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Urban African American Women’s Explanations of Recurrent Chlamydia Infections Melva Craft-Blacksheare, Frances Jackson, and Theodore K. Graham
Correspondence Melva Craft-Blacksheare, DNP, CNM, RN Department of Nursing School of Health Professions and Studies University of Michigan-Flint 303 East Kearsley WSW 2180 Flint, MI 48502. [email protected] Keywords Chlamydia Health Belief Model African American urban teens
ABSTRACT Objective: To explore reasons for the high chlamydia recurrence rate among African American (AA) urban women. Design: In this phenomenological qualitative study, young AA urban women with recurrent chlamydia were interviewed using open-ended questions guided by the conceptual framework of the health belief model (HBM). Setting: The study was set in three urban health clinics in Michigan. Participants: Ten African American adolescents, age 15 to 19, participated. Methods: In face-to-face recorded interviews, participants shared their personal experiences and viewpoints on what led to their recurrent chlamydia infections. The data were transcribed and analyzed through hand coding and NVivo 8 a qualitative software package. Results: Overall, participants demonstrated significant knowledge deficits about the seriousness of chlamydia compared to other sexually transmitted infections (STIs). After reinfection, their perceived susceptibility changed: condom use was seen as beneficial and perceived barriers to condom use diminished as participants gained a new sense of empowerment. Conclusion: Chlamydia infection among African American urban adolescents is nearly 3 times that of the general population. Lack of education is still a barrier to STI prevention. Participants reported a desire to receive counseling and support from the health care staff. A STI care model that includes education, counseling, and regular screening of high-risk adolescents should be considered. Further research, using the HBM or similar theoretical models, are needed to gauge the success of any planned or implemented intervention.
JOGNN, 43, 589-597; 2014. DOI: 10.1111/1552-6909.12484 Accepted May 2014
Melva Craft-Blacksheare, DNP, CNM, RN, is an assistant professor in the Department of Nursing, School of Health Professions and Studies, University of Michigan–Flint, Flint, MI. Frances Jackson, PhD, MSN, MA, BSN, RN, is a professor emerita at Oakland University School of Nursing, Rochester, MI.
(Continued)
The authors report no conflict of interest or relevant financial relationships.
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he Centers for Disease Control and Prevention (CDC; 2010) estimates that approximately 19 million new sexually transmitted infections (STIs) occur each year in the United States; almost one half of these are among young people age 15 to 24. Chlamydia remains the most commonly reported infectious disease in the United States, with an estimated 2.8 million new infections each year. An estimated 30% to 40% of untreated chlamydia infection progress to pelvic inflammatory disease (PID), and common sequelae of PID include ectopic pregnancy, infertility and chronic pain, with estimated annual costs exceeding $3.1 billion (Blake, Quinn, & Gaydos, 2008). Moreover, among developed countries, the United States has the highest rates of curable STIs (Advocates for Youth, 2003).
T
Young women are more susceptible to STIs than their male counterparts because their columnar
epithelial cells, which are especially sensitive to invasion by sexually transmitted organisms such as chlamydia and gonorrhea, extend out over the surface of the cervix, where they are unprotected by cervical mucus (Eng & Butler, 1997). As women age, their STI risk is reduced as their columnar epithelial cells recede to a more protected location. The CDC 2012 reported that the 2012 chlamydia rate for women was almost 2½ times higher than that of males (643.3 vs. 262.6 per 100,000 people). Among women, the highest age-specific rates of reported Chlamydia in 2012 occurred in 15 to 19 (3,291.5 cases per 100,000 women) and 20- to 24-year-olds (3,695.5 per 100,000 women). Women age 15 to 19 had the highest rate until 2010, when the chlamydia rate increased in the 20 to 24 years category. African American women age 15 to 19 had the highest rate of any group (7, 7191.1), followed by American Indian/Alaska Native (4,235.1), Hispanic (2,013.6), and White
C 2014 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
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Chlamydia remains the most commonly reported infectious disease in the United States with an estimated 2.8 million new infections each year.
(1458.3) women. The CDC reported an overall chlamydia rate of 1613.6 per 100,000 African American women, which is more than 6 times that of White women (260.5), almost 3 times that of Hispanic women (574.7), and close to 2 times that of American Indians/Alaska Natives (1126.4). Chlamydia reinfection is common among young adults, especially women. Anschuetz et al. (2008) investigated infection and reinfection rates of chlamydia and gonorrhea among adolescents in the Philadelphia public high schools during the 2002 to 2006 school years. In the primary analysis, the unadjusted female chlamydia/gonorrhea rate was more than double that of males (6.0 vs. 2.4 cases per 100 personyears, respectively). Among students with positive test results, 13.6% were reinfected within the same school year. Female adolescents with named partners not treated had a higher reinfection rate than all others (85.5 vs. 40.1 – 45.2 cases per 11 person-years, respectively). Among those reinfected, the median time until the second infection was detected was 127 days (range: 62 – 232 days). Williams et al. (2002) reported that chlamydia often goes undetected because as many as 75% of infected women and 50% of infected men experience no symptoms. This fact increases the likelihood that undetected infections will result in costly reproductive outcomes, including PID, ectopic pregnancy, chronic pelvic pain, salpingitis, and infertility. To reduce the chlamydia infection and reinfection rate, it is important to design interventions that will be effective for the population most vulnerable to this disease: young African American women who live in urban areas. The purpose of this study was to understand African American urban women’s reasoning on their nonuse of condoms after initial diagnosis and treatment of chlamydia.
Theodore K. Graham, MD, is an assistant clinical professor, Wayne State University School of Medicine, Detroit, MI.
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who care for them may be more empathetic to and understanding about their experiences. Therefore, a qualitative phenomenological research study design was used to explore the essential elements of the lived experiences of African American urban female adolescents diagnosed with recurrent chlamydia infection and to describe the meanings these teens made of their experiences. The aim of this approach was to listen to individuals and determine their thoughts and explanations for why they continue to practice risky sexual behavior even after initial infection. Through this approach, we hoped to gain insights that health care providers and educators could use to develop effective strategies for preventing chlamydia infection and reinfection among African American urban female adolescents and, consequently, their sexual partners.
Health Belief Model The health belief model (HBM), which focuses on individuals’ beliefs and attitudes, is a psychological model for the explanation and prediction of health behaviors. This model was initially developed in the 1950s by three social psychologists, Hochbaum, Rosenstock, and Kegels, in response to the failure of a free tuberculosis screening program. Since then, it has been used to explain a variety of health behaviors, including sexual risk behaviors and HIV/AIDS transmission. Before this study, the HBM had not been used as a framework to understand African American urban female adolescents with recurrent chlamydia infections (Rosenstock, Strecher, & Becker, 1988). The HBM is based on the understanding that a person will take a health-related action (e.g., condom use and nonrisky sexual behavior) only if he or she
r r
r
believes that a negative health condition (recurrent STI) can be avoided; has a positive expectation that taking the recommended action (using condoms) will prevent a negative health condition (recurrent chlamydia); and believes that the recommended health action (comfortably and confidently insisting on condom use) can be undertaken successfully.
Phenomenology describes the experience of individuals related to specific situations so that those
The original HBM has four constructs representing what participants identify as threats and benefits: perceived susceptibility, perceived severity, perceived benefits, and perceived barriers
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Table 1: Interview Questions 1. How much at risk do you think you are for becoming reinfected with chlamydia? (Perceived Susceptibility) 2. How was your life disrupted when you were diagnosed with chlamydia a second time? (Perceived Severity) 3. How do you rate the seriousness of chlamydia compared to other sexually transmitted infections like HIV/AIDS, herpes, gonorrhea, syphilis, genital warts, and pelvic inflammatory disease? (Perceived Severity) 4. What do you know about some of the health problems that chlamydia can cause? (Perceived Severity) 5. To what extent is your decision to use a condom influenced by your friends? (Perceived Barriers) 6. Consistent condom use decreases chlamydia reinfection. Tell me about the barriers that exist that prevent you from using a condom all the time you have sex. How can these barriers be controlled, removed, or reduced? (Perceived Barriers) 7. What do you think would make you more confident in using a condom correctly all the time? (Self-Efficacy) 8. What roles, if any, does your partner play in your decision to use a condom? (Perceived Barriers) 9. What are some things that the health providers in the clinic can help you with or do for you to assist you in remaining chlamydia free? (Self-Efficacy)
(Rosenstock et al., 1988). For this study, perceived susceptibility reflects the participants’ beliefs about their likelihood of chlamydia reinfection. Perceived severity indicates the participants’ beliefs about the seriousness of a recurrent chlamydia infection and the severity of its consequences. Perceived benefits reflect the participants’ belief in the advised action’s efficacy to reduce the risk or seriousness of disease effects. Perceived barriers indicate the participants’ beliefs about the advised action’s tangible and psychological costs. Rosenstock et al. (1988) later added two concepts: cues to action are strategies to activate readiness, and self-efficacy is the participants’ confidence in their ability to take action. For this study, these six HBM constructs were used to help develop nine openended interview questions to elicit complete and honest participant feedback (see Table 1) and frame the discussion of the results.
Setting and Participants Following approval from the University’s Institutional Review Board, a plan was developed to re-
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cruit participants from three Michigan urban health clinics. This plan included disseminating recruitment flyers and posters throughout the clinics. Eligible clients were female African American urban adolescents age 15 to 19, who self-reported recurrent chlamydia infections within the previous 12 months. This population was chosen because the previous research indicated that they exhibit the greatest incidence of chlamydia infection. Participants were screened to ensure all inclusion criteria were met. Interviews were held in private clinic offices. The total sample (N = 10) consisted of African American female adolescents, aged 15 to 19, with a mean (SD) age of 17 years. Of the 10 participants, three were age 15, one was 16, two were 17, one was 18, and three were 19 . Education ranged from ninth to 12th grade. Present grade level ranged from 10th grade to college freshman. Two participants attended a vocational training school, and one did not reveal this information. Mothers’ educational level ranged from 10th grade to college, including one with a Graduate Equivalency Diploma (GED), one who
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Participants lacked consistent access to education on sexually transmitted infection, prevention counseling, and condoms before and after their initial diagnoses.
attended medical assistant school, and two whose specific educational levels are unknown. Fathers’ education ranged from ninth to 12th grade, including one with a GED and one whose specific educational achievement is unknown. Number of sexual partners (in last 12 months) ranged from one to four, with a mean of 2.8. Household relations included mother, father, stepfather, sisters, brothers, cousins, aunts, uncle, and grandmother. Two households did not have a mother present, and seven did not have a father/stepfather present.
Results Qualitative results are presented according to the six HBM constructs of perceived susceptibility, perceived severity, perceived barriers, perceived benefits, cues to action and self-efficacy.
Perceived Susceptibility Perception of personal risk or susceptibility can be a powerful motivator for adolescents to adopt less risky sexual behavior. Participants were asked “How much at risk do you think you are for becoming re-infected with chlamydia?” After chlamydia reinfection, nine participants claimed they would take measures to prevent another infection. However, they may have felt this way after their first chlamydia diagnoses but still failed to take steps to prevent reinfection. Lack of education was a common problem. One participant expressed that she did not think she was susceptible to reinfection:
Procedures The researcher explained to participants/parents the study’s purpose and the confidentiality of all information obtained. Prior to interviews, informed consent was obtained from adult participants and parental permission for minor participants. Study participants completed demographic questionnaires before their interview and received a $10.00 gift card. Data collection occurred from June to September 2010 via audiotaped interviews with 10 female teenagers in three urban health clinics until data saturation was achieved. The tapes were transcribed and transcripts reviewed to ensure accuracy. To maintain data confidentiality, participants were assigned a code number and no names were used on typed transcripts.
Data Analysis Results were analyzed using the Giorgi method of phenomenological evaluation. Hand coding and a qualitative software package (NVivo 8) were used to create and classify codes. After transcribing the interviews, reading and reflecting on the transcripts, and reviewing field notes for overall meaning and ideas, study themes were generated. To ensure the analysis was systematic and verifiable, an expert with more than 25 years of experience in urban women’s health reviewed the data. The expert also discussed the data and transcripts with the first author to increase rigor and to uncover additional data impressions or themes/patterns. Themes were then categorized according to the HBM’s conceptual framework.
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I thought when I first had that [chlamydia], since I got the medicine, it would work for a long time . . . I didn’t know it would stop working and you could get it again; I thought it would work for a long time. This participant may have thought chlamydia treatment worked like an immunization. All participants reported understanding that abstinence and/or consistent condom use decreases the incidence of chlamydia. However, the idea of being able to determine if a person has an STI based solely on appearance is still pervasive among this population. One participant said, “I always thought I was careful, and the guys I was with were clean and didn’t have anything like that.” According to the National Chlamydia Coalition (2011) this response correlates with other qualitative research studies where individuals believe that they could tell if someone, including their partners had an STI. A respondent who acquired chlamydia twice from the same partner said: I stopped messing with that boy, and I’m talking to another boy, and I trust him. We still use condoms and sometimes we don’t, but we have our regular checkups so we’ll know. But if I knew that he was not going to get himself checked out, then it would be on my mind to use a condom. Even after two chlamydia infections, this participant continued to trust her partner instead of using proven prevention methods.
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Perceived Severity Perceived severity reflects an individual’s belief about the seriousness of a disease. Two interview questions addressed this phenomenon. Participants were asked to rate the seriousness of chlamydia and to compare it to that of other STIs (e.g. HIV/AIDS, herpes, gonorrhea, etc. See Table 1). The responses demonstrated a clear lack of knowledge about the nature of the disease. One respondent stated, I have no clue, but chlamydia is probably better than those [HIV/AIDS] because you can take a pill to clear it up. AIDS is worse because you can pass it on to people and stuff. I think you pass herpes and gonorrhea and syphilis on, too. Even though some participants indicated that all STIs were the same, they would still express that HIV/AIDS was the worst one. Few participants received educational information after their first chlamydia exposure. Several participants were diagnosed with chlamydia in a pediatric clinic, and their prescriptions were given to their mothers. One participant stated, “They didn’t tell me anything. They gave my Mama some pills and I just took them. No one told me [about] any problems.” After receiving education about the severity of the disease after their second infection, some participants expressed more willingness to protect themselves from further reinfection. Another participant said, At first I just thought, okay, I have chlamydia. I can get rid of this, but the second time we had a long discussion, and [the doctor] was telling me . . . how bad it could be and that is when I really realized how serious it was. Another participant mentioned the importance of not being afraid to talk to her partner.
Perceived Benefits People tend to adopt healthier behaviors when they believe the new behaviors will decrease their chances of developing disease. The participants agreed that the benefit of consistent condom use was knowing that “I won’t get nothing.” This new behavior was valued because it could decrease the risk of chlamydia reinfection. Some of the emotional effects expressed upon the second chlamy-
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dia diagnosis ranged from, “I felt nasty. I was depressed. I didn’t go anywhere, I just stayed in the house, and I didn’t have sex for five months” to a pregnant teen who expressed concern about the health of her fetus, indicating that “the baby could be blind.” Due to the negative connotations of chlamydia reinfection, participants indicated that they would use condoms all the time to prevent “going through this again.” According to the participants, condom use is directly related to the benefit of remaining chlamydia free. Only one participant said that she sometimes does not use condoms because she trusts her new partner, but she does obtain chlamydia cultures every 3 months.
Perceived Barriers To adopt consistent condom use, participants need to believe that the benefits of this new behavior outweigh the consequences of the old behavior. Several interview questions were posed to promote discussion about this topic and identify barriers that need to be removed, controlled, or reduced. Barriers queried were influence of friends and lack of communicative confidence with partner. According to participants, their friends did not influence their condom use. In fact, after the participants’ exposure to chlamydia, many encouraged their friends to use condoms. Before reinfection, partners had a larger role in condom use. According to participants, however, the partner’s role had diminished since reinfection: Nothing at all is standing in the way [of using a condom]. I say it now because I look at things totally different. If I would of use that condom, I wouldn’t be in this predicament that I’m in now. Like my mom don’t let me go to many places like I use to. It’s nothing now for me to want to use a condom all the time now. Like where is the condom at? Caught up in the moment make me not use a condom . . . not even thinking about my actions and my consequences of what would happen if I didn’t use a condom, have fun, not thinking about my consequences. I know for a fact that I won’t be caught up in the moment. That is something I don’t want to take a chance in; no one can talk me into that anymore. Participants also expressed having control over condom use, suggesting that they now felt a sense of empowerment. One participant’s chlamydia
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exposure diminished her partner’s role in condom negotiation, “He can get mad, but there is nothing you can really do. Either put the condom on, or you’re not getting any [sex], so you better put the condom on.” Several participants ended relationships with the initial partners, moved to new partners, and became reinfected. After reinfection, those participants indicated they would use a condom all the time, “nothing at all stands in the way of using a condom now.” One participant presented herself as an outlier in the study. She insisted she uses condoms all the time; however, she was reinfected with chlamydia and pregnant.
Cues to Action Participants expressed several common factors that helped them change their behaviors. The repeated chlamydia diagnosis, particularly from the same partner, was a “wake-up call” for most participants to change their behavior and insist on consistent condom use. One participant, who was in a 2-year monogamous relationship, expressed confusion and hurt when she was diagnosed the second time: “Are you messing around with someone else? He denied it, however, I left him alone after that; twice is two times too many.” A participant told the story about her close girlfriend who was pregnant and had an STI from her child’s father. She was totally surprised because she knew he supposedly “loved her” and would never have believed that he would give her an STI. Several participants became infected the second time with a new partner because they continued to believe that they could see if someone was infected. After learning about the health problems chlamydia could cause, most participants were more aware about the importance of condom use.
Self-Efficacy Participants were asked, “What do you think would make you more confident in using a condom correctly all the time and what are some things the health provider in the clinic can do to assist you in remaining chlamydia free?” All participants indicated growing confidence in their ability to consistently use condoms to prevent reinfection. One participant who trusted her partner to be monogamous determined that it was her decision to use condoms inconsistently. She, along with her partner, has frequent STI screenings (every 3 months for her). Additionally she also indicated it was her decision to use a condom if she thought her partner was not getting frequent check-ups. Al-
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though self-efficacy was present, all participants suggested that further support from the health clinic in the form of free condoms and educational information would complement their ability to take more consistent action to protect themselves from recurrent infection.
Discussion Many of our findings regarding susceptibility, screening, and education align with previous studies about adolescents and chlamydia infection. Despite its limitations, this study also yielded new discoveries that can affect nursing practice in the area of chlamydia prevention. Initially, most participants did not think they were susceptible to chlamydia. Similarly, Ethier, Kershaw, Niccolai, Lewis, and Ickovics (2003) found that uninfected adolescents failed to perceive their vulnerability to STIs, and 81.3% of those infected with STIs still perceived themselves at little or no risk. Our results also are similar to those supporting the claim that approximately 75% of women are asymptomatic and do not realize they are infected with chlamydia (Burstein et al., 2001; Oster, Rothenberg, McPhillips-Tangum, Gazmararian, & Franks, 2003; Williams et al., 2002). The majority of participants were asymptomatic and diagnosed during routine gynecologic exams. Several diagnoses were made by urine ligase during a pediatric exam. One third of gynecologic physicians surveyed by Oster et al. (2003) indicated that they would not test asymptomatic sexually active teenage women for chlamydia during routine gynecologic examinations. This approach to clinical practice may mean that many chlamydia infections go undetected and result in more serious health complications. In a longitudinal study where the mean age of PID diagnosis was 16.8, Trent, Chung, Forrest, and Ellen (2008), suggested routine chlamydia screenings could reduce reinfection. In addition to routine screening, STI education is an important tool in chlamydia prevention. All participants were aware of the fatal characteristics of HIV/AIDS and, unfortunately, this belief overshadowed the risks of chlamydia, which is 3 times more common among the adolescent population. Except for HIV/AIDS, most participants had limited knowledge about the severity of chlamydia and other STIs. Interview responses indicated most participants did not receive educational materials about chlamydia after their first diagnosis. Perhaps if they had, some reinfections could have
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been prevented. Health care facilities should consider providing age appropriate educational materials to all teens diagnosed with an STI. Historically, there has been much debate on sex education in the public school system including discussion about when it should start, whether abstinence only curriculum is effective, and the importance of consistent condom use. According to a report of the content of federally funded abstinence only education programs (2004), more than two thirds of abstinence-only education programs were using curricula with multiple scientific and medical inaccuracies. These curricula contained misinformation about condoms, abortion, and basic scientific facts. They also blurred religion and science and present gender stereotypes as fact (Waxman, 2004). Additionally Underhill, Montgomery, and Operario (2007) concluded that the most methodologically rigorous reviews have consistently documented that there is no evidence that abstinence-only programs can reduce risky sexual behavior. Not all our study participants received sex education in their high schools. According to participant responses, the public school system failed to offer materials that could be helpful in deterring STI exposure. Public school systems should consider providing students with effective teen-oriented STI educational materials. Our data showed that participants who were diagnosed by their pediatricians or in an emergency facility also did not receive health information. Unfortunately, many health professionals are leaving adolescents defenseless by not providing them with the necessary prevention information or tools. Health offices and clinics often are quite busy. However, time spent educating young, sexually active adolescents could help prevent chlamydia infection/reinfection and promote safer sex practices. All study participants demonstrated an eagerness to learn about chlamydia and other STIs during the interviewing process. It was obvious that their inadequate knowledge was not due to willful ignorance, or as some participants stated, “being stupid,” but more from a lack of opportunities to acquire knowledge.
Implications By using the HBM, we used the voices of the adolescents themselves to reveal unique phenomena not previously reported in the literature. This information suggests new areas to investigate to
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help deter the problem of chlamydia infection and recurrence. Participants overwhelmingly demonstrated the need for STI education, counseling, and support. Many commented on the importance of being able to “talk with someone about their concerns.” Participants demonstrated a sense of pride that they were sharing their experience, thoughts, and ideas because they were told it could possibly help deter someone else from becoming infected with chlamydia. Personal Health vs. Trusting a Partner. One participant refused to use condoms because she “trusted” her partner. Although she agreed that consistent condom use prevents chlamydia infection, she held to the concept of trust. Her concurrent decision to receive STI screening every 3 months, however, indicated her unwillingness to ignore her health concerns completely. Although only one participant raised the issue of trust, this may highlight a concern for other teens. The conflicting values of personal health and trusting sexual partners should be explored within additional research. Researchers should examine why and how trust can outweigh confirmed knowledge. After teens have STI education and condoms access, why do they continue to practice risky sexual behavior? According to Piaget’s developmental theory, adolescents are egocentric, with feelings of invincibility, who often demonstrate risky behaviors (Browning, 2008). Therefore, to adequately support the needs of teenagers, health care professionals must be aware of normal adolescent development and consistently advocate and support the benefits of safe sex practices. Continuity of Care. The health care system’s lack of continuity of care is also a confounding issue. Pursuant to the CDC (2010), the current standard of care requires that clients diagnosed with chlamydia receive specific care instructions including pelvic rest, partner notification, and (if pregnant or re-infected < 60 days) follow-up tests to confirm a cure. This standard of care should be expanded to mandate that all health care professionals who diagnose chlamydia, including those in pediatric clinics and emergency departments, counsel adolescents on prevention and provide educational information. Unfortunately, most of this study’s participants received no such followup care. The adolescents’ own words can be used by the health community to develop strategies and policies to support and to empower this population to prevent chlamydia.
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Nurses are advocates for community health. Education, counseling, and promotion of condom use are crucial strategies for abating chlamydia infections among African American urban women.
Nursing Implications We investigated some of the underlying reasons African American urban adolescents continue to practice risky sexual behavior. The interviews offered an understanding of African American urban adolescents’ psychosocial issues upon which the nursing community can build better counseling and educational support. Educating adolescents and offering support, by providing counseling and condoms, are some of the approaches suggested by these participants. The nursing community can use these findings to evaluate and to improve existing STI follow-up procedures and to develop new care models to address this crisis.
the responses of several participants. Additional qualitative studies could help identify if and/or how participant/parent education relates to chlamydia recurrence. In future studies, recruiting a diverse racial sample of urban women could be beneficial in increasing the applicability of findings. Despite these limitations, this study’s findings should be of interest to and useful for health care professionals who serve this population.
Conclusion Chlamydia infection among African American adolescents is nearly 3 times that of the general population. The primary risk factors for chlamydia are reinfection, previous exposure, lack of preventative education, and inconsistent condom use. According to study participants, they experienced a lack of education, counseling and support from health professionals after initial diagnosis. Presently, there is not a universal model of care for adolescents diagnosed with chlamydia.
Nurses and nurse practitioners can work with the public school system to develop and to teach a (proposed mandatory) biannual health maintenance workshop. Workshops could commence in ninth grade and include such topics as health screenings (including self-breast and testicular exams), disease prevention (including exercise, diet, and nutrition), male and female bodily changes, and reproductive education, including pregnancy and STI prevention.
Nurses can take the initial steps to develop a care model for adolescents who are diagnosed with chlamydia. This model would include appropriate screening, treatment, education, and counseling. Once tested, the model could be incorporated into nursing curriculum to encourage continuity of care. In addition, further research is needed to address the topic of adolescents, relationship dynamics, and risky sexual behavior.
Nurses and nurse practitioners who work with adolescents can help develop a standardized model of care that promotes routine STI screening according to CDC guidelines. The proposed care model also could stipulate that health care providers give treatment medication and counseling—which address medical and psychosocial risk factors and promote follow-up care—directly to patients, regardless of minor status. In the state of Michigan there are no specific statutes on the issue of family planning and related services to minors; therefore, parental consent is not required. This is considered a federal constitutional “right of privacy” (Network for Public Health Law, 2013).
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educational programs. Washington, DC: U.S. House of Repre-
edge of parents. Retrieved from www.networkforphl.org/_asset/ kbctjq/MinorsPrivacyFINAL.pdf
sentatives. Williams, K. M., Wingood, G. M., DiClemente, R. J., Crosby, R. A., Hub-
Oster, N. V., Rothenberg, R., McPhillips-Tangum, C. A., Gazmararian ,
bard McCree, D., Liau, A., . . . Hook, E. W. (2002). Prevalence
J., & Franks, A. L. (2003). Chlamydia screening in a metropoli-
and correlates of chlamydia trachomatis among sexually ac-
tan Atlanta primary care clinic. Southern Medical Journal, 96(9),
tive African-American adolescent females. Preventive Medicine,
863–867.
35(6), 593–600.
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Urban African American Women’s Explanations of Recurrent Chlamydia Infections Melva Craft-Blacksheare, Frances Jackson, and Theodore K. Graham
Correspondence Melva Craft-Blacksheare, DNP, CNM, RN Department of Nursing School of Health Professions and Studies University of Michigan-Flint 303 East Kearsley WSW 2180 Flint, MI 48502. [email protected] Keywords Chlamydia Health Belief Model African American urban teens
ABSTRACT Objective: To explore reasons for the high chlamydia recurrence rate among African American (AA) urban women. Design: In this phenomenological qualitative study, young AA urban women with recurrent chlamydia were interviewed using open-ended questions guided by the conceptual framework of the health belief model (HBM). Setting: The study was set in three urban health clinics in Michigan. Participants: Ten African American adolescents, age 15 to 19, participated. Methods: In face-to-face recorded interviews, participants shared their personal experiences and viewpoints on what led to their recurrent chlamydia infections. The data were transcribed and analyzed through hand coding and NVivo 8 a qualitative software package. Results: Overall, participants demonstrated significant knowledge deficits about the seriousness of chlamydia compared to other sexually transmitted infections (STIs). After reinfection, their perceived susceptibility changed: condom use was seen as beneficial and perceived barriers to condom use diminished as participants gained a new sense of empowerment. Conclusion: Chlamydia infection among African American urban adolescents is nearly 3 times that of the general population. Lack of education is still a barrier to STI prevention. Participants reported a desire to receive counseling and support from the health care staff. A STI care model that includes education, counseling, and regular screening of high-risk adolescents should be considered. Further research, using the HBM or similar theoretical models, are needed to gauge the success of any planned or implemented intervention.
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Melva Craft-Blacksheare, DNP, CNM, RN, is an assistant professor in the Department of Nursing, School of Health Professions and Studies, University of Michigan–Flint, Flint, MI. Frances Jackson, PhD, MSN, MA, BSN, RN, is a professor emerita at Oakland University School of Nursing, Rochester, MI.
(Continued)
The authors report no conflict of interest or relevant financial relationships.
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he Centers for Disease Control and Prevention (CDC; 2010) estimates that approximately 19 million new sexually transmitted infections (STIs) occur each year in the United States; almost one half of these are among young people age 15 to 24. Chlamydia remains the most commonly reported infectious disease in the United States, with an estimated 2.8 million new infections each year. An estimated 30% to 40% of untreated chlamydia infection progress to pelvic inflammatory disease (PID), and common sequelae of PID include ectopic pregnancy, infertility and chronic pain, with estimated annual costs exceeding $3.1 billion (Blake, Quinn, & Gaydos, 2008). Moreover, among developed countries, the United States has the highest rates of curable STIs (Advocates for Youth, 2003).
T
Young women are more susceptible to STIs than their male counterparts because their columnar
epithelial cells, which are especially sensitive to invasion by sexually transmitted organisms such as chlamydia and gonorrhea, extend out over the surface of the cervix, where they are unprotected by cervical mucus (Eng & Butler, 1997). As women age, their STI risk is reduced as their columnar epithelial cells recede to a more protected location. The CDC 2012 reported that the 2012 chlamydia rate for women was almost 2½ times higher than that of males (643.3 vs. 262.6 per 100,000 people). Among women, the highest age-specific rates of reported Chlamydia in 2012 occurred in 15 to 19 (3,291.5 cases per 100,000 women) and 20- to 24-year-olds (3,695.5 per 100,000 women). Women age 15 to 19 had the highest rate until 2010, when the chlamydia rate increased in the 20 to 24 years category. African American women age 15 to 19 had the highest rate of any group (7, 7191.1), followed by American Indian/Alaska Native (4,235.1), Hispanic (2,013.6), and White
C 2014 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
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Chlamydia remains the most commonly reported infectious disease in the United States with an estimated 2.8 million new infections each year.
(1458.3) women. The CDC reported an overall chlamydia rate of 1613.6 per 100,000 African American women, which is more than 6 times that of White women (260.5), almost 3 times that of Hispanic women (574.7), and close to 2 times that of American Indians/Alaska Natives (1126.4). Chlamydia reinfection is common among young adults, especially women. Anschuetz et al. (2008) investigated infection and reinfection rates of chlamydia and gonorrhea among adolescents in the Philadelphia public high schools during the 2002 to 2006 school years. In the primary analysis, the unadjusted female chlamydia/gonorrhea rate was more than double that of males (6.0 vs. 2.4 cases per 100 personyears, respectively). Among students with positive test results, 13.6% were reinfected within the same school year. Female adolescents with named partners not treated had a higher reinfection rate than all others (85.5 vs. 40.1 – 45.2 cases per 11 person-years, respectively). Among those reinfected, the median time until the second infection was detected was 127 days (range: 62 – 232 days). Williams et al. (2002) reported that chlamydia often goes undetected because as many as 75% of infected women and 50% of infected men experience no symptoms. This fact increases the likelihood that undetected infections will result in costly reproductive outcomes, including PID, ectopic pregnancy, chronic pelvic pain, salpingitis, and infertility. To reduce the chlamydia infection and reinfection rate, it is important to design interventions that will be effective for the population most vulnerable to this disease: young African American women who live in urban areas. The purpose of this study was to understand African American urban women’s reasoning on their nonuse of condoms after initial diagnosis and treatment of chlamydia.
Theodore K. Graham, MD, is an assistant clinical professor, Wayne State University School of Medicine, Detroit, MI.
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who care for them may be more empathetic to and understanding about their experiences. Therefore, a qualitative phenomenological research study design was used to explore the essential elements of the lived experiences of African American urban female adolescents diagnosed with recurrent chlamydia infection and to describe the meanings these teens made of their experiences. The aim of this approach was to listen to individuals and determine their thoughts and explanations for why they continue to practice risky sexual behavior even after initial infection. Through this approach, we hoped to gain insights that health care providers and educators could use to develop effective strategies for preventing chlamydia infection and reinfection among African American urban female adolescents and, consequently, their sexual partners.
Health Belief Model The health belief model (HBM), which focuses on individuals’ beliefs and attitudes, is a psychological model for the explanation and prediction of health behaviors. This model was initially developed in the 1950s by three social psychologists, Hochbaum, Rosenstock, and Kegels, in response to the failure of a free tuberculosis screening program. Since then, it has been used to explain a variety of health behaviors, including sexual risk behaviors and HIV/AIDS transmission. Before this study, the HBM had not been used as a framework to understand African American urban female adolescents with recurrent chlamydia infections (Rosenstock, Strecher, & Becker, 1988). The HBM is based on the understanding that a person will take a health-related action (e.g., condom use and nonrisky sexual behavior) only if he or she
r r
r
believes that a negative health condition (recurrent STI) can be avoided; has a positive expectation that taking the recommended action (using condoms) will prevent a negative health condition (recurrent chlamydia); and believes that the recommended health action (comfortably and confidently insisting on condom use) can be undertaken successfully.
Phenomenology describes the experience of individuals related to specific situations so that those
The original HBM has four constructs representing what participants identify as threats and benefits: perceived susceptibility, perceived severity, perceived benefits, and perceived barriers
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Table 1: Interview Questions 1. How much at risk do you think you are for becoming reinfected with chlamydia? (Perceived Susceptibility) 2. How was your life disrupted when you were diagnosed with chlamydia a second time? (Perceived Severity) 3. How do you rate the seriousness of chlamydia compared to other sexually transmitted infections like HIV/AIDS, herpes, gonorrhea, syphilis, genital warts, and pelvic inflammatory disease? (Perceived Severity) 4. What do you know about some of the health problems that chlamydia can cause? (Perceived Severity) 5. To what extent is your decision to use a condom influenced by your friends? (Perceived Barriers) 6. Consistent condom use decreases chlamydia reinfection. Tell me about the barriers that exist that prevent you from using a condom all the time you have sex. How can these barriers be controlled, removed, or reduced? (Perceived Barriers) 7. What do you think would make you more confident in using a condom correctly all the time? (Self-Efficacy) 8. What roles, if any, does your partner play in your decision to use a condom? (Perceived Barriers) 9. What are some things that the health providers in the clinic can help you with or do for you to assist you in remaining chlamydia free? (Self-Efficacy)
(Rosenstock et al., 1988). For this study, perceived susceptibility reflects the participants’ beliefs about their likelihood of chlamydia reinfection. Perceived severity indicates the participants’ beliefs about the seriousness of a recurrent chlamydia infection and the severity of its consequences. Perceived benefits reflect the participants’ belief in the advised action’s efficacy to reduce the risk or seriousness of disease effects. Perceived barriers indicate the participants’ beliefs about the advised action’s tangible and psychological costs. Rosenstock et al. (1988) later added two concepts: cues to action are strategies to activate readiness, and self-efficacy is the participants’ confidence in their ability to take action. For this study, these six HBM constructs were used to help develop nine openended interview questions to elicit complete and honest participant feedback (see Table 1) and frame the discussion of the results.
Setting and Participants Following approval from the University’s Institutional Review Board, a plan was developed to re-
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cruit participants from three Michigan urban health clinics. This plan included disseminating recruitment flyers and posters throughout the clinics. Eligible clients were female African American urban adolescents age 15 to 19, who self-reported recurrent chlamydia infections within the previous 12 months. This population was chosen because the previous research indicated that they exhibit the greatest incidence of chlamydia infection. Participants were screened to ensure all inclusion criteria were met. Interviews were held in private clinic offices. The total sample (N = 10) consisted of African American female adolescents, aged 15 to 19, with a mean (SD) age of 17 years. Of the 10 participants, three were age 15, one was 16, two were 17, one was 18, and three were 19 . Education ranged from ninth to 12th grade. Present grade level ranged from 10th grade to college freshman. Two participants attended a vocational training school, and one did not reveal this information. Mothers’ educational level ranged from 10th grade to college, including one with a Graduate Equivalency Diploma (GED), one who
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Participants lacked consistent access to education on sexually transmitted infection, prevention counseling, and condoms before and after their initial diagnoses.
attended medical assistant school, and two whose specific educational levels are unknown. Fathers’ education ranged from ninth to 12th grade, including one with a GED and one whose specific educational achievement is unknown. Number of sexual partners (in last 12 months) ranged from one to four, with a mean of 2.8. Household relations included mother, father, stepfather, sisters, brothers, cousins, aunts, uncle, and grandmother. Two households did not have a mother present, and seven did not have a father/stepfather present.
Results Qualitative results are presented according to the six HBM constructs of perceived susceptibility, perceived severity, perceived barriers, perceived benefits, cues to action and self-efficacy.
Perceived Susceptibility Perception of personal risk or susceptibility can be a powerful motivator for adolescents to adopt less risky sexual behavior. Participants were asked “How much at risk do you think you are for becoming re-infected with chlamydia?” After chlamydia reinfection, nine participants claimed they would take measures to prevent another infection. However, they may have felt this way after their first chlamydia diagnoses but still failed to take steps to prevent reinfection. Lack of education was a common problem. One participant expressed that she did not think she was susceptible to reinfection:
Procedures The researcher explained to participants/parents the study’s purpose and the confidentiality of all information obtained. Prior to interviews, informed consent was obtained from adult participants and parental permission for minor participants. Study participants completed demographic questionnaires before their interview and received a $10.00 gift card. Data collection occurred from June to September 2010 via audiotaped interviews with 10 female teenagers in three urban health clinics until data saturation was achieved. The tapes were transcribed and transcripts reviewed to ensure accuracy. To maintain data confidentiality, participants were assigned a code number and no names were used on typed transcripts.
Data Analysis Results were analyzed using the Giorgi method of phenomenological evaluation. Hand coding and a qualitative software package (NVivo 8) were used to create and classify codes. After transcribing the interviews, reading and reflecting on the transcripts, and reviewing field notes for overall meaning and ideas, study themes were generated. To ensure the analysis was systematic and verifiable, an expert with more than 25 years of experience in urban women’s health reviewed the data. The expert also discussed the data and transcripts with the first author to increase rigor and to uncover additional data impressions or themes/patterns. Themes were then categorized according to the HBM’s conceptual framework.
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I thought when I first had that [chlamydia], since I got the medicine, it would work for a long time . . . I didn’t know it would stop working and you could get it again; I thought it would work for a long time. This participant may have thought chlamydia treatment worked like an immunization. All participants reported understanding that abstinence and/or consistent condom use decreases the incidence of chlamydia. However, the idea of being able to determine if a person has an STI based solely on appearance is still pervasive among this population. One participant said, “I always thought I was careful, and the guys I was with were clean and didn’t have anything like that.” According to the National Chlamydia Coalition (2011) this response correlates with other qualitative research studies where individuals believe that they could tell if someone, including their partners had an STI. A respondent who acquired chlamydia twice from the same partner said: I stopped messing with that boy, and I’m talking to another boy, and I trust him. We still use condoms and sometimes we don’t, but we have our regular checkups so we’ll know. But if I knew that he was not going to get himself checked out, then it would be on my mind to use a condom. Even after two chlamydia infections, this participant continued to trust her partner instead of using proven prevention methods.
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Perceived Severity Perceived severity reflects an individual’s belief about the seriousness of a disease. Two interview questions addressed this phenomenon. Participants were asked to rate the seriousness of chlamydia and to compare it to that of other STIs (e.g. HIV/AIDS, herpes, gonorrhea, etc. See Table 1). The responses demonstrated a clear lack of knowledge about the nature of the disease. One respondent stated, I have no clue, but chlamydia is probably better than those [HIV/AIDS] because you can take a pill to clear it up. AIDS is worse because you can pass it on to people and stuff. I think you pass herpes and gonorrhea and syphilis on, too. Even though some participants indicated that all STIs were the same, they would still express that HIV/AIDS was the worst one. Few participants received educational information after their first chlamydia exposure. Several participants were diagnosed with chlamydia in a pediatric clinic, and their prescriptions were given to their mothers. One participant stated, “They didn’t tell me anything. They gave my Mama some pills and I just took them. No one told me [about] any problems.” After receiving education about the severity of the disease after their second infection, some participants expressed more willingness to protect themselves from further reinfection. Another participant said, At first I just thought, okay, I have chlamydia. I can get rid of this, but the second time we had a long discussion, and [the doctor] was telling me . . . how bad it could be and that is when I really realized how serious it was. Another participant mentioned the importance of not being afraid to talk to her partner.
Perceived Benefits People tend to adopt healthier behaviors when they believe the new behaviors will decrease their chances of developing disease. The participants agreed that the benefit of consistent condom use was knowing that “I won’t get nothing.” This new behavior was valued because it could decrease the risk of chlamydia reinfection. Some of the emotional effects expressed upon the second chlamy-
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dia diagnosis ranged from, “I felt nasty. I was depressed. I didn’t go anywhere, I just stayed in the house, and I didn’t have sex for five months” to a pregnant teen who expressed concern about the health of her fetus, indicating that “the baby could be blind.” Due to the negative connotations of chlamydia reinfection, participants indicated that they would use condoms all the time to prevent “going through this again.” According to the participants, condom use is directly related to the benefit of remaining chlamydia free. Only one participant said that she sometimes does not use condoms because she trusts her new partner, but she does obtain chlamydia cultures every 3 months.
Perceived Barriers To adopt consistent condom use, participants need to believe that the benefits of this new behavior outweigh the consequences of the old behavior. Several interview questions were posed to promote discussion about this topic and identify barriers that need to be removed, controlled, or reduced. Barriers queried were influence of friends and lack of communicative confidence with partner. According to participants, their friends did not influence their condom use. In fact, after the participants’ exposure to chlamydia, many encouraged their friends to use condoms. Before reinfection, partners had a larger role in condom use. According to participants, however, the partner’s role had diminished since reinfection: Nothing at all is standing in the way [of using a condom]. I say it now because I look at things totally different. If I would of use that condom, I wouldn’t be in this predicament that I’m in now. Like my mom don’t let me go to many places like I use to. It’s nothing now for me to want to use a condom all the time now. Like where is the condom at? Caught up in the moment make me not use a condom . . . not even thinking about my actions and my consequences of what would happen if I didn’t use a condom, have fun, not thinking about my consequences. I know for a fact that I won’t be caught up in the moment. That is something I don’t want to take a chance in; no one can talk me into that anymore. Participants also expressed having control over condom use, suggesting that they now felt a sense of empowerment. One participant’s chlamydia
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exposure diminished her partner’s role in condom negotiation, “He can get mad, but there is nothing you can really do. Either put the condom on, or you’re not getting any [sex], so you better put the condom on.” Several participants ended relationships with the initial partners, moved to new partners, and became reinfected. After reinfection, those participants indicated they would use a condom all the time, “nothing at all stands in the way of using a condom now.” One participant presented herself as an outlier in the study. She insisted she uses condoms all the time; however, she was reinfected with chlamydia and pregnant.
Cues to Action Participants expressed several common factors that helped them change their behaviors. The repeated chlamydia diagnosis, particularly from the same partner, was a “wake-up call” for most participants to change their behavior and insist on consistent condom use. One participant, who was in a 2-year monogamous relationship, expressed confusion and hurt when she was diagnosed the second time: “Are you messing around with someone else? He denied it, however, I left him alone after that; twice is two times too many.” A participant told the story about her close girlfriend who was pregnant and had an STI from her child’s father. She was totally surprised because she knew he supposedly “loved her” and would never have believed that he would give her an STI. Several participants became infected the second time with a new partner because they continued to believe that they could see if someone was infected. After learning about the health problems chlamydia could cause, most participants were more aware about the importance of condom use.
Self-Efficacy Participants were asked, “What do you think would make you more confident in using a condom correctly all the time and what are some things the health provider in the clinic can do to assist you in remaining chlamydia free?” All participants indicated growing confidence in their ability to consistently use condoms to prevent reinfection. One participant who trusted her partner to be monogamous determined that it was her decision to use condoms inconsistently. She, along with her partner, has frequent STI screenings (every 3 months for her). Additionally she also indicated it was her decision to use a condom if she thought her partner was not getting frequent check-ups. Al-
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though self-efficacy was present, all participants suggested that further support from the health clinic in the form of free condoms and educational information would complement their ability to take more consistent action to protect themselves from recurrent infection.
Discussion Many of our findings regarding susceptibility, screening, and education align with previous studies about adolescents and chlamydia infection. Despite its limitations, this study also yielded new discoveries that can affect nursing practice in the area of chlamydia prevention. Initially, most participants did not think they were susceptible to chlamydia. Similarly, Ethier, Kershaw, Niccolai, Lewis, and Ickovics (2003) found that uninfected adolescents failed to perceive their vulnerability to STIs, and 81.3% of those infected with STIs still perceived themselves at little or no risk. Our results also are similar to those supporting the claim that approximately 75% of women are asymptomatic and do not realize they are infected with chlamydia (Burstein et al., 2001; Oster, Rothenberg, McPhillips-Tangum, Gazmararian, & Franks, 2003; Williams et al., 2002). The majority of participants were asymptomatic and diagnosed during routine gynecologic exams. Several diagnoses were made by urine ligase during a pediatric exam. One third of gynecologic physicians surveyed by Oster et al. (2003) indicated that they would not test asymptomatic sexually active teenage women for chlamydia during routine gynecologic examinations. This approach to clinical practice may mean that many chlamydia infections go undetected and result in more serious health complications. In a longitudinal study where the mean age of PID diagnosis was 16.8, Trent, Chung, Forrest, and Ellen (2008), suggested routine chlamydia screenings could reduce reinfection. In addition to routine screening, STI education is an important tool in chlamydia prevention. All participants were aware of the fatal characteristics of HIV/AIDS and, unfortunately, this belief overshadowed the risks of chlamydia, which is 3 times more common among the adolescent population. Except for HIV/AIDS, most participants had limited knowledge about the severity of chlamydia and other STIs. Interview responses indicated most participants did not receive educational materials about chlamydia after their first diagnosis. Perhaps if they had, some reinfections could have
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been prevented. Health care facilities should consider providing age appropriate educational materials to all teens diagnosed with an STI. Historically, there has been much debate on sex education in the public school system including discussion about when it should start, whether abstinence only curriculum is effective, and the importance of consistent condom use. According to a report of the content of federally funded abstinence only education programs (2004), more than two thirds of abstinence-only education programs were using curricula with multiple scientific and medical inaccuracies. These curricula contained misinformation about condoms, abortion, and basic scientific facts. They also blurred religion and science and present gender stereotypes as fact (Waxman, 2004). Additionally Underhill, Montgomery, and Operario (2007) concluded that the most methodologically rigorous reviews have consistently documented that there is no evidence that abstinence-only programs can reduce risky sexual behavior. Not all our study participants received sex education in their high schools. According to participant responses, the public school system failed to offer materials that could be helpful in deterring STI exposure. Public school systems should consider providing students with effective teen-oriented STI educational materials. Our data showed that participants who were diagnosed by their pediatricians or in an emergency facility also did not receive health information. Unfortunately, many health professionals are leaving adolescents defenseless by not providing them with the necessary prevention information or tools. Health offices and clinics often are quite busy. However, time spent educating young, sexually active adolescents could help prevent chlamydia infection/reinfection and promote safer sex practices. All study participants demonstrated an eagerness to learn about chlamydia and other STIs during the interviewing process. It was obvious that their inadequate knowledge was not due to willful ignorance, or as some participants stated, “being stupid,” but more from a lack of opportunities to acquire knowledge.
Implications By using the HBM, we used the voices of the adolescents themselves to reveal unique phenomena not previously reported in the literature. This information suggests new areas to investigate to
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help deter the problem of chlamydia infection and recurrence. Participants overwhelmingly demonstrated the need for STI education, counseling, and support. Many commented on the importance of being able to “talk with someone about their concerns.” Participants demonstrated a sense of pride that they were sharing their experience, thoughts, and ideas because they were told it could possibly help deter someone else from becoming infected with chlamydia. Personal Health vs. Trusting a Partner. One participant refused to use condoms because she “trusted” her partner. Although she agreed that consistent condom use prevents chlamydia infection, she held to the concept of trust. Her concurrent decision to receive STI screening every 3 months, however, indicated her unwillingness to ignore her health concerns completely. Although only one participant raised the issue of trust, this may highlight a concern for other teens. The conflicting values of personal health and trusting sexual partners should be explored within additional research. Researchers should examine why and how trust can outweigh confirmed knowledge. After teens have STI education and condoms access, why do they continue to practice risky sexual behavior? According to Piaget’s developmental theory, adolescents are egocentric, with feelings of invincibility, who often demonstrate risky behaviors (Browning, 2008). Therefore, to adequately support the needs of teenagers, health care professionals must be aware of normal adolescent development and consistently advocate and support the benefits of safe sex practices. Continuity of Care. The health care system’s lack of continuity of care is also a confounding issue. Pursuant to the CDC (2010), the current standard of care requires that clients diagnosed with chlamydia receive specific care instructions including pelvic rest, partner notification, and (if pregnant or re-infected < 60 days) follow-up tests to confirm a cure. This standard of care should be expanded to mandate that all health care professionals who diagnose chlamydia, including those in pediatric clinics and emergency departments, counsel adolescents on prevention and provide educational information. Unfortunately, most of this study’s participants received no such followup care. The adolescents’ own words can be used by the health community to develop strategies and policies to support and to empower this population to prevent chlamydia.
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Nurses are advocates for community health. Education, counseling, and promotion of condom use are crucial strategies for abating chlamydia infections among African American urban women.
Nursing Implications We investigated some of the underlying reasons African American urban adolescents continue to practice risky sexual behavior. The interviews offered an understanding of African American urban adolescents’ psychosocial issues upon which the nursing community can build better counseling and educational support. Educating adolescents and offering support, by providing counseling and condoms, are some of the approaches suggested by these participants. The nursing community can use these findings to evaluate and to improve existing STI follow-up procedures and to develop new care models to address this crisis.
the responses of several participants. Additional qualitative studies could help identify if and/or how participant/parent education relates to chlamydia recurrence. In future studies, recruiting a diverse racial sample of urban women could be beneficial in increasing the applicability of findings. Despite these limitations, this study’s findings should be of interest to and useful for health care professionals who serve this population.
Conclusion Chlamydia infection among African American adolescents is nearly 3 times that of the general population. The primary risk factors for chlamydia are reinfection, previous exposure, lack of preventative education, and inconsistent condom use. According to study participants, they experienced a lack of education, counseling and support from health professionals after initial diagnosis. Presently, there is not a universal model of care for adolescents diagnosed with chlamydia.
Nurses and nurse practitioners can work with the public school system to develop and to teach a (proposed mandatory) biannual health maintenance workshop. Workshops could commence in ninth grade and include such topics as health screenings (including self-breast and testicular exams), disease prevention (including exercise, diet, and nutrition), male and female bodily changes, and reproductive education, including pregnancy and STI prevention.
Nurses can take the initial steps to develop a care model for adolescents who are diagnosed with chlamydia. This model would include appropriate screening, treatment, education, and counseling. Once tested, the model could be incorporated into nursing curriculum to encourage continuity of care. In addition, further research is needed to address the topic of adolescents, relationship dynamics, and risky sexual behavior.
Nurses and nurse practitioners who work with adolescents can help develop a standardized model of care that promotes routine STI screening according to CDC guidelines. The proposed care model also could stipulate that health care providers give treatment medication and counseling—which address medical and psychosocial risk factors and promote follow-up care—directly to patients, regardless of minor status. In the state of Michigan there are no specific statutes on the issue of family planning and related services to minors; therefore, parental consent is not required. This is considered a federal constitutional “right of privacy” (Network for Public Health Law, 2013).
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Small sample size and participant homogeneity are limitations. Although the interview included questions developed according to the HBM, the questions were not pretested. Further, we did not address self-esteem, relationship quality, or parent involvement, issues that may have explained
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