Running head: EXAMINING THE ASSOCIATION BETWEEN SELF-REPORTED GONORRHEA AND BEHAVIORAL DETERMINANTS AMONG ADOLESCENT WOMEN

Transcription

1 Running head: EXAMINING THE ASSOCIATION BETWEEN SELF-REPORTED GONORRHEA AND BEHAVIORAL DETERMINANTS AMONG ADOLESCENT WOMEN Maribel Gonzalez Walden University PUBH Instructor: Wen-Hung Kuo

2 BEHAVIORAL DETERMINANTS AMONG ADOLESCENT WOMEN 2 Abstract Gonorrhea (the clap) is one of the top sexually transmitted infections in the United States, along with chlamydia and remains as a medical and public health challenge. Although the only treatment today is antibiotics, certain gonorrhea strains are drug resistant, and researchers are working toward discovering new methods to prevent infection. The burden of gonorrhea is higher among young people especially women, and the disease poses a particular health risk to women. The following literature reveiw examines the association between self-reported gonorrhea and behavioral determinants among adolescent women.

3 BEHAVIORAL DETERMINANTS AMONG ADOLESCENT WOMEN 3 Introduction Gonorrhea, an infectious disease produced by the bacterium Neisseria gonorrhoeae, is sexually transmitted through oral or genital contact and most commonly highest among teens and young adults (Centers for Disease Control and Prevention, 2011). Neisseria gonorrhoeae can easily spread to the female reproductive tract, throat, urethra, eyes, and a baby during birth. Symptoms can take up to 5 days to appear, some men may experience no symptoms or begin to show signs weeks later, and women generally experience mild symptoms (Centers for Disease Control and Prevention, 2011). Moreover, some of the signs and symptoms are sore throat, rectum or vaginal discharge, burning urination, abdominal cramps, and swollen neck glands. Gonococcal infections can lead to serious fatal complications (e.g., infertility, spread to the joints, and ectopic pregnancy) if left without treatment (Fung, Scott, Kent, and Klausner, 2006). Early diagnosis and treatment of gonorrhea infection among asymptomatic people can prevent re-infection, spread to uninfected partners and provides the opportunity for screening sexual contacts potentially at risk (Fung, Scott, Kent, and Klausner, 2006). There are several gonorrhea testing options, however, culture samples provide accurate evidence of infection, and patients may receive a confirmed diagnosis as early as 72 hours (Centers for Disease Control and Prevention, 2011). Although antibiotics are highly effective to treat gonococcal infections, inappropriate use of drugs has played a significant role in certain strains becoming resistant to specific antibiotics (e.g., penicillin and sulfa drugs) causing increase re-infection rates among patients (Fung, Scott, Kent, and Klausner, 2006; Bokaeian, Qureshi, Dabiri, & Mohagheghi Fard, 2011). Between

4 BEHAVIORAL DETERMINANTS AMONG ADOLESCENT WOMEN and 2009, a cross-sectional study conducted in Iran with 400 (358 men and 42 women) gonorrhea patients to discover the newest drug resistance form of N.gonorrhoeae strains revealed a higher incidence of penicillin resistance among participants (Bokaeian, Qureshi, Dabiri, & Mohagheghi Fard, 2011). The results showed 77 cases tested positive for gonorrhea (66 men and 11 women) and the frequency for men was 66/358 whereas for women was 11/42. As for the resistance against administered antibiotics, 61 cases possessed resistance against penicillin and 53 cases presented multiresistant property (Bokaeian, Qureshi, Dabiri, & Mohagheghi Fard, 2011). The possible reasons for the resistance rate against penicillin might be convenience of the antibiotic and victim s familiarity, and diverse cultural attitudes cause hesitation to seek medical attention. The objective of this cross-sectional study is to examine a high risk population, among adolescent women, the association between self-reported gonorrhea, inconsistent condom use, number of sex partners, and sex under the influence. Employing prospective data from Add Health to test the hypothesis that adolescents engaging in risky behaviors predict their selfreported prevalence of gonorrhea during school years. Epidemiology Literature Review Despite advances in detection and treatment, gonococcal infections continue to be a significant public health concern around the globe. The rates were steadily declining until 2005, when the western area suffered a sudden increase in rates (Pennan, Kent, & Klausner, 2008). Today, gonorrhea is still the second largest sexually transmitted disease in the nation and the prevalence is highest among young single females (Pennan, Kent, & Klausner, 2008). In 2006,

5 BEHAVIORAL DETERMINANTS AMONG ADOLESCENT WOMEN 5 a case-control study with 225 participants was conducted in San Francisco, CA to combat the alarming increase of gonorrhea cases among heterosexuals, and the findings showed behavioral risk factors like age, anonymous partner, and Black race associated with gonorrhea infection (Pennan, Kent, & Klausner, 2008). Another study conducted in San Francisco with a sample of 541 men having sexual relations with other men and infected with rectal gonorrhea or chlamydia revealed that 27 patients contracted HIV (Bernstein, Marcus, Nieri, Phillip, & Klausner, 2009). The patients included in the study tested positive for STI (gonorrhea or chlamydia) and negative for HIV between The results of this study confirmed the reports of numerous studies that prior history rectal STDs is correlated with a high risk (8 fold) of HIV contagion and transmission (Bernstein, Marcus, Nieri, Phillip, & Klausner, 2009). A research study conducted to review the evidence of gonorrhea and chlamydia reinfections between 1998 and 2006 found that men had a significantly higher rate of repeat STD s than women (Pennan, Kent, & Klausner, 2008). In addition, Chacko, Phillips, and Jacobson found pharyngeal gonorrhea prevalent among adolescents (1982). For this reason, the authors conducted a retrospective study with an urban population of 546 teenagers, mostly African American women to investigate the incidence of pharyngeal gonorrhea, and the findings revealed 80 participants were infected and 19% tested positive for oral gonorrhea (Chacko, Phillips, and Jacobson, 1982). According to the Centers for Disease Control and Prevention (n.d.), the incidence of gonorrhea in 2006 increased nearly 5%, the highest rate was among teens < 600 subjects per 100,000, and woman had a marginally higher rate than men. Although the highest rate (per 100,000) reported was among young adults (528 subjects) between 20 to 24 years, the rate of teens (308 subjects per 100,000) translates to < 600 subjects who are sexually active (Centers for

6 BEHAVIORAL DETERMINANTS AMONG ADOLESCENT WOMEN 6 Disease Control and Prevention, n.d.). Similar to all STDs, there is strong link between gonorrhea and youth. The figure below illustrates the rates by sex and age: Table 1. Gonorrhea Age- and sex-specific rates: United States, 2006 (Centers for Disease Control and Prevention/2006 Sexually Transmitted Diseases Surveillance, n.d.) Health Risk Factors Inconsistent Condom Use Unprotected sex among young individuals can lead to dangerous consequences. Proper and consistent use of latex condoms decreases the risk of contracting an STD. Shafil, Stovel, & Holmes (2007) found that 62% of adolescents in high school conveyed having their first sexual debut during the senior year. Although monogamy is considered a safe sex strategy against STD s, women who practice safe sex are at increase risk of exposure to infection (Calonge 2005). In addition, serial monogamists, people who date short-term and immediately engage in another relationship are more likely to spread STI s and even HIV. The leading reason for this is due to less frequency use of condoms among committed relationships. In the United States, a

7 BEHAVIORAL DETERMINANTS AMONG ADOLESCENT WOMEN 7 longitudinal survey conducted from 1994 to 2002 using a total of 4018 adolescents to examine the use of condom during sexual activity found that initial condom users engaged in consecutive condom use (Shafil, Stovel, & Holmes, 2007). Number of Sex Partners In the United States, research studies show that sexually transmitted infections (STI s) are reaching epidemic proportions, and the adolescent population has the highest rate of chlamydia and gonorrhea infections than any other population (Shafil, Stovel, & Holmes, 2007; Ott, Katschke, Tu, & Fortenberry, 2011). Every year, approximately 19 million (48%) new STD cases are reported of sexually active youth ages 15 to 24 years with females suffering the highest rates (Crosby & Danner, 2008). Several studies have revealed that sexual risk behaviors such as adolescents changing or having sex with numerous partners increases the risk of contracting gonorrhea or any other STI (Ott, Katschke, Tu, & Fortenberry, 2011; Calonge 2005). In addition, subsequent STI is linked to dissolution of relationships (Ott, Katschke, Tu, & Fortenberry, 2011). Sex Under the Influence People under the influence, e.g., alcohol and other drugs experience poor judgment, less inhibitions and have difficulty in decision making. Sexually active teens and young adults who experiment with alcoholic beverages and drugs are more likely to participate in unprotected sex, routinely have several sexual partners and consequently acquire an STD (Hutton, McCaul, Santora, & Erbelding, 2008). Also, binge drinking, the act of consuming excessive amounts of alcoholic beverages is correlated with risky sexual behaviors and other negative effects. Hutton, McCaul, Santora, & Erbelding found that a study conducted in a clinic with youth patients

8 BEHAVIORAL DETERMINANTS AMONG ADOLESCENT WOMEN 8 between the ages of years, results showed women with a 39.6% rate of alcoholic beverage intake while men had a 48% (2008). All information presented on prevalence, populations at risk and health risk factors demonstrate the widespread of gonorrhea in the nation and higher rates among the youth population specially women. Although a study revealed that among females, binge drinking is linked to STD diagnosis the results might not be generally applicable to other heavy drinking populations since participants were all African American from an urban area (Hutton, McCaul, Santora, & Erbelding, 2008). Shafil, Stovel, & Holmes (2007), in a longitudinal study of condom use among an adolescent population reported that early users decreased the risk of testing postive for gonorrhea or any other STI. However, the self-reported use of condom and sexual habits possibly produced measurement error and differential recall. Furthermore, the findings of a longitudinal study of 332 adolescent women demonstrated that the number of sex partners highly increases the chance of developing an STI, but the analysis lacked data on all partners limiting the possibility to investigating the cause of STI (Ott, Katschke, Tu, & Fortenberry, 2011). The purpose of this study is to examine the association between self-reported gonococcal infections and behavioral determinants among adolescent women utilizing a sample from existing data from the National Longitudinal Study of Adolescent Health (Add Health). Methods and Materials This study employs data from the National Longitudinal Study of Adolescent Health (Add Health). Add Health was established in 1994 to examine the national issues related to teenage health, sexuality and other behavioral risk factors (National Institute of Health, n.d.). During the spring of 1994, a random sample of approximately 90,000 students across the United

9 BEHAVIORAL DETERMINANTS AMONG ADOLESCENT WOMEN 9 States from 7 th 12 th grade were administered an in-school survey which covered topics such as crime, sexuality, and drugs (National Institute of Health, n.d.). A year later, researchers conducted an in-home interview to parents and students. Then in 1996, students participated in a follow up in-home interview. A total of about 10,000 adolescents participated in all 3 interviews. At this time, participants provided urine samples that were screened for sexually transmitted diseases (STD). In addition, schools facilitated researchers with data on school particpants and transcipts from high school students. (For more details on Add Health study and method visit: cfm). Participants As part of a cross-sectional study of gonorrhea, we used a national representative sample of 3,356 adolescent women who participated in Add Health. Participants were followed from 1994 to 1995 and the inclusion criteria included female gender, ages years and sexually active. Dependant variable survey. Dependant variable was self-reported gonorrhea on Wave I during in-home student Independent variables Inconsistent condom use was measured by self-report at Wave I, and recoded as CondomFrequencyUse. Number of sex partners was also measured by self-report at Wave I, and recoded as GonorrheaPartners. Lastly, sex under the influence could not be measured due to data was not available in Add Health.

10 BEHAVIORAL DETERMINANTS AMONG ADOLESCENT WOMEN 10 Statistical Analysis This analysis reports data collected from National Longitudinal Study of Adolescent Health (Add Health) Wave I field work conducted by the National Opinion Research Center located at the University of Chicago (National Institute of Health, n.d.). The data set is available in the Inter-University Consortium for Political and Social Research (ICPSR) website. To be able to analyze the Add Health Wave I public use data online using software named Survey Documentation and Analysis (SDA), it is necessary to sign in and agree to the contract terms (Inter-University Consortium for Political and Social Research, 2011). Quantitative analysis was conducted on online web. Data collected from selfadministered questionnaires and interviews were analyzed using only a female sample. First, to create a common analytical sample, it was necessary to exclude a substantial number of respondents from the survey. Second, only a sample of adolescent women who were enrolled in high school grades 9-12 and sexually experienced at the time of the interview date was included in this analysis. Lastly, the sample was further restricted to adolescent women who self-reported ever diagnosed with gonorrhea as of Wave I, and examined the association between condom use, total number of sex partners, and sex under the influence. To analyze the independant variable condom use, the question employed was thinking of all the times you have had sexual intercourse, about what proportion of the time have you/has a partner of yours used a condom? Then, to examine the relationship between self-reported gonorrhea and condom use I created a new variable named CondomFrequencyUse. In addition, to analyze the relationship between self-reported gonorrhea and total number of sex partners, the question employed was with how many people, in total, including romantic

11 BEHAVIORAL DETERMINANTS AMONG ADOLESCENT WOMEN 11 relationship partners, have you ever had a sexual relationship? and I created a new variable named GonorrheaPartners. Unfortunately, under the Add Health data set, there are no data available to analyze variable sex under the influence. Bivariate cross tabulation including summary statistics with chi-square and probability was used to compare self-reported gonorrhea and condom frequency use among females. Lastly, multivariate cross tabulations was utilized to examine the association between self-reported gonorrhea and condom frequency use by gender, and self-reported gonorrhea and number of sex partners by gender. Results Add Health data set showed that 51% (n=3,356) adolescent females participated in the survey. Significance was found among females who self-reported ever having sexual intercourse. From a total of 3,322 females, a total of 37.9% (n=1,260, 95% CI ) answered yes to the question have you ever had sexual intercourse? When we say sexual intercourse, we mean when a male inserts his penis into a female s vagina and 62.1% (n=2,062, 95% CI ) answered no. Because the sample size of self-reported gonorrhea was small, there was no significance found in the rate of gonorrhea. A total of 1,259 females responded the question have you ever been told by a doctor or nurse that you had gonorrhea? Only 1.7% (n=21, p=0.27, 95% CI ) answered yes, and 98.3% (n=1,238, 95% CI ) answered no. Condom Use There was no significance found in this analysis. A total of 195 females responded the question how often do you use a condom? However, among 21 females who were diagnosed with gonorrhea, only 8 responded the question how often they used a condom? 100% (n=8)

12 BEHAVIORAL DETERMINANTS AMONG ADOLESCENT WOMEN 12 responded they did not use a condom all of the time and 0 responded all of the time. (See Table 1) Number of Sex Partners A total of 657 females answered the question with how many people, in total, including romantic relationship partners, have you ever had a sexual relationship? From the 21 females diagnosed with gonorrhea, only 14 responded this question (n=2; 95 CI ) answered they had 3 or less sex partners and 85.7% (n=12; 95% CI ) answered having 4 or more sex partners. Significance differences were observed in lifetime prevalence of gonorrhea diagnosis (Pearson s Chi Square = 9.48; p = 0.00). Interestingly, based on the number of sex partners vs. gonorrhea rates, it did not really matter the amount of partners because those who had multiple partners were at greater risk of contracting a sexually transmitted disease (STD). (See Table 2) Sex under the influence Add Health did not have data set to analyze the variable sex under the influence. In the future, Add Health should include in their survey the question have you ever had sex while under the influence or alcohol or drugs? However, I decided to analyze the variable Protection is a big hassle and found that there was no statistical significance (Chisq 2.22; p=0.70) due to the small sample size. A total of 1,118 women answered the question it would be a big hassle to do the things necessary to fully protect yourself from getting a sexually transmitted disease. From the 21 women diagnosed with gonorrhea, only 20 answered this question. 10.0% (n=2; 95% CI ) strongely agreed, 15.0% (n=3; 95% CI ) agreed, 0 neither agree nor disagree, 35.0 (n=7; 95% CI ) disagreed, and 40.0% (n=8; 95% CI ) strongly disagreed. Although these

13 BEHAVIORAL DETERMINANTS AMONG ADOLESCENT WOMEN 13 respondents contracted gonorrhea, a total of 5 women perceived it was a big hassle to protect themselves against a sexually transmitted disease. Therefore, further research is necessary to investigate why and how is it a big hassle. (See Table 3) Discussion Using Add Health data, this study examined the association between gonorrhea, inconsistent condom use, number of sex partners and sex under the influence. Contrary to expectations, I found no significance in gonorrhea rates among females, despite the fact that they were sexually active, did not consistently use a condom, and had multiple sex partners. Lack of larger sample size may have contributed to this finding. Examination of inconsistent condom use revealed that 100% of women diagnosed with gonorrhea had sexual intercourse and did not use a condom all of the time. This suggests that their negative attitude towards completely protecting themselves from contracting a sexually transmitted disease can lead to reacquiring gonorrhea in the future. This may also suggest that the perception that there are obstacles to engaging in condom use makes it less likely that adolescent women will practice safe sex. In addition, these findings may support previous research showing that early condom use is associated with subsequent condom use (Shafil, Stovel, & Holmes, 2007). Despite the fact that it is widely known that proper and consistent condom use can decrease the risk of a STD, adolescents still refused to use them during sexual intercourse. Many sexually active adolescents engage in risky sexual behaviors. Although it is wellestablished that having more than one sex partner is a risk factor for STD, teenagers continue to report concurrent sexual partners. Evidence from this nationally representative sample suggests that 85.7% of the sexually active females diagnosed with gonorrhea self-reported having more

14 BEHAVIORAL DETERMINANTS AMONG ADOLESCENT WOMEN 14 than 4 sex partners. This finding is consistent with previous reports in the literature that engaging in sexual intercourse with multiple sex partners increases the risk of STI (Ott, Katschke, Tu, & Fortenberry, 2011; Calonge 2005). The infection might be transmitted from an old relationship into a new relationship. Add Health survey does not ask respondents whether they ever had sexual intercourse while under the influence. For this reason, I chose to analyze variable Protection a big hassle. Contrary to expectations, the results showed no significance which sample sample size may have contributed to this finding. However, 25% of women diagnosed with gonorrhea reported it was a big hassle to protect themselves from acquiring subsequent STD. Research studies have demonstrated that some of the possible barriers may be the belief that condoms reduce pleasure, would be difficult to convince a partner to use, and takes too much planning to have on hand (Pal, Roy, & Pal, 2011). Condom use remained inconsistent regardless of how susceptible adolescent women felt they were to a STD. This study involved both strengths and limitations. Measures of gonorrhea, condom use, number of sex partners and protection a big hassle among adolescent females relied on selfreports, although bias was reduced by the use of audio-computer-assisted self-interview techniques during Wave I of the study. The Add Health study design is longitudinal, but many items are retrospective in nature, potentially introducing recall bias and measurement error. The sample size of gonorrhea cases was small, and Add health did not provide data to analyze all variables included in this study. Despite these limitations, the data supported the hypothesis that adolescents engaging in risky behaviors predict their self-reported prevalence of gonorrhea during school years. Also, this study is important and unusual because it relied on a nationally

15 BEHAVIORAL DETERMINANTS AMONG ADOLESCENT WOMEN 15 representative longitudinal investigation of adolescent sexual behavior that included a measurement of gonorrhea. Further research is needed to explore more about the dynamics of adolescent sexual partnerships and the pattern of condom use. Most importantly, we need to understand how to encourage adolescents who refuse to use a condom consistently to adopt the practice of using protection.

16 BEHAVIORAL DETERMINANTS AMONG ADOLESCENT WOMEN 16 References Bernstein, K. T., Marcus, J. L., Nieri, G., Phillip, S. S., & Klausner, J. D. (2009). Rectal gonorrhea and chlamydia reinfection is associated with increased risk of HIV seroconversion. Acquir Immune Defic Syndr, 00(0), 1-7. Bokaeian, M., Qureshi, M. I., Dabiri, S., & Mohagheghi Fard, A. H. (2011). An investigation on antibiotic resistance of Neisseria gonorrhoeae isolated from gonorrheal patients in Zahedan, Iran from 2007 to African Journal of Microbiology Research, 5(17), Calonge, N. (2005). Screening for gonorrhea: recommendation statement. Annuals of Family Medicine, 3(2), doi: /afm.337 Centers for Disease Control and Prevention (n.d.) Sexually Transmitted Diseases Surveillance. Retrieved from Centers for Disease Control and Prevention (2011). Sexually Ttransmitted diseases (STDs). Retrieved from Chacko, M. R., Phillips, S., & Jacobson, M. S. (1982). Screening for pharyngeal gonorrhea in the urban teenager. Pediatrics, 70(4), Crosby, R., & Danner, F. (2008). Adolescents' sexually transmitted disease protective attitudes predict sexually transmitted disease acquisition in early adulthood. Journal Of School Health, 78(6), doi: /j x Fung, M., Scott, K. C., Kent, C. K., & Klausner, J. D. (2006). Chlamydia and gonorrhea reinfection among males: a systematic review of data to evaluate the need for re-testing. Sexually Transmitted Infections, doi: /sti

17 BEHAVIORAL DETERMINANTS AMONG ADOLESCENT WOMEN 17 Hutton, H. E., McCaul, M. E., Santora, P. B., & Erbelding, E. J. (2008). The relationship between recent alcohol use and sexual behaviors: gender differences among sexually transmitted disease clinic patients. Alcoholism: Clinical and Experimental Research, 32(11), doi: /j x Inter-University Consortium for Political and Social Research (2011). Analyze & subset-study No Retrieved from National Institute of Health (n.d.). Add Health Study. Retrieved from Ott, M. A., Katschke, A., Tu, W., & Fortenberry, J. D. (2011). Longitudinal associations among relationship factors, partner change, and sexually transmitted infection in adolescent women. Sexually Transmitted Diseases, 38(3), Pal, R., Roy, S., & Pal, S. (2011). Opportunities and barriers of sexual health and condom use among tea plantation workers. International Journal of User-Driven Healthcare, 1(2), doi: /ijudh Pennan, M. B., Kent, C. K., & Klausner, J. D. (2008). Risks of gonorrhea among heterosexuals - San Francisco, Sexually Transmitted Diseases, 35(12), 1-5. doi: /olq.0b013e31815faab8 Shafil, T., Stovel, K., & Holmes, K. (2007). Association between condom use at sexual debut and subsequent sexual trajectories: a longitudinal study using biomarkers. Research and Practice, 97(6),

18 Percent BEHAVIORAL DETERMINANTS AMONG ADOLESCENT WOMEN 18 Table 1 Table 2 Percent of Ever Diagnosed with Gonorrhea and Partner frequency among Females or less partners 4 or more partners

19 BEHAVIORAL DETERMINANTS AMONG ADOLESCENT WOMEN 19 Table 3