Papers

Qualitative analysis of psychosocial impact of diagnosis of Chlamydia trachomatis: implications for screening

Barbara Duncan, research associate ^a, Graham Hart, associate director ^a, Anne Scoular, consultant physician ^b, Alison Bigrigg, clinical director ^c. 

^a MRC Social and Public Health Sciences Unit, University of Glasgow, Glasgow G12 8RZ, ^b Department of Genitourinary Medicine, Sandyford Initiative, Glasgow G3 7NB, ^c Family Planning and Reproductive Health Directorate, Sandyford Initiative

Correspondence to: B Duncan barbara.duncan{at}strath.ac.uk

	Abstract

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Objectives: To investigate the psychosocial impact for women of a diagnosis of Chlamydia trachomatis and discuss the implications for the proposed UK chlamydia screening programme.
Design: Qualitative study with semistructured interviews. Interview transcripts analysed to identify recurrent themes.
Participants: Seventeen women with a current or recent diagnosis of chlamydia.
Setting: A family planning clinic and a genitourinary medicine clinic in Glasgow.
Results: Three themes were identified: perceptions of stigma associated with sexually transmitted infection, uncertainty about reproductive health after diagnosis, and anxieties regarding partner's reaction to diagnosis. Most women had not previously perceived sexually transmitted infections as personally relevant; this was a function of stereotypical beliefs about who was "at risk" of sexually transmitted infection. These beliefs were pervasive and negatively affected reactions to diagnosis and produced anxiety about disclosure of the condition to others (particularly sexual partners) and future reproductive morbidity. This anxiety, given the uncertain natural history of chlamydia, may prove difficult to dispel.
Conclusions: There are three primary areas of concern for women after a diagnosis of chlamydia which need to be examined in the proposed screening programme. Information provided should normalise and destigmatise chlamydial infection and positively promote genitourinary medicine services. Support services should be available because notification of partner can cause anxiety. Uncertainty about future reproductive morbidity may be inevitable; staff providing screening will require guidance in providing advice under such conditions.

	Introduction

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The sexually transmitted infection Chlamydia trachomatis is a leading cause of reproductive morbidity in women, including pelvic inflammatory disease and infertility.¹ Detection is difficult as it is largely symptomatic. Screening has been shown to reduce the prevalence of chlamydia in women² and the incidence of pelvic inflammatory disease.³ Currently, on the recommendation of an expert advisory group to the chief medical officer, two pilot studies are being undertaken to assess the feasibility of implementing a screening programme in the United Kingdom. A major target group for screening would be young women attending primary care providers.⁴

Women being screened will need information and support and may experience psychosocial problems associated with screening. Because of the complex emotional investments and social taboos surrounding sexual relationships⁵ reactions to a diagnosis of a sexually transmitted infection are likely to be complex. Qualitative methods of research are appropriate for such complex issues. ^{6 7} We used these methods to explore women's experiences of diagnosis of C trachomatis and identify salient issues before the implementation of the pilot screening programmes. We investigated the psychosocial impact of diagnosis and discussed the implications of the results for the proposed national screening programme.

	Methods

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Participants and recruitment
We recruited women with a current or recent diagnosis of chlamydia who were currently attending either a genitourinary medicine clinic or a family planning clinic in central Glasgow. Women were either approached directly by the researcher (BD) after their consultation or treatment, or both, and invited to take part, or approached by clinic staff, who obtained written consent from women to release contact details to the researcher. Written consent was obtained from all women before interview, and ethical approval was given by both health trusts involved.

Interviews and analysis
All interviews were conducted by BD in a clinic setting at the MRC Unit or in the women's homes. Interviews lasted between 40 minutes and two hours and were tape recorded and transcribed verbatim. We used a semistructured interview schedule, which explored women's experiences of being diagnosed with chlamydia. Questions were open ended, and we adopted a non-directive approach to encourage women to develop and elaborate their own narratives about their experiences (details of the interview schedule can be found on the BMJ's website).

	Results

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The themes that have implications for future screening programmes were perceptions of stigma associated with sexually transmitted infections, uncertainty about future reproductive health, and anxieties regarding male partners' attitudes to diagnosis.

Stigma
Before diagnosis most participants had perceived themselves as relatively invulnerable to infection. In the women's accounts, sexually transmitted infections were associated with stereotypical notions of contamination and delinquency. Participants distanced themselves from the "type" of person likely to contract a sexually transmitted infection (see box 2), which led them to believe that chlamydia and other sexually transmitted infections were not personally relevant. These stereotypes also affected expectations of the genitourinary medicine clinic, and initial reactions to referral were generally negative. While six women reported some knowledge of chlamydia before diagnosis, only two acknowledged any sense of personal vulnerability to infection. Of the eight women who had presented with symptoms associated with sexually transmitted infections, only four reported that, before attending a health provider, they had correctly attributed their symptoms to such an infection (one woman with urinary symptoms, one with abdominal pain, one with irregular menstruation, and one with genital warts).

Future reproductive health
All of the women reported receiving verbal or written information, or both, and advice from clinic staff about chlamydial infection, treatment, and possible effects. Provision of such information varied; all attenders of genitourinary medicine clinics reported receiving information and advice from health advisors, a service not available to women attending the family planning clinic. When participants were asked about the content of such information, they most often recalled the possibility of infertility after infection (see box 3). This provoked a mixed reaction: relief that the infection had been diagnosed and treated but also anxiety about future reproductive morbidity. These anxieties were exacerbated by clinical uncertainty about the natural course of chlamydia and the difficulty of providing a prognosis in relation to reproductive effects.¹ The largely asymptomatic nature of the infection (13 of the women reported no related symptoms before diagnosis) meant that many of the participants were unsure about the length of time that they had been infected. As most women believed that there was a positive association between duration of infection and probability of future infertility, this provided a further source of continuing anxiety.

Anxieties about attitudes of male partners
Participants' sexual relationships were mainly serially monogamous, with some women having sex with casual partners between relationships. For women with chlamydia, guidelines suggest that all partners in the past six months should be contacted.¹⁰ This relatively long period of possible infectivity meant that women often attributed the source of infection to a previous relationship. Diagnosis of a sexually transmitted infection introduced the possibility of a current partner's infidelity, a possibility that could be discounted if the source of infection was thought to be a previous relationship. Clinic staff encouraged this belief; there was wide variation in the reported likely duration of infection (from a few weeks to seven years). Given this variation, a plausible explanation is that health professionals were exploiting the uncertainty surrounding the natural course of chlamydia infection to mitigate the threat to the current relationship. Emphasis of the uncertainty about duration of infection may lessen fears about a partner's infidelity but could also increase anxiety about possible reproductive morbidity.

	Discussion

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Our results identified three primary areas of concern after a diagnosis of chlamydia: the perceived stigma of sexually transmitted infections, worry about future reproductive health, and anxiety associated with notifying partners. Our results have several implications for the proposed screening programme. Firstly, information given to women before screening should seek to normalise and destigmatise chlamydial infection to reduce the negative psychological impact of a positive diagnosis. Secondly, although it was clear that the information given to women by staff served to lessen, if not eradicate, stigma, disclosure of the condition to others remained a source of anxiety (specifically, that others would react badly). This anxiety may be exacerbated if women feel unable to access their usual support network. Thus, support services should be available if required. Women attending a genitourinary medicine clinic highlighted the important role of health advisors in providing advice and reassurance. Given the uncertainties associated with chlamydial infection and that reassurance about one factor can increase anxiety about another, staff outside specialised services may require guidance in providing support to women diagnosed with infection. Finally the chief medical officer's report recommends that women with positive diagnoses should be referred to genitourinary medicine clinics for support and advice about telling partners. It acknowledges that some patients may not take up referral and that education is required to destigmatise genitourinary medicine services.⁴ The data reported here support this position. This is not simply a matter of partner notification; comorbidity is of concern, and those identified positive for chlamydia may require a full sexual health screen to ensure that other infections are diagnosed and managed appropriately. Genitourinary medicine clinics must be represented as accessible and non-judgmental sexual health services.

Our data were not from women who had undergone chlamydia screening as part of a national screening programme, but these accounts can help inform our understanding of some of the possible reactions of women identified through such a programme to the news that they are infected with C trachomatis. We do not make any claims regarding the generalisability of this exploratory study, but, given the lack of available research in this area, the data provide important insights. Some of our results echo those of other studiesfor example, the stigma, ^{11 12} and isolation¹¹ associated with a diagnosis of sexually transmitted infection and relatively low levels of knowledge of chlamydia.¹³ It is notable that only six of the women in the study (three who had attended the genitourinary medicine clinic and three who had attended the family planning clinic) had, before diagnosis, perceived themselves to be personally vulnerable to a sexually transmitted infection and had actively sought treatment for this reason. Thus, this sample of women is unlikely to differ substantially from women recruited to a national screening programme in terms of perceived risk of chlamydia, and their reactions to diagnosis (and to referral to a genitourinary medicine clinic) are likely to be comparable. A recent study of 20 women who had been screened for chlamydia in general practice yielded similar results.¹⁴

From the accounts of these women, a diagnosis of chlamydia triggered rather than allayed uncertainty about future reproductive morbidity. Current knowledge of the natural course of chlamydia is insufficient to provide complete reassurance for individual women about their future reproductive health. It is imperative that care is taken to ensure that women do not develop unrealistic expectations of chlamydia screeningfor example, accompanying information should not inadvertently imply that diagnosis and treatment of chlamydia will, in itself, prevent infertility. Indeed, given the current state of knowledge about chlamydia, some uncertainty about future reproductive health may be an inevitable cost of screening for those with positive diagnoses; this should be made clear to women before participation.

The proposed chlamydia screening programme has the laudable public health aim of reducing the incidence, and possibly eradicating, a treatable sexually transmitted infection with potentially serious effects on reproductive health. Before the implementation of any new national screening programme, however, research is required to identify strategies to maximise the uptake of the service while minimising uncertainty and allaying anxiety associated with positive test results.

	Acknowledgments

   Contributors: GH had the original idea for the study, designed the study with BD, and was involved in data analysis and drafting the paper. BD collected the data, carried out primary data analysis, wrote the first draft of the paper, and is guarantor. AS and AB assisted in design, interpretation of data, and drafting the paper.

	Footnotes

Funding: UK Medical Research Council.

Competing interests: None declared.

Details of the interview schedule can be found on the BMJ's website

	References

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(Accepted 28 September 2000)