Sexually Transmitted Diseases:
A Prospective Study of the Psychosocial Impact of a Positive Chlamydia trachomatis Laboratory Test
Gottlieb, Sami L. MD, MSPH*; Stoner, Bradley P. MD, PhD†; Zaidi, Akbar A. PhD*; Buckel, Christina MSW†; Tran, Molly MD†; Leichliter, Jami S. PhD*; Berman, Stuart M. MD, ScM*; Markowitz, Lauri E. MD*
From the *Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA; and †Department of Anthropology and Division of Infectious Diseases, Washington University, St. Louis, MO
Supplemental digital content is available for this article. A direct URL citation appears in the printed text, and a link to the digital file is provided in the HTML text of this article on the journal's Web site (http://www.stdjournal.com).
Correspondence: Lauri Markowitz, MD, Division of STD Prevention, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, MS E-02, Atlanta, GA 30333. E-mail: firstname.lastname@example.org.
Received for publication January 7, 2011, and accepted June 1, 2011.
Background: Few data exist on potential harms of chlamydia screening. We assessed the psychosocial impact of receiving a positive Chlamydia trachomatis test result.
Methods: We prospectively studied women ≥16 years of age undergoing chlamydia testing in 2 Midwestern family planning clinics. We surveyed women at baseline and about 1 month after receiving test results, using 9 validated psychosocial scales/subscales and chlamydia-specific questions. Changes in scale scores were calculated for each woman. Mean percent changes in scores for chlamydia-positive and -negative women were compared using a t test.
Results: We enrolled 1807 women (response rate, 84%). Of the 1688 women with test results, 149 (8.8%) tested positive. At follow-up, chlamydia-positive women (n = 71) had a 75% increase in anxiety about sexual aspects of their life on the Multidimensional Sexual Self-Concept Questionnaire (P < 0.001), significantly greater than the 26% increase among 280 randomly selected chlamydia-negative women (P = 0.02). There were no differences for the other 8 scales/subscales, including general measures of anxiety, depression, and self-esteem. Chlamydia-positive women were more likely than chlamydia-negative women to be “concerned about chlamydia” (80% vs. 40%, P < 0.001) and to report breaking up with a main partner (33% vs. 11%, P < 0.001) at follow-up. Women testing positive reported a range of chlamydia-specific concerns.
Conclusions: Chlamydia-positive women had significant increases in anxiety about sex and concern about chlamydia, but did not have marked changes in more general measures of psychosocial well-being about 1 month after diagnosis. Chlamydia diagnoses were associated with some disruption of relationships with main partners. Chlamydia-specific concerns may guide counseling messages to minimize psychosocial impact.
Chlamydia trachomatis infection (chlamydia) is the most common bacterial sexually transmitted infection (STI) in the United States1 and can lead to adverse reproductive consequences such as pelvic inflammatory disease, infertility, and ectopic pregnancy in women.2 Because most women with chlamydia have no symptoms and are unaware of their infections, routine screening is recommended nationally for all sexually active women ≤25 years of age.3 The US Preventive Services Task Force has strongly recommended chlamydia screening of sexually active young women (an “A” grade recommendation) based on direct evidence that screening reduces adverse reproductive health outcomes and that the benefits substantially outweigh the harms.4 However, in its review, the US Preventive Services Task Force noted the lack of data about potential harms associated with chlamydia screening, specifically psychosocial harms, and the need for research in this area.4
Very little is known about the frequency and intensity of adverse psychosocial consequences following the receipt of positive chlamydia tests. A better understanding of the psychosocial impact of a chlamydia diagnosis would be useful for decision analyses about the benefits and risks of chlamydia screening in various populations.5 This is especially important for populations with very low chlamydia prevalence, where false-positive tests may be a substantial concern.6 In addition, to improve the quality of care for a prevention service recommended for millions of young women each year, it would be important to know whether tailored counseling messages are needed to address psychosocial concerns of women with positive chlamydia tests. There is currently no formal guidance on the most appropriate counseling of such women. We sought to determine the psychological and social consequences of receiving a positive chlamydia laboratory test result.
We conducted a longitudinal study of women undergoing chlamydia testing to evaluate psychosocial status before and after receiving chlamydia test results in women testing positive versus negative. The study was conducted in 2 family planning clinics in urban area of St. Louis, MO. A small number of women (n = 19) were enrolled from a third family planning study site, which was discontinued because of slow enrollment. During February 2007 through April 2008, we attempted to enroll all girls and women ≥16 years of age having chlamydia testing performed as part of their routine clinic appointments. Study staff was present in the clinics on all days in which chlamydia testing was likely to be performed (e.g., excluding days on which only colposcopies were performed). The standard practice in the 2 clinics is to screen for chlamydia annually (using nucleic acid amplification tests) in sexually active women who are <25 years of age, have new or multiple sex partners, or a symptomatic partner. We excluded women who did not speak English or who knew they would not be available for follow-up for 1 month. Study protocols were approved by the Institutional Review Boards of Washington University and the Centers for Disease Control and Prevention.
After providing informed consent, participants completed a written questionnaire at the time of their chlamydia testing visit. The baseline questionnaire included questions on sociodemographics, sexual behavior, and STI history, and the main reason for the family planning clinic visit, as well as psychosocial and chlamydia-specific questions (mentioned in the “Study Instrument” section). Study participants received their chlamydia test results and were treated according to standard clinic protocols approximately 1 week after testing. Existing clinic protocols stated that women with positive tests should receive counseling messages about (1) the nature of chlamydial infection, its complications, and its tendency to cause asymptomatic infection; (2) the potential for reinfection and the recommendation to be tested again in 3 to 4 months; and (3) the importance of partner treatment. We verified that women had received their positive test results and were treated through the clinics' medical record system. We then attempted to reinterview all of the women who tested positive for chlamydia and a subset of those who tested negative, approximately 1 month after they received their test results. We randomly selected 4 women with negative tests for every 1 woman with a positive test during the same week of testing. Follow-up interviews included psychosocial and chlamydia-specific questions and were conducted through telephone 5 to 8 weeks after the chlamydia testing date (i.e., 4 to 6 weeks after test results were given). Study staff made a maximum of 5 attempts to contact patients until 8 weeks after the testing date.
We developed the study instrument after conducting qualitative formative research about the impact of positive chlamydia test results in the same family planning clinic population.7 Based on the qualitative findings, we selected the main measures of the study, which were assessed at baseline and follow-up for women testing both positive and negative, as shown in Table 1. The measures included following 9 previously validated psychosocial scales or subscales: the Rosenberg Self-Esteem Scale,8 5 subscales of the Brief Symptom Inventory (BSI),9,10 and 3 subscales of the Multidimensional Sexual Self-Concept Questionnaire (MSQ)11,12; general thoughts and concerns about chlamydia (“I think about chlamydia a lot” and “I am concerned about chlamydia”); and items related to relationship status, including breaking up with a partner in the past 30 days.
In addition, we developed new chlamydia-specific survey questions based on findings from the qualitative research,7 to assess concerns about chlamydia at follow-up only among women testing positive (Appendix, Supplemental Digital Content, http://links.lww.com/OLQ/A25). Women were asked their agreement with a series of statements after the phrase: “After I was told that my chlamydia test was positive…” with response options of strongly disagree, disagree, feel neutral, agree, and strongly agree. We cognitively tested the survey instrument with 18 women before the study to ensure that survey instructions and items were clear and to confirm that participants interpreted items as intended.
The study was designed to compare changes in psychological and social factors before and after receiving test results in women testing positive versus negative. Scores for psychosocial scales and subscales were calculated according to previously published methods.8,10,12 We first evaluated mean psychosocial scores at baseline, using t tests to compare women who ultimately tested positive for chlamydia with those who ultimately tested negative. Next, we calculated the difference in psychosocial scale scores before and after receiving test results and the percent change for each woman. Mean differences between baseline and follow-up scores among chlamydia-positives and among chlamydia- negatives were assessed using paired t tests. The mean percent change in scores among chlamydia-positive women was compared with the mean percent change among chlamydia-negative women using a t test. With our sample size of chlamydia-positive women at follow-up, the study had >80% power to detect a 10% absolute difference in mean percent changes between women testing positive and negative, for all scales and subscales except the MSQ-Anxiety and MSQ-Fear subscales. To assess general thoughts and concerns about chlamydia and relationship status at baseline and follow-up, χ2 tests were used to compare proportions between chlamydia-positive and -negative women at each time point, and McNemar χ2 was used to compare proportions within each group over time. Statistical analyses were conducted using SAS 9.2 (SAS Institute, Cary, NC).
We enrolled 1807 women (participation rate, 84%; Fig. 1). Of these, 1688 women had chlamydia test results available, of whom 149 (8.8%) had positive tests. Of 142 chlamydia-positive women eligible for follow-up, 71 (50%) completed follow-up interviews. Of 573 chlamydia-negative women selected for follow-up, 280 (49%) completed follow-up interviews within the specified interview period. Women who followed up and those who did not were not significantly different with respect to chlamydia testing status nor any of the participant characteristics displayed in Table 2.
Among the 1688 study participants with chlamydia test results, median age was 23 years (Table 2). Sixty-five percent of participants reported their race/ethnicity as black or African-American, 27% as white, and 7% as Hispanic or other. Most (73%) participants were not married or living with a partner, and most (76%) had only one sex partner in the past 30 days. Overall, the median number of lifetime sex partners was 5, and 34% of study participants reported a history of chlamydia. The main reasons for the baseline clinic visit (participants could mark >1) included annual examination/Pap test (69%), birth control (32%), and checkup or screening for STIs (38%). Only 7% reported any genitourinary symptoms, and 4% reported being exposed to an STI. Women testing positive for chlamydia were more likely than women testing negative to be younger, black, less educated, visiting the clinic for STI screening or exposure to an STI, reporting >1 sex partner in the past 30 days, and reporting a history of chlamydia (P < 0.05 for each).
At baseline, women ultimately testing positive for chlamydia had significantly worse psychosocial status than women testing negative, as measured by 5 of 9 scales/subscales (BSI-Paranoia, BSI-Hostility, BSI-Sensitivity, MSQ-Anxiety, and MSQ-Optimism; Table 3). Differences in psychosocial scale scores between baseline and follow-up are shown in Table 4. Among women diagnosed with chlamydia, there was a large change in anxiety about the sexual aspects of their life (MSQ-Anxiety subscale: mean 75% increase [95% confidence interval: 34%–115%], P < 0.001), approximately 1 month after receiving chlamydia test results. This increase in anxiety about the sexual aspects of their life among chlamydia-positive women was significantly greater than the 26% increase (95% confidence interval: 13%–39%) observed among chlamydia-negative women (P = 0.02). We found no statistically significant differences before and after testing between chlamydia-positive and -negative women for any of the other 8 scales or subscales.
Regarding general thoughts and concern about chlamydia, we found that even before receiving test results, women ultimately testing positive for chlamydia were more likely than women testing negative to agree that they “think about chlamydia a lot” (20% vs. 10%, P = 0.02) and that they are “concerned about chlamydia” (46% vs. 33%, P = 0.03). A substantially greater proportion of chlamydia-positive women reported being “concerned about chlamydia” at follow-up than at baseline (80% vs. 46%, P < 0.001). There was no significant change among chlamydia-negative women (40% vs. 33%, P = 0.07).
Relationship status with main partners was similar for chlamydia-positive and -negative women at baseline. Sixty-four (90%) women testing positive had a main partner within the 30 days before baseline and 16% (10/64) broke up with a main partner in that period; 256 (91%) women testing negative had a main partner before baseline and 11% (28/256) broke up (P = 0.30). However, at follow-up, chlamydia-positive women were more likely to report breaking up with a main partner in the previous 30 days (and thus in approximately the month after receiving chlamydia test results); 22 (33%) of 66 chlamydia-positive women with main partners in this period reported breaking up versus 28 (11%) of 249 chlamydia-negative women (P < 0.001). Of the 22 chlamydia-positive women who reported breaking up with a main partner in the 30 days before follow-up, 10 (45%) stated that their chlamydia diagnosis was the main reason for the breakup, 8 (36%) said the chlamydia diagnosis was somewhat the reason, and 4 (18%) said the chlamydia diagnosis had nothing to do with the breakup.
Selected chlamydia-specific concerns evaluated about 1 month after receipt of positive test results are shown in Figure 2. Women had a range of concerns after receiving positive chlamydia test results; only 4% agreed that they “do not really care that much.” Almost all (99%) chlamydia-positive women were worried about having been exposed to other STIs. In addition, most women had concerns related to partner betrayal and trust; 70% felt betrayed by their partners and 87% felt it will be difficult to trust future partners. Only 38% of women stated that their chlamydia diagnoses had not changed their relationships with their partners. Even after receiving results and treatment from a clinician, a substantial proportion of women were worried about future infertility (44%) and that chlamydia would not be cured (37%).
In this longitudinal study, women testing positive for chlamydia had significant increases in anxiety about the sexual aspects of their life and in concern about chlamydia approximately 1 month after receiving chlamydia results, compared with women testing negative. Although chlamydia-positive women had generally worse psychosocial profiles than chlamydia-negative women before testing, chlamydia-positive women did not appear to have marked changes in more global measures of anxiety, depression, and self-esteem after testing. Receiving positive chlamydia test results was associated with some disruption of relationships with main partners, and issues of partner fidelity and trust were prominent areas of concern. In fact, women testing positive for chlamydia had a wide range of chlamydia-specific concerns about 1 month after receiving their test results; only 4% of women stated “I do not really care that much.”
These data provide the first comprehensive, longitudinal assessment of the psychosocial impact of receiving positive chlamydia test results using validated psychosocial scales. Most prior research on the psychosocial impact of a chlamydia diagnosis has involved small qualitative assessments with in-depth interviews of about 20 women each.7,13–15 Major themes identified in the qualitative research included stigma and shame of having an STI, the perception of personal responsibility for sexual health, impact on self-esteem and self-worth, partner fidelity and trust within relationships, impact on future reproductive health and medical consequences, and impact on future sexual relationships.7,13,14 The only previously published quantitative study of receiving positive chlamydia test results was a cross-sectional evaluation of 277 adults in Denmark.16 This study generally supported findings from the qualitative research, in that a portion of women with positive tests had adverse psychosocial responses, especially related to stigma, relationships, and fertility concerns. However, it did not use validated psychosocial scales to compare chlamydia-positive and -negative individuals and was not longitudinal. We observed baseline differences in psychosocial status of women ultimately testing positive and negative, consistent with studies linking adverse psychosocial factors with sexual risk taking and STIs,17,18 which highlights the importance of using longitudinal data. Of note, there has been a longitudinal study of the psychosocial impact of receiving negative chlamydia test results.19 Unlike our study, that longitudinal study found that generalized anxiety decreased after receipt of negative test results; reactions to positive tests were not assessed.
In our study, we found that a substantial proportion of chlamydia-positive women did, in fact, have many of the individual chlamydia-related concerns found in previous research.7,13–16 However, chlamydia-positive women did not have significant changes in global measures of psychosocial functioning 1 month after receiving test results compared with women testing negative. We observed the most profound changes in the MSQ-Anxiety subscale, which measures the tendency to feel tension, discomfort, and anxiety about the sexual aspects of one's life.11 Mean MSQ-Anxiety scores increased by 75% among women testing positive, significantly different from women testing negative. To put the findings in the context, however, mean MSQ-Anxiety scores after a chlamydia diagnosis in this study were still substantially lower than mean MSQ-Anxiety scores observed in a study of patients with a history of symptomatic genital herpes or genital warts.20 Although anxiety about sex and concern about chlamydia may be psychologically distressing, some degree of concern might also be beneficial in terms of receptiveness to counseling about safer sex or chlamydia screening behavior.21 Future studies should explore strategies to minimize unnecessary anxiety related to chlamydia while assessing how responses to chlamydia test results might influence future behavior and prevention efforts.
We observed important disruption of relationships with main partners related to positive chlamydia test results. This may have the largest implications for decision making about the risks and benefits of screening in various populations and the approach to potential false-positive tests. Nucleic acid amplification tests, the most widely used screening tests for chlamydia, are more sensitive than prior tests and are thought to have relatively high specificity.22 However, in low-prevalence populations, even tests with high specificity may lead to a substantial number of false-positives.6 Thus, screening strategies in general, but especially in low-prevalence populations, must take into account the potential harm of incorrectly diagnosing chlamydia infection in a portion of women screened. There have been few, if any, data to guide such decision making. Our data suggest that although most women do not have major changes in general psychosocial well-being after a chlamydia diagnosis, disruptions to relationships and anxiety about sex and future fertility cannot be ignored as potential harms of positive tests.
In the past, additional “confirmatory” testing of positive specimens was suggested as one way to minimize the burden of false-positive tests in low-prevalence settings.22 However, because of the concerns about the use of this approach23 and its substantial economic and logistical costs, this is no longer recommended routinely.24 In addition to avoiding screening in low-prevalence populations for whom such screening is not recommended, such as women aged >25 at low risk,25,26 tailored counseling might minimize psychosocial impact. For example, discussing the fact that most people are unaware that they have chlamydia and that infection may last for >1 year27 may help to alleviate concerns about partner fidelity and trust for some patients. In low-prevalence populations, providers could use their judgment about discussing that, as with any test, a proportion of tests may be falsely positive, while nonetheless stressing the need for patient and partner treatment. Future studies should assess the impact of counseling strategies such as this, as it is unknown whether discussing false-positive tests would minimize psychosocial harm and/or whether it may have the downside of reducing completion of therapy or partner notification and treatment.
The concerns reported by chlamydia-positive women in our study could guide additional counseling messages. More than 95% of the women were worried about other STIs to which they could have been exposed. Thus, it would be important to explicitly state which STIs have been tested for and address concerns about exposures and how to minimize risk. This would be an opportune time to emphasize important STI-related screening and prevention recommendations, such as universal HIV testing and human papillomavirus vaccination for unvaccinated young women.28,29 Over 40% of women testing positive for chlamydia in our study were concerned about future fertility. Providers could point out to patients that, although risk is slightly increased, overall there is a very low long-term risk of adverse reproductive sequelae after a detected and treated chlamydial infection.30 They could also reinforce the value of the current chlamydia testing episode, as well as the importance of future yearly screening, because the greatest risk of infertility would result from ongoing undetected, untreated chlamydial infection. The majority of women in this study were worried about getting chlamydia again. Providers should capitalize on this concern as a “teachable moment” to stress the importance of partner treatment, the need to return for re-screening in 3 months, and ongoing behavioral risk reduction and screening strategies.21,31
This study had several limitations. First, it was conducted in a relatively high-risk population; psychosocial impact may be different in a low-prevalence population with fewer past chlamydia diagnoses and potentially more false-positive results. Second, 50% of participants were lost to follow-up. Although it was reassuring that those who did and did not follow-up had similar baseline demographic and behavioral characteristics, this loss to follow-up may have introduced some bias. Third, unfortunately, we did not have sufficient power to analyze psychosocial outcomes stratified by subgroups, and thus were not able to assess whether there were particular characteristics that might be more predictive of adverse psychosocial outcomes. Finally, we assessed psychosocial concerns at just one point in time about 1 month after receiving test results. We chose this time point to capture more lasting psychosocial concerns than simply immediate reactions to a positive result. However, as with the psychosocial reactions to a positive serologic test for herpes, observed adverse effects may decrease over a longer time period.32,33
In conclusion, we found that chlamydia diagnoses did not appear to have major effects on general psychosocial well-being, but did cause significant increases in concern about chlamydia and in anxiety about the sexual aspects of women's lives, along with disruption of relationships for a proportion of women. These findings do not diminish the importance of chlamydia screening to prevent adverse reproductive health consequences for sexually active young women. Rather, our findings about the psychosocial impact of a chlamydia diagnosis can be used to weigh the risks and benefits of screening in various populations, particularly in low-prevalence settings where false-positive tests are a concern. The impact on relationships and anxiety about sex and future fertility should be considered as potential harms of positive tests. In addition, the range of chlamydia-specific concerns reported by women in this study suggest that tailored counseling messages should be developed to address these concerns, which may minimize the psychosocial impact of a positive chlamydia diagnosis.
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