...Transmitted Infections (PHAC, 2006) recommend routine testing all sexually active women in this age group and some prior sexual health assessment interviewing is therefore needed as well. Respondents were 251 physicians (52% male; 48% female) practicing in Toronto who worked predominantly in general/family practice and/or walk-in clinics. When asked about their likelihood of recommending Chlamydia testing for 15- to 24-years-olds in different contexts or types of visit, over 90% said they would do so if the patient asked, about half would do so in annual checkups or as an add on to Pap test, but only 3% said they would do so in visits for other reasons. This suggests situational rather than routine assessment and testing, which was also reflected in actual self-reported practices in the past month. Female physicians did sexual health assessment and Chlamydia testing in a greater percentage of visits than male physicians. Physicians endorsed few barriers to offering Chlamydia testing except for "not having enough time" (31.5% of respondents). Possible explanations of the findings and applications to professional education and support are discussed.

Introduction

Chlamydia trachomatis is the most common bacterial sexually transmitted infection (STI) in Canada. The highest reported rates of infection are among adolescent and young adult women. In 2004, the Chlamydia rate was 1443.6 per 100,000 among women aged 15-19 and 1489.4 among women aged 20-24 (Public Health Agency of Canada, 2006a). There have been no large scale Chlamydia prevalence studies conducted in Canada. In a review of existing Canadian studies, Davies and Wang (1996) noted Chlamydia prevalence rates among sexually active adolescents, college students, women attending community clinics, family planning units, and abortion clinics ranging from 7% to 25% and Richardson, Sellors, Mackinnon et al. (2003) found a prevalence of 6% among women aged 16-30 years in Hamilton, Ontario. These prevalence rates are in line with the results of the much larger, geographically diverse prevalence studies conducted by the Centers for Disease Control and Prevention (2006) in the United States that have found a Chlamydia prevalence rate of 6.3% among 15- to 24-year-old women attending family planning clinics. Chacko, Wiemann, and Smith (2004) report that asymptomatic Chlamydia infection is highly prevalent among economically disadvantaged females in the United States. In the city of Toronto, it has been shown that living in areas characterized by socio-economic disadvantage is associated with higher rates of STI, including Chlamydia (Hardwick & Patychuk, 1999).

Most Chlamydia infections are asymptomatic and, if left untreated, may lead to pelvic inflammatory disease (PID) and its sequelae, most notably infertility, chronic pelvic pain, and ectopic pregnancy (Banikarin & Chacko, 2005; Hills, Owens, Marchbanks et al., 1997; Kelver & Nagamani, 1989). According to the Public Health Agency of Canada (2005), ectopic pregnancy is a leading cause of maternal death in the first trimester. In 20% to 60% of cases, ectopic pregnancy leads to permanent sterility.

Using a randomized control design, Scholes et al. (1996) demonstrated that a screening strategy that identified, tested, and treated women at increased risk for Chlamydia reduced the incidence of PID by 56% in one year of follow-up. Additional case studies have shown that screening programs significantly reduce the prevalence of genital tract infections and PID (Pimenta, et al., 2002).

The Canadian Guidelines on Sexually Transmitted Infections (Public Health Agency of Canada, 2006b) recommend that sexually active females under age 25 be screened for Chlamydia infection and that patients be assessed for sexual risk factors for Chlamydia infection. Chlamydia screening of all sexually active women under age 25 is also recommended in the United States (Centers for Disease Control and Prevention, 2002) and England (Pimenta et al., 2002). The purpose of the current study was to assess the current Chlamydia screening of young women aged 15 to 24 by primary care physicians practising in the city of Toronto.

The Taking Action on Chlamydia social marketing campaign

To reduce the prevalence of Chlamydia among youth and young adults, in 2004, Toronto Public Health began a five-year social marketing campaign targeting physicians and youth. The first phase of the campaign included a series of five information packages mailed to primary care physicians practising in the city of Toronto. The information packages included materials designed to encourage proactive Chlamydia testing of sexually active youth under age 25. As a first phase of an evaluation of the physician campaign, baseline data was collected to comprehensively assess current physician practices related to Chlamydia testing of youth and to determine variables associated with high or low levels of testing. Results from the baseline study reported here can be utilized to inform physician education programming and to identify key area for emphasis. The baseline data collection was informed by previous research examining levels of physician Chlamydia testing of youth and the variables associated with it.

Previous research

Research from both Canada and the United States has indicated that physicians do not routinely test youth for Chlamydia in accordance with recommended screening guidelines. For example, in the largest Canadian study of its kind, conducted in Manitoba, Moses and Elliot (2002) found that only about 25% of females aged 15 to 24 years who visited a physician were tested for Chlamydia in the year 1997. Surveys of primary care physicians in the United States have found screening rates well below those suggested by screening guidelines with most studies indicating that less than one third routinely screen for STIs (Burnstein et al., 2001; Mangione-Smith, McGlynn & Hiatt, 2000; St. Lawrence et al., 2002). A primary objective of the baseline data collection in the present study, therefore, was to determine the frequency with which primary care physicians tested female patients aged 15-19 and 20-24 for Chlamydia in a one month period.

In order to adhere to screening guidelines that recommend Chlamydia testing for sexually active females under age 25, it is necessary for the physician to conduct a brief sexual health risk assessment of the patient. Previous research has suggested that such inquiry often does not occur. For example, in a study of 963 Quebec physicians, Maheux, Haley, Rivard and Gervais (1999) found that only 56% of general practitioners routinely inquired about sexual activity with their adolescent patients (although 72% inquired about contraceptive method). Studies from the United States have also revealed less than optimal rates of sexual health assessment of youth by general practice physicians (Boekeloo et al., 1991; Torkko et al., 2000). Therefore, an equally important objective of the baseline data collection was to determine the likelihood that physicians would have done a sexual health assessment with female patients...

NOTE: All illustrations and photos have been removed from this article.



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