Examining socioeconomic inequalities in chlamydia screening and disease in young people

Lead Research Organisation: University College London
Department Name: Epidemiology and Public Health

Abstract

Chlamydia is a common sexually transmitted infection, which can cause infertility in later life. Most people with chlamydia do not know they are infected – they experience no symptoms. Screening can detect chlamydia in a urine sample or swab, so those infected can be treated.

In England, the National Chlamydia Screening Programme (NCSP) offers screening to sexually active people under 25. To be most effective, the NCSP needs to screen people most at risk of chlamydia. Although we do not know which young people are at greatest risk, in general people in deprived circumstances often suffer poorer health than affluent groups, so the NCSP need to make sure screening is offered to these people. Researchers measure deprivation in many ways, e.g. using income, education, characteristics of the local area. However, we do not know which measures are most relevant for young people at risk of chlamydia.

I plan to improve how we measure deprivation in young people, in order to investigate inequalities associated with chlamydia and screening. The findings of this study will help the NCSP to monitor service use and to identify those at high risk of chlamydia. It should also help other services to reduce inequalities in young people.

Technical Summary

Background: Chlamydia trachomatis is a significant public health problem. It affects up to one in 10 young people in England, increasing their risk of ectopic pregnancy and infertility, and may be more common in deprived groups. Screening has been developed using reliable diagnostic techniques to detect the high proportion of asymptomatic infections. The National Chlamydia Screening Programme (NCSP) in England offers screening to sexually active people under the age of 25 regardless of socioeconomic status.

However, the Inverse Care Law - The availability of good medical care tends to vary inversely with the need for it in the population served - has been demonstrated across NHS services including screening programmes. Initial analysis, based on routine area deprivation indicators, suggested the Law may not apply to chlamydia screening, but it did highlight two methodological problems:
a) it is not clear which indicators should be selected to investigate associations between deprivation and sexually transmitted infections (STIs);
b) commonly used deprivation measures may not be appropriately applied to young people.

Aims: This project will
- identify the most appropriate indicators of deprivation to use in young people;
- apply these indicators to the NCSP dataset to examine socioeconomic inequalities in chlamydia positivity and screening, to assess progress towards reducing inequalities.

Design: a mixed methods approach will be employed, combining a qualitative study in young people to inform a cross-sectional, quantitative analysis of chlamydia positivity and screening.

Methodology
Study 1: a systematic literature review will explore advantages and limitations of using different deprivation measures in STI research in young people, and will bring together existing theory and empirical literature to develop a theoretical model linking deprivation and chlamydia. This will be tested in study 3;
Study 2: focus groups with young people will be conducted to understand how geographical contexts influence risk behaviours, networks and service use that impact on STIs, in order to select appropriate areas for deprivation analysis;
Study 3: NCSP will collect further individual and area deprivation data, informed by studies 1 and 2, from screening providers. This multilevel dataset will be analysed to examine associations between deprivation, chlamydia screening coverage and positivity in young people.

Scientific and medical opportunities: This study will enable NCSP to monitor service use and to identify groups at higher risk of chlamydia. The identification of appropriate deprivation indicators for young people will also be of generalisable significance for analyses of social variations in healthcare use.
 
Description Multi-centre cross sectional study 
Organisation King's College London
Department Institute of Psychiatry, Psychology & Neuroscience
Country United Kingdom 
Sector Academic/University 
PI Contribution I have set up the study design, working with the sites to align the protocol to their existing care pathways. I have secured NHS approvals and Portfolio registration for the study and service support costs to fund sites' participation.
Collaborator Contribution Solent are taking part in a cross-sectional study conducted as part of my PhD and funding through my MRC Fellowship. They are collecting data from up to 4000 patients seeking chlamydia screening as part of this study. Terrence Higgins Trust, are taking part in a cross-sectional study conducted as part of my PhD and funding through my MRC Fellowship. Doncaster, Bassetlaw, Rotherham and Barnsley Chlamydia Screening Offic are collecting data from up to 8000 patients seeking chlamydia screening as part of this study. Camberwell Sexual Health Centre are taking part in a cross-sectional study conducted as part of my PhD and funding through my MRC Fellowship. They are collecting data from up to 2000 patients seeking chlamydia screening as part of this study.
Impact Collaboration is multidisciplinary. It involved administrative, reception staff, chlamydia screening outreach workers and clinical staff (GUM physicians and nurses). Summary of findings was published in the thesis. Findings led to further study at Camberwell Sexual health Centre.
Start Year 2010
 
Description Multi-centre cross sectional study 
Organisation Solent NHS Trust
Department Genito-Urinary Medicine Department
Country United Kingdom 
Sector Hospitals 
PI Contribution I have set up the study design, working with the sites to align the protocol to their existing care pathways. I have secured NHS approvals and Portfolio registration for the study and service support costs to fund sites' participation.
Collaborator Contribution Solent are taking part in a cross-sectional study conducted as part of my PhD and funding through my MRC Fellowship. They are collecting data from up to 4000 patients seeking chlamydia screening as part of this study. Terrence Higgins Trust, are taking part in a cross-sectional study conducted as part of my PhD and funding through my MRC Fellowship. Doncaster, Bassetlaw, Rotherham and Barnsley Chlamydia Screening Offic are collecting data from up to 8000 patients seeking chlamydia screening as part of this study. Camberwell Sexual Health Centre are taking part in a cross-sectional study conducted as part of my PhD and funding through my MRC Fellowship. They are collecting data from up to 2000 patients seeking chlamydia screening as part of this study.
Impact Collaboration is multidisciplinary. It involved administrative, reception staff, chlamydia screening outreach workers and clinical staff (GUM physicians and nurses). Summary of findings was published in the thesis. Findings led to further study at Camberwell Sexual health Centre.
Start Year 2010
 
Description Multi-centre cross sectional study 
Organisation Terrence Higgins Trust
Country United Kingdom 
Sector Charity/Non Profit 
PI Contribution I have set up the study design, working with the sites to align the protocol to their existing care pathways. I have secured NHS approvals and Portfolio registration for the study and service support costs to fund sites' participation.
Collaborator Contribution Solent are taking part in a cross-sectional study conducted as part of my PhD and funding through my MRC Fellowship. They are collecting data from up to 4000 patients seeking chlamydia screening as part of this study. Terrence Higgins Trust, are taking part in a cross-sectional study conducted as part of my PhD and funding through my MRC Fellowship. Doncaster, Bassetlaw, Rotherham and Barnsley Chlamydia Screening Offic are collecting data from up to 8000 patients seeking chlamydia screening as part of this study. Camberwell Sexual Health Centre are taking part in a cross-sectional study conducted as part of my PhD and funding through my MRC Fellowship. They are collecting data from up to 2000 patients seeking chlamydia screening as part of this study.
Impact Collaboration is multidisciplinary. It involved administrative, reception staff, chlamydia screening outreach workers and clinical staff (GUM physicians and nurses). Summary of findings was published in the thesis. Findings led to further study at Camberwell Sexual health Centre.
Start Year 2010
 
Description NCSP policy analysis 
Organisation Public Health England
Department National Chlamydia Screening Programme NCSP
Country United Kingdom 
Sector Public 
PI Contribution Developed study methods, conducted interviews/lit reviews, analysed data, disseminated findings
Collaborator Contribution Resulted in a poster presentation, a paper published in BMC Public Health and changes in practice at the National Chlamydia Screening Programme
Impact poster presentations (Society for Social Medicine Conference, HPA conference - Sept 2011) publication (BMC Public Health 2012)
Start Year 2010
 
Description Chlamydia talk to Health in Adolescence conference, Kuwait 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact Presentation to ~40 policymakers and clinicians working in adolescent health in Gulf states. Resulted in questions and discussion on sexual health and highlighted contrasting public health issues affecting UK and resource-rich Middle East countries.

Resulted in requests for further advice on evaluation designs in Kuwait.
Year(s) Of Engagement Activity 2009
 
Description NCSP conference 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Health professionals
Results and Impact Poster displayed at the annual conference for chlamydia screening nurses and coordinators working in the NHS.

useful feedback and idea for methods for recruiting group participants
Year(s) Of Engagement Activity 2009
 
Description Presentation of multicentre study findings 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Health professionals
Results and Impact interim and final results presented to participating sites:
- at the academic health slot to clinic staff (n=20) at the Camberwell Sexual Health Centre, which sparked questions on the reasons for disparities between men and women's outcomes and changed practice in recruiting for research staff at the centre
- to outreach workers and staff at Terrence Higgins Trust (n=6)

further research now in progress at Camberwell to understand disparities betwen men and women's risk of chlamydia and health care seeking behaviour
Year(s) Of Engagement Activity 2011
 
Description Presentation to public health trainees conference 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Health professionals
Results and Impact About 60 public health trainees and trainers attended the talk on the National Chlamydia Screening Programme, and asked questions.

No notable impacts, but positive feedback received both formally and informally.
Year(s) Of Engagement Activity 2010