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What Sexually Transmitted Disease Screening Method Does the Adolescent Prefer?
Adolescents' Attitudes Toward First-Void Urine, Self-collected Vaginal Swab, and Pelvic Examination
Michelle Serlin, MD;
Mary-Ann Shafer, MD;
Kathleen Tebb, PhD;
Afua-Adoma Gyamfi, BS;
Jeanne Moncada, MT;
Julius Schachter, PhD;
Charles Wibbelsman, MD
Arch Pediatr Adolesc Med. 2002;156:588-591.
ABSTRACT
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Objective To assess sexually active adolescents' attitudes toward 3 screening
collection techniques for detection of Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis using first-void urine (FVU), self-collected
vaginal swab specimens, and pelvic examination with clinician-collected endocervical
swab specimens.
Design Participants completed a preexamination health survey, provided FVU
and self-collected vaginal swab samples, and had a pelvic examination with
endocervical swab specimen collection. In a confidential postexamination interview,
patients ranked the 3 screening techniques according to preference and responded
to qualitative positive and negative descriptors to evaluate each technique.
Setting San Francisco area health maintenance organization and university clinics.
Participants A convenience sample of 155 ethnically diverse females aged 12 to 21
years, who were sexually active and were to have a pelvic examination.
Main Outcome Measures Adolescents' preferences for and evaluations of 3 sexually transmitted
disease screening techniques.
Results Participants preferred the FVU test for sexually transmitted disease
screening over the pelvic examination and the self-administered vaginal swab
test (P<.001). These results were consistent when
controlling for potentially mitigating experiences, including previous pelvic
examination, tampon or condom use, and prior pregnancy. In evaluating what
they liked and disliked about each of the 3 screening methods, participants
described the FVU most positively, the pelvic examination most negatively,
and the vaginal swab technique slightly less positively than the FVU.
Conclusion Most sexually active adolescents attending clinics for pelvic examination
prefer to be screened for sexually transmitted diseases first by the FVU,
second by the self-collected vaginal swab test, and last by the pelvic examination.
INTRODUCTION
THE RATE of chlamydial infection remains epidemic among 15- to 19-year-old
females, with 2359 cases in every 10 000.1
All major health policy organizations recommend annual chlamydial screening
for sexually active adolescent females.2-4
The nucleic acid amplification technique applied to urine samples provides
a sensitive noninvasive method to screen adolescents for Chlamydia trachomatis and Neisseria gonorrhoeae5-6 and are more cost-effective compared
with pelvic examinations.7 Recently, self-collected
vaginal swab tests have been successfully implemented as another method of
obtaining sexually transmitted disease (STD) specimens from adolescent and
adult women,8-10
although this technique awaits approval by the Food and Drug Administration
(Rockville, Md). Yet, such STD testing advances have not resulted in universal C trachomatis screening in adolescent females since currently
fewer than 1 in 5 eligible adolescents are screened for chlamydia.11
Why is the screening rate so poor? Clinician-linked barriers to screening
have been explored,12-14
including lack of time and skill in performing pelvic examinations and in
taking sexual histories. Adolescent-linked barriers include fear of the pelvic
examination.7, 12, 15-16
However, before recommending universal adoption of any new STD collection
technique, it is important to review available information on the adolescent
client's experience with such methods as first-void urine (FVU) and the self-collected
vaginal swab. In one study, adolescents readily accepted urine-testing methods
but no comparisons against any other testing methods were presented.17 Two other studies showed that teenagers preferred
the self-collected swab test to the pelvic examination.9-10
However, to our knowledge, no study to date has evaluated the adolescent's
preferences after experiencing multiple distinct STD screening techniques
simultaneously. Therefore, this study was designed specifically to examine
adolescents' preferences for and attitudes toward 3 different STD screening
techniques: the FVU, the self-collected vaginal swab test, and the pelvic
examination.
PARTICIPANTS AND METHODS
PARTICIPANTS
Participants were recruited from adolescent women attending either a
university- or health maintenance organization-based clinic for adolescents.
Non–English speakers were ineligible to participate.
PROCEDURES
Recruitment
Human subject use review boards at both participating institutions approved
this study. Participants were recruited on 3 afternoons per week when most
pelvic examinations were scheduled. All young women who were at the clinic
for pelvic examination were approached to participate by a trained female
research assistant and gave standard demographic recruitment information and
signed a consent form.
STD Specimen Collection
Participants were instructed on the proper collection of the FVU (first
20 mL in marked cup) and vaginal specimens (insert swab 1-2 in, rotate around
vagina 3 times; repeat procedure with second swab), and then underwent a pelvic
examination, at which time 2 endocervical swab samples were obtained by the
clinician.
Laboratory Processing
The FVU, 1 vaginal, and 1 endocervical swab specimen (a second endocervical
swab specimen was processed in parallel in the hospital laboratory per routine)
were assayed for C trachomatis and N gonorrhoeae (LCx®; Abbott Laboratories, Chicago, Ill) in the
laboratory of one of the authors (J.S.) The second self-collected vaginal
swab sample was tested for Trichomonas vaginalis
using the Trichomonas In-Pouch TV (Biomed Diagnostics, San Jose, Calif) according
to the manufacturer's instructions. Participants were considered to have a
specific STD if any specimen yielded a positive result from either laboratory.
Result discrepancies between laboratories were not significant.
MEASURES
Before STD specimen collection, the research assistant obtained demographic
information (age, ethnicity, household makeup, work experience, and grade
in school) on all potential participants using a recruitment survey. All surveys
were piloted for correct wording and content on 26 adolescent females attending
the target clinics. Following the recruitment survey, a preexamination survey
on reproductive health was given, which consisted of 10 items about the participant's
sexual and reproductive history (ie, sexual risk behaviors, pregnancy, and
contraceptive history).
Finally, each participant took part in a postexamination interview in
which she was asked to rank the 3 STD testing techniques by preference. She
was then asked to rate 10 statements (Table
1) according to how well they described her experience with each
testing method (5 positive and 5 negative items) using a 10-point scale (1
= disagree completely and 10 = agree completely with description). These descriptors
were developed during the pilot phase and were the most common terms elicited
from an open-ended query (ie, "Describe what you like and dislike about each
method").
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Table 1. Qualitative Descriptors by Sexually Transmitted Disease Screening
Technique*
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STATISTICAL ANALYSES
To analyze rankings, the Friedman test was conducted to evaluate differences
in medians among the 3 methods (this tests the null hypothesis, ie, no difference
in preference among the 3 methods). Scores for each variable (pelvic examination,
vaginal swab, and FVU) were ranked (first choice = 1, second choice = 2, and
third choice = 3) and median ranks for variables were compared (the lower
the ranking, the higher the preference). For significant findings (P<.05), Wilcoxon rank sum follow-up tests were conducted to evaluate
comparisons between pairs of medians and controlled for the type I errors
across these comparisons at the .05 level. This procedure was used for the
total population and for specific subgroups (regular tampon use, condom use
at last intercourse, past pelvic examination, and prior pregnancy).
To analyze qualitative descriptors of each testing method, within-subject
repeated-measures analyses of variance were used. Because this design gathered
responses from each participant for each of the 3 testing methods, within-subject
differences could be analyzed, with between-subject differences removed. This
method first calculates the mean for each participant for each method and
then examines the mean differences for the testing techniques being compared.
To adjust for multiple comparisons, a 97.5% confidence interval was used for
these analyses.
RESULTS
SUBJECTS
A total of 189 sexually active young women who were to have a pelvic
examination on the day of the visit were invited to participate. One hundred
fifty-five patients participated (mean age, 16.7 years; range, 12-21 years).
They were racially/ethnically diverse: 34% were African American, 19% were
white, 17% were Asian American, 13% were Latin American, and 17% were of mixed
or other races. Those who refused to participate (n = 34) gave the following
reasons for nonparticipation: lack of time (n = 12), unwillingness to do the
vaginal swab test (n = 11), pelvic examination discomfort (n = 4), confidentiality
concerns (n = 1), and 6 cited other miscellaneous reasons. Those who refused
were older (mean age, 17.39 vs 16.70 years; P = .01)
and more likely to be African American (59% vs 34%; P
= .01) than participants.
CLINICAL VISIT
Reasons for the visit included (>1 response possible) annual pelvic
examination (54%), STD screen (40%), contraception (28%), pregnancy test (15%),
other gynecologic problems (9%), and reasons not related to reproductive health
(13%). Clinical diagnoses included normal results in 69% of patients, reproductive
health–related in 29%, and other nonreproductive diagnoses in 2%. Sexually
transmitted diseases detected included C trachomatis
(6.1%), N gonorrhoeae (3.1%), and T vaginalis (4.7%).
ADOLESCENTS' PREFERENCES TOWARD THE 3 STD SCREENING METHODS
The median rank for the FVU method was significantly lower (greater
preference) (median, 1.59) than the self-collected vaginal swab (median, 2.01)
and the pelvic examination (median, 2.39) (Table 2). There were no differences in rankings by prior pelvic
examination, regular tampon use, condom use at last sexual intercourse, age,
ethnicity, or prior STD history. When asked what they liked and disliked about
each method, using a list of 5 positive and 5 negative descriptors, the participants
scored the pelvic examination more negatively and the FVU more positively,
with the vaginal swab method scoring slightly less positively than the FVU
(Table 1). In general, they felt
more comfortable and less embarrassed with the FVU and vaginal swab methods
compared with the pelvic examination and described more pain and inconvenience
with the pelvic examination compared with the other methods. However, they
trusted the results of the pelvic examination more than the vaginal swab and
FVU methods (P<.001). Participants seemed to worry
that they might self-administer the vaginal swab test incorrectly, thus having
less faith in that test compared with the FVU (P<.001)
and pelvic examinations (P<.05).
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Table 2. Adolescents' Ranking of Sexually Transmitted Disease Screening
Methods*
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COMMENT
Participants ranked the pelvic examination last, the self-collected
vaginal swab method second, and the FVU first in preference for STD screening
(Table 2). This preference was
upheld in analyses of subgroups with more reproductive experiences, eg, tampon
use and prior pelvic examination. The pelvic examination, the current standard
of care for STD screening, not only was ranked last by preference but also
was consistently evaluated highest for the negative attributes, such as anxiety
and pain, and lowest for the positive attributes, such as comfort and control
over collection method. This last-place finish for the pelvic examination
occurred even though most participants were prescheduled for a pelvic examination
and most had prior pelvic examination experience. In contrast, the self-collected
vaginal swab method was ranked higher than the pelvic examination on both
preference and the participants' evaluation profiles regarding negative and
positive attributes; yet, none of the participants had prior self-collected
swab experience. Analyses of the vaginal swab method revealed one unique result
compared with the other methods: participants more often felt that they might
be "doing something wrong" during the collection compared with the other methods.
In addition, 11 of those initially approached (6%) refused to participate
in the study because of concern about the self-collected swab component (only
persons having a pelvic examination were approached to participate, which
potentially yielded a more positive bias toward the pelvic examination since
those who refused were not approached to participate in the study). Participants
clearly preferred the FVU as the method of choice for STD screening. In addition,
participants scored the FVU lowest on negative attributes (eg, least anxious
or painful) and highest on positive attributes (eg, most comfortable or most
relaxed) compared with the other methods.
This study illustrates the importance of including the young consumer's
preferences and attitudes when developing new STD screening strategies. There
exist only a handful of studies reporting success in alternative STD specimen
collection methods for adolescents.7-10,17
Although our study supports adolescents' acceptance of alternative methods
of STD screening, the participants' responses were not uniformly positive
for each method. For example, some participants were fearful that they were
doing the vaginal sampling wrong and were more confident with the results
of the pelvic examination. They also trusted the results of the pelvic examination
more than those of the FVU. The FVU method, while preferred by these adolescents,
is not a perfect specimen from a system's perspective: it is more difficult
to store, transport (requires cold chain maintenance), and process (requires
additional laboratory steps) compared with the vaginal or endocervical swab
methods (which can be mailed in), resulting in increased laboratory costs.
The performance of the vaginal swab method is more comparable with that of
the endocervical swab in detecting chlamydial infections, and both perform
slightly better than the FVU.8-10,17
Although generally ranked last on most parameters, the pelvic examination
was uniformly chosen as the most trusted method of screening by the adolescent,
which may reflect tradition and the overall interaction with the clinician
during a pelvic examination. A major limitation of this study is the generalizability
of the findings beyond the clinical setting.
In summary, chlamydia is a major public health concern in the female
adolescent. With urine and vaginal sampling possible for STD screening, the
invasive, costly, time-consuming, and often uncomfortable pelvic examination
can now be reserved to obtain a Papanicolaou smear as needed and to assess
pregnancy and gynecologic pathology as warranted. A revolution of STD testing
is at hand but more research is needed to look at barriers to STD screening
from all aspects of the health care system before consumer-friendly universal
STD screening can be successful.
| What This Study Adds
New nucleic acid amplification–based STD testing techniques are
more accurate and cost-effective. However, little investigation has been done
to assess the adolescent consumer's acceptance of different specimen collection
techniques. A few available studies have found that adolescents readily accept
FVU and vaginal swab testing methods. To our knowledge, this is the first
study specifically designed to examine adolescents' preferences for and attitudes
toward 3 different STD screening techniques after experiencing each technique
in parallel during a clinic visit: the FVU sample, the self-collected vaginal
swab technique, and the pelvic examination with endocervical sampling.
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AUTHOR INFORMATION
Accepted for publication February 14, 2002.
This study was supported by funding from the Yen Chuang Foundation,
San Francisco, Calif, and Dr Shafer was supported in part by grant MC00003
from the Maternal and Child Health Bureau, Rockville, Md.
We thank Biomed Diagnostics for providing the InPouchTM TV test
kits.
Corresponding author: Mary-Ann Shafer, MD, University of California–San
Francisco, School of Medicine, Department of Pediatrics, Division of Adolescent
Medicine, Box 0503, San Francisco, CA 94143-0503 (e-mail: shafer{at}itsa.ucsf.edu).
From the Children's Hospital, Oakland, Calif (Dr Serlin), Division
of Adolescent Medicine, Department of Pediatrics (Drs Shafer and Tebb and
Ms Gyamfi); Department of Laboratory Medicine (Dr Schachter and Ms Moncada),
School of Medicine, University of California–San Francisco, and Kaiser
Permanente (Dr Wibbelsman), San Francisco.
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