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Sexually Transmitted Diseases:
doi: 10.1097/OLQ.0b013e318254c837
Case Report

Self-Reported Chlamydia Testing Rates of Sexually Active Women Aged 15–25 Years in the United States, 2006–2008

Tao, Guoyu PhD; Hoover, Karen W. MD, MPH; Leichliter, Jami S. PhD; Peterman, Thomas A. MD, MS; Kent, Charlotte K. PhD

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From the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA

Correspondence: Guoyu Tao, PhD, Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road NE, MS-E80, Atlanta, GA 30333. E-mail: gat3@cdc.gov.

Received for publication October 14, 2011, and accepted March 8, 2012.

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Abstract

Using the 2006–2008 National Survey of Family Growth, we estimated a 37.9% annual chlamydia testing rate for sexually active US women aged 15 to 25 years, defined as having ≥1 sex partner in the past year. Our results highlight the need for increased testing among sexually active young women.

Chlamydial infection is the most common bacterial sexually transmitted disease (STD) in the United States, especially among women aged 15 to 24 years.1,2 Because most infections in women are asymptomatic but can progress to serious sequelae,3,4 annual chlamydia screening of sexually active women aged ≤25 years is recommended by several organizations, including the Centers for Disease Control and Prevention (CDC).47 Despite these recommendations, chlamydia testing rates have been low. Several studies have reported a range of testing rates from 35% to 60%.812 These testing rates, including screening tests for asymptomatic patients and diagnostic tests for patients with symptoms or signs of chlamydial infection, have been measured for different populations using various data sources and methods, such as survey data for the general population and claims data for insured persons. Using the data from the Healthcare Effectiveness Data and Information Set (HEDIS), a chlamydia testing rate of 41.6% was estimated for sexually active women aged 16 to 25 years who had enrolled in commercial and Medicaid health insurance plans in 2007.9 Another study reported a chlamydia testing rate of 57% for sexually active women aged <25 years who visited federally funded reproductive health clinics.12 An analysis of the 2002 National Survey of Family Growth (NSFG) found a self-reported STD testing rate of 42% for sexually active women aged 16 to 25 years in the United States in 2002, but this estimate was for all STD testing rather than specifically for chlamydia.8

With the addition of an NSFG question to the 2006–2008 survey that asks specifically about chlamydia testing, we estimated the proportion of sexually active US women aged 15 to 25 years who self-reported chlamydia testing in the past year.

We analyzed data from the 2006–2008 NSFG. Details of this survey have been published elsewhere.13,14 Briefly, the 2006–2008 NSFG included a sample of 7356 women aged 15 to 44 years who were interviewed in person from June 2006 through December 2008, with a response rate of 76%. Audio computer-assisted self-interviewing was used to ask sensitive questions during the interview.

Our analysis was performed using data provided by 2944 sampled women aged 15 to 25 years. A woman was considered as sexually active if she answered that she had at least one partner when asked “Thinking about the last 12 months, how many male sex partners have you had in the past12 months? Please count every partner, even those you had sex with only once in those 12 months.” A sexually active woman had a chlamydia test if she answered yes to “In the past 12 months, have you been tested for chlamydia?” Among women who were tested for chlamydia, chlamydial infections were estimated as the number of women who indicated that they had been treated or received medication from a doctor or other medical care provider for chlamydia in the past 12 months. Women were also asked several questions about their use of reproductive health services. Women were classified having a reproductive health service if they reported any health care service in response to 14 questions that were related to contraception, cervical cancer screening, pelvic examination, pregnancy testing, prenatal care, postpregnancy care, abortion, or STD care in the past12 months.

Self-reported chlamydia testing rates were estimated by age, race/ethnicity, health insurance, metropolitan statistical area, and federal poverty level of the respondent's household. To account for the complex sampling design of the NSFG, we used SAS version 9.2 (SAS Institute, Inc., Cary, NC) and SUDAAN version 10.0.1 (Research Triangle Institute, Research Triangle Park, NC) to analyze survey data and generate weighted chlamydia testing rates and standard errors. Bivariate analyses were used to estimate the association of women's characteristics with chlamydia testing. Variables that were significantly associated with testing in bivariate analyses were included in a multivariate logistic regression model, with chlamydia testing as the dependent variable, to estimate adjusted odds ratios and 95% confidence intervals for the associations. In all analyses, a statistically significant difference was defined as a 2-tailed probability of <0.05.

Of 22.6 million women aged 15 to 25 years in the United States, 66.6% (14.8 million) were estimated to be sexually active, ranging from 24.0% of 15 year olds to 89.4% of 25 year olds. Similarly, of those 22.6 million women, 62.1% (12.3 million) reported having a reproductive health service in the past 12 months, ranging from 19.3% of 15 year olds to 82.8% of 25 year olds. Among 14.8 million sexually active women aged 15 to 25 years, 83.1% reported having a reproductive health service in the past 12 months.

Chlamydia testing was reported by 26.2% of all women aged 15 to 25 years, 37.9% of sexually active women aged 15 to 25 years, 41.4% of women aged 15 to 25 years who had reproductive health services in the past 12 months, and 44.8% of sexually active women aged 15 to 25 years who had reproductive health services in the past 12 months (Table 1). Among sexually active women aged 15 to 25 years, chlamydia testing was more likely if they were non-Hispanic black compared with non-Hispanic white, were insured by Medicaid or SCHIP compared with a private insurance plan, had 2 or more sex partners rather than one partner, or had a reproductive health services compared with no reproductive health services in the past 12 months (Table 2). A positivity rate of 9.2% was estimated among women who reported a chlamydia test.

Table 1
Table 1
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Table 2
Table 2
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The data that only 37.9% of sexually active women aged 15 to 25 years were tested for chlamydia, and 44.8% of sexually active women aged 15 to 25 years who also had reproductive health services in the past 12 months, confirm findings in other studies of suboptimal chlamydia screening as currently recommended. We also found that the chlamydia testing was significantly associated with women's race/ethnicity, insurance status, sexual behavior, and use of reproductive health services. Although several previous studies have identified interventions that can increase chlamydia testing rates,1517 other barriers, such as high patient cost sharing, need to be resolved.

The self-reported chlamydia testing rate in our study is at the lower end of a range of estimates.911 Although our estimate of chlamydia testing of sexually active women is similar to the HEDIS estimate, both methods have strengths and weaknesses that impact the estimate. For example, the HEDIS measure may include a greater number of valid chlamydia tests as documented in its claims data compared with the self-reported chlamydia tests in NSFG. On other hand, self-reported sexual activity in NSFG is considered to be a better indicator of women who should be tested. The self-reported sexual activity variable in NSFG is more likely to capture sexually active women than the reproductive health care claims used for identifying sexually active women in the HEDIS measure because the HEDIS measure includes only women who used reproductive health care services.18 Our study has shown that many sexually active women did not have reproductive health services, and some women who had reproductive health services did not have a sex partner in the past year.

NSFG had a high response rate, collected sensitive data using careful methods with audio computer-assisted self-interviewing, and provided a nationally representative estimate of chlamydia testing coverage. Our study has several limitations. First, self-reported chlamydia testing and positivity are subject to recall bias and reporting errors, with possible under- or overestimation of the chlamydia testing rate and test positivity. Second, chlamydia testing or positivity could not be validated. Our estimate of 9.2% chlamydia positivity is higher than the 2002 NSFG estimate of 4.9% for all STD positivity and the 2009 Centers for Disease Control and Prevention surveillance estimate of 3.3% for chlamydiaal infection rate among all women aged 15 to 25 years.8,1 Further, our study could not identify the proportion of chlamydial infections that were due to screening or diagnostic testing. Finally, the NSFG has only limited geographic information; therefore, we could not estimate chlamydia testing rates by state or region.

In summary, fewer than half of sexually active women reported a chlamydia test, even if they also reported using reproductive health care services. These findings underscore the need for interventions to increase testing of young women and perhaps to develop empirically based algorithms to improve screening criteria to maximize yield under the current testing levels.

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REFERENCES

1. CDC. Sexually Transmitted Disease Surveillance 2009. In. Atlanta, GA: U.S. Department of Health and Human Services, 2010.

2. Datta SD, Sternberg M, Johnson RE, et al.. Gonorrhea and chlamydia in the United States among persons 14 to 39 years of age, 1999 to 2002. Ann Intern Med 2007; 147:89–96.

3. Westrom L, Joesoef R, Reynolds G, et al.. Pelvic inflammatory disease and fertility. A cohort study of 1,844 women with laparoscopically verified disease and 657 control women with normal laparoscopic results. Sex Transm Dis 1992; 19:185–192.

4. Workowski KA, Berman S. Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep 2010; 59:1–110.

5. American College of Obstetricians and Gynecologists. Spotlight on Chlamydia: Annual screenings a must for young women. Available at: http://www.acog.org/About_ACOG/News_Room/News_Releases/2007/Spotlight_on_Chlamydia_Annual_Screenings_a_Must_for_Young_Women, 2007.

6. Screening for chlamydial infection: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2007; 147:128–134.

7. Hollblad-Fadiman K, Goldman SM. American College of Preventive Medicine practice policy statement: Screening for Chlamydia trachomatis. Am J Prev Med 2003; 24:287–292.

8. Tao G, Tian LH, Peterman TA. Estimating Chlamydia screening rates by using reported sexually transmitted disease tests for sexually active women aged 16 to 25 years in the United States. Sex Transm Dis 2007; 34:180–182.

9. Chlamydia screening among sexually active young female enrollees of health plans–United States, 2000–2007. MMWR Morb Mortal Wkly Rep 2009; 58:362–365.

10. Levine WC, Dicker LW, Devine O, et al.. Indirect estimation of Chlamydia screening coverage using public health surveillance data. Am J Epidemiol 2004; 160:91–96.

11. St Lawrence JS, Montano DE, Kasprzyk D, et al.. STD screening, testing, case reporting, and clinical and partner notification practices: A national survey of US physicians. Am J Public Health 2002; 92:1784–1788.

12. Fowler C, Lioyd SW, Gable J, et al.. Family Planning Annual Report: 2010 National summary. In: Health and Human Services, ed., 2011.

13. Lepkowski JM, Mosher WD, Davis KE, et al.. The 2006–2010 National Survey of Family Growth: Sample design and analysis of a continuous survey. Vital Health Stat 2 2010; 150:1–36.

14. Chandra A, Mosher WD, Copen C, et al.. Sexual behavior, sexual attraction, and sexual identity in the United States: Data from the 2006–2008 National Survey of Family Growth. Natl Health Stat Rep 2011; 36:1–36.

15. Burstein GR, Snyder MH, Conley D, et al.. Chlamydia screening in a health plan before and after a national performance measure introduction. Obstet Gynecol 2005; 106:327–334.

16. Shafer MA, Tebb KP, Pantell RH, et al.. Effect of a clinical practice improvement intervention on Chlamydial screening among adolescent girls. JAMA 2002; 288:2846–2852.

17. Bull SS, Jones CA, Granberry-Owens D, et al.. Acceptability and feasibility of urine screening for Chlamydia and gonorrhea in community organizations: Perspectives from Denver and St Louis. Am J Public Health 2000; 90:285–286.

18. Tao G, Walsh CM, Anderson LA, et al.. Understanding sexual activity defined in the HEDIS measure of screening young women for Chlamydia trachomatis. Jt Comm J Qual Improv 2002; 28:435–440.

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