Sexually transmitted infections (STIs) are among the most common communicable diseases in the United States. An estimated 110 million cases exist nationwide and nearly 20 million new infections are diagnosed each year, the majority of which remain incurable.1 More than 30 infectious diseases are known to be transmitted sexually, yet patients are routinely screened for few of these.2 In 2015, the CDC reported that the combined total of chlamydia, gonorrhea, and syphilis cases reached the highest number ever recorded in US history.
The CDC has developed five major strategies to prevent and control the spread of STIs:
- accurate risk assessment, education, and counseling of at-risk patients on ways to avoid STIs through changes in sexual behaviors and use of recommended prevention services
- identification of asymptomatically infected patients and those with symptoms associated with STIs
- effective diagnosis, treatment, counseling, and follow-up of patients with an STI
- evaluation, treatment, and counseling of sex partners of patients who are infected with an STI
- preexposure vaccination of patients at risk for vaccine-preventable STIs.3
The current, albeit limited, research indicates that patients attending STI clinics and/or presenting to physician offices for STI testing have a general misunderstanding of STI screening procedures.4,5 A study by Royer and colleagues found that 40% of participants incorrectly believed that routine STI screening included testing for gonorrhea, chlamydia, syphilis, herpes, HIV/AIDS, human papillomavirus (HPV), hepatitis B, and trichomoniasis.4 Research by Blake and colleagues highlights these misperceptions, with 78% of adolescent participants believing that a Pap test is synonymous with STI testing.5 These misperceptions present a major public health problem as patients attempt to take responsibility for their sexual health and also represent an area for improved patient education.
CDC guidelines state that patients should be informed about all the STIs for which they are being tested and should be notified about tests for common STIs (such as genital herpes and HPV) that are available but for which patients are not being tested.3 Despite these recommendations and multiple campaigns in the United States to encourage STI screening in sexually active patients, a literature search failed to find any studies on whether patients seeking STI screening are aware of which tests were performed.
A survey research study was conducted to determine whether patients attending an urban STI clinic in Paterson, N.J., could accurately identify which STIs they had been tested for during their visit. This study was reviewed and approved by the institutional review board at the University of Medicine and Dentistry of New Jersey (UMDNJ), New Brunswick/Piscataway.
All patients attending the STI clinic during the 4-week study period between July and August 2011 were eligible for participation. Patients were excluded if they had previously participated in the study. Paterson was selected as the location for this study as it had one of the highest rates of STIs in the state at the time.6 Patients were recruited by the principal investigator at the end of each visit and provided with a consent form and survey in English and Spanish.
A seven-item survey was developed and pretested at an urban clinic with a similar demographic population. Pretest participants were asked to review the survey and were then queried on their interpretation of all questions and suggestions for items needing clarification. The final survey was determined to be at a 4th-grade reading level using the Flesch-Kincaid Grade Level readability test. The survey collected data on demographic questions (age, sex, race or ethnicity, and education), the reason(s) for the participant's visit to the clinic, which STIs the participant believed he or she had been tested for during the visit, and whether the participant's concerns had been addressed by the clinic staff. The STIs included in the questionnaire were those STIs identified by Royer as most commonly believed to be included in routine STI screening; to ensure that any testing perceived by the patient to have been performed was accounted for, an other option was available on the survey.4 Lay terms for STIs (such as trich for trichomoniasis, and herpes for herpes simplex virus) were included in the survey, along with the accepted medical terms and abbreviations of STIs as used in Royer's study (Table 3).4 The phrase sexually transmitted infection/disease (STI/STD) was used on all survey materials for the purpose of this study, as previous research has demonstrated that beliefs about the meanings of these terms vary among patients and providers.7 To ensure anonymity, participants were instructed to place completed surveys in a sealed box to which only the principal investigator and participants had access. All clinic staff directly involved with patient testing and treatment were blinded to the purpose of the study, survey content, and participant responses.
Surveys were linked to patient medical charts through a number or letter provided to patients during registration and listed on completed surveys. Descriptive statistics were employed for population demographics. To measure each participant's knowledge of which STIs they had been tested for during the study visit, surveys were compared with the corresponding participant's medical chart. When a participant correctly identified testing for a specific STI, a score of 0 was assigned for this test. Conversely, a value of 1 was assigned to inconsistent responses; a +1 when a participant was unaware of a test performed, and a -1 when a participant believed a test had been performed when it was not. The sum for each STI test was calculated and the mean score for that participant was reported. Agreement between the participant's knowledge and the actual test status was measured using Cohen's kappa statistic. Using ANOVA F-test, the average number of correct STI tests as determined for each participant prior was compared by demographic variables, provider seen, and week of the patient's visit. Any differences in correct identification of STI tests performed between groups were statistically significant at a P value of .05 or less. Statistical analysis was conducted using SAS version 9.4.
During the study period, 229 patients completed the survey (85% response rate). Most (93.4%) surveys were completed in English. As shown in Table 1, there were slightly more female than male participants. Participants ranged in age from 15 to 68 years; however, the sample was relatively young, with a mean age of 27.71 years (SD 9.6). Most participants identified as black (51.5%) or Hispanic (34.1%). About half (52.4%) of participants reported having more than a high school education.
In comparison to demographic data for the city of Paterson, the median age of participants was younger than the median age of the city (24 versus 32.1 years), and participants ages 15 to 34 years were notably overrepresented in the survey (80.3% versus 31.2%).8 Participants who identified as black also were overrepresented in comparison to the surrounding area (51.5% versus 31.7%).8 These findings, however, are consistent with current STI trends.9 The educational level of participants was higher than that of the general population, with considerably more participants reporting an education greater than a high school diploma (52.4% versus 29.9%).10 Sex was consistent with population demographics.8
Reason for visit
Participants' reason(s) for attending the STI clinic are shown in Table 2. The most commonly stated reason for attending the clinic was the participant wanting to be screened for STIs (61.8%), followed by the participant experiencing symptoms of an STI (22.2%), a partner requesting that the participant be screened (12%), exposure to an STI (7.1%), to receive treatment for a positive test result (5.8%), and to receive results of tests performed on a previous visit (4%).
A statistically significant difference was demonstrated by sex among participants who attended the clinic because a partner had requested screening. Men were significantly more likely (P = .039) to state that their partner had requested screening (17%) than were women (8%). No difference among sex was found for any of the other reasons provided for attending the clinic.
A statistically significant difference between participants' level of education and reason for clinic visit was found for the presence of symptoms (P = .017) and wanting to be screened (P = .005). Participants with less than a high school diploma were more likely to visit the clinic because of symptoms (37.7%) than were participants with a high school diploma (21.2%), some college (21.3%), an associate's or technical school degree (8.9%), or a bachelor's degree or higher (13%). Participant level of education was inversely proportional to the percentage of participants who came to the clinic to be screened in the absence of symptoms. Participants with a bachelor's degree or higher were most likely to come to the clinic (78.3%) to be screened, followed by participants with some college (75.4%), an associate's or technical school degree (52.9%), a high school diploma (61.5%), and less than a high school diploma (42.3%). The only variation between level of education completed and reason for visiting the clinic to be screened was seen among participants with a high school diploma and those with an associate's or technical school degree; however, when the latter was further divided it was found that 69.2% of those with an associate's degree selected this reason compared with only 42.9% of those who attended technical school.
A statistically significant difference (P = .047) was found among age-groups selecting that they were visiting the clinic to receive treatment, with participants ages 15 to 19 years more likely (P = .047) to cite this reason than older participants. However, the exclusion of returning participants from further survey completion, and thus the decreased selection of this response, makes this association less remarkable. No statistically significant difference was found for visit reason when compared by race or ethnicity of participants.
STI tests performed for 214 participants and their responses are summarized in Table 3. Gonorrhea was most frequently (92.6%) tested for at the clinic, followed by chlamydia (90.2%), syphilis (89.3%), HIV/AIDS (71.5%), and trichomoniasis (27.1%).
Only 40.7% of participants were able to accurately identify all the STIs for which they had been tested. Agreement on testing status was greatest for trichomoniasis (kappa = 0.6782), followed by HIV/AIDS (kappa = 0.5156), gonorrhea (kappa = 0.339), chlamydia (kappa = 0.2834), and syphilis (kappa = 0.2547). Trichomoniasis (34.5%) was the most common STI for which participants did not know they had been tested; chlamydia (33.3%) was the most common STI for which participants were not tested but believed that they had been.
Three of the STIs most commonly believed to be included in routine STI testing as identified by Royer's survey—herpes, HPV, and hepatitis B—were not available at the clinic, yet 12.6%, 7%, and 6.1% of participants, respectively, believed that they had been tested for them.5
The average number of tests for which participants correctly identified their testing status based on participant demographics, provider seen, and week of visit is shown in Table 4. The mean number of STI tests (maximum N = 8) correctly identified by participants was 6.78 tests (SD 1.36). Education level was found to be marginally significantly associated with a participant's ability to correctly identify his or her STI testing status (P = .0597). Participants with an education level greater than a high school diploma had higher rates of correct identification of tests performed than those participants who did not graduate from high school or who had only a high school diploma. This association was found independent of the age of participants. There was no significant difference in rates of correct identification of testing status based on sex (P = .2455), language (P = .2523), race or ethnicity (P = .5286), age (P = .408), or provider seen (P = .6624); however, a significant difference was demonstrated based on which week of the study period a patient attended the clinic (P = .0301).
Slightly more than 95% of participants stated that their concerns had been addressed. Although most participants were satisfied with the services provided, participants who provided additional feedback most commonly addressed the lack of availability of testing for herpes simplex virus, HPV, and hepatitis as well as the demeanor and education of providers as the reason for their dissatisfaction.
This study found that most patients were not aware of which STIs they had been tested for, as fewer than half of participants were able to correctly identify which STI tests had been performed during their visit.4 Participants frequently cited having been tested for STIs for which the clinic did not test. STI prevalence rates remain high in most of the United States and the incidence of new infections has reached a historic high, despite the availability of effective methods of prevention, availability of screening initiatives, and therapeutic techniques that can cure or significantly decrease the infectivity of many STIs.11 Although access to healthcare undoubtedly plays a large role in this, the lack of patient knowledge of which tests are performed during routine or requested STI screening, as demonstrated by this study, may significantly contribute to this trend. The fact that there was no difference in patient knowledge among different providers implies that these findings are likely the result of a more systematic problem.
The CDC guidelines recommend routine screening for chlamydia and gonorrhea in women under age 25 years, with testing in other age-groups based on patient sexual behavior and local disease prevalence.3 Although the frequency of testing for gonorrhea and chlamydia was not specifically evaluated in this age-group, gonorrhea and chlamydia were identified as the two STIs most frequently screened for overall. Recommendations from a previous version of the CDC guidelines (current at the time of this study) included women age 25 years as well; however, this change does not affect the data found in this study, as we were evaluating perception of testing rather than whether providers were following current screening guidelines.12 Recommendations for screening of other STIs (such as syphilis and HIV) are based on local population prevalence and patient risk factors and are not routinely recommended based on age alone.
Over one-third of participants who were tested for trichomoniasis were unaware that they had been tested. This finding presents significant economic challenges to already limited STI funding, as patients who are unaware that they have received specific testing may unintentionally request repeat testing in the future, further stressing the healthcare system. Conversely, one-third of participants who received STI testing in this study believed that they had been tested for chlamydia when they had not. These examples illustrate missed opportunities for patient education.
Of the STIs believed to have been tested for that were not offered at the clinic, herpes was the most frequently misidentified. This again presents a major public health challenge, as herpes is incurable and has been identified by the CDC as one of the most prevalent STIs in the United States.1 Routine screening for herpes is not recommended in the general population; however, type-specific serologic testing should be considered for patients presenting for an STI evaluation, those with HIV infection, and men who have sex with men and are at increased risk for HIV.4 Patients' belief that they have been tested for specific STIs when they have not presents a unique risk in clinics that contact patients only when test results are abnormal. In this setting, the STIs for which tests are performed must be accurately conveyed to patients at the time of testing.
CDC guidelines state that patients seeking treatment or screening for an STI should be offered an evaluation for all common STIs.3 Therefore, centers providing STI testing should offer tests for such STIs (herpes, trichomoniasis, hepatitis B, chlamydia, gonorrhea, syphilis, and HIV) or referral to another location offering such testing. Although budget concerns likely limit the plausibility of offering additional testing at many clinics, patient concerns and current guidelines should be taken into consideration by administration when developing testing procedures at public clinics. For patients embarking on a mutually monogamous relationship, screening for common STIs before engaging in sexual activity may reduce the risk of future disease transmission. The STIs most commonly tested for at this clinic were those that are curable and reportable to the state, providing a strong rationale for increased frequency of testing. However, this justification overlooks the importance of identifying patients asymptomatically infected with incurable STIs, so sexual partners can be notified, patients can adopt sexual practices known to reduce disease transmission to current and future sexual partners.
A statistically significant difference between participants' level of education and reason for clinic visit was found for the categories experiencing symptoms and wanted to be screened. Participants' level of education was inversely proportional to the percentage of participants who came to the clinic to be screened, as participants with a higher level of education were more likely to visit the clinic to be screened in the absence of symptoms; participants with a lower level of education were more likely to visit the clinic due to the presence of symptoms. These findings may suggest that patients with a higher level of education are more likely to understand the importance of screening for asymptomatic infections than are those with less education, highlighting a specific vulnerability for less-educated patients and providing support for incorporating sexual health education as part of primary school education.
In contrast to Royer's study, which found that STI-related symptoms were the most common reason (99%) why a woman would request STI testing, only 22.2% of participants surveyed at the Paterson STI clinic sought STI testing due to the presence of symptoms.4 The most common reason provided for attending the clinic in this study was to be screened for STIs (61.8%); most patients (87.8%) did not report symptoms. This finding illustrates a positive belief among patients that infection with an STI may occur in the absence of symptoms and suggests effective education of such high-risk populations about the importance of asymptomatic screening for STIs.
A major limitation of this study is the inability to generalize these findings. Although the findings reported here are consistent with other literature on general patient knowledge of STI testing, the fact that this research involved only one recruitment site limits its application to other practices. Further research should expand on this study by surveying multiple practice settings with varying patient demographics.
Additionally, this study may be a conservative estimate of patient knowledge of STI tests performed due to several factors. Patient consent forms provided during clinic registration stated which STI screening tests were offered at the clinic; herpes simplex virus, hepatitis B, and HPV were not included. Participants who asked the principal investigator administering the survey which tests were performed during their visit as a result of the survey were provided with this information by a member of the clinic staff who was not blinded to the purpose of the study. This occurred infrequently but may have falsely elevated the number of tests correctly identified by patients. Lastly, patients seeking STI testing at an STI clinic may be more informed about testing procedures in general, compared with patients attending a private office for an unrelated concern who are subsequently screened for STIs.
Clinic staff were blinded to the actual purpose of the study and did not have access to survey materials at any time during the research period. Clinicians were informed at the start of the study that a patient satisfaction survey was being performed; however, information about eliciting patient knowledge of testing was not shared, to avoid a change in clinician behavior related to patient education as a result of the survey. Clinic staff also were told not to ask patients about the items listed on the survey. The time period that a patient visited the clinic during the study was included to detect any differences in the education of participants by providers that may have occurred as a result of the survey itself. Interestingly, although a significant difference (P = .0301) was demonstrated in the correct patient identification of tests performed based on when during the study period a patient attended the clinic, the change demonstrated was not in the assumed direction. As the study progressed, the identification of correct testing status by participants decreased. This finding may be coincidental; however, the presence of the survey itself may have caused a change in provider behavior in a manner that actually resulted in a negative effect on patient education. Research has demonstrated that the quality of patient counseling is improved when counselors are periodically evaluated and patients are asked to evaluate their level of satisfaction with services received. However, this study demonstrated that the evaluation process in itself led to a statistically significant decrease in patient education levels about STI tests performed.12
Lastly, although 95% of patients felt that their concerns had been addressed, only 40.7% of these patients were able to identify accurately all of the tests that had been performed during their visit. This finding may demonstrate a falsely elevated sense of patient satisfaction based on an inaccurate belief of which tests were performed during their visit. Had these patients known which tests were and were not performed, they may have stated that their concerns, in fact, had not been addressed.
Most healthcare providers, regardless of practice specialty, will encounter patients infected with STIs. All providers should maintain a working knowledge of current CDC guidelines in order to provide appropriate testing and treatment. Providers performing testing should make a concerted effort to educate patients on which tests are being performed, as well as those common STIs for which testing is not being performed, to avoid misunderstanding and wasted testing. As emphasized by previous studies, healthcare providers should not assume that patients understand the STI testing process. Educational efforts targeted at healthcare providers should highlight the CDC's guidelines for testing and the importance of patient education about STI testing. Preventing STIs and correctly identifying infected patients is critical to reducing the prevalence and potentially negative outcomes of these infections. Clear communication between healthcare providers performing STI testing in all settings is essential to meeting this goal.