Individuals who face barriers to obtaining routine health care may miss opportunities to be screened for chlamydia infection, which is frequently asymptomatic. It is, therefore, not surprising that poor access to health care was associated with chlamydia risk among young adults participating in the National Longitudinal Study of Adolescent Health (Add Health); however, some associations differed for men and women.1 A lack of continuous health insurance coverage over the last year was associated with an increased risk of infection for both genders, but receipt of health care in the past year was associated with a reduced risk only among men. Furthermore, for young adults who typically obtained services from a source other than a primary care provider, associations between provider type and the risk of infection differed by gender.
Analysts used data from Wave 3 of Add Health (conducted in 2001–2002) to study the prevalence of chlamydia infection among young adults. Respondents, who were aged 18–27 when the data were collected, were included in the analytic sample if they were sexually experienced, had provided urine specimens for chlamydia testing at the time of the interview and had completed questions about health care–seeking behavior. Using weighted logistic regression, the analysts sought to identify indicators of health care access that are significantly associated with the risk of chlamydia infection, controlling for age and race or ethnicity; they examined data on males and females separately.
Roughly equal proportions of the 9,347 respondents in the sample were men and women; eight in 10 were in their early 20s. Sixty-seven percent of the young adults were white, and most of the rest were black (17%) or Hispanic (12%).
The overall prevalence of chlamydia infection was 5%. Women had a significantly higher prevalence than men (5% vs. 4%), and Native Americans and blacks had higher infection rates (13% each) than Hispanics (7%), whites or Asians (2% each). Patterns of racial and ethnic variations differed among men and women; within each gender, however, Native Americans and blacks had the highest prevalence rates, and whites and Asians the lowest. Chlamydia prevalence did not differ by respondents' age.
Twenty percent of all respondents had had no health insurance coverage during the 12 months preceding the interview; 20% had been covered for some of the time, and 60% for the entire year. The proportion who had been uninsured throughout was significantly higher among men than among women; within each gender, a consistent lack of coverage was most common among Hispanics. Results of the multivariate analysis indicate that men with any coverage or continuous coverage had a significantly lower chlamydia risk than those with no coverage (odds ratios, 0.7 and 0.6, respectively); among women, the risk was reduced only among those who had had coverage for all of the preceding 12 months (0.7).
By far the most frequently reported site of usual health care was a primary care provider; 47% of respondents gave this reply. Hospital clinics and emergency rooms were the next most common sources of usual care (16% and 11%, respectively), and a variety of other types of facilities were each reported by 2–9% of the sample. Seven percent of respondents said that they never got sick or needed care, and had no usual source of care. Men reported greater reliance on emergency rooms and less on primary care providers than women; they also were more inclined to say that they did not need regular health care. Among men, whites and Asians reported the greatest reliance on primary care providers, and blacks the greatest reliance on emergency rooms. Among women, whites and Hispanics used primary care providers more often than others; blacks and Native Americans were the groups who most frequently considered emergency rooms their usual source of care. Men who went to emergency rooms or unspecified facility types had significantly higher odds of being infected than those who saw primary care providers (odds ratios, 2.0 and 3.1, respectively); men who typically went to hospital clinics had a reduced risk (0.5). Among women, those who regularly attended school or college clinics had sharply reduced odds of infection (0.2).
The last indicator examined was whether respondents had visited a health care provider in the last 12 months; 79% had. Reports of a recent health care visit were significantly more common among women than among men (90% vs. 69%); within each gender, Hispanics and Asians reported the lowest levels of recent health care receipt. In the adjusted analysis, men who had seen a provider within the previous year had a reduced likelihood of chlamydia infection (odds ratio, 0.6); this measure was not associated with chlamydia risk among women.
While acknowledging several limitations of the sample and the available measures, the analysts nevertheless feel confident that their findings establish a relationship between chlamydia infection in young adults and the indicators studied. Given this relationship, they draw three broad conclusions. First, by improving access to screening, diagnostic and treatment services (including services for infected individuals' partners), efforts to expand health care coverage for young people may help reduce reproductive health problems stemming from chlamydia infection. Second, educational efforts aimed at young adults and their health care providers should emphasize that chlamydia infection is often asymptomatic and that yearly health care visits that include screening are essential. Third, providers should be encouraged to follow the chlamydia screening recommendations issued by the Centers for Disease Control and Prevention and the U.S. Preventive Services Task Force. "Screening and treatment programs," the analysts observe, "are critical elements of current control efforts."—D. Hollander
1. Geisler WM et al., Health insurance coverage, health care–seeking behaviors, and genital chlamydial infection prevalence in sexually active young adults, Sexually Transmitted Diseases, 2006, 33(6):389–396.