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Original article
Where do sexually active female London students go to access healthcare? Evidence from the POPI (Prevention of Pelvic Infection) chlamydia screening trial
  1. Ruth Green1,
  2. Sarah R Kerry1,
  3. Fiona Reid1,
  4. Phillip E Hay2,
  5. Sally M Kerry3,
  6. Adamma Aghaizu1,
  7. Pippa Oakeshott1
  1. 1Division of Population Health Sciences and Education, St George's, University of London, London, UK
  2. 2Department of Genitourinary Medicine, St George's Hospital, London, UK
  3. 3Centre for Public Health and Primary Care, Queen Mary, University of London, London, UK
  1. Correspondence to Dr Pippa Oakeshott, Reader in General Practice, Population Health Sciences and Education, St George's, University of London, London SW17 0RE, UK; oakeshot{at}sgul.ac.uk

Abstract

Background Little is known about where sexually active female students access healthcare.

Objectives Using data from the Prevention of Pelvic Infection (POPI) cohort, the authors aimed to:

  1. Describe where sexually active female students aged ≤27 years reported accessing healthcare.

  2. Investigate the association between numbers of sexual partners during 12 months of follow-up and healthcare usage, health-related quality of life (EQ-5D) and demographic and behavioural characteristics.

Methods Participants provided vaginal swabs and completed questionnaires on sexual health and quality of life at baseline and at a 12-month follow-up. The follow-up questionnaire also asked about healthcare attendances during the previous 12 months. Mann–Whitney tests were used to relate healthcare seeking behaviour and other characteristics to reported numbers of partners during follow-up.

Results Of 1865 women included in the analysis, 79% paid at least one visit to their general practice during follow-up, 23% attended an accident and emergency/walk-in clinic, 21% a family planning clinic and 14% a genitourinary medicine clinic. As the number of sexual partners increased (0–1, 2–3, 4+), women were more likely to have visited a genitourinary medicine clinic (10%, 16%, 30%, p<0.001) or accident and emergency/walk-in clinic (21%, 26%, 29%, p<0.002). Women with more sexual partners were also more likely to smoke, use condoms, be aged <16 years at sexual debut, have bacterial vaginosis, chlamydia or gonorrhoea at baseline and to have lower EQ5-D scores.

Conclusion This is the first UK study of healthcare attendance in multiethnic female students recruited outside healthcare settings. The high attendance in general practice may represent a valuable opportunity for screening for sexually transmitted infections.

  • Antiretroviral therapy
  • vaginosis
  • AIDS
  • chlamydia infection
  • general practice
  • HPV
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Introduction

Sexually transmitted infections (STIs) are a major health concern with significant morbidity and cost associated with their complications. Genital infection with Chlamydia trachomatis is the most common bacterial STI and has been associated with pelvic inflammatory disease, tubal infertility and ectopic pregnancy. More than 111 000 new diagnoses of chlamydia were made in women in the UK in 2010, with over 19 000 in London alone.1

Women who have had two or more sexual partners in the last year have been shown to be at an increased risk of being infected with C trachomatis,2 ,3 but little is known about their health-related quality of life. It is important to find out which healthcare facilities such women are most likely to attend in order to target sexual health services in the most appropriate setting. However, there are few data on the health-seeking behaviour of women with multiple partners from a community perspective.

Using data from the Prevention of Pelvic Infection (POPI) chlamydia screening trial,4 our aims were:

  1. To describe where sexually active female students report accessing healthcare over a 12-month period.

  2. To assess if healthcare usage is related to reported number of sexual partners during 12-month follow-up.

  3. To compare health-related quality-of-life scores, age, ethnicity, smoking, condom use, age at sexual debut and genital infection at baseline related to number of sexual partners during follow-up.

Methods

Data collection

Details of the POPI trial have been published elsewhere.4 In 2004–2006, 2529 sexually active female students (aged 16–27 years) in universities and further education colleges across London were recruited to a randomised controlled trial to determine whether screening and treating women for chlamydia reduce the incidence of pelvic inflammatory disease over the subsequent 12 months. Women who had been tested for chlamydia in the past 3 months and women who had never had sexual intercourse were excluded. Participants completed a paper questionnaire on sexual health and quality of life at baseline and an electronic, postal or telephone questionnaire at follow-up after 12 months. The follow-up questionnaire also asked about healthcare attendances during the last 12 months. At baseline, participants also provided self-taken vaginal swabs, which were tested for C trachomatis, bacterial vaginosis, Mycoplasma genitalium5 and Neisseria gonorrhoeae.

Sample size

Of 2529 women recruited, 76% (1928) answered the questions on the number of sexual partners and healthcare attendance in the 12-month follow-up questionnaire. A further 63 women from the intervention group were excluded as they tested positive for chlamydia at baseline and were advised to attend a GP or a GUM clinic for treatment. This left 1865 women who were included in the analysis.

Statistical analysis

The percentage of women who reported visiting each healthcare destination (general practice (GP), accident and emergency (A&E)/walk-in clinic, genitourinary medicine (GUM) clinic, family planning (FP) clinic) at least once in the past year was calculated. We categorised women according to number of reported sexual partners during 12-month follow-up (0–1, 2–3, 4+).6 Mann–Whitney tests were used to relate healthcare attendance to number of partners. We also looked at healthcare attendance related to undiagnosed chlamydia at baseline.

Baseline and follow-up questionnaires included questions for the generic health-related quality-of-life measure EQ5-D, which has five dimensions: mobility, self-care, usual activities, pain and anxiety/depression.7 Weighted UK values were linked to the self-reported health state scores for a 0–1 index, where 0 is death and 1 is perfect health.8 As most women ticked the top boxes implying that they had no problems in any of the five dimensions, we divided them into those scoring 1 versus the remainder. We compared quality of life (perfect health vs not), age, ethnicity, smoking, condom use, age at sexual debut and having a baseline positive swab for chlamydia, bacterial vaginosis, gonorrhoea or M genitalium between women with different numbers of partners during 12 months of follow-up using Mann–Whitney tests.

Results

Sample demographics

Of 1865 women included in the analysis, 40% (736) were aged younger than 20 years, 35% (653) were from an ethnic minority group, including 23% (425) of black ethnicity, and 74% (1380) were recruited from universities and the remainder from further education colleges. The percentage of women reporting zero to one sexual partner during follow-up was 63% (1172), two to three partners 27% (499) and four or more partners 10% (194). Compared with women included in the analysis, the 664 (26%) women who were not included were younger (average age 19 years (SD 2.5) vs 21 (SD 2.8), p<0.0001) and more likely to be of black ethnicity (39% (257/664) vs 23% (427/1865), p<0.0001).

Healthcare attendance overall

Most women (79%) paid at least one visit to the GP in the 12-month period, 23% attended A&E or walk-in clinic, 21% family planning clinic and 14% genitourinary medicine clinic. A small proportion (11%) did not report attending any healthcare provider. The mean number of visits over 12 months to the GP was 2.4 (range 0–30), FP clinic 0.39 (range 0–10), A&E/walk-in centre 0.35 (range 0–15) and GUM clinic 0.21 (range 0–10).

Healthcare attendance related to undiagnosed chlamydia at baseline

Of 51 women with chlamydia at baseline, 69% (35) reported visiting a GP, 29% (15) a family planning clinic, 29% (15) a GUM clinic, 20% (10) A&E, while 18% (9) did not report attending any healthcare provider. Women with chlamydia at baseline were more likely than those without to report attending a GUM clinic: 29% (15/51) versus 13% (243/1814, p=0.001).

Healthcare attendance related to number of sexual partners

As the number of reported sexual partners increased (0–1, 2–3, 4+), women were more likely to have visited a GUM clinic and/or A&E/walk-in clinic (table 1).

Table 1

Comparison of healthcare attendance one or more times by number of sexual partners during 12 months of follow-up in 1865 sexually active young women

Characteristics, genital infection and quality of life related to number of sexual partners

As the number of reported sexual partners increased, women were more likely to be aged younger than 20 years, to be smokers, use condoms, be aged younger than 16 years at sexual debut and have bacterial vaginosis, chlamydia or gonorrhoea at baseline (table 2). They were also less likely to score 1 (indicating perfect health) on the EQ5-D scale at baseline and follow-up.

Table 2

Comparison of baseline characteristics and EQ5-D scores at baseline and follow-up by reported number of sexual partners during 12 months of follow-up

Discussion

Principle findings

Around four-fifths of women in the study had paid at least one visit to the GP in the previous 12-month period, but only 14% had visited a GUM clinic. As the number of reported sexual partners during follow-up increased, women were more likely to have visited a GUM clinic or A&E/walk-in clinic, to smoke, use condoms, have had bacterial vaginosis, chlamydia or gonorrhoea, to be aged younger than 16 years at sexual debut and to report worse quality of life. Women with baseline chlamydia were more likely than those without to have attended a GUM clinic.

Strengths and weaknesses

This is the first UK study of healthcare attendance in sexually active young, multiethnic female students recruited away from healthcare facilities. It provides valuable observational data on their characteristics and health-seeking behaviour. In addition, no other UK studies have provided data on health-related quality of life in association with number of sexual partners in young women in the community. Although it is an opportunistic rather than population-based sample, this may be the best available data on the healthcare attendance of a relatively high-risk group of multiethnic young women. As in other studies,2 ,6 data on behaviour and healthcare attendance were self-reported and may be unreliable and subject to recall bias. Another limitation is that we excluded 63 women who tested positive for chlamydia at baseline because they were advised to attend a GUM clinic or their GP to obtain treatment. These women would be expected to be at greater risk of STIs. Finally, although all women were sexually experienced at recruitment, 6% (114) reported having had no sexual intercourse during follow-up.

Comparison with other studies

To our knowledge, there has only been one other community-based study of healthcare attendance related to sexual behaviour. This was a birth cohort study from New Zealand,6 which showed that high-risk women with multiple partners were just as likely to visit the GP as lower risk women. In line with a large population-based UK study9 and our findings, it also demonstrated high overall levels of GP attendance. Despite these high attendance rates, data from the National Chlamydia Screening Programme (2010–2011) show that only 14% of chlamydia screening tests for women aged 15–24 years in England were performed in general practice.10 Our study also furthers the understanding of health-seeking behaviour beyond primary care11 by showing that women at greater risk of STI by virtue of having multiple sexual partners are more likely than women at lower risk to present to GUM clinics. The same applied to women with undiagnosed chlamydia at baseline. However, another study showed that 35% (348/1000) of GUM attenders had attended primary care initially.12

Implications

The association between increasing numbers of sexual partners and worse health-related quality of life may be related to a less stable lifestyle.7 Most women (87%, 550/633 at follow-up) with less than perfect health on EQ5-D had raised depression/anxiety scores. Although women reporting multiple sexual partners were more likely than those reporting fewer to attend a GUM clinic, 80% of women reporting two or more sexual partners and 71% of those with chlamydial infection at baseline did not attend GUM. This highlights the importance of screening in other types of healthcare facility. As previously suggested,9 ,12 the high rate of attendance at general practice in this group may represent a valuable and underused opportunity for screening for STIs. This supports the strategy adopted by the National Chlamydia Screening Programme13 of targeting sexually active women in a variety of healthcare settings, including primary care.

Key messages

  • Nearly 80% of sexually active young women reported attending a GP in the last 12 months, and 14% attended a genitourinary medicine clinic.

  • As numbers of reported sexual partners increased, women were more likely to report attending a genitourinary medicine clinic or A&E department.

  • Women reporting more sexual partners were more likely than those with fewer to smoke, use condoms and have lower health-related quality of life scores.

  • Attendance in primary care may represent a valuable and underused opportunity to screen for STIs.

References

View Abstract

Footnotes

  • Funding BUPA Foundation Grant 684/GB14B and Medical Research Council Grant 80280. Gen-Probe provided the Aptima test kits.

  • Correction notice This article has been corrected since it was published Online First. The following sentence has been amended to read: Of 1865 women included in the analysis, 79% paid at least one visit to their general practice during follow-up, 23% attended an accident and emergency/walk-in clinic, 21% a family planning clinic and 14% a genitourinary medicine clinic.

  • Competing interests PO and PEH are members of the eSTI2 consortium funded by the UK Clinical Research Collaboration http://www.esti2.org.uk.

  • Patient consent Obtained.

  • Ethics approval The study was reviewed by Wandsworth Research Ethics Committee (reference 03.0012) and Bromley Research Ethics Committee (reference: 07/Q0705/16).

  • Provenance and peer review Not commissioned; externally peer reviewed.

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