Journal of Public Health | Vol. 30, No. 4, pp. 466 471 | doi:10.

1093/pubmed/fdn060 | Advance Access Publication 23 July 2008

Opportunistic screening for Chlamydia: a pilot study into male perspectives on provision of Chlamydia screening in a UK university
Rishika Chaudhary1, Catherine M. Heffernan2, Amy L. Illsley1, Laura K. Jarvie1, Catherine Lattimer1, Anana E. Nwuba1, Edward W. Platford1
University of Leeds Medical School, UK Institute of Health Sciences and Public Health Research, University of Leeds, Room 8E57, Floor 8, Quarry House, Leeds LS2 7UE, UK Address correspondence to: Catherine Heffernan, E-mail: hefferc@yahoo.com or catherine.heffernan@leeds.ac.uk
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A B S T R AC T
Background Since 2003, the University of Leeds has been a pilot site for the National Chlamydia Screening Programme (NCSP), which offers opportunistic screening to asymptomatic people under the age of 25. Uptake among men is low. The purpose of this study is to explore perceptions and acceptability of the provision of Chlamydia screening in the University of Leeds among 18 25-year-old male students. Methods Using a purposive sample of 15 male students aged between 19 and 24, two focus group sessions were conducted within university grounds. Results Thematic analysis of the data revealed that male attitudes about Chlamydia screening were affected by: (1) lack of knowledge about Chlamydia and screening; (2) social embarrassment about Chlamydia; (3) reluctance to seek medical help; (4) perception that Chlamydia was a womans disease and (5) indifference about health promotion campaigns. Conclusion To encourage the uptake of opportunistic screening of Chlamydia, men under 25 years should be made aware of their responsibility for their own sexual health. Emphasis can also be placed on the non-invasiveness, ease and privacy of the test. Keywords Chlamydia trachomatis, opportunistic screening, university students, young men

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Introduction
Chlamydia trachomatis is the most commonly diagnosed sexually transmitted infection (STI) in the UK.1,2 Although the majority of cases are asymptomatic,3,4 if left untreated, the infection can have serious consequences in both women and men.5 7 The highest incidences occur in the 18 25 age group.2,6 10 In 2003, the National Chlamydia Screening Programme (NCSP) was established offering opportunistic screening to asymptomatic people under the age of 25 in sites not traditionally associated with sexual health.3,11 Emphasis is on screening sexually active women under 25 years old for Chlamydia.6,9,12,13 It has been argued that screening asymptomatic women is more cost-effective than screening men,12,14 that women suffer greater long-term morbidity and that they are easier to target opportunistically because they are greater users of the health services.9,13,15 In the rst year of the NCSP, 15 241 women were screened compared with 1172 men.3 The small number of males is

worrying because men are equally at risk from Chlamydia. Chlamydia is associated with male sub-fertility,14 prostate cancer16 and increased transmission of human immunodeciency virus (HIV).7 Crucially, the emphasis on women overlooks the role of men in the spread of the infection.6,17 The purpose of this study is to explore perceptions and acceptability of the provision of Chlamydia screening in the University of Leeds among 1825-year-old males. The University of Leeds is one of the largest universities within

Rishika Chaudhary, Medical Student Catherine M. Heffernan, Specialist Trainee in Public Health and Hon. Lecturer in Public Health Amy L. Illsley, Medical Student Laura K. Jarvie, Medical Student Catherine Lattimer, Medical Student Anana E. Nwuba, Medical Student Edward W. Platford, Medical Student

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# The Author 2008, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved.

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the UK18 and was a pilot site for the NCSP. The screening programme, entitled C-Swab, has been running on campus for the past 4 years.19 It consists of free drop-in sessions held weekly in the students union on campus. Leeds Student Medical Practice with the University of Leeds deliver the programme.20,21 It is promoted using posters, leaets and websites.20 22 An audit of this programme and the accompanying promotional material has not yet been performed.20

Tapes were fully transcribed and analysed using thematic analysis.27 Textual data were scrutinized for differences and similarities within themes. Issues that generated the most discussion were prioritized. Data analysis involved two independent researchers and was checked by a third. Given the homogeneity of our focus groups, we make no claims for the generalizability of our ndings to the UK male student population.

Methods
A qualitative approach was utilized as this was an exploratory study of male views about Chlamydia screening. Focus group methodology was selected as it generates data quickly and efciently within a short period of time.23 Focus groups have been shown to be less inhibiting than one-to-one interviews24,25 and are suitable for capturing the dominant discourses of a social group.26,27 They are also a useful means to engage peoples views on sexual health. Since sexuality of students is shaped and inuenced by interactions with peers, focus groups provide the conditions under which people share sexual experiences.28,29 Social desirability bias has been found to be no different to that of surveys and qualitative research on other topics.29 31 Participants were recruited through advertisements placed on notice boards throughout the campus. The inclusion criteria were males aged between 18 and 25 and who were students of the University of Leeds. No specic attempt was made to enrol students with prior knowledge of the Chlamydia screening programme. We sampled purposively to obtain two groups of eight men. Only 15 attended the focus group sessions. The missing participant gave no reason for the absence. Those who agreed to take part were aged 1924 and were from a range of academic courses. Ethical approval was sought and approved by the Medical School Ethics Committee at the University. Both focus groups lasted 2 h and were conducted in a teaching room on campus during term-time. This was an accessible and familiar site for participants, creating a comfortable and relaxed environment for open discussion. A male moderator stimulated discussion using a question guide, probing knowledge about Chlamydia and the C Swab campaign. However, participants interacted easily and most of the discussion on beliefs was participant-led and unprompted, providing rich data for the analysis. The groups were observed discretely by two others. All participants signed a consent form, assuring condentiality and anonymity. Random pseudonyms were assigned to participants to protect identities.

Results
Five themes emerged from the data: (1) lack of knowledge about Chlamydia and screening; (2) social embarrassment about Chlamydia; (3) reluctance to seek medical help; (4) perception that Chlamydia was a womans disease and (5) indifference about health promotion campaigns.
Lack of knowledge about Chlamydia and screening

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The participants were only vaguely aware about the screening programme and were not sure what screening entailed and why it was benecial: I know that its sort of encouraged, I mean they suggest it. Like when I went for my MMR last year they were giving out like, packs [on C-Swab] and in the union last week, and other places. When I went for my MMR there were loads of [Chlamydia] tests given out, they basically gave this pack to everyone. (John, Group 1) Only one participant (Phil, Group 1) had been screened and he took the opportunity to inform the others about the process and symptoms. This prompted the others to state that partaking in focus groups was a good way to learn about Chlamydia. Of the others, seven knew it was a urine test, while some thought it involved an invasive swab (a probe-type thing). Another thought testing would cost him money. Most participants had heard of Chlamydia but had limited knowledge about the disease. There were misconceptions about the symptoms caused by Chlamydia, with some citing a rash or warts, while others thought that it might lead to complications such as infertility and impotency. Only two participants knew that Chlamydia can be asymptomatic. Participants held a greater awareness about other STIs, namely syphilis, herpes and HIV and viewed Chlamydia as being less serious than other STIs: It is treatable though, I mean, maybe that makes you more laissez faire about it. You think its not, like, the end of the world. You can go to your GP and get it sorted, not like something that would last for life. (James, Group 1)

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Social embarrassment about Chlamydia

Interestingly, the participants did not view Chlamydia as a stigmatized disease like HIV gonorrhoea and syphilis. It is possible , that Chlamydia is seen to be similar to genital warts, which tends not to be stigmatized due to the discourse surrounding it, avoiding the historical high-risk groups and association with sexual deviance.32,33 However, being publicly seen to seek medical help provoked embarrassment. Participants were selfconscious about even reading a poster promoting the C-swab programme: Andy, Group 1: You dont want to stop and stare at it. James, Group 1: No. Fred, Group 1: No, with everyone looking at you! Andy, Group 1: Thinking, hmm, hes infected! Many participants feared meeting an acquaintance at the GP surgery or GUM clinic. It would suggest that something was wrong with them. Phil (Group 1) attempted to alleviate others fears of GUM clinics with his outburst: Ive been to the clinic. It was a bit embarrassing, going for the rst time. Its not all that bad after you know what it is like. It has been suggested that although there will always be people who are embarrassed about issues relating to sexual health, providing information and tests in informal settings (e.g. nightclubs34) can boost mens willingness to be tested.35,36 However, the participants maintained that openness about Chlamydia screening was almost farcical: Yeah, cant have people lining up for Chlamydia testing in the union. Imagine if you walk into a friend: Hi mate, what are you doing? Just lining up for Chlamydia screening! Everybody laughs (Gaz, Group 1)

Well, I think that if you are sensible, you can be reasonably condent that you wont have a problem. But at the same time, I think, I know some people who would be reluctant to go even if they havent been sensible. I guess it is irrational, I dont know why. (Chris, Group 2) This was partially explained by participants being discomted about talking about sexual health to GPs: Its difcult to talk to strangers about personal things as its not really the type of thing that you would want to chat to someone you dont know about. (Chris, Group 2) It was also suggested that Chlamydia did not rank highly among the variety of risk that men take on a daily basis: You just dont want to believe that that sort of thing would happen to you so you sort of ignore it. I think that it would drive you insane if you started to think about every type of illness, not just STIs. (Tom, Group 2) Both groups admitted that they rarely visited a GP. It was evident that the mens reluctance to partake in Chlamydia screening was linked to a general feeling that real men do not need to visit doctors: Guys dont admit that they are ill as easily as women. For example, my dad has never admitted to being ill in the last 20 years and my mother will tell you that she is ill the day before she falls ill. (Ian, Group 2) However, participants advocated promotion of routine health checkups among men: It would be good if it was like going to the dentist, you just did it regularly. (Tom, Group 2)
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Reluctance to seek medical help

The majority of participants stated that they would be unlikely to partake in opportunistic Chlamydia screening. They spoke of urban myths of invasive treatments and other peoples bad experiences as justication: After I heard that it involved a probe up your penis, there was no way I was going to get tested! (John, Group 1) Another participant thought that sexual health-seeking behaviour was detrimental to general health because he had heard that multiple visits to the GUM clinic put you at risk of being refused life insurance. Sexual health-seeking behaviours were not considered the norm for men:

This would normalize sexual health-seeking behaviours: It wouldnt be, like, Im at risk. It would just be something everyone did. (Andy, Group1). There was a strong contention that men were a forgotten group whose needs were not considered as important as those of women. They maintained that the health services were more user friendly for women and that health professionals were more knowledgeable about womens problems: Other specialties in medicine have a supportive community, e.g. gynaecology for women, but there really isnt anything for men.

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Perception that Chlamydia was a womans disease

Most participants perceived heterosexual men as being relatively invulnerable to infection, instead viewing it as a problem for women and maybe, like, I dont know, gay men? I know that they are more at risk of HIV. This misconception has been reported elsewhere.29,37,38 At-risk and infected males who believe Chlamydia to be a womens disease may not perceive themselves to be at risk and therefore may not modify their sexual behaviours or get tested.15 Participants maintained that they could avoid Chlamydia by being wary of risky types of women. They could tell by looking at a girl whether or not she would have Chlamydia: John, Group 1: I know this sounds bad, but I think it is how guys think. It sort of depends on what the girls like. If you thought she did it before or, like, regularly, or if you didnt know her thats different from a friend. Ben, Group 1: Yeah, it would be different if it was someone you knew. Fred, Group 1: I mean, that is probably the way I would think. I know its not right but you do think differently depending on the girl. Like someone you know, versus someone you met at a club or something. This is similar to Connell et al. 39, who found that men relied on visual cues and a womans reputation gleaned from male friends to assess the risk of STIs. Focus Group 1 associated students and university life with engagement with risky sexual behaviours. At Uni. people get drunk and have unprotected sex, they are obviously gonna be at a greater risk. Interestingly, the focus group distanced themselves from likelihood of infection by connecting it solely with behaviour exhibited in Freshers Week. Students sleep around in freshers week: fact! The connection with Freshers Week acted as a mental barrier to the possibility of being at risk of infection now. Even discussion on health promotion revolved around targeting the young freshers.

campus would require a more innovative approach than the usual yer and poster. It seems that the bombardment of health messages on posters has caused students to be blase. Suggestions to raise awareness on campus included the use of campus web or screen savers in the library, information on the back of yers for nightclubs or on bus tickets and articles in the student paper. They also thought that screening should come to them, such as having a van circulating halls of residences collecting samples or sending urine pots to halls of residence so that you could take the test in your own time. They preferred this to visiting the GP service on campus or a GUM clinic. Of particular importance to the men was the emphasis on the non-invasive nature of testing:
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Gaz, Group 2:

You need to emphasise that it would be painless, quick, no effort and they will be given privacy. Oliver, Group 2: Showing that you dont have to get naked. Knowing that it is a urine sample would also make a big difference. Use of humour was considered very important to grab males attention: Mike, Group 1: In Freshers Week, there were these people dressed up as massive condoms outside the union (Laughter of group) . . . I think they were sort of, promoting, kind of condoms and safe sex and that. . . John, Group 1: If its funny. . . Pete, Group 1: You pay attention. Fred, Group 1; It catches your eye and you think about it. Andy, Group 1: Because they are making a joke of it, its not you know, embarrassing or anything. Mike, Group 1: And people dressed up as massive condoms strutting around outside the union. . . hilarious! (Laughter of group)

Discussion
Indifference about health promotion campaigns Main ndings

The dominant feeling was that the posters advertising Chlamydia screening on campus were boring and that posters in general are not read by men unless they contain drink or food offers. Apart from the embarrassment of having to read the posters and yers in public, one participant maintained that there was only one way to get men to think about Chlamydia testing and that was to put them above urinals. The groups maintained that increasing awareness about Chlamydia and the availability of Chlamydia screening on

Males distanced themselves from Chlamydia by labelling it as a womans disease. It is possible that the emphasis on women in the Chlamydia screening campaign has led men to misinterpret that they are not affected. Duncan and Hart6 have argued that mens beliefs and attitudes about sexual health are underresearched because of the responsibility and accountability being dened as being exclusively female in health promotion. Similar to Lears study37 on sexual behaviours in American universities, the men tended to negotiate the risk

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of STIs by avoiding risky women rather than through condom use. Lears study was over 10 years ago yet male roles and actions within relationships are still not seen to be detrimental to sexual health. The participants unashamedly demonstrated lack of knowledge about Chlamydia and had justications for not wanting to be tested. They also thought that services were geared towards women. Apart from one, they did not view their actions as having consequences for their female partners. There is a tendency in the epidemiological and medical literature to construe women as a high risk group like homosexuals for STIs.38 This insinuates that the general population are heterosexual men who are affected by rather than responsible for their own sexual risk taking.
What is known about this topic

individuals are concerned about restricting behaviours in order to maintain healthy bodies.48 Our ndings can be extrapolated in larger qualitative studies on university students and used to help tailor future campaigns to the young male audience.

Conclusion
To encourage uptake of opportunistic screening of Chlamydia, men under 25 years should be made aware of their responsibility for sexual health. Emphasis can also be placed on the non-invasiveness, ease and privacy of the test.

References
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Little is known about male perceptions of Chlamydia screening despite research consistently showing that young men are the least informed about STIs. 6,29 There are studies on the effectiveness and cost-effectiveness of Chlamydia screening13,40,41 and evaluations of innovative methods for targeting young men in sexual health campaigns.7 The use of Internet,42 popular print media,36 face-to-face communication,43 hotlines,44 stalls at college events45 and games46 improved the uptake of Chlamydia screening.
Limitations of this study

1 Adams EJ, Charlett A, Edmunds WJ et al. Chlamydia trachomatis in the United Kingdom: a systematic review and analysis of prevalence studies. Sex Transm Infect 2004;80(5):354 62. 2 LaMontagne DS, Fenton KA, Randall S et al. Establishing the National Chlamydia Screening Programme in England: results from the rst full year of screening. Sex Transm Infect 2004:80;335 41. 3 Summary and Conclusions of CMOs Expert Advisory Group on Chlamydia Trachomatis. (http://www.dh.gov.uk/PublicationsAnd Statistics/Publications/PublicationsPolicyAndGuidance/Publications PolicyAndGuidanceArticle/fs/en?CONTENT_ID=4005254&chk= 2nAMls, accessed 15/05/06). 4 Cates JW, Wasserheit J. Genital Chlamydia infections: epidemiology and reproductive sequelae. Am J Obstet Gynaecol 1991;164(6): 1773 81. 5 Kumar P, Clarke M. Clinical Medicine. London: Elsevier, 2005. 6 Duncan B, Hart G. Education and debate: sexuality and health: the hidden costs of screening for Chlamydia trachomatis. Br Med J 1999;318:931 3. 7 The Men and Chlamydia Project 2002 2004. http://www.menshealthforum.org.uk/userpage1.cfm?item_id=1533 14/05/06 12:12. 8 Ofce TCR. A Pilot Study of Opportunistic Screening for Genital Chlamydia Trachomatis Infection in England (1999 2000): Detailed report: Portsmouth pilot Site. http://www.dh.gov.uk/assetRoot/04/07/18/ 16/04071816.pdf (13 May 2006, date last accessed). 9 Ofce TCR. A Pilot Study of Opportunistic Screening for Genital Chlamydia Trachomatis Infection in England (1999 2000): Detailed Report: Wirral Pilot Site. http://www.dh.gov.uk/assetRoot/04/07/ 18/16/04071816.pdf (13 May 2006, date last accessed). 10 Mckay J. Genital Chlamydia trachomatis infection in a subgroup of young men in the UK. Lancet 2003;361(9371):1792. 11 Fenton K, Ward H. National Chlamydia screening programme in England: making progress. Sex Transm Infect 2004;80:331 3. 12 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(6):406 12. 13 Boekeloo BO, Snyder MH, Bobbin M et al. Provider willingness to screen all sexually active adolescents for Chlamydia. Sex Transm Infect 2002;78:369 73.

This is a small-scale study restricted to two focus groups on one screening site. There were time and nancial constraints due to the study being part of a degree course. It is also possible that the researchers have accessed individuals who are the most willing to partake in a focus group and to vocalize views on Chlamydia. The focus groups were peer-led and such groups can lead to a loss of objectivity. To combat this, an older experienced researcher examined the transcripts and helped the research group sustain a distance while analysing the data. It is intended that this study would act as a pilot to a larger qualitative study in the future.
What this study adds

Behaviour can be argued to be affected by attitudes, selfefcacy and perceived control and consequence.47 Participants beliefs about Chlamydia screening were informed by risk perception, lack of knowledge, social embarrassment about seeking help and indifference about health promotion campaigns. There was a consciousness amongst participants that sexual health-seeking behaviours should be normalized, which can be done through the promotion of mens health. This reects the risk thesis that states that since the 1990s,

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14 Idhal A. Demonstration of Chlamydia trachomatis IgG antibodies in the male partner of the infertile couple is correlated with a reduced likelihood of achieving pregnancy. Hum Reprod 2004;19(5):1121 6. 15 Duncan B, Hart G, Scoular A et al. Qualitative analysis of psychosocial impact of diagnosis of Chlamydia trachomatis: implications for screening. Br Med J 2001;322:195 9. 16 Oliver RTD. Prostate cancer: identifying the tiger tumours. J Men Health 2002;1(3):93 5. 17 Ford CA, Jaccard J, Millstein SG et al. Perceived risk of Chlamydia and Gonococcal infection among sexually experienced young adults in the United States. Persp Sex Reprod Health 2004;36(6):258 64. 18 Personal correspondence with University of Leeds, April 2007. 19 Leeds Combined PCT: Sexual Health Modernisation Team. Sexual Health and HIV Framework for Action (November 2004). www. leedspct.nhs.uk 20 Squire C, Fell G, Cameron I. Sexual Health and Teenage Pregnancy Strategy (2005 2008). Leeds North West Primary Care Trust. 2005. (http://www.leedsinitiative.org/initiativeDocuments/200647_ 19437807.pdf (11 May 2006, date last accessed). 21 Leeds North West PCT: Sexual Health and Teenage Pregnancy strategy (March 2005). 22 www.luu-online.com (14/05/06, date last accessed) 23 Bowling A. What People Say about Prioritising Health. London: Kings Fund, 1993. 24 Crabtree BF, Miller WL. Doing Qualitative Research. London: Sage publications, 1999. 25 Kitzinger J. Introducing focus groups. Br Med J. 1995;31:299 302. 26 Mays N, Pope C. Qualitative Research in Healthcare. London: Blackwell Publishing, 2006. 27 Ritchie J, Spencer L. Qualitative data analysis for applied policy research. In Bryman A, Burgess A (eds). Analysing Qualitative Data. London: Routledge, 1994. 28 Power R. The application of qualitative research methods to the study of sexually transmitted infections. Sex Transm Infect 2002;78: 87 9. 29 Ericksen JA, Steffen SA. What can we learn from sexual behavior surveys? The U.S. Example. In Zeidenstein S, Moore K (eds). Learning about Sexuality: A Practical Beginning. New York: International Womens Health Coalition, 1996. 30 Wellings K, Field J, Johnson AM et al. Sexual Behaviour in Britain: The National Survey of Sexual Attitudes and Lifestyles. London: Penguin Books, 1994. 31 Firth H. Focusing on Sex: Using Focus Groups in Sex Research. Sexualities 2000;3(3):275 97. 32 Posner N. Herpes Simplex. London: Routledge, 1998.

33 Heffernan C. Sexually Transmitted Infections, Sex and the Irish. Irish Sociological Monographs, University of Maynooth, 2004. 34 Debattista J, Clementson C, Mason D et al. Screening for Neisseria gonorrhoeae and Chlamydia trachomatis at entertainment venues among men who have sex with men. Sex Transm Dis 2002;29(4): 216 21. 35 Salisbury C, Macleod J, Egger M et al. Opportunistic and systematic screening for chlamydia: a study of consultations by young adults in general practice. Br J Gen Pract 2006;56:99 103. 36 Andersen B, Ostergaard L, Moller JK et al. Effectiveness of a mass media campaign to recruit young adults for testing of Chlamydia trachomatis by use of home obtained and mailed samples. Sex Transm Infect 2001;77: 416 418. 37 Lear D. Sex and Sexuality: Risk and Relationships in the Age of AIDS. Thousand Oaks, California: Sage, 1997. 38 Waldby C. AIDS and the Body Politic: Biomedicine and Sexual Difference. Routledge: New York, 1996. 39 Connell P, McKevitt C, Low N. Investigating ethnic differences in sexual health: focus groups with young people. Sex Transm Infect, 2004;80:300 5. 40 Low N. Screening programmes for chlamydial infection: when will we ever learn? BMJ 2007;334:725 728. 41 Salisbury C, Macleod J, Egger M et al. Opportunistic and systematic screening for chlamydia: a study of consultations by young adults in general practice. Br J Gen Pract 2006;56:99 103. 42 Mason L. Knowledge of sexually transmitted infection and sources of information amongst men. J Roy Soc Promot Health 2005;125(6): 266 71. 43 Michelson KN, Thomas JC, Boyd C et al. Chlamydia trachomatis infection in a rural population: the importance of screening men. Int J STD AIDS 1999;10(1):32 7. 44 Oh MK, Grimley DM, Merchant JS et al. Mass media as a population-level intervention tool for Chlamydia trachomatis screening: report of a pilot study. J Adolesc Health 2002;31:40 7. 45 McClean H, Sutherland J, Searle S et al. An exploratory study of information-giving used to promote Chlamydial test-seeking by students at a college family planning clinic. Br J Fam Plan 2000;26(4): 2009 212. 46 Low N, Connell P, McKevitt C et al. You cant tell by looking: pilot study of a community-based intervention to detect asymptomatic sexually transmitted infections. Int J STD AIDS. 2003;14: 830 4. 47 Ajzen I. The theory of planned behavior. Organ Behav Human Decis Process 1991;50:179 211. 48 Shilling C. The Body and Social Theory. London: Sage Publications, 1993.
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