The need for innovative sexually transmitted infection screening initiatives for young men: evidence from genitourinary medicine clinics across England

Abstract

The study objectives were to ascertain behavioural, access-related, health-seeking factors and sexually transmitted infection (STI) prevalence in young men (<25 years) attending genitourinary (GU) medicine clinics and compare them with older men (≥25 years) and young women (<25 years). Between October 2004 and March 2005, 4600 new attendees at seven sociodemographically and geographically contrasting GU medicine clinics across England completed questionnaires, which were linked to routine clinical data. Young men waited significantly less time to be seen in clinic compared with older men and young women. They were less likely to report symptoms than older men (P = 0.021) yet more likely to be diagnosed with chlamydia (P = 0.001) and gonorrhoea (P = 0.007). They were also more likely to be diagnosed with an acute STI relative to young women (P = 0.007). Our data confirm the need to make comprehensive STI screening readily available for young men and to develop effective and innovative screening strategies in different settings.

Keywords

young men access sexually transmitted infection survey screening

INTRODUCTION

Young people aged 16–24 years bear the brunt of sexually transmitted infections (STIs) in the UK.¹ In 2006, young men accounted for 56% and young women 74% of all male and female genitourinary (GU) medicine clinic attendees, respectively.¹ On a population level, chlamydia prevalence has been found to be as high in young men as in young women: in a national survey in 2000, the prevalence of chlamydia in young men and young women aged 18–24 years was 2.7% (95% confidence interval [CI] 1.2–5.8) and 3.0% (1.7–5.0), respectively.² Of those screened through the National Chlamydia Screening Programme in 2005, 10% of men and women below 25 years of age were chlamydia positive, with men aged 20–24 years having the highest prevalence compared with women and men aged 16–19 years (12.4%, 11.6% and 8.8%, respectively).³

Knowledge about sexual health services has been found to be poor among young men in Britain. A national tracking survey conducted as part of the Teenage Pregnancy Strategy Evaluation found that 65% of all young men aged 13–21 years knew of a place where they could get information about sex compared with 77% of young women.⁴ Similarly, a survey of young men aged over 16 years recruited from community settings in the north-west of England found that only 13% knew the location of their local GU medicine service.⁵ The perception of sexual health services as ‘female-orientated’^6,7 or for ‘old men’⁷ may act as a deterrent to accessing sexual health services.

We use data from a large survey of GU medicine clinic attendees to explore barriers to effective STI health care for young men in comparison with other groups. Specifically, we describe the behavioural, access-related, health-seeking factors and STI prevalence in young men (<25 years) attending GU medicine clinics, and compare them with data from older men (≥25 years) and young women (<25 years).

METHODS

Population and sampling

Seven GU medicine clinics across England were purposively recruited, representing contrasting demographic, geographic and service configuration characteristics likely to affect sexual health need and service use. Full details of the survey have previously been published.^8,9 Briefly, all new patients attending the clinics were given written information about the study by the receptionist and invited to complete a short, 22-item self-completion pen-and-paper questionnaire in English. This questionnaire explored patients' health-seeking behaviour and contact with services in relation to their current problem(s). To protect confidentiality, questionnaires were anonymous apart from the clinic identification number which was used to link the questionnaire to the clinic's routine database to obtain data on patient's gender, age, ethnicity, STI diagnosis/es made at that clinic visit and whether or not any STI was likely to have been homosexually-acquired. Data collection took place from October 2004 to March 2005. The denominator for each clinic was estimated as the number of new clinic numbers issued minus, if applicable, those issued in the week in November 2004 when the Department of Health conducted its Waiting Time Survey, as questionnaires were not distributed during this week.

This analysis uses data from all seven clinics, regardless of response rate, which ranged from 17.8% to 70.1% for all respondents, and from 32% to 54% for all men aged <25 years across all the clinics, reflecting, it is thought, reception staff not offering questionnaires to all new patients. We adopt this strategy here since the only significant differences observed between the three clinics' samples excluded from some earlier analyses,⁸ and the four clinic included samples were (i) women in the included samples were more likely to report daily work or college and (ii) women in the included samples were more likely to go to the clinic from home rather than elsewhere. This strategy also maximizes the number of young men for whom we have data, which for the purpose of these analyses, are defined as those aged below 25 years at their clinic visit. We refer to these men as ‘young men’ hereon.

Statistical analysis

We compare young men relative to (i) men aged 25 years and older and (ii) women aged under 25 years, from here on referred to as ‘older men’ and ‘young women’, respectively, for brevity. We determined statistical significance using the chi-square statistic for categorical variables and the Mann-Whitney statistic for continuous variables (because of the skewed distributions of the variables considered). Analyses were undertaken using the survey commands in STATA 9.0 to take account of clustering by clinic.¹⁰ Statistical significance is considered as P < 0.05 for all analyses.

Ethical approval was obtained from south west multi-centre ethics committee.

RESULTS

A total of 5322 questionnaires were completed in the seven clinics, of which 4600 (86.4%) could be linked to clinical data, resulting in a sample of 2255 men and 2345 women. Of these 2255 men, 855 (35.0%) were young men, and of these, a quarter (207) was aged less than 20 years. In contrast, 1243 women (53.0%) were considered as young women, and of these, 41.1% (511) were aged below 20 years.

Sample characteristics

Background characteristics, in terms of sociodemographic and health-related factors, are shown in the Table 1 for young men relative to older men and also relative to young women. As might be expected, young men were less likely to be living with a partner or spouse or have childcare responsibilities, relative to older men or young women. Young men were also less likely than older men to be in work or college every day the clinic was open. Although there were significant educational differences when young men were compared with older men and younger women, clear patterns in differences were not observed. In terms of health-related factors, young women were more likely to report being registered with a general practitioner (GP) than either young or older men (93.1% versus 87.7% versus 87.0%), while young women and older men were both more likely to report previous STI diagnosis/es (17.4% and 18.1%, respectively, relative to 10.5% of young men).

Table 1

Sociodemographic and health-related factors of sample by gender and age group

	Young men (aged <25 years)	Older men (aged ≥25 years)	Young women (aged <25 years)
Denominator	855	1395	1243
Sociodemographic factors	Median (IQR)	Median (IQR)	Median (IQR)
Age	21 (3)	32 (11)	20 (4)
	Column (%)	Column (%)*	Column (%) ^†
Ethnicity		P = 0.204	P = 0.239
White	60.7	65.5	64.5
Black African	4.8	6.2	3.9
Black Caribbean	11.7	8.2	9.6
Asian	6.5	8.1	4.4
Other/mixed	16.3	12.0	17.6
Cohabiting with partner/spouse	10.7	P < 0.0001 39.0	P = 0.007 16.1
Childcare responsibilities	3.7	P = 0.0009 14.3	P = 0.019 7.6
Go to work/attend college when the clinic is open		P = 0.004	P = 0.061
Yes, every day	55.8	65.9	52.0
Yes, some days	27.3	18.3	31.9
No	16.9	15.8	16.2
Highest educational qualification ^‡		P = 0.013	P = 0.022
Degree/higher degree	31.6	39.6	38.1
A level/AS level/higher	24.8	15.2	26.9
GCSE	17.3	18.8	16.5
GNNQ/NVQ/HNC/HND/other	21.4	18.4	16.5
No qualifications	4.9	8.0	2.1
Health-related factors		P = 0.636	P = 0.044
Registered with a GP	87.7	87.0	93.1
Previous STI diagnosis/es		P = 0.003	P = 0.028
	10.5	18.1	17.4

IQR = inter-quartile range; GP = general practitioner; STI = sexually transmitted infection

*P values in this column refer to the difference in proportions for young men relative to older men

^† P values in this column refer to the difference in proportions for young men relative to young women

^‡Among patients aged at least 21 years

How patients found out about the clinic

The three most common ways of finding out about the clinic among young men were, firstly from a friend (29.8%), secondly from a GP or a nurse at their GP surgery (25.6%), and thirdly from a partner (13.0%). These were also the most common ways reported by older men, although a larger proportion of older men (31.5%) reported finding out about the clinic from a GP or a nurse at their GP surgery (P = 0.025), and a significantly smaller proportion of older men (17.3%) reported from a friend (P = 0.001), while a similar proportion reported from a partner (14.0%, P = 0.559). The same responses were also reported by young women with no significant differences in the magnitude of proportions, relative to young men.

Why patients went to clinic

Young men were more likely than older men to be asymptomatic (53.5% versus 46.8%, P = 0.021), and in this respect were more similar to young women (50.4%, Table 2). They were also more likely than older men to report no symptoms but that they wanted a check-up (41.6% versus 31.0%, P < 0.001), but were less likely to report wanting an HIV test compared with older men (11.6% versus 17.7%, P = 0.024). However, all patient groups most commonly cited having (had) symptoms as their reason for attendance, with no significant difference in the amount of time symptomatic patients reported having had their symptoms (median of 14 days for the 3 gender/age-groups considered).

Table 2

Reason(s) for going to GU medicine clinic by gender and age group

	Young men (aged <25 years)	Older men (aged ≥ 25 years)		Young women (aged <25 years)
Denominator	855	1,395		1,243
Reasons	%*	%*	P value ^†	%*	P value ^‡
I have (or had) symptoms (e.g. itching, discharge)	46.8	53.5	0.021	50.4	0.169
My partner had (or had) symptoms	9.5	10.0	0.827	12.7	0.296
My partner has been diagnosed with an infection and I needed to come to the clinic	10.8	11.2	0.720	10.6	0.881
I was contacted by a clinic/health adviser	0.6	2.3	0.025	3.1	0.006
I did not have symptoms but wanted a check-up	41.6	31.0	0.0001	41.3	0.895
I wanted a HIV test	11.6	17.7	0.024	9.3	0.113
GP advised me or told me to go	0.8	1.6	0.143	2.2	0.007
Hospital referral	0.3	0.3	0.829	0.3	0.808

GP = general practitioner; GU = genitourinary

*Percentages sum to more than 100% as patients could report multiple reasons

^† P values in this column refer to the difference in proportions for young men relative to older men

^‡ P values in this column refer to the difference in proportions for young men relative to young women

Getting into clinic

Although there were no differences between the three groups in terms of the time taken to seek care, or in the proportions who reported seeking care from other health-care professionals (including their GP), prior to going to the study clinic, there was a difference in provider delay⁸ that is, the time between first contacting the service and being seen in the study clinic. Young men waited a median of three days to be seen in clinic, so less time than reported by older men (median of 5 days, P = 0.005) and young women (median of 5 days, P = 0.037). While men reporting symptoms had a median wait of five days (regardless of age), asymptomatic young men only waited two days on average to be seen, compared with a median of seven days among asymptomatic older men (P = 0.002).

STI diagnosis/es made at clinic visit

Despite no difference in the proportion of young men and older men who were diagnosed with acute STI(s) at clinic (40.4% versus 36.9%, P = 0.151) genital chlamydia and gonorrhoea diagnoses were more common among young men relative to older men (14.7% versus 8.8%, P < 0.001, and 4.8% versus 3.1%, P = 0.007, respectively). (Acute STIs were defined as infectious syphilis [KC60 codes: A1, A2], uncomplicated gonorrhoea [KC60 codes: B1, B2], complicated gonorrhoea [KC60 code: B5], chancroid/lymphogranuloma venereum/donovanosis [KC60 codes: C1, C2 and C3]; chlamydial infection [uncomplicated/complicated] [KC60 codes: C4a, C4b and C4c]; uncomplicated non-gonococcocal/non-specific urethritis in males [KC60 code: C4h]; complicated non-gonococcocal/non-specific infection [KC60 code: C5]; herpes simplex [first attack] [KC60 code: C10a]; genital warts [first attack] [KC60 code: C11a] and trichomoniasis [KC60 code: C6a].) Relative to young women, young men were more likely to have acute STI(s) diagnosed at their clinic visit (40.4% versus 31.5%, P = 0.007). While there was no difference in the rate of chlamydia diagnoses by gender among those aged under 25 years, young men were more likely than young women to have gonorrhoea diagnosed (4.8% versus 2.3%, P = 0.004). This was of borderline significance (3.5% versus 2.3%, P = 0.090) after excluding young men who were recorded as having acquired their infection homosexually. Although young men who did not report symptoms were less likely to have STI(s) diagnosed at clinic than symptomatic young men, (25.6% versus 55.1%, P < 0.001), still a quarter of asymptomatic young men had STI(s) diagnosed.

Behavioural characteristics

In all, 44.3% of symptomatic men continued to have sex after their symptoms had begun. While this proportion did not vary by age-group, symptomatic young men were less likely than symptomatic young women to report this (43.9% versus 61.2%, P = 0.001), although the proportion reporting sex without condom(s) did not differ between groups (4.2% of all respondents). Although young men were seen promptly at clinic, it is worth noting that they reported being prepared to wait a median of seven days to get an appointment at a GU medicine clinic (as did older men and young women). There was also no difference in the proportion that reported they would not have sought care if their symptoms had disappeared by gender/age group (29.5% of all symptomatic respondents).

DISCUSSION

In this study of seven contrasting GU medicine clinics, we found that young men tend to be seen quickly by clinics and have a high prevalence of STIs, even if asymptomatic. However, their attendance at sexual health services is disproportionately low, which may be related to similar factors as the poor health-seeking behaviour reported across a spectrum of health issues among men generally,^11,12 and specifically young men.^13,14 Some have suggested that young men's poor health-seeking behaviour with regard to sexual health services is due to a lack of knowledge about their local GU medicine services and what they provide,⁵ while others argue that concerns about confidentiality,⁶ and misconceptions about STI testing¹⁵ may also deter men from attending. Convenience and cost may also play a part, so, although condoms may be freely available, the cost of travel to a sexual health service may be perceived as outweighing the cost of buying condoms.⁶ Some young men would prefer to attend designated young people's services that provided integrated care in one site rather than mainstream GU medicine clinics, although in one study young gay men generally stated a preference for the latter.¹⁶ It is vital that services take account of these findings as they develop new initiatives to target and engage with young men to address the disproportionately low numbers of young male attendees identified by our study.

We acknowledge that there were wide variations in response rates between the seven GU medicine clinic samples but, as discussed in the methods section, there were few significant differences between the clinics with relatively high versus relatively low response rates. Additionally, we observed no evidence of differences between patients who completed the questionnaire and those who did not, with respect to routinely collected data on gender, age, ethnicity and whether or not STI(s) were diagnosed. Furthermore, as we found very few significant differences between male participants aged 16–19 years and those aged 20–24 years we chose to define ‘young men’ as men aged less than 25 years rather than just teenage men. However, it is important to note that teenage men in the study were significantly less likely to report living with a partner or spouse, having childcare responsibilities or previous STI diagnosis/es than men aged 20–24 years (data not shown). These differences are as expected and thought to reflect less ‘time at risk’ among teenagers relative to men in their early 20s. Our decision to define men aged under 25 as ‘young men’ is also consistent with the age range of England's National Chlamydia Screening Programme.³

Our data confirm the importance of published standards for developing comprehensive sexual health services for young people,¹⁷ following identification of young people as high-risk populations in the National Strategy for Sexual Health,¹⁸ and the Teenage Pregnancy Strategy.¹³ Our study emphasizes the urgent need to develop young men-friendly sexual health promotion initiatives¹⁹ and sexual health services that are easily accessible and offer the full range of non-invasive screening in a variety of clinical^16,20 and community settings²¹ in collaboration with local youth services and users.

Footnotes

ACKNOWLEDGEMENTS

This study was funded by the Medical Research Council (MRC), with funding allocated from the Health Departments, under the aegis of the MRC/UK Health Departments Sexual Health and HIV Research Strategy Committee. The MRC has had no role in the collection, analysis and interpretation of data; in the writing of the report or in the decision to submit the paper for publication. The views expressed are those of the authors and not necessarily those of the MRC or the Health Departments. EJ had the original idea for this analysis. JAC was the principal investigator of the study and obtained funding from the MRC. Plans for analysis were led by CHM, who undertook all data management and statistical work, and coordinated the writing of the paper. SSD wrote the first draft of the paper, with all authors contributing to subsequent drafts. EJ and JAC are joint guarantors.

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