D. Fine, S. Goldenkranz and W. Nakatsukasa-Ono Cardea, Seattle WA National STD Prevention Conference

Transcription

1 Social Determinants, Epidemiologic Context, and Individual Risk Factors for Chlamydia (CT) Infection Among Women Attending Family Planning (FP) Clinics in the Region X Infertility Prevention Project (IPP), 2010 D. Fine, S. Goldenkranz and W. Nakatsukasa-Ono Cardea, Seattle WA 2012 National STD Prevention Conference

2 Goals Describe rationale Raise method issues Show preliminary results

3 Rationale Recent theoretical frameworks propose multi-level models to describe STI transmission Social determinants, e.g. community poverty, crime Neighborhood indicators, e.g. racial composition Clinic characteristics, e.g. CT screening coverage Sexual network characteristics, e.g. SP concurrency Individual risk behaviors

4 Multi-level models imply multiple data sources IPP: Individual behaviors, sexual network and CT test Other data sources needed to describe social determinants and clinic service characteristics Challenges bringing these data together within IPP

5 Objective Assess individual-level risks, sexual network measures, clinic service characteristics, and area-based socioeconomic measures (ABSM) associated with CT among Region X female FP clients aged years.

6 Methods Data sources, Region X CY2010 1) Title X FP client clinic visit records (CVRs) 2) U.S. Census 2000 tables* 3) IPP CT test records *Forthcoming 2010 ZCTA tables will be included in future analyses.

7 1) Data: 2010 Region X FP client visit records (CVRs) 219,921 Title X FP visit records, female clients aged y Clinics Patients N % N % Total % 137, % 100+ FP clients/clinic % 134,301 97% FP clinic in IPP data % 104,549 76% 100+ clients/clinic and in IPP % 102,294 74%

8 2) Data: U.S. Census 2000 ZCTA records Areal community summary measures ZIP-code tabulation areas: drawn around US Postal Service ZIP-code routes Measures Race and ethnicity populations (SF1, 2010 Census) Socioeconomic position (SF3, 2000 Census) Measures summarized as ordered categories Followed federal guidance (e.g. FPL) or past research These variables are sometimes referred to as areabased socioeconomic measures or ABSM

9 3) 2010 Region X IPP and FP clinics All clinics: 79,664 CT tests, female clients aged y Clinics IPP CT Tests N % N % IPP FP clinics % 63, % FP clinics in Title X CVR % 53,858 84% FP Title X w/ 100+ clients % 49,470 78%

10 Sample for analysis Critical to select clinics where FP CVR and IPP data systems have consistent clinic CT testing volumes Step 1: Explored documentation of CT test done in Title X FP CVR data Step 2: Assessed conformance between clinics IPP test volume and CT testing in FP CVR data Steps 1 and 2 took some time

11 Region X 2010 IPP Sample progression Clinics CT Tests* N % N % FP clinics % 63, % FP clinics in Title X CVR % 53,858 84% FP Title X w/ 100+ clients % 49,470 78% FP Title X clinics, 100+, consistent CVR-IPP test volume 85 44% 32,931 52% *Female clients aged years.

12 Sample for analysis 125 FP clinics 49,470 IPP tests, CY clinics excluded CT test volume differences between CVR and IPP, 20+% 85 FP clinics 32,931 IPP tests, CY2010 Female FP clients aged years, WSM & WSMW, and FP area within AK and ID integrated clinics

13 Measures: IPP test records Based on Region X IPP lab slip CT/GC test records Demographics Visit reasons History of CT infection Sexual risk behaviors (individual) Sex partner concurrency (network) Clinical signs CT test result

14 Measures: FP clinic service characteristics Based on Title X FP CVR data aggregated to the clinic-level (n=85) merged into IPP via clinic ID number CT screening coverage Patient volume Comprehensive exams Patient status (new vs. continuing) Adolescents y Racial minority clients Hispanic clients

15 Measures: Social determinants (ABSM) Based on aggregate ZIP-code level U.S. Census 2000 data* (n~1,500) merged into IPP via tested client s ZIP code Poverty, % FPL Median household income Limited education Racial minority Hispanic ethnicity * As of March 2012, Census 2010 ZCTA data not available for all 4 Region X states

16 (Interim) Results

17 Individual-level risk factors and chlamydia Characteristic Percent % CT+ Total sample 100% 6.5% Age % 7.9% % 5.5% Race/ethnicity NH White 65% 5.9% NH Black 10% 12.5% American Indian/AK Native 2% 8.3% Asian 5% 9.0% Hawaiian or Pacific Islander 2% 14.6% Hispanic 16% 5.9%

18 Percent % CT+ Chlamydia infection in prior year No 91% 6.1% Yes 9% 12.9% Multiple SP, past 60 days No 79% 5.8% Yes 17% 12.1% Don t know 4% 7.2% New SP, past 60 days No 65% 5.5% Yes 30% 10.2% Don t know 5% 6.6% Symptomatic SP, past 60 days No 82% 6.0% Yes 5% 24.8% Don t know 13% 7.9%

19 Percent % CT+ Reason for visit, sex partner w/ CT No 94% 6.2% Yes 6% 40.8% Condom used, last sex No 79% 6.7% Yes 21% 5.6% Clinical findings, one or more No 45% 5.6% Yes 6% 12.1% No exam or data 49% 7.1% SP concurrency Yes, definitely 17% 8.1% No sure, possibly 51% 7.6% No, unlikely 32% 4.8%

20 Aggregate FP clinic service characteristics Percent % CT+ FP clinic screening coverage < 50% 29% 6.4% 50% % 55% 6.4% 75%+ 16% 7.2% FP clinic patient volume < % 6.0% % 6.8% 1,000 1,499 18% 6.1% 1,500 1,999 8% 8.5% 2, % 6.4%

21 Aggregate FP clinic service characteristics Percent % CT+ FP clinics, clients aged y < 30% 8% 4.7% 30% 39% 16% 6.1% 40% 49% 56% 6.7% 50% - 59% 14% 6.6% 60%+ 7% 8.6% FP clinics, clients w/ comprehensive exam < 20% 21% 7.8% 20% - 29% 17% 6.9% 30% - 39% 23% 6.6% 40% - 49% 9% 6.0% 50% - 59% 10% 5.0% 60% - 69% 12% 7.4% 70%+ 8% 5.0%

22 Aggregate FP clinic service characteristics Percent % CT+ FP clinics, new FP patients, 2010 < 40% 13% 5.8% 40% 49% 45% 6.6% 50% - 59% 23% 7.3% 60%+ 20% 5.9%

23 Census ABSM and chlamydia Percent % CT+ Household median income, quintiles* 1 (Lowest) 5% 5.9% 2 15% 6.1% 3 26% 6.4% 4 30% 6.5% 5 (Highest) 24% 6.6% % Below 100% federal poverty level < 5% 3% 5.5% 5.00% % 34% 6.7% 10.00% % 42% 6.3% 15.00% % 16% 6.4% 20.00%+ 5% 5.6% *State-specific quartiles based on median incomes for all ZCTAs

24 Census ABSM and chlamydia Percent % CT+ Limited education* < 5% 2% 4.8% 5.00% % 16% 6.4% 10.00% % 35% 6.2% 15.00% % 24% 6.8% 20.00% % 17% 6.7% 25%+ 6% 6.9% *% of adults aged 25 or older without a high school diploma

25 Census ABSM and chlamydia Percent % CT+ Racial minority < 5% 8% 5.2% 5.00% % 29% 6.0% 10.00% % 22% 6.4% 15.00% % 11% 6.1% 20.00% % 8% 6.4% 25.00% % 7% 7.9% 30.00% % 6% 8.6% 35.00% % 4% 7.2% 40%+ 6% 10.0%

26 Census ABSM and chlamydia Percent % CT+ Hispanic ethnicity < 5% 46% 5.7% 5.00% % 32% 7.3% 10.00% % 13% 7.5% 15.00% % 4% 8.0% 20.00% % 3% 6.0% 25%+ 3% 6.5%

27 RUCA* ABSM and chlamydia Percent % CT+ Urban-rural status Urban 75% 6.8% Large rural 17% 6.2% Small rural 6% 4.6% Isolated 3% 4.9% *RUCA: Rural-urban commuting areas. Developed by the University of Washington Rural Health Research Center

28 Multivariate results Individual factors Characteristic Adj. OR Age, years 1.37 Race/ethnicity NH White Ref. NH Black 1.83 AI/AN 1.67 API 1.33 Hispanic 1.04

29 Multivariate results Individual factors Characteristic Adj. OR SP w/ chlamydia 7.02 New SP, past 60 days 1.44 Multiple SP, past 60 days 1.32 Sx SP, past 60 days 1.70 Clinical findings 1.88 SP concurrency No, unlikely Ref. Not sure, possibly 1.36 Yes definitely 1.40

30 Multivariate results Aggregate factors Characteristic Adj. OR Clinic-level Clinic size, female client volume 1.07 % female clients aged years 1.16 Census ABSM Urban-rural status (RUCA) Urban Ref. Large rural 1.03 Small rural 0.65 Isolated 0.68 % Racial minority 0.94 % Hispanic ethnicity 1.13

31 Conclusions It is feasible to access and use other data systems to supplement IPP CT test records But, there are technical challenges Multi-level analyses using individual- and aggregate-level data may help inform the field s more comprehensive models of STD acquisition Hogben and Leichliter, 2008 In Region X, CT positivity for young women screened at FP clinics is a function of individual, sexual network, clinic, and community characteristics.

32 For further information: David Fine, PhD Cardea Seattle, WA p: (206) f: (206)