Advanced Pharmacology: Metformin; Theoretical and nursing: Pregnancy and STD; Capstone project (Due 26 and 48 hours)

RESEARCH Open Access

The future of STI screening and treatment for youth: a National Survey of youth perspectives and intentions Vinaya Gogineni1, Marika E. Waselewski2, Cornelius D. Jamison2,3, Jasmine A. Bell4, Nicole Hadler5, Kiren A. Chaudhry6, Tammy Chang2,3,7 and Okeoma O. Mmeje3,4,6*

Abstract

Background: Sexually transmitted infection (STI) rates continue to rise in the U.S., with disproportionately high rates among those aged 15–24 years. Effective programs and policies are necessary to address this growing public health problem. The purpose of this study is to assess the perspectives of a national sample of youth on access to STI care and behaviors regarding STIs.

Methods: MyVoice, a national text message survey of youth, was used to pose four open-ended questions on STI screening and treatment to 1115 youth aged 14–24 in August 2018. A mixed-methods strategy was employed for the study. Qualitative data was analyzed using a modified grounded theory approach. Summary statistics were calculated for demographic data and prevalence of themes.

Results: Of the 800 participants who responded to at least one question (72% response rate), mean age was 19 years (SD = 3.1), 55% identified as female, 61% identified as non-Hispanic white, and 33% qualified for free/reduced lunch. A majority felt it would be easy to get screened (69%) or treated (68%) for an STI. Nearly all respondents (95%) stated they would share an STI diagnosis with their sexual partners.

Conclusions: Despite high rates of STIs among youth, most respondents reported that STI screening and treatment is accessible, and they would share an STI diagnosis with their partner.

Keywords: Sexual and reproductive health, Text message, School-based health centers, Adolescent health

Background The continuous rise in sexually transmitted infections (STIs), specifically among youth, raises concerns for the U.S. population’s reproductive health outcomes. The Centers for Disease Control and Prevention’s (CDC) an- nual STI surveillance report in 2018 revealed more than 1.7 million cases of Chlamydia trachomatis (CT) and more than 583,000 cases of Neisseria gonorrhoeae (NG)

in the United States [1]. Youth aged 15–24 years account for nearly half of the new cases of STIs due to riskier sexual behavior such as multiple concurrent partners or unprotected intercourse and lower access to sexual healthcare [2]. Recurrent or untreated CT and NG infec- tions increase the risk of pelvic inflammatory disease in women and infertility and HIV infection in men and women. Additionally, there are increasing rates of anti- biotic resistance in NG infections, which affect both men and women [1]. Therefore, it is critical that effect- ive preventive measures be utilized to prevent STI trans- mission and STI-related morbidity.

© The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

* Correspondence: [email protected] 3University of Michigan Institute for Healthcare Policy and Innovation, 2800 Plymouth Rd. Bldg. 16, Ann Arbor, MI 48109, USA 4University of Michigan Department of Obstetrics and Gynecology, 1500 E. Medical Center Dr., L4100 Women’s Hospital, Ann Arbor, MI 48109, USA Full list of author information is available at the end of the article

Gogineni et al. BMC Public Health (2021) 21:2006 https://doi.org/10.1186/s12889-021-12091-y

Understanding youth perceptions and behaviors re- garding STIs is a crucial first step in the development and implementation of effective STI treatment and pre- vention methods for this population [2]. Despite the high incidence of CT and NG, a 2016 national survey of youth aged 15–25 years reported only 16.6% of female respondents and 6.6% of male respondents had received STI screening within the past year [2]. Previous work has suggested potential barriers to youth STI screening and according to a 2013–2015 national survey, youth aged 15–25 years had concerns about privacy and confi- dentiality that hindered many individuals from obtaining STI screening [3]. In some cases, youth do not believe they are at risk for contracting an STI and therefore do not seek these sexual health services [4]. However, there is currently a lack of research that addresses youth- specific STI interventions [2]. This gap in literature in- troduces an opportunity for our study to provide new insight on youth perceptions of STI testing and treat- ment, access to care, and notification of partners. We sought to understand youth perceptions of their

access to STI screening and treatment to better shape the delivery of reproductive healthcare services to youth populations. We posed open-ended questions to a na- tional sample of diverse youth regarding their perspec- tives on their access and willingness to pursue CT and NG screening and treatment.

Methods We used a longitudinal text message survey, MyVoice, of 1115 youth aged 14–24 years, to characterize youth perspectives on STI screening and treatment [5]. MyVoice participants are recruited to the survey cohort via targeted Facebook® and Instagram® advertisements based on demographic benchmarks (age, gender, race and ethnicity, and region of the country) from weighted samples of the American Community Survey [6]. Eligi- bility criteria include age 14–24 years, ability to under- stand and respond in English text, and access to a device with text messaging capabilities. MyVoice participants meet the minimum age requirement where parental con- sent is not required for STI services [7]. Once recruited, participants in the MyVoice cohort are asked open- ended questions via text message each week on a variety of health and health policy topics. Questions posed are iteratively developed by a team of physicians, methodol- ogists, statisticians, and students to ensure clarity and ease of response for participants. In August 2018, the MyVoice participants were

prompted to respond to a set of four questions related to STI screening, treatment, and disclosure of their STI infections: 1) We want to talk about chlamydia and gon- orrhea, two of the most common sexually transmitted in- fections (STIs). Would it be hard for you to get TESTED

for chlamydia or gonorrhea if you wanted? 2) If you tested positive, would it be hard for you to get TREATED for chlamydia or gonorrhea? 3) If you thought you had chlamydia or gonorrhea, where would you go to get treat- ment? 4) If you got chlamydia or gonorrhea, would you tell your sexual partner(s)? Why or why not? Grounded theory methodology was used to review the

responses by identifying themes and iteratively develop- ing a codebook that consisted of categories representing the most common responses. Two reviewers independ- ently coded each question, with discrepancies resolved by a third reviewer. Summary statistics were calculated for demographic data collected at enrollment and in- cluded gender, race, U.S. geographic region [8], educa- tion level, and receipt of free or reduced school lunch (a proxy for socioeconomic status). The frequency of coded themes was also analyzed using summary statistics (Microsoft Corporation. 2016. Microsoft Excel). The mean age of individuals in each response category for question 1 and 2 were compared using t-test with p < 0.05 representing statistical significance (SAS Institute Inc. 2013. SAS® 9.4).

Results Among the 800 participants who responded to at least one question (72% response rate), the mean age was 19 years (SD = 3.1), 55% identified as female, 61% identified as non-Hispanic white, and 33% qualified for free or re- duced lunch (Table 1). Quotes from respondents are in- cluded below as representative examples of specific themes.

Most respondents felt it would be easy to get screened and treated for an STI When prompted about ease of access to STI services, the majority of youth felt that it would not be difficult to both get screened (69%) and treated (68%) for an STI (Table 2). STI screening was reported to be easily ac- cessible by the majority of respondents primarily because “there are a lot of ways that you are able to get tested whether it be at the doctor or at a clinic” and “the doctor [is] close by and I believe testing is very cheap.” A few re- spondents (n = 10) who believed they were not at risk or did not have STIs stated that “It wouldn’t be hard for me to get tested because I know I do not have chlamydia or gonorrhea.” For those who expressed difficulty in obtain- ing testing (21%), the most common reason was due to their minor status (37%) because they had “been told by doctors in the past that they don’t know how STI tests show up on bills and my parents would be very upset to learn I was having sex.” Respondents who reported that it was hard to get tested or treated for STIs (6.5%) were on average younger than those who reported no (i.e., no, unsure, and other) difficulty (17.4 years vs 19.0 years; p <

Gogineni et al. BMC Public Health (2021) 21:2006 Page 2 of 8

0.001 and 17.4 years vs. 18.9 years; p < 0.001, respect- ively). They commonly cited that “I have no idea where I would go to get tested, so I’m not really sure if it would be difficult or not. I guess the first thing I would need to do is find out where or who would even have that kind of service” (31%). See Additional file 1 for detailed response patterns. Many participants (41%) noted that STI treatment

would be easy to get because they “have insurance and are financially stable enough to treat it.” Respondents who thought treatment would be difficult to get (16%) had concerns about how “my health insurance doesn’t cover STDs” (42%) and “I won’t feel so comfortable talk- ing to my parents which I would probably have to I guess. But I wouldn’t know how to handle it myself” (25%).

Those who remained uncertain (16%) primarily indi- cated they “don’t actually know what [their] options would be for treatment” (24%).

Primary care offices were the most common place youth would go for STI treatment Youth indicated preference for STI treatment via pri- mary care providers by stating that “my doctor” (49%), free clinics (14%), or hospitals (14%) were the main loca- tions they would seek health services. Less common lo- cations included a gynecologist (11%) and “If it was during the school year, I would start with on-campus health services” (9%). An additional 11% of respondents were unsure about where they would go for their STI treatment.

Table 1 Demographic characteristics of survey respondents and non-respondents from the MyVoice cohort

Characteristic Respondents (n = 800) n (%) or Mean (SD)

Non-Respondents (n = 315) n (%) or Mean (SD)

Age 18.6 (3.1) 18.6 (3.1)

Gender

Male 305 (38.1) 143 (45.8)

Female 443 (55.4) 144 (46.2)

Other gender 52 (6.5) 25 (8.0)

Race

Asian 82 (10.3) 37 (11.9)

Black or African American 69 (8.6) 32 (10.3)

White or Caucasian 546 (68.3) 201 (64.4)

Mixed race 69 (8.6) 24 (7.7)

Other race 34 (4.3) 18 (5.8)

Ethnicity

Hispanic or Latino 98 (12.3) 50 (16.0)

Non-Hispanic or Latino 702 (87.8) 262 (84.0)

Education Level

Less than high school 434 (54.3) 158 (50.6)

High school graduate 70 (8.8) 35 (11.2)

Some college or tech school 185 (23.1) 70 (22.4)

Associate’s degree or tech graduate 21 (2.6) 9 (2.9)

Bachelor’s degree or higher 90 (11.3) 40 (12.8)

Region

Midwest 389 (48.9) 172 (55.3)

Northeast 84 (10.5) 32 (10.3)

South 186 (23.3) 48 (15.4)

West 138 (17.3) 59 (19.0)

Free and reduced lunch eligibility

Yes 263 (33.2) 91 (30.0)

No 530 (66.8) 212 (70.0)

Gogineni et al. BMC Public Health (2021) 21:2006 Page 3 of 8

Almost all respondents would share an STI diagnosis with their sexual partners Nearly all respondents to this question (95%) also stated they would communicate their STI diagnosis with their

sexual partners because “they could have it too,” “it would be important for them to know and get tested and contact any other sexual partners to also be checked,” and “it’s the right thing to do.” Those who would not

Table 2 Questions, themes, and representative respondent quotes

Question, Theme n (%)a Representative Quote

Would it be hard for you to get TESTED for chlamydia or gonorrhea if you wanted? (n = 782)b

No 539 (68.9)

Easy access to care 385 (71.4) “there are clinics everywhere”

Access to insurance/funds 81 (15.0) “I have insurance so I could get tested free”

Importance of health 33 (6.1) “No I want to see if I’m STD free”

Yes 162 (20.7)

Notification of parents 60 (37.0) “Yes, I am not going to tell my parents I’m sexually active”

Embarrassment/stigma 38 (23.5) “There is some stigma”

Unsure of process or location 39 (24.1) “Yes, as I am not sure how and where to get tested”

Cost/insurance 29 (17.9) “I don’t have health insurance”

Unsure 51 (6.5)

Unsure of process or location 16 (31.4) “Probably not, but I don’t know where or how to”

If you tested positive, would it be hard for you to get TREATED for chlamydia or gonorrhea? (n = 771)b

No 523 (67.8)

Access to insurance/funds 216 (41.3) “I have health insurance and am financially stable enough … “

Easy access 202 (38.6) “I have access to many good medical facilities”

Importance of health 41 (7.8) “that is the only option for me to get better and healthy”

Yes 122 (15.8)

Cost/insurance 51 (41.8) “My health insurance doesn’t cover STDs”

Notification of parents 30 (24.6) “difficult to explain to parents”

Embarrassment/stigma 21 (17.2) “The social stigma surrounding STIs would prevent me from asking for help about any treatment”

Unsure 122 (15.8)

Unsure of process 29 (23.8) “I don’t know enough about treatment.”

Depends on cost/insurance 23 (18.9) “If my healthcare covers it, then no. If it doesn’t, that’s a different story.”

If you thought you had chlamydia or gonorrhea, where would you go to get treatment? (n = 745)b

Doctor’s office 368 (49.4) “… my PCP for a consultation and to get treated/tested”

Free clinic/Planned Parenthood 106 (14.2) “Planned Parenthood or a walk-in-clinic if … at school”

Hospital 105 (14.1) “university system or other local hospital”

Gynecology/STI doctor 85 (11.4) “My gynecologist, preferably. If I couldn’t schedule an appointment for a while, I’d go to a clinic.”

Unsure 83 (11.1) “I’m not sure, the doctor?”

School clinic 65 (8.7) “If it was during the school year, I would start with on campus health services.”

If you got chlamydia or gonorrhea would you tell your sexual partner(s)? Why or why not? (n = 774)b

Yes 736 (95.1)

Effects partner 185 (23.9) “it’s not something that only affects you, but anyone else you may have been with”

Morality 180 (23.3) “Yes, that is the right thing to do”

Importance of testing/treatment 146 (18.9) “Absolutely. He would need to get treated/tested too.”

No 16 (2.1)

Social stigma 10 (62.5) “I would be too ashamed” aNumbers may not add to 100%, as codes are not mutually exclusive; not all codes are displayed bN = the number of coded responses to each question; not all respondents answered each question STI = sexually transmitted infection

Gogineni et al. BMC Public Health (2021) 21:2006 Page 4 of 8

disclose their status to their partner (2%) cited “I would be too ashamed” and “it would be embarrassing” as rea- sons for not informing their partner of their infection.

Discussion Our study found that most youth consider both STI screening and treatment to be accessible because of easy access to healthcare or access to insurance and funding. Additionally, youth in our sample noted a preference for going to their established doctors or primary care pro- viders for treatment services. Most notably, we found that nearly all MyVoice youth respondents indicated they would confide in their partners about an STI diag- nosis, with more than half of these respondents report- ing reasons such as how the diagnosis impacts their partners and that it is morally right. While other studies report that many youth have ac-

cess to general healthcare, there is limited literature on youth knowledge of included health services [9, 10]. Our study provides insight here by noting that our cohort be- lieves STI screening and treatment services to be access- ible via established or local health providers. This highlights the importance of youth having a healthcare home at sites that they routinely encounter, such as school-based health centers and federally qualified health centers. During the COVID-19 pandemic, the use of telehealth services has increased to support wider ac- cess to health services, but virtual healthcare services may not replace necessary clinical services when inequi- ties in technology access remain [11]. Harnessing the interest and willingness of youth to seek sexual health- care services at locations they are comfortable with is critical given that access to reproductive health services continues to decline [12], despite the growing incidence of STIs among youth [13]. Similar to our findings, access to care and insurance has previously been noted to make screening and treatment easy for youth [14]. However, our data does not support limited knowledge of health services as the primary barrier to care. Youth in our sample noted other barriers in accessing these services like cost or insurance coverage, embarrassment, and concerns about notifying their parents. Youth concerns about confidentiality regarding an STI

diagnosis note difficulty “… because it would be some- thing that I would have to tell my parents and that would be very uncomfortable,” or “… because treatment would require health care, which would require me tell- ing my parents.” This is consistent with existing litera- ture that reports how perceptions of confidentiality may pose a barrier to healthcare for youth [3, 4]. Addressing youth concerns about cost and confidentiality must be considered when developing and implementing STI treatment and prevention services. Providers and health departments can encourage positive communication

about sexual health between parents and their children, thus promoting safer sex practices and better health out- comes [15, 16]. In addition, providers can educate youth on the rules of confidentiality between minor patients and providers. Despite their perceived ease of access to STI screening

and treatment, actual use of these services remains low among U.S. youth. A possible explanation for this dis- crepancy, as noted in previous work, may be due to youth assuming that they are STI-free or generally not at risk [4]. Our study supports this conclusion, with some respondents reporting “It wouldn’t be hard for me to get tested because I know I do not have chlamydia or gonorrhea” and “No I go to the doctors often and they ask if I want to get tested but I’ve been with the same person since the last test I have no reason to get tested.” Youth must also want to, or perceive a need to, get STI screen- ing. This barrier to use of STI screening services illus- trates the need for local and federal health officials to support initiatives that emphasize—to youth and pro- viders—the importance of regular STI screening, even in asymptomatic individuals. Findings from our work also suggest primary care of-

fices as the preferred location for STI screening and treatment in youth. This is congruent with previous work on STI screening amongst youth in the U.S. that indicated the majority of those who sought STI screen- ing were evaluated at primary care physicians’ offices [4]. Youth preferences for STI screening and treatment at primary care clinics and concern for costs may require additional support and education for primary care health professionals. Furthermore, STI screening and preven- tion counseling for youth during their routine clinic visits will serve to increase awareness of STI screening methods and treatment options. Our study also reports the important finding that

nearly all respondents (95%) stated they would share their STI results with their partners. Common responses included “Yes because they need to know, in case they have it too. Also, they can help prevent the spread.” and “Yes it’s the most responsible thing to do. They would de- serve to know.” A previous study on sexual health behav- iors of U.S. college-age men similarly reported that the majority of participants were willing to disclose their STI status to their partners [17]. Our results contrast with previous data on youth concerns of STI stigma and the general misperception of youth being less willing to notify their partners [3, 4, 18, 19]. Youth willingness to confide in their sexual partners and concern about health effects on their sexual partners supports potential use of expedited partner therapy (EPT) to increase treat- ment of STIs. EPT—a treatment option where individ- uals can obtain STI medications or prescriptions for their sexual partners—may provide a useful opportunity

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to support youth treatment as it is quick, convenient, and respects patient privacy [20]. Clinician education on youth willingness to share STI results and use of EPT may also be beneficial to their efforts to increase screen- ing and treatment in their patient populations. Addition- ally, it may address the hesitancy and uncertainty that some clinicians may face regarding the permissibility of this therapeutic measure [21]. It is important to note that youth willingness to participate in partner notifica- tion does not necessarily reflect youth behaviors. Cur- rently, there is a gap in literature on the rates of partner notification specifically in the youth population [22]. In an Australian evaluation of individuals > 16 years diag- nosed with chlamydia (median age of 27 and 24 years in males and females, respectively), 31 and 46% of hetero- sexual males and females notified their partners [23]. However, partner notification is increased in youth (ages 13–20 years) with higher levels of self-efficacy and in re- lationships with stronger emotional ties [24]. This mir- rors the findings noted in adult populations, where partner notification is highest for spousal partners than for causal or commercial partners [22]. Thus, further evaluations of partner notification in youth ages 15–24 years are needed to quantify the efficacy of interventions like EPT among youth. Though the MyVoice cohort sample recruits nationally

from youth aged 14–24 years, there are some limitations. While MyVoice recruits based on benchmarks for na- tional data on age, gender, race and ethnicity, and region of the country, respondents are not nationally represen- tative because there is no assurance that the recruitment advertisements will reach all eligible participants. Add- itionally, recruitment via social media may bias the

sample by including only those who use social media, limiting generalizability. Specifically, MyVoice respon- dents are oversampled in the Midwest region (Fig. 1) of the U.S., thereby providing data that may not necessarily reflect the perceptions and practices of youth in other parts of the country. Another limitation stems from the lack of concurrence between the time at which the sur- vey was administered and analyzed and the onset of the COVID-19 pandemic. The majority of the cohort re- ported access to healthcare services at the time the sur- vey was administered, yet youth have experienced decreased access to reproductive healthcare services dur- ing the COVID-19 pandemic [25]. To protect our re- spondents from having to self-report their past STI history, the open-ended questions posed to youth also asked about their theoretical behaviors. This may lead to desirability bias, as individuals may over- or under- report to conform to societal norms [26]. The other limitation of assessing theoretical behaviors is that inten- tions may not always lead to actions. Finally, the an- onymous nature of this protocol prevented us from clarifying any unclear or missing responses. This is illus- trated by our inability to discern if sexual partners were primary or casual in nature.

Conclusions Understanding youth insights on their sexual health per- spectives is instrumental in mitigating the disproportion- ately high rates of STIs that affect this population. Our findings suggest that youth are committed to both their and their partners’ sexual health, presenting an invalu- able opportunity for eventual large-scale intervention through partner-based referral and treatment options

Fig. 1 MyVoice survey participant heat map, by state

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such as EPT. However, before such solutions can be ex- plored, the discrepancy between youth intentions and actions must be addressed to provide insight on how to encourage positive behavioral change that could poten- tially reduce STI rates in this population. Longer-term societal efforts toward educating parents and youth on appropriate sexual health education, STI screening and treatment costs, and resources may support reduction in STI transmission [16, 27, 28]. Health and education de- partments can also partner to implement policies and programs that support and normalize regular STI screening. Ultimately, promotion of STI prevention ser- vices and reduction of the perceived barriers are needed to help combat the increasing STI incidence rates among youth.

Abbreviations STI: sexually transmitted infection; CDC: Centers for Disease Control and Prevention; CT: Chlamydia trachomatis; NG: Neisseria gonorrhoeae

Supplementary Information The online version contains supplementary material available at https://doi. org/10.1186/s12889-021-12091-y.

Additional file 1. Details of Q2 responses based on Q1 responses. Description: Details showing the relationship between the responses for those who completed question 2 in relation to their response to question 1.

Acknowledgements Data from this study was accepted for virtual presentation at the Centers for Disease Control and Prevention STD Prevention Conference, September 14- 24, 2020.

Authors’ contributions OM conceived of and managed the conduct of the project and led the writing and review process. TC led the iterative development and review of the survey items. MW completed the quantitative analysis and led the qualitative evaluation. CJ, MW, and VG organized and drafted the manuscript. VG led the manuscript writing. Two reviewers independently applied the codebook to each question (CJ, VG, JB, NH) with a third reviewer, MW, reviewing all discrepancies. All authors have read and approved the final manuscript.

Funding Dr. Mmeje was supported by the University of Michigan’s Office of the Provost and the University of Michigan Medical School Department of Obstetrics and Gynecology. This research was funded by the Michigan Institute for Clinical & Health Research, the University of Michigan MCubed program, and the University of Michigan Department of Family Medicine. These funders had no role in the study design; the collection, analysis, and interpretation of data; the writing of the report; or the decision to submit the manuscript for publication.

Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate The MyVoice study is approved by the University of Michigan Institutional Review Board (HUM00119982) and participants provided consent via the study website, which including a waiver of parental consent for minor

participants. All study methods were carried out in accordance with relevant guidelines and regulations.

Consent for publication Not applicable.

Competing interests The authors declare that they have no competing interests.

Author details 1The University of Toledo College of Medicine and Life Sciences, 3000 Arlington Ave, Toledo, OH 43614, USA. 2University of Michigan Department of Family Medicine, 1500 E. Medical Center Dr, Ann Arbor, MI 48109, USA. 3University of Michigan Institute for Healthcare Policy and Innovation, 2800 Plymouth Rd. Bldg. 16, Ann Arbor, MI 48109, USA. 4University of Michigan Department of Obstetrics and Gynecology, 1500 E. Medical Center Dr., L4100 Women’s Hospital, Ann Arbor, MI 48109, USA. 5University of Michigan Medical School, 1301 Catherine St, Ann Arbor, MI 48109, USA. 6Department of Health Behavior and Health Education, University of Michigan School of Public Health, 415 Washington Heights, Ann Arbor, MI 48109, USA. 7National Clinician Scholars Program, University of Michigan, 2800 Plymouth Rd. Bldg. 16, Ann Arbor, MI 48109, USA.

Received: 11 May 2021 Accepted: 18 October 2021

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