use school-based health centers for reproductive health care services in North Carolina. Ambul Pediatr 2003; 3:196–202.
42. Tebb KP, Paukku MH, Pai-Dhungat MR, et al. Home STI testing: The adolescent female's opinion. J Adolesc Health 2004; 35:462–467.
43. Gaydos CA, Dwyer K, Barnes M, et al. Internet-based screening for Chlamydia trachomatis
to reach nonclinic populations with mailed self-administered vaginal swabs. Sex Transm Dis 2006; 33:451–457.
44. Dobkin L, Kent C, Klausner, et al. Is text messaging key to improving adolescent sexual health? J Adolesc Health 2007; 40(suppl 3):S14
45. Gaydos CA, Rizzo PA, Barnes M, et al. Internet based chlamydia screening using vaginal swabs: What young women say about home sampling and the Internet. In: Proceedings of the European Society for Chlamydia Research, September 1–4, 2004; Budapest, Hungary.
46. Anderko L, Uscian M. Academic-community partnerships as a strategy for positive change in the sexual behavior of rural college-aged students. Nurs Clin North Am 2002; 37:341–349.
47. Vandevanter NL, Messeri P, Middlestadt SE, et al. A community-based intervention designed to increase preventive health care seeking among adolescents: The Gonorrhea Community Action Project. Am J Public Health 2005; 95:331–337.
48. Rust G, Minor P, Jordan N, et al. Do clinicians screen Medicaid patients for syphilis or HIV when they diagnose other sexually transmitted diseases? Sex Transm Dis 2003; 30:723–727.
49. Tao G, Patterson E, Lee LM, et al. Estimating prenatal syphilis and HIV screening rates for commercially insured women. Am J Prev Med 2005; 28:175–181.
50. Wilson EK, Gavin NI, Adams EK, et al. Patterns in prenatal syphilis screening among Florida Medicaid enrollees. Sex Transm Dis 2007; 34:378–383.
51. Tao G, Irwin KL, Kassler WJ. Missed opportunities to assess sexually transmitted diseases in US adults during routine medical checkups. Am J Prev Med 2000; 18:109–114.
52. Centers for Disease Control and Prevention. Incorporating HIV prevention into the medical care of persons living with HIV. Recommendations of CDC, HRSA, NIH and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR Recomm Rep 2003; 52:1–24.
53. Aberg JA, Gallant JE, Anderson J, et al. Primary care guidelines for the management of persons infected with HIV: Recommendations of the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis 2004; 39:609–629.
© Copyright 2008 American Sexually Transmitted Diseases Association
What does "Remember me" mean?
By checking this box, you'll stay logged in until you logout. You'll get easier access to your articles, collections,
media, and all your other content, even if you close your browser or shut down your
To protect your most sensitive data and activities (like changing your password),
we'll ask you to re-enter your password when you access these services.
What if I'm on a computer that I share with others?
If you're using a public computer or you share this computer with others, we recommend
that you uncheck the "Remember me" box.
Data is temporarily unavailable. Please try again soon.
Readers Of this Article Also Read