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Original Article

Delayed Presentation to Clinics for Sexually Transmitted Diseases by Symptomatic Patients: A Potential Contributor to Continuing STD Morbidity

HOOK, EDWARD W. III MD*†; RICHEY, CHARITY M. MPH*; LEONE, PETER MD; BOLAN, GAIL MD§; SPALDING, CORA MD, MPH; HENRY, KEITH MD; CLARKE, PEGGY MPH; SMITH, MARK MD, MBA**; CELUM, CONNIE L. MD, MPH††

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Abstract

MANY PATIENTS WHO attend clinics for sexually transmitted diseases (STDs) do so for evaluation of genitourinary symptoms.1 Provision of expeditious and effective therapy for symptomatic patients with bacterial STDs is an important component of efforts to prevent STD-related morbidity, particularly risks for complications2–4 and the likelihood of transmission of infection to others.5 Although the likelihood of transmission by symptomatic infected individuals to others is unknown for most STDs, several studies indicate that up to one third of individuals with symptomatic gonorrhea continue sexual activity in the interval between the onset of STD symptoms and presentation for diagnosis and therapy.6,7 Thus, better understanding of characteristics of symptomatic individuals who delay presentation for STD diagnosis and therapy might provide important information to help shape new interventions to control STDs.

In April through September 1995, a five-site survey of nearly 2,500 patients attending publicly funded clinics for STDs was conducted in Birmingham, AL; Raleigh, NC; San Francisco, CA; Seattle, WA; and St. Paul, MN to evaluate patients attending STD clinics for their past utilization and preferences for choosing STD clinics as sites for care.1 This report describes the nearly two thirds of survey participants who presented to these clinics for symptom evaluation in terms of the intervals between the symptom onset and clinic presentation, self-reported reasons for any delays in clinic attendance, and the frequency of STD diagnoses among these symptomatic individuals at the time they presented to the participating STD clinics.

Materials and Methods

Study Design

Between April and September 1995, a standardized 23-item questionnaire was administered to clients attending publicly funded, urban STD clinics in Birmingham, AL; Raleigh, NC; St. Paul, MN; San Francisco, CA; and Seattle, WA.1 Participating clinics were chosen on the basis of their relatively high patient volumes and their willingness to participate in the study and in an effort to conduct the survey at clinics from a variety of geographic settings and serving clients with a spectrum of demographic characteristics and STD morbidity. At each site, enrollment goals were 250 men and 250 women attending the clinics for new problem visits or for STD screening. Clients were excluded if they were attending the clinics for follow-up, test results, research visits, or solely for human immunodeficiency virus (HIV) counseling and testing without STD screening. Enrollment of equal numbers of men and women required oversampling of women attending these clinics because the majority of patients attending each of these STD clinics is male. Convenience-based sampling methods were used to recruit patients.

Trained study interviewers recruited patients after registration and before their evaluation by clinicians. In private rooms, survey questions were read to each participant as open-ended questions and answers were recorded by the interviewer. After the interview, at a date when all STD laboratory tests results were available, each participant's clinic record was reviewed to determine the clinical diagnoses and the results of laboratory tests that were obtained at the interview visit. All participants provided informed consent before the interview and for medical record review. The survey instrument and study design were approved by the Human Subjects Review Committee at each of the five sites.

The laboratory tests performed on participants were those routinely provided at each site according to local clinic protocol. Tests were performed at the laboratories that routinely provided laboratory support to each of the clinics.

Data Analysis

All survey responses were entered into a computerized database using Epi-Info 6.0 software (Centers for Disease Control and Prevention, Atlanta, GA). Cross-tabulations and descriptive statistics were calculated using chi-square tests for categorical variables and STD laboratory test results and nonparametric tests (eg, Mann-Whitney) for continuous variables.

Separate multivariable regression analyses were performed for some of the variables (age, race, education, income, and prior clinic attendance). Mantel-Haenszel chi-squared tests were used for these individual variables. These variables were then included in a more complex model to adjust potential risk factors and to determine whether interaction between risk factors exists. SAS' Backward Elimination Procedure (SAS Institute, Cary, NC) was used to perform this multivariable regression.

Results

Descriptions of the entire study population, their prior patterns of STD and non-STD related health care, their preferences for future STD care, and STD morbidity diagnosed in respondents have been described in detail elsewhere.1 Briefly, between April and September 1995, 2,590 patients were surveyed at the five study sites: 548 from Seattle; 500 from St. Paul; 562 from Raleigh; 509 from Birmingham; and 471 from San Francisco. During the study period, interviews were administered to approximately 15% of all patients attending these STD clinics for new problems. (Data not shown.)

In general, the study population was young (51% less than 25 years of age), was nonwhite (60% persons of color), heterosexual (90%), and had a relatively low level of educational attainment (55% had completed high school or less, a finding strongly correlated with the proportion of participants <18 years of age).1 When compared with the demographic characteristics of all clients seen at the five participating STD clinics during the study period, the study population varied significantly from site to site in demographic characteristics, was younger, and had a higher proportion of female respondents (by design-see Methods) but had similar race/ethnicity and sexual orientation distributions.1 (Data not shown.) For instance, in Birmingham nearly three quarters of clients were less than 25 years of age compared with only 30% of those attending the San Francisco Clinic. Birmingham and Raleigh had the highest proportion of African-American participants (92% and 66%, respectively), whereas at all other sites 25% to 40% of respondents were African-American. Overall, 1,621 (65.2% of men, 59.7% of women) patients attending these clinics who participated in the survey complained of genitourinary symptoms as one of their reasons for clinic attendance (Table 1). Among the participating clinics, with one exception, 64% to 68% of participants reported genitourinary symptoms; in Raleigh, NC, 51% of participants reported symptoms on the day of clinic attendance. The proportions of clients with and without symptoms who had previously attended the STD clinic were also similar both overall and when subset by gender. This group of 1,621 symptomatic patients comprise the study population for the following analyses.

TABLE 1
TABLE 1:
Selected Characteristics of Symptomatic Patients Attending Five Urban STD Clinics

Over one third of the 1,621 symptomatic patients attending the five participating STD clinics (35% of men, 37% of women) presented only after more than 1 week of genitourinary symptoms (Table 2). Of those patients who presented after more than 7 days of symptoms, 21.5% of men and 28% of women reported 8 to 30 days of symptoms and 11.5% (13.5% [120] men and 9.1% [67] women) reported that symptoms had been present for more than 1 month.

TABLE 2
TABLE 2:
Duration of Genitourinary Symptoms in Patients Attending Five Urban STD Clinics

Despite the fact that many patients did not seek care immediately after onset of symptoms, at the time of STD clinic evaluation, most patients had indications for immediate treatment (eg, clinically diagnosed urethritis, cervicitis, vaginal infections, a history of recent sexual contact to an infected partner; Table 3). Only 16.7% of men presenting to the STD clinics with genitourinary symptoms were classified as having normal examinations. Over 46% of symptomatic men received clinical diagnoses of urethritis; 6.4% were diagnosed with genital herpes; and 0.33% had early syphilis. The proportion of symptomatic patients who presented to the clinics after more than 1 week varied by disease (Table 3). For instance, whereas only 6.5% of men with symptomatic gonococcal urethritis delayed more than 7 days before clinic attendance, 23.1% of men with nongonococcal urethritis (NGU) and 36.3% of symptomatic men who reported they had been recently exposed to a sex partner with an STD presented after more than 7 days of genitourinary symptoms (p < 0.001 for each vs. men with gonorrhea). Over 73% of men diagnosed with genital warts had delayed more than a week before clinic attendance.

TABLE 3
TABLE 3:
Clinical Diagnoses Made in Symptomatic STD Clinic Patients by Delays in Clinic of More Than or Less Than 7 Days

As for men, the majority (77.3%) of symptomatic women survey participants received clinical diagnoses and/or were treated for STD at the time of clinic attendance. Other than women who had clinically apparent warts (N = 44), 20% to 43.8% of symptomatic women attending participating STD clinics delayed attendance for more than 7 days after the onset of symptoms before being treated at the STD clinics (Table 3). Women diagnosed with genital herpes and gonorrhea were least likely to delay clinic attendance (20% and 25%, respectively), although substantially larger proportions of women diagnosed with cervicitis syndromes (42.8%) or pelvic inflammatory disease (43.8%) presented to the clinics only after 7 days of symptoms. Over one third (range 35.3% to 36.9%) of women with the most common causes of symptomatic vaginal discharge (bacterial vaginosis, trichomoniasis, or fungal vaginitis) presented to the clinic only after symptoms had been present for more than 1 week. Similarly, 34.8% of symptomatic women who were also sexual contacts to men with STDs delayed for more than a week before presenting to the STD clinics.

Multivariate analyses were performed separately for men and for women to evaluate correlates of delayed (>7 days) clinic attendance, adjusting for interactions between those factors. The models each included age, race, educational attainment, self-reported income, and prior STD clinic attendance. For men, participants who were over age 34 years or black were significantly less likely to delay STD clinic attendance (relative risk [RR] [95% confidence intervals (CI)], 0.92 [0.85 to 0.99], and 0.73 [0.69 to 0.78], respectively). In contrast, men with college or higher levels of education were significantly more likely to delay presentation to STD clinics for more than 7 days (RR [95% CI] 1.09 [1.01 to 1.19]). For women, only race/ethnicity was significantly associated with the timing of STD clinic attendance. Women who were white or Filipino/Pacific Islanders (RR [95% CI] 1.13 [1.05 to 1.21] and 1.41 [1.03 to 1.94], respectively) were more likely to delay attendance, whereas black women were less likely to delay clinic attendance (RR [95% CI] 0.88 [0.82 to 0.95]).

Symptomatic patients who did not present to the STD clinics on the day their symptoms occurred were asked why they did not immediately present for evaluation (Table 4). For all symptomatic men, the most common reasons reported were that they had hoped their symptoms would resolve (35.6%), difficulty getting time off from work (18.2%), or that their symptoms were not a priority for them (10.2%). Among men who delayed for more than a week before clinic attendance, hoping that their symptoms would go away and believing that the symptoms were not a priority were the two most common reasons for delaying clinic attendance (48.5% and 21.2%, respectively). Interestingly, the proportion of men who indicated that they were hoping their symptoms would resolve did not differ significantly when men who had previously attended the STD clinics (152 [33%] of 460) were compared with those attending the clinics for the first time (164 [38.4%] of 427, p = 0.09). In addition, 11.3% of men who delayed for more than 7 days reported that they did not know where to go for care.

TABLE 4
TABLE 4:
Reasons for Delay in Attending STD Clinics for Evaluation by Gender and Duration of Symptoms

Similarly, for all symptomatic women, by far the most common reason cited for delaying STD clinic attendance was their hope/belief that their symptoms would resolve, cited by 43.3% of all symptomatic women and 49.4% of those who delayed attendance for a week or more (Table 4). Difficulties in getting time off from work and believing that their symptoms were not a priority were also cited relatively frequently as reasons for not presenting for evaluation earlier, being mentioned by 13.9% and 17.5% of women, respectively. As for the male participants, there were no significant differences in the frequency that women cited they had hoped symptoms would resolve as their reason for delay when women who had previously attended the clinics were compared with those who did not (166 [40.5%] of 410 vs. 152 [46.9%] of 325, p = 0.08). Another similarity with the male responses is that 10.6% of women delaying clinic attendance for more than 7 days stated they did not know where to go for care.

Discussion

The majority of patients treated at STD clinics are present for evaluation of genitourinary symptoms. Timely evaluation of symptomatic patients has been emphasized as an important contributor to STD control, both for the purpose of preventing complications2–4 and for reducing transmission of infection to others.5 Although ensuring ready availability of clinical services is one important component of provision of clinical services, unless individuals expeditiously seek care after onset of STD symptoms, they remain at risk for complications and transmission of infection. This study found that over one third of symptomatic patients attending five busy urban STD clinics indicated that their genitourinary symptoms had been present for periods of more than 1 week before seeking evaluation. Access to care did not appear to be a major problem for these individuals seeking care at publicly funded facilities. Less than 10% of symptomatic patients overall and less than 1% of those who procrastinated for more than 7 days indicated that the clinic was closed or unable to see them as a reason for delayed evaluation. In contrast, far more attributed their delays to either the ill-founded hope that their symptoms would go away or the fact that their symptoms were not enough of a priority to come to clinic sooner. It may be understandable that individuals with genitourinary symptoms would hope that they did not have STDs. Failure to quickly seek care may also suggest misperceptions regarding typical STD symptoms, a lack of understanding of the potential consequences of delay, denial, and low prioritization of genitourinary signs and symptoms.

The findings of this study are consistent with those in a recent study of 208 adolescents attending a Chicago STD clinic8 that also found that one third of symptomatic subjects delayed seeking care for more than 1 week. However, our study extends this observation to patients of all ages attending STD clinics. In addition, the multicenter nature of this study suggests that the problem of delayed clinic attendance by symptomatic STD clinic clients may not only be generalizable across gender and age groups but also for different regions of the country. In his study, Fortenberry8 found associations between failure to expeditiously seek care and both lower self-efficacy and low estimates of the seriousness of STDs for both men and women.

The majority of patients with slowly progressive, chronic viral STDs such as genital warts reported signs or symptoms for periods of more than a week before clinic attendance. However, more troublesome was that substantial numbers of patients with more acute, readily treatable bacterial STDs also delayed clinic attendance. For instance, 6.5% of men with gonorrhea and over 23% of men with NGU delayed STD clinic attendance for more than a week. The differences in the proportions of men with gonococcal and nongonococcal urethritis (NGU) who delayed seeking care for a week or more have been described previously (as “incubation periods”) and may relate to the relative severity of symptoms.9,10 Nonetheless, the public health impact of such delays has not been emphasized as a target for interventions to promote STD control. Although participants in this survey were not questioned regarding sexual activity, based on earlier studies of patients with gonorrhea,6,7 it appears likely that a substantial number of these men with symptomatic STDs may have had sexual contact with a new or an uninfected sexual partner in the interval between the onset of their symptoms and clinic attendance.

Similar to men, a substantial proportion of symptomatic women also delayed attendance at the STD clinics. As for men, the majority of women who received clinical diagnoses of genital wart infections reported symptoms for periods of more than a week. However, also similar to men is that 20% to 44% of symptomatic women with transmissible infections or STD syndromes also delayed attendance. Like male clinic attendees, the most common response in female patients who delayed for periods of more than a week were that they were hoping that their symptoms of disease would go away. The consequences of failure to seek timely evaluation and care for genitourinary symptoms for women include not only transmission of infection to others but also complications of untreated infection, in particular pelvic inflammatory disease and infertility. The observation that over 40% of women enrolled in this study who received a clinical diagnosis of pelvic inflammatory disease delayed clinic evaluation for more than a week supports the likelihood that failure to seek care may have contributed to increased STD-related morbidity for these women.4

Several limitations of this study should be acknowledged. Participants for this survey were not randomly selected. However, the large sample size, the similarities in demographic characteristics to the entire clinic population,1 and the substantial proportion (∼15%) of all clinic patients seen during the study period increase the likelihood that the findings of this study accurately represent the characteristics of patients attending the participating clinics. In addition, that study participants were recruited from clients attending STD clinics may limit the generalizability of these data. It is possible that patients seeking evaluation of genitourinary symptoms from private providers, from health maintenance organizations, or from other sources of care may differ in the proportions who delay seeking care for symptoms of possible STD, the durations of delay, and in their reasons for delay. Nonetheless, given the fact that 58% of reported gonorrhea, 69% of reported early syphilis, and 33% of reported chlamydia infections in the United States are from public clinics,11 it is likely that our findings are relevant for a substantial proportion of STD morbidity. Finally, African-Americans are disproportionately represented in the study population, as is typical of clients attending publicly funded clinics for STDs. However, because this group also experiences a disproportionate share of national STD morbidity,11 the findings of this study warrant attention.

In addition to the previously described limitations, it must be emphasized that these analyses have focused on only a portion of patients with STDs. The proportion of individuals who are symptomatic varies from one STD to another and for STDs by gender. Thus, the potential contribution of failure to recognize or act on STD symptoms is likely to vary for different diseases and in different patient populations.

Prior studies have not explored the reasons that individuals failed to seek care for genitourinary symptoms in a timely fashion. Our data, as well as anecdotal experience of the authors, suggests that a large proportion of patients attending STD clinics are unaware that STD symptoms may be mild and may vary in severity. In addition, the observation that for over 17% of women and 20% of men reporting genitourinary symptoms for more than a week stated that their symptoms were simply not a priority suggests that these individuals may be unaware of the serious long-term sequelae associated with STDs. These data are further reinforced by the observation that even when patients had two “cues to action” such as genitourinary symptoms and notification of recent exposure to sex partners with STDs, over one third of patients (36.3% of men and 34.8% of women) still delayed for more than 1 week before seeking care. Thus, the data of this study suggest an opportunity to improve STD control and reduce STD-related morbidity through efforts to increase public awareness that STD symptoms may be nonspecific (eg, vaginal discharge), mild, or even absent and that all patients who notice genitourinary symptoms should seek evaluation at their earliest opportunity. To do so would likely reduce complications of genitourinary tract infections in women and reduce transmission of infections to uninfected sexual partners. Interventions to encourage individuals with genitourinary symptoms to seek expeditious evaluation and treatment represent an opportunity to reduce STD morbidity from transmission of infection to others as well as complications resulting from prolonged, untreated infections.

References

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7. Upchurch DM, Brady WE, Reichart CA, Hook EW, III. Behavioral contributions to acquisition of gonorrhea in patients attending an inner city Sexually Transmitted Disease clinic. JID 1990; 161:938-941.
8. Fortenberry JD. Care-seeking behaviors related to sexually transmitted diseases among adolescents. Am J Pub Health. In Press.
9. Jacobs NF, Kraus SJ. Gonococcal and nongonococcal urethritis in men. Ann Intern Med 1975; 82:7-12.
10. McCutchan JA. Epidemiology of venereal urethritis: comparison of gonorrhea and nongonococcal urethritis. J Infect Dis 1984; 6:669-688.
11. Division of STD Prevention. Sexually Transmitted Diseases Surveillance, 1994. US Department of Health and Human Services, Public Health Service. Atlanta: Centers for Disease Control and Prevention, September 1995.
© Copyright 1997 American Sexually Transmitted Diseases Association