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Perceived risk of chlamydial and gonococcal infection among sexually experienced young adults in the United States.

Article Excerpt
Chlamydia trachomatis causes the most common bacterial sexually transmitted disease (STD) in the United States. (1) Five percent of U.S. women aged 18 26 and 4% of men that age have chlamydia; prevalences are elevated among black women (14%), black men (11%) and Hispanic men (7%) in this age-group. (2) In comparison, the overall prevalence of gonococcal infection is low (0.4%), but is elevated among blacks (2%). These results, from Wave 3 of the National Longitudinal Study of Adolescent Health (Add Health), are consistent with findings from a growing literature that has documented wide racial disparities in rates of HIV and other STDs. (3)

In women, Chlamydia trachomatis and Neisseria gonorrhoeae can cause acute and long-term morbidity, including pelvic inflammatory disease, infertility from scarring of the fallopian tubes, chronic pelvic pain and ectopic pregnancy. (4) Chlamydial infection may also be linked to an increased risk of cervical cancer, (5) and both chlamydial and gonococcal infections may increase transmission of HIV in men and women. (6) The direct medical costs associated with chlamydial and gonococcal infections among 15-24-year-olds in the United States in 2000 were an estimated $325 million. (7)

Perceived risk of infection is an important aspect of efforts to reduce the prevalence of chlamydia and gonorrhea for efforts reasons. First, risk perceptions can influence sexual behavior. Several theoretically driven STD intervention programs seek to change sexual behavior in part by altering risk per captions. (8) Although empirical data on perceived risk and condom use have yielded mixed results, in a prospective study of 14 19-year-olds attending an STD clinic, Ellen and colleagues found that participants' perceived risk of being infected by a main partner was an independent predictor of condom use with that partner. (9) Few studies have examined the association between sexual behavior and perceived risk of current infection, but the two may be related. For example, a person who thinks he or she could be infected may be more likely than someone who does not to abstain or use condoms because of concerns about transmitting infection.

Second, risk perceptions can influence health care--seeking behavior. (10) A person who thinks he or she could have an STD may be more likely to seek a doctor or nurse's evaluation than someone with no perceived risk. Health care could be highly effective in reducing the prevalence of chlamydia and gonorrhea, because both infections are easy to diagnose and curable with a single dose of oral antibiotics. (11) Early detection and treatment prevents complications and stems the spread of infection through sexual networks.

Risk perceptions are complicated by the fact that many STDs do not produce physical symptoms. More than 95% of Wave 3 Add Health respondents who tested positive for chlamydia reported no symptoms within the previous 24 hours; findings for gonorrhea were similar. (12) Within this context, it is important to understand risk perceptions among asymptomatic populations in nonclinical settings. However, most of what we currently know about perceived risk of STDs comes from clinic-based or regional studies. (13)

Wave 3 of Add Health provides a unique opportunity to increase our understanding of perceived risk because it is based on a nationally representative sample and included biological tests for chlamydia and gonorrhea. In this study, we used bivariate and multivariate analyses to examine relationships between perceived risk and respondents' demographic characteristics, sexual risk behaviors and other SYD-related lectors. Analyses were conducted among two groups: sexually experienced Wave 3 respondents aged 18-26 and a subsample of respondents who tested positive for chlamydia or gonorrhea at the time of the survey. We also examine the association between Wave 3 test results and perceived risk of infection.

METHODS

Study Design

Add Health is a prospective cohort study designed to follow almost 20,000 participants from adolescence to adulthood. Add Health sampling methods have been described in detail elsewhere. (14) In brief, the original sample (Wave 1) was selected from enrollment rosters for grades 7-12 early in the 1994-1995 school year. The rosters came from 80 high schools and 52 middle schools. Schools were selected to be representative of U.S. schools in regard to region, urbanization, type of school, proportion of white students and size of school. Black students from relatively affluent families and certain Hispanic groups were oversampled to increase the precision of estimates for these groups. Appropriate weighting and analytic techniques that account for the sampling design can be used to ensure that the Add Health cohort provides a nationally representative study sample.

Wave 3 was conducted between August 2001 and April 2002. All Wave 1 respondents who were living in one of the 50 states and could be contacted were asked to participate in an interview and to provide a urine specimen for STD testing. Our study is based on the 11,821 Wave 3 respondents who were sexually experienced and provided a response to our measure of perceived risk, and for whom weights were available. Sexual experience was established by a positive response to the question "Have you ever had vaginal intercourse? (Vaginal intercourse is when a man inserts his penis into a woman's vagina.)."

Procedures

Wave 3 interviewers traveled to each respondent's home or to another suitable location identified by the potential participant. After respondents gave written consent, 90-minute interviews were conducted in as private an area as possible. Interviewers entered responses directly into a computer, and participants used compute>assisted self-interview to answer potentially sensitive questions (e.g., questions about sexual behavior and perceived risk of STDs).

At the end of the interview, participants were asked to consent to STD testing. Those who provided written consent were instructed to collect 20 ml of first-void urine in specimen containers. Urine...