Chlamydia screening in at-risk adolescent females: An evaluation of screening practices and modifiable screening correlates

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1 Journal of Adolescent Health 38 (2006) Original article Chlamydia screening in at-risk adolescent females: An evaluation of screening practices and modifiable screening correlates Jennifer B. McClure, Ph.D. a, *, Delia Scholes, Ph.D. a, Lou Grothaus, M.S. a, Paul Fishman, Ph.D. a, Robert Reid, M.D., Ph.D. a,b, Jeffrey Lindenbaum, M.D. c, and Robert S. Thompson, M.D. a,b a Center for Health Studies, Group Health Cooperative, Seattle, Washington b Department of Preventive Care, Group Health Cooperative, Seattle, Washington c Group Health Permanente, Group Health Cooperative, Seattle, Washington Manuscript received March 14, 2005; manuscript accepted July 11, 2005 Abstract Keywords: Purpose: To identify modifiable correlates of chlamydia screening that could offer intervention targets to enhance screening. Methods: We surveyed a representative sample of primary care providers (n 186) at an integrated healthcare delivery system to document their self-reported adherence to annual screening of sexually-active adolescents and to identify specific, modifiable constructs that were correlated with annual chlamydia screening. To cross-validate providers self-report, we also used automated data to examine adolescent screening in an anonymous sample of primary care providers (n 143). Results: Forty-two percent of providers reported annual chlamydia screening of sexually-active adolescents. Univariate correlates of annual screening were: provider type (non-physician) (p.01), female gender (p.001), fewer years of clinical experience (p.001), greater perceived knowledge about chlamydia (p.001), greater confidence across a range of screening-related activities (p.01), greater comfort recommending screening for sexually transmitted diseases (p.001), and greater perceived patient comfort discussing sexual issues (p.01). In multivariate analyses, providers perceived knowledge, confidence, comfort, and perceived patient comfort continued to be significantly associated with annual chlamydia screening after controlling for other relevant provider characteristics. Self-reported screening practices were consistent with observed screening rates in the anonymous provider sample. Conclusions: Routine chlamydia screening among asymptomatic, at-risk adolescent females could be enhanced through additional intervention targeting specific provider attitudes and beliefs about chlamydia screening Society for Adolescent Medicine. All rights reserved. Chlamydia trachomatis; Screening; Preventive care; Adolescents; Female Chlamydia trachomatis is the most common bacterial sexually-transmitted disease in the United States [1]. Most chlamydia infections occur in women under the age of 25 years, but the highest reported rates are among adolescent females *Address correspondence to: Jennifer B. McClure, Ph.D., Center for Health Studies, Group Health Cooperative, 1730 Minor Avenue, Suite 1600, Seattle, WA address: McClure.J@GHC.org [2,3]. Five to 14% of routinely screened year-old females are infected with chlamydia; however, up to 70% of cases are asymptomatic and may go undetected and untreated [4]. The health consequences of untreated chlamydia can be severe. Females with chlamydia are at increased risk for pelvic inflammatory disease, infertility, ectopic pregnancy, and chronic pelvic pain [2,5]. Chlamydial infection also increases the risk of transmitting and acquiring HIV infec X/06/$ see front matter 2006 Society for Adolescent Medicine. All rights reserved. doi: /j.jadohealth

2 J.B. McClure et al. / Journal of Adolescent Health 38 (2006) tion [6,7]. Common risk factors for infection include multiple sexual partners and inconsistent use of non-barrier contraceptives, but the single greatest risk factor is age [8]. Annual screening of all females under the age of 25 has been a best practice recommendation since 1997 [9]. It is endorsed by the US Preventive Services Task Force [10], the American Medical Association [11], the American Academy of Pediatrics [12], and other leading practice organizations [2,13,14]. Routine chlamydia screening is recognized as both an effective and cost-effective intervention [5,15 18]. It reduces the incidence of pelvic inflammatory disease [19] and subsequently reduces overall treatment costs, especially when age-based screening criteria are followed [16]. Despite evidence that chlamydia is prevalent among adolescent females and that annual screening is an effective means of detecting disease and improving health outcomes, actual screening rates among adolescents are less than optimal. According to the National Committee for Quality Assurance s Health Plan Employer Data and Information Set (HEDIS) report, on average, only 30% of sexuallyactive women aged in commercial managed care health plans were screened for chlamydia in 2003 [20]. This rate has steadily improved since 1999, but falls short of the 100% goal established by the leading practice guidelines. While guidelines are important clinical tools, they are not sufficient to alter practice behavior alone [21,22]. Additional strategies may be necessary to enhance chlamydia screening. Understanding the factors that influence adolescent screening will help identify appropriate targets for intervention. Several correlates of self-reported and hypothetical chlamydia screening have been identified from provider surveys. This research suggests that providers may be more likely to screen for chlamydia if they are female [23 25], are an Advanced Registered Nurse Practitioner (ARNP) as opposed to a physician (MD) [24], work in a clinic as opposed to solo practice [23], have a significant proportion ( 20%) of African American patients [23], or routinely take sexual histories [24]. Several attitudes and beliefs have also been linked with hypothetical screening behavior. Primary care physicians were more likely to report they would screen a 19-year-old sexually-active, asymptomatic female presenting for a gynecological exam if they believed most 18-year-olds in their practice were sexually active, they felt responsible for providing sexually-transmitted disease (STD) counseling, or they recognized the benefits of chlamydia screening [23]. Similarly, providers who endorsed more favorable attitudes toward STD screening-related behaviors in general (assessed as a single overall attitude summary score) were more likely to report that they ask year-old patients about their sexual activity and provide counseling on STD transmission and prevention [26]. The present study builds on this research. We examine the association between self-reported adherence to chlamydia screening guideline recommendations for adolescent females and several additional potentially important constructs including providers perceived knowledge of chlamydia, comfort discussing sexual issues with adolescents, perceived patient comfort, confidence in their relevant practice abilities, and other specific attitudes and beliefs related to screening adolescents. We chose these constructs because they are theoretically relevant to explaining behavior and they represent modifiable targets for intervention. Unlike prior research, we examined the association between specific individual attitudes and beliefs and self-reported screening behavior. Identifying specific modifiable correlates of screening should offer more precise targets for intervention. The sample was restricted to primary care providers. Most routine and preventive healthcare, including chlamydia screening, occurs in primary care settings. Therefore, it is important to better understand the association between primary care providers attitudes and STDrelated practices [26]. Methods Setting This study was conducted at Group Health Cooperative (GHC). GHC is the oldest and second largest consumergoverned, non-profit healthcare organization in the United States. It provides medical care to over 550,000 patients through both an integrated group practice (IGP) and network providers in Washington state and Idaho. Providers and patients discussed in this paper participated in the IGP. Within the IGP, patient care is substantially, but not exclusively, coordinated through one s primary care provider. Primary care providers and specialty care providers are contracted to practice within the IGP, and they share access to integrated data systems, facilities, and other resources and materials. This study was reviewed and approved by the GHC Institutional Review Board (IRB); however, IRB restrictions prevented us from linking survey data with data on providers actual screening practices. At the time of this study, most chlamydia screening exams (99.6%) performed at GHC used cervical swab DNA probes. Participants Primary care providers were identified through automated records and surveyed as part of a related study to promote chlamydia screening in young adult and adolescent females. Three hundred eighty-three primary care practitioners who treated females aged were identified from automated records. This group included family physicians, pediatricians, general internists, nurse practitioners (ARNPs), and physician assistants (PAs). All providers were responsible for a defined patient panel, although ARNPs and PAs had more limited independent practice

3 728 J.B. McClure et al. / Journal of Adolescent Health 38 (2006) abilities. From this sample, 300 providers were randomly chosen and mailed a baseline survey. Twenty-seven providers could not be contacted because they no longer practiced at GHC. Forty-seven of the remaining 273 providers either failed to respond or declined participation, resulting in an 83% response rate. For this paper, we further restricted the sample to clinicians who treated adolescent females aged (n 186). This age range was chosen because it encompasses the group with the highest reported rates of chlamydia (15 19-years-old) [3] and it was aligned with a planned, but not yet implemented, GHC guideline to annually screen adolescent females 20-years-old and younger. Provider survey Providers completed a brief (10 minute) mailed survey. Those who returned the survey received a $20 bookstore gift certificate. We assessed self-reported chlamydia screening practices, hypothesized barriers to screening, and hypothesized correlates of screening. Items were chosen based on their relevance to chlamydia screening in the literature [23,25 27], their theoretical relevance to behavior based on Social Cognitive Theory and Self-Efficacy Theory [28,29], and their role in the Precede-Proceed Model [30]. Individual items and wording were refined by a panel of physicians with expertise in family medicine, adolescent health, preventive care, and STDs. Specific assessment constructs included: provider demographics, specialty certification, STD training, comfort discussing sexual activity with adolescents, providers confidence in their ability to assess sexual history and to assess and treat chlamydia, knowledge of chlamydia, perceived knowledge of chlamydia, perceived patient comfort discussing sexual activity with the provider, and self-reported chlamydia screening practices (e.g., how often providers routinely screen sexually-active year-olds, under what conditions they screen). Survey items addressed providers attitudes, beliefs, and behaviors with regard to adolescent females (14 20-years-old) specifically. Comfort, confidence, and perceived knowledge items were scored on a five-point Likert scale. Actual knowledge of chlamydia was assessed with an 11-item scale (e.g., percentage of asymptomatic women with chlamydia, prevalence of chlamydia, associated conditions). Correct answers were tallied to create an index score (0 11 range). Reasons for not screening for chlamydia more often (i.e., perceived barriers to screening) were assessed using a checklist of common barriers (e.g., lack of time, cost, provider discomfort) with an open-ended response option. Open-ended responses were grouped by theme and tallied. Usual screening practice was also characterized with a checklist (e.g., screen at least once a year, at least once every 2 years, at least once every 3 5 years, unsure, or not applicable to my practice). Finally, providers were asked to indicate when they typically screen adolescents for chlamydia (e.g., routine physicals, if change in sex partner reported, if use of non-barrier contraception reported). The survey was pilot tested in a group of primary care providers within our healthcare organization prior to implementation. Observed screening rates among providers To estimate how well providers self-reported behavior reflected actual chlamydia screening practices among primary care providers, we examined screening rates among all sexually-active year-old females seen by an anonymous representative sample of primary care providers (n 143) in the IGP delivery system. This sample included all primary care providers who treated at least 20 females aged during the year preceding September Screening rates were determined using automated data from September 1999 to August This time period coincided with the timing of the survey and predated system-wide intervention efforts to increase chlamydia screening. Analyses Bivariate comparisons were made of providers who reported annual chlamydia screening versus those who did not using 2 for binary and categorical variables and t-tests for continuous variables. Item collinearity among continuous variables was examined using Spearman correlation coefficients. Finally, we examined the relation between providers descriptive characteristics, knowledge, attitudes, and beliefs and whether they reported at least annual chlamydia screening of sexually-active adolescent females [yes/no] using multivariate logistic regression models. Adjusted models included all variables whose unadjusted relation to annual screening was significant at p.10 or less. Based on the size of each comparison group, we had 80% power to detect a difference of 11% (or about.42 units) in the group means for each variable. This calculation assumes a mean of 4.0 and standard deviation of 1.0, which was typical for the items compared. Results Providers Provider characteristics are reported in Table 1. Nearly 70% were physicians (MD or DO), 22% were physician assistants, and 9% were nurse practitioners. Most specialized in family practice (83%). On average, it had been 18 years since completion of their medical training. Physicians had been in practice significantly longer than physician assistants (19 vs. 14 years, p.001), but not nurse practitioners (19 vs. 17 years, ns). One half of all providers reported post-graduate training in STD screening and 9% reported continuing medical education in chlamydia screening in the past year. One half of the sample was female.

4 J.B. McClure et al. / Journal of Adolescent Health 38 (2006) Table 1 Provider characteristics All Screen annually a No Yes N % N % N % p-value b N Degree.01 MD/DO ARNP PA Specialty.23 Family practice Pediatrics Internal medicine Female Postgraduate STD training CT training in last year Years since completed training (mean [SD]) 17.7 [8.0] 20.2 [0.7] 14.5 [0.9].001 a Self-reported annual screening. b Comparison of providers who reported annual chlamydia screening versus those who did not using 2 for binary and categorical variables and t-tests for continuous variables. Self-reported screening practices Forty-two percent of providers reported annual screening of adolescent females, 14% indicated screening at least every 2 years, 2% indicated every 3 5 years (Table 2). One third (32%) were unsure how often they screened adolescents, and 9% felt chlamydia screening was not applicable to their practice. Nearly all (96%) indicated they tested adolescent females for chlamydia when it was indicated based on the presenting symptoms, but only 57% indicated screening if patients reported a change in sexual partners and 30% if patients reported use of non-barrier contraception. Forty-four percent of providers felt they screened for chlamydia as often as is warranted in their practice. Table 2 Self-reported screening practices Practice % How often sexually-active adolescent females screened At least once a year 42 Once every 2 years 14 Once every 3 5 years 2 Unsure 32 Not applicable to my practice 9 Main reasons for screening sexually-active adolescent females If indicated based on symptoms 96 Change in sex partner reported 57 Use of non-barrier contraception reported 30 Percent of each provider group reporting at least annual screening a MD 34 PA 54 ARNP 63 a 2 comparison (p.01). Among providers who reported at least annual screening, 58% were physicians, 29% were physician assistants, and 13% were nurse practitioners. This reflects a higher proportion of physicians in the sample, but when examined within each provider type, nurse practitioners were more likely to report annual screening. Nearly two thirds of nurse practitioners (62.5%), 54% of physician assistants, and 34% of physicians reported annual screening (p.01). Provider knowledge, attitudes, and beliefs about chlamydia Provider knowledge Providers perceived themselves to be fairly knowledgeable about chlamydia. Scores averaged 3.8 of a possible 5 (Table 3). The mean score on our composite knowledge scale was 7.5 of a possible 11. There was no significant correlation between perceived knowledge and actual knowledge scores. Provider confidence Providers were generally confident in their ability to discuss sexual history and STD screening with adolescents and to choose appropriate chlamydia treatment (Table 3). They were slightly less confident in their ability to identify at-risk females for whom chlamydia screening is appropriate, but 54% rated themselves as mostly or very confident in this ability. Provider comfort Most providers said they were comfortable discussing sexual practices with adolescents and recommending STD screening to sexually-active females. Sixty-nine percent reported they were mostly or very comfortable discussing sex with females aged 14 20, 77% were mostly or very comfortable recommending STD screening to sexually-active,

5 730 J.B. McClure et al. / Journal of Adolescent Health 38 (2006) Table 3 Provider knowledge, attitudes, and beliefs about chlamydia screening and their relation to annual screening of at-risk adolescent females Construct/Variable Overall Screen annually a No Yes N 186 M (SD) N 108 Mean N 78 Mean p-value b Knowledge Perceived chlamydia trachomatis (CT) knowledge c 3.8 (.64) Composite knowledge score d 7.5 (1.6) Confidence e In own ability to identify females for whom CT is appropriate 3.5 (1.1) In own ability to choose appropriate CT treatment 4.3 (0.8) In own ability to discuss sexual history and STD screening with sexually-active asymptomatic year-olds 4.0 (0.9) In own ability to discuss sexual history and STD screening with sexually-active asymptomatic year-olds 4.3 (0.8) Comfort f Discussing sexual practices with females aged (1.1) Recommending STD screening to sexually-active, asymptomatic year-olds 4.1 (1.0) Recommending routine CT screening for sexually-active females 3.9 (1.1) Other attitudes/beliefs Perceived patient comfort discussing sexual history f 3.5 (0.9) Inappropriate to discuss sex with female patients under age 16 g 1.3 (0.7) Screening asymptomatic 14-year-olds would anger their parents g 2.7 (1.1) I screen for CT as often as is warranted in my practice g 3.2 (1.1) N % N % N % p-value b Reasons for not screening more Uncomfortable recommending CT screening during non-gynecological exams Lack of time or resources Cost Lack of screening guidelines Don t think about it a Self-reported annual screening. b Comparison of providers who reported annual chlamydia screening vs. those who did not using 2 for binary and categorical variables and t-tests for continuous variables. c Likert scale 1 5 (not at all very knowledgeable). d Maximum knowledge score 11. e Likert scale 1 5 (not at all confident very confident). f Likert scale 1 5 (very uncomfortable very comfortable). g Likert scale 1 5 (strongly disagree strongly agree). asymptomatic females, and 69% were mostly or very comfortable recommending routine chlamydia screening to sexually-active females. Other provider attitudes and beliefs Our expert consultants suggested that some providers may fail to screen young adolescents either out of the belief that it is inappropriate to discuss sex with younger females, or the belief that screening will anger the girls parents. Most providers in this sample (94%) agreed that it is appropriate to discuss sexual behavior with young females under the age of 16, but 20% also agreed that chlamydia screening in 14-year-olds would potentially anger the girls parents. One half (52%) believed their female patients are comfortable discussing their sexual history. Reasons for not screening more often Nearly one half of those sampled (48%) indicated they did not screen for chlamydia more often because they were uncomfortable recommending screening, especially during non-gynecological exams. Other widely-endorsed barriers to screening were a lack of time or resources (30%), lack of chlamydia screening guidelines (21%), and cost to the health plan (9%). Correlates of self-reported annual screening Correlates of self-reported annual chlamydia screening among at-risk adolescents are presented in Tables 1 and 3. Providers who reported annual screening were more likely

6 J.B. McClure et al. / Journal of Adolescent Health 38 (2006) to be female and non-physicians than those who reportedly did not screen annually. They tended to be in practice for fewer years; perceived themselves to be more knowledgeable about chlamydia; and reported greater confidence in their ability to identify females for whom screening is appropriate, to discuss sexual issues, and to choose appropriate treatment options. They also reported greater comfort recommending STD screening to asymptomatic adolescents and had a greater perception that patients were comfortable discussing sexual issues with them. Multivariate analyses A primary aim of this investigation was to identify targets for intervention to increase chlamydia screening. Consequently, we were interested in examining the association between modifiable factors (i.e., knowledge, attitudes, and beliefs) and self-reported annual chlamydia screening after controlling for other significant provider characteristics that we could not alter (i.e., gender, provider type, and years of treatment experience). Due to high collinearity among items assessing providers perceived knowledge, confidence, and comfort, we ran separate multivariate logistic regression models, each examining a key modifiable factor while controlling for all significant provider characteristics named above. In each model, providers perceived chlamydia knowledge, confidence in their relevant practice abilities, and beliefs about patient comfort were significantly associated with their self-reports of annual chlamydia screening (Table 4 shows adjusted odds ratios and p-values). Observed chlamydia screening based on automated medical records Using the health plan s automated records, we assessed actual chlamydia testing among all sexually-active adolescents who were assigned to the patient panels of 143 anonymous primary care providers. During the 1-year sample period, 35% of sexually-active females aged were screened for chlamydia. By comparison, average chlamydia screening rates among commercial managed care plans during the same calendar year was 24% [20]. Discussion It is recommended that sexually-active adolescents be screened for chlamydia at least annually and again following changes in their risk factors [10 14,31]. Despite uniform guideline agreement on these recommendations, screening rates in the US are less than optimal [20]. Even within the current healthcare organization, where observed screening rates were comparable with those at similar organizations nationwide [20], less than half of primary care providers surveyed (42%) reported that they screen sexually-active adolescents annually, only 57% reported that they screen if there is a change in sex partners, and 30% reported screening if there is use of non-barrier contraception. These Table 4 Multivariate predictors of self-reported annual chlamydia screening Construct/Variable Adjusted a odds ratio (95% CI) p-value Knowledge Perceived chlamydia trachomatis (CT) knowledge 2.3 ( ).003 Confidence In own ability to identify females for whom CT is appropriate 1.7 ( ).003 In own ability to choose appropriate CT treatment 1.8 ( ).01 In own ability to discuss sexual history and STD screening with sexually-active asymptomatic yearolds 1.5 ( ).05 In own ability to discuss sexual history and STD screening with sexually-active asymptomatic yearolds 1.3 (.8 2.0).29 Comfort Recommending STD screening to sexually-active, asymptomatic yearolds 1.6 ( ).008 Recommending routine CT screening for sexually-active females 1.3 (.9 1.8).11 Other Attitudes/beliefs Perceived patient comfort discussing sexual history 1.4 ( ).05 a Adjusted odds ratios and p-values from multivariate logistic regression models, which adjusted for provider type (MD/DO vs. other), gender, and years of treatment experience (dependent variable if report annual CT screening). practices fall far short of the guideline goals to screen 100% of the time in each of these instances. One contributing factor is likely the lack of awareness of existing screening guidelines; 20% of this sample cited a lack of guideline recommendations as a reason for not screening more often. Other reasons included the perceived cost to the health plan and a lack of time or resources, but the predominate barrier reported by providers was discomfort recommending screening during non-gynecological exams. During the study period, nearly all chlamydia screening exams performed in our organization used cervical specimens. Providers might be more comfortable with routine screening if they used less invasive urine tests, which were just becoming widely available at the time of this survey. Urine tests have also been found to be acceptable to adolescent patients. In a recent study, 71% of adolescent females seen in an urban emergency room and offered a urine chlamydia test agreed to screening [32]. To understand more fully why clinicians did not rou-

7 732 J.B. McClure et al. / Journal of Adolescent Health 38 (2006) tinely screen sexually-active adolescent females for chlamydia, we examined the association between self-reported annual screening and a range of factors hypothesized to be related to screening. Consistent with prior research, female providers and non-physicians were more likely to report annual chlamydia screening [23,25]. Fewer years of clinical experience was also a significant factor. This latter finding may reflect a difference in medical training, as older providers may have less training with chlamydia screening, or it may reflect an association between non-physician status and years of clinical practice. In this sample, physician assistants had been practicing significantly fewer years than physicians and were more likely to report annual screening. We also found a strong association between providers confidence in their ability to perform several specific screening-related activities, their comfort in dealing with sexual issues, and whether they reported screening adolescents at least annually. For example, providers who were more confident in their ability to identify females for whom screening was appropriate and to discuss sexual issues with adolescents were more likely to say they screen annually. Clinician s perceived knowledge about chlamydia, as opposed to actual knowledge, and their perceived patient comfort regarding sexual issues were also strong correlates of routine screening. In multivariate analyses, each of these factors continued to be highly associated with annual screening, even after we controlled for clinician s gender, degree, and years of experience. These findings confirm and extend those of prior research in this area [23,26]. An important caveat to these results should be noted. Some of these findings may not generalize to other practice settings or types of providers. For example, providers who use urine screening tests may have less discomfort screening during non-gynecological exams; practitioners in other settings may have more or less concern about the cost of testing to medical insurers; and screening rates and selfperceived barriers to screening may be different among specialty care providers. However, the main conclusions of this study should generalize beyond this practice setting. That is, whether or not providers screen their adolescent patients for chlamydia will in part depend on their own confidence in their practice abilities and comfort discussing sexual issues with their patients. As such, these constructs represent targets for intervention. The findings from this study are limited by reliance on self-reported screening behavior, as opposed to providers actual screening behavior. This is a common limitation because it is difficult to link specific provider data with the actual provision of care in many healthcare settings. In our case, IRB limitations restricted linking individual provider performance with self-report data. Thus, we cannot make a direct comparison between the percent of providers reporting annual screening (42%) and the aggregate observed annual screening rate of sexually-active adolescents (35%); however, the data from these sources were compatible. Both suggested that most providers were not routinely screening their adolescent patients for chlamydia. And although the observed screening rate is lower than is ideal, there is no indication that this group of providers was less adherent to screening guidelines than their peers. In fact, the screening rate of sexually-active adolescents during the observation period ( ) was slightly higher than that found at comparable healthcare facilities in the US during the same time period [20]. In summary, while knowledge, attitudes, and beliefs are known predictors of behavior, we identified several specific STD screening-related attitudes and beliefs that were associated with clinician s adherence to chlamydia screening guidelines with their sexually-active adolescent patients. Moreover, many clinicians were not aware of relevant screening guidelines and nearly half were uncomfortable recommending screening outside of gynecological exams. Screening asymptomatic adolescents for chlamydia is a high priority, cost-effective intervention [33], but guideline recommendations alone are not sufficient to improve practice [21,22]. Based on the results of this study, future interventions to promote chlamydia screening may be more effective if they not only advise providers when to screen, but incorporate strategies to enhance providers comfort recommending screening to sexually-active adolescents and to improve their confidence in their abilities to discuss sexual issues with adolescents, identify those for whom screening is appropriate, and choose appropriate treatment. Medical training and continuing medical education programs, particularly those pertaining to adolescent STDs, would be well-served to include enhanced activities to foster providers confidence in and comfort with these relevant screening issues. Efforts to promote greater awareness of existing guidelines may also be useful, but in isolation from efforts to change providers attitudes and beliefs, they may be insufficient to alter chlamydia-screening practices. Acknowledgments This study was supported by R01 HS10514 (R. Thompson, P.I). Additional support for the preparation of this manuscript was provided by K07 CA84603 and R01 CA (J. McClure, P.I.). The authors wish to thank Cynthia Sisk, Jane Grafton, and Katie Saunders for their work on this project. We would also like to thank the providers at Group Health Cooperative who participated in this study. References [1] Cates W Jr. Estimates of the incidence and prevalence of sexually transmitted diseases in the United States. American Health Association Panel. Sex Trans Dis 1999;26:S2 7. [2] CDC. Sexually transmitted diseases treatment guideline, MMWR 2002;51(RR-6):1 84.

8 J.B. McClure et al. / Journal of Adolescent Health 38 (2006) [3] Feroli KL, Burstein GR. Adolescent sexually transmitted diseases: New recommendations for diagnosis, treatment, and prevention. MCN Am J Matern Child Nurs 2003;28: [4] CDC. Chlamydia screening among sexually active young female enrollees of health plans United States, MMWR 2004; 53: [5] Mangione-Smith R, O Leary J, McGlynn EA. Health and cost-benefits of chlamydia screening in young women. Sex Transm Dis 1999;26: [6] Cohen CR, Nguti R, Bukusi EA, et al. Human immunodeficiency virus type 1-infected women exhibit reduced interferon-gamma secretion after Chlamydia trachomatis stimulation of peripheral blood lymphocytes. J Infect Dis 2000;182: [7] Farley TA, Cohen DA, Wu SY, Besch CL. The value of screening for sexually transmitted diseases in an HIV clinic. Acquir Immune Defic Syndr 2003;33: [8] Nelson HD, Helfand M. Screening for chlamydial infection. Am J Prev Med 2001;20: [9] Huppert JS, Adams Hillard PJ. Sexually transmitted disease screening in teens. Curr Womens Health Rep 2003;3: [10] Berg AO, US Preventive Services Task Force. Screening for chlamydial infection: Recommendations and rationale. Am J Prev Med 2001;20:90 4. [11] American Medical Association. Guidelines for Adolescent Preventive Services. Chicago, IL: American Medical Association, [12] American Academy of Pediatrics. Recommendations for preventive pediatric health care (RE9939). Pediatrics 2000;105: [13] Hollblad-Fardiman K, Goldman SM. American College of Prevention Medicine practice policy statement. Am J Prev Med 2003;24: [14] American Academy of Family Physicians. Summary of Policy Recommendations for Periodic Health Examinations. Leawood, KS: American Academy of Family Physicians, [15] Honey E, Augood C, Templeton A, et al. Cost effectiveness of screening for Chlamydia trachomatis: A review of published studies. Sex Transm Infect 2002;78: [16] Howell MR, Quinn TC, Gaydos CA. Screening for Chlamydia trachomatis in asymptomatic women attending family planning clinics. A cost-effectiveness analysis of three strategies. Ann Intern Med 1998;128: [17] Hu D, Hook EW, Goldie SJ. Screening for Chlamydia trachomatis in women 15 to 29 years of age: A cost-effectiveness analysis. Ann Intern Med 2004;141: [18] Welte R, Kretzschmar M, van den Hoek JAR, Postma MJ. A population based dynamic approach for estimating the cost effectiveness of screening Chlamydia trachomatis. Sex Transm Infect 2003;79:426. [19] Scholes D, Stergachis AHFE, Andrilla H, et al. Prevention of pelvic inflammatory disease by screening for cervical chlamydial infection. N Engl J Med 1996;34: [20] National Committee for Quality Assurance. The State of Health Care Quality: Available at: SOMC/ SOHC2004.pdf. Accessed February [21] James PA, Cowan TM, Graham RP, Jameroni BA. Family physicians attitudes about and use of clinical practice guidelines. Fam Pract 1997;45: [22] Wolff M, Bower DJ, Marbella AM, Casanova JE. U.S. family physicians experiences with practice guidelines. Fam Med 1998;30: [23] Cook RL, Wiesenfeld HC, Ashton MR, et al. Barriers to screening sexually active adolescent women for chlamydia: A survey of primary care physicians. J Adolesc Health 2001;28: [24] Torkko KGK, Crane L, Hamman R, Baron A. Testing for Chlamydia and sexual history taking in adolescent females: Results from a statewide survey of Colorado primary care providers. Pediatrics 2000; 106:E32. [25] Westgrath F, Crofts N, Gertig D. Genital chlamydia infection: Diagnostics practices of general practitioners in Melbourne, Australia. Sex Transm Dis 1994;21: [26] Ashton MR, Cook RL, Wisenfeld HC, et al. Primary care physician attitudes regarding sexually transmitted diseases. Sex Transm Dis 2002;29: [27] Boekeloo BO, Snyder MH, Bobbin M, et al. Provider willingness to screen all sexually active adolescents for chlamydia. Sex Transm Infect 2002;78: [28] Bandura A. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice Hall, [29] Bandura A. Self-Efficacy: The Exercise of Control. New York: W.H. and Freeman Company, [30] Green LW, Kreuter MW. Health Promotion Planning: An Educational and Environmental Approach. 2nd edition. Mountain View, CA: Mayfield, [31] CDC. Chlamydia trachomatis Screening Recommendations. MMWR 2002;51(RR15):37. [32] Monroe KW, Weiss HL, Jones M, Hook EW 3rd. Acceptability of urine screening for Neisseria gonorrheae and Chlamyida trachomatis in adolescents at an urban emergency department. Sex Transm Dis 2003;30: [33] Coffield AB, Maciosek MV, McGinnis M, et al. Priorities among recommended clinical preventive services. Am J Prev Med 2001;21: 1 9.