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INFECTIOUS DISEASE 



CQ\CTION 



Chlamydia screening practices among 
physicians and community nurses in 
Yukon, Canada 

Karolina Machalek 1 ' 2 *, Brendan E. Hanley 3 , Joy N. Kajiwara 2 , 
Paula E. Pasquali 2 and Cathy J. Stannard 2 

1 Canadian Public Health Service, Public Health Agency of Canada, Ottawa, Ontario, Canada; 2 Departmment 
of Health and Social Services, Government of Yukon, Whitehorse, Yukon Territory, Canada; 3 Government of 
Yukon, Whitehorse, Yukon Territory, Canada 



Background. Yukon, a territory in northern Canada, has one of the highest reported sexually transmitted 
chlamydia infection rates in the country. 

Objective. We examined screening practices among physicians and community nurses to elucidate factors that 
may be contributing to the high rates. 
Design. Cross-sectional survey. 

Methods. A questionnaire was distributed to all physicians in Yukon and all community nurses in Yukon's 
communities. We surveyed sexual health assessment frequency, chlamydia testing frequency and barriers to 
screening. Comparison of physician testing practices was performed to another Canadian jurisdiction, which 
previously undertook a similar survey. Survey results were compared to the available laboratory data in Yukon. 
Results. Eligible physicians and nurses, 79% and 77%, respectively, participated in the survey. Physicians 
tested 15 to 24-year-old females more frequently than 15 to 24-year-old males for chlamydia (p =0.007). 
Physicians who asked sexual health assessment questions were more likely to test for chlamydia in both 
females (p < 0.001) and males (p =0.032). More physicians screened females based on risk factors compared 
to males. General practice physicians in Yukon were more likely to test females for chlamydia than general 
practice physicians in Toronto, Canada (p < 0.001). Community nurses had different testing patterns than 
physicians, with a lower overall frequency of testing, equal frequency of testing males and females, and in 
applying risk factor-based screening to both males and females. Barriers to screening included testing causing 
patient discomfort, patients reluctant to discuss screening, health provider uncomfortable conducting sexually 
transmitted infection tests and sexual health assessments, among others. Laboratory data in Yukon appear to 
confirm provider screening patterns. 

Conclusions. This survey provides valuable information on health provider screening patterns. We have some 
evidence which suggests that chlamydia testing rates may be higher among patients seen by physicians in 
Yukon in comparison to another Canadian jurisdiction. However, more consistent application of optimal 
screening methods with support to "start the conversation" around sexual health may assist in overcoming 
barriers to screening and in addressing Yukon's high rate of chlamydia. 

Keywords: chlamydia; Yukon Territory; Canada; sexually transmitted diseases; screening; physicians; general practitioners; 
public health nursing; adolescent 



Chlamydia, an infection caused by the bacteria 
Chlamydia trachomatis, is the most commonly 
reported sexually transmitted infection (STI) in 
Canada (1). Yukon, a territory in northern Canada, 
has one of the highest chlamydia infection rates in the 
country. In 2011, chlamydia infection rates were 602.9 
per 100,000 population in Yukon, compared to 290.2 
per 100,000 population for Canada (2, preliminary data). 



The epidemiology of chlamydia is similar in Yukon to that 
of Canada as a whole: rates are highest among females 
aged 15-24 years and males aged 20-24 years, and re- 
ported rates are higher for females than for males (1-3). 
In Yukon, chlamydia rates are reportedly higher in rural 
communities than in the urban capital, Whitehorse (3). 

Screening 1 plays an integral role in detecting and 
treating existing chlamydia cases. Despite the fact that 



Screening is explicitly defined neither in the Canadian Guidelines on Sexually Transmitted Infections (STIs) nor in our survey instrument. Screening could be defined 
as "case-finding for patients with asymptomatic disease" and the implication is for case-finding by lab testing. 

Int J Circumpolar Health 2013. © 2013 Karolina Machalek et al. This is an Open Access article distributed under the terms of the Creative Commons 1 
Attribution 3.0 Unported (CC BY 3.0) Licence (http://creativecommons.Org/licenses/by/3.0/), permitting all non-commercial use, distribution, and 
reproduction in any medium, provided the original work is properly cited. 

Citation: Int J Circumpolar Health 2013, 72: 21607 - http://dx.doi.org/10.3402/ijch.v72i0.21607 

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Karolina Machalek et al. 



chlamydia can be treated and eradicated, infection is 
frequently asymptomatic in the early stages among both 
males and females (4,5). As a result, individuals unaware 
of their infection status may unknowingly transmit the 
infection to their sexual partners (4,5). If left untreated, 
chlamydia can lead to pelvic inflammatory disease (PID) 
and its sequelae, including chronic pelvic pain, infertility 
and ectopic pregnancy in women; complications in men 
include rare cases of epididymoorchitis and infertility (4,5). 
The economic cost of chlamydia in Canada has recently 
been estimated to total more than $50 million per year (6). 

Canadian Guidelines on Sexually Transmitted Infections 
(STIs) recommend that sexually active females below 25 
years of age be routinely screened for chlamydia infection, 
and the guidelines also recommend it prudent to screen 
for chlamydia in all sexually active males less than 25 years 
of age (4). The Canadian Guidelines on STIs also specify 
that screening should be done in accordance with risk 
factors for chlamydia infection (which include, among 
others, sexual contact with person(s) with known STI, 
sexually active youth below 25 years of age, a new sexual 
partner or more than 2 sexual partners in the past year), 
identified through STI risk assessments during patient 
visits (4). The Centers for Disease Control and Prevention 
in the United States recommend chlamydia screening 
of all sexually active women aged less than 25 years, and 
Australian guidelines recommend annual chlamydia test- 
ing of all sexually active individuals aged 15-29 years 
(7,8). However, research has indicated that health provi- 
ders do not routinely test youth (typically, those aged 
15-24 years) for chlamydia in accordance with recom- 
mended screening guidelines (9-13). In addition, research 
has indicated that sexual health risk assessments, which 
are precursors to chlamydia testing, are not carried out 
to the extent warranted by screening guidelines (11,14,15). 

To our knowledge, no study has established the practice 
patterns of primary health care providers in a northern 
Canadian jurisdiction as they relate to the frequency of 
conducting STI risk assessments and testing for chlamy- 
dia. We undertook the current cross-sectional study to 
contribute to understanding health providers' STI screen- 
ing practices in Yukon and to elucidate barriers to 
discussing and offering screening. We surveyed chlamydia 
and STI screening practices among health care providers 
(physicians and community nurses) in Yukon to identify 
the extent to which screening practices are optimal and 
reflect Canadian screening guidelines and to elucidate 
factors that may be contributing to the high rates of 
chlamydia in Yukon. 

Methods 

Setting 

Yukon is one of Canada's 3 northern territories and the 
westernmost one. It borders Alaska to the west, Beaufort 



Sea to the north, Northwest Territories to the east and 
British Columbia (province of Canada) to the south. 
Yukon has a population of approximately 35,800 people, 
with 482,443 km 2 of land (16,17). The capital city is 
Whitehorse, with a population of approximately 27,000 
people (about three quarters of the population of the 
whole territory). There are 16 main communities, with 
populations ranging from less than 50 to approximately 
2,000 people (17). 

Family physicians or general practitioners deliver 
primary health care in Whitehorse and 2 of the larger 
Yukon communities, whereas community nurses deliver 
primary health care in all of Yukon's rural communities. 
Physicians and most community nurses (those working in 
rural communities without a physician presence) have in 
their scope of practice testing for STIs. 

Survey instrument and study group 

The survey instrument was adapted with permission from 
a similar questionnaire carried out by Toronto Public 
Health in Toronto, Ontario, Canada. The Yukon ques- 
tionnaire surveyed health providers on the frequency 
of patients presenting with a sexual health concern or 
complaint, sexual health assessment (STI risk assess- 
ment) frequency and chlamydia testing frequency. Fre- 
quencies were surveyed from all types of patient visits in 
the previous month and were categorized as "never," 
" <25%," "25-50%," "51-75%" and "76-100%." Health 
providers were surveyed separately for male and female 
patients and by the following age groups: 15-24 years; 
25-34 years; 35-50 years; 51-65 years and >65 years. 
The questionnaire also surveyed barriers to discussing 
and offering screening; these were close-ended questions. 
In this report, we have focused on health provider reports 
specific to the 15 to 24-year-old age group of male and 
female patients, as this group comprises the majority of 
chlamydia cases in Yukon. 

We distributed the Physician Survey on STI Screening 
Practices to all physicians in Yukon at a Yukon Medical 
Association meeting in the fall of 2009. The survey 
consisted of a total of 18 questions: 12 questions on 
STI screening practices and 6 questions on physician 
demographic information. The questionnaire was dis- 
tributed to physicians in a hard copy format for self- 
completion during this 2-day meeting. Surveys were 
completed anonymously. The questionnaire was dis- 
tributed and collected by B.E.H., second author. The 
majority of physicians completed the survey on site, 
with a few submitting them to B.E.H. over the next few 
days. 

We adapted the Physician Survey on STI Screening 
Practices to the Community Nursing Survey on STI 
Screening Practices and distributed the survey to com- 
munity nurses working in Yukon's rural communities in 
March of 2010 by email, as an attachment to the email in 



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Citation: Int J Circumpolar Health 2013, 72: 21607 - http://dx.doi.org/10.3402/ijch.v72i0.21607 



Chlamydia screening practices in Yukon 



Microsoft Word Document format. The survey consisted 
of a total of 20 questions: 12 questions on STI screening 
practices, 6 questions on nurse demographic informa- 
tion and an additional 2 qualitative questions. Surveys 
were completed anonymously and returned to K.M., first 
author, by fax, mail or email (using a clinic email address, 
not a personal email address). 

Readers can request a copy of both survey instruments 
by contacting the corresponding author. 

An ethics review was not undertaken since the re- 
search was conducted to inform practice and the subjects 
of the research were health care providers and not 
patients. 

Analysis 

All analyses were conducted using the statistical software 
SAS version 9.2 (18). To allow for statistical power to 
make comparisons, most analyses for frequencies of 
patients presenting with a sexual health concern or 
complaint, health providers asking sexual health assess- 
ment questions and health providers testing for chlamy- 
dia were sub-categorized into 2 groups: the first category 
was "less than or equal to 50%, or half, of the time," 
which included the categories "never," " <25%," and 
"25-50%," and the second category was "greater than 
50%, or half, of the time," which included the categories 
"51-75%" and "76-100%." Chi-square analysis was 
used to test for differences in proportions, except when 
the count in a cell was below 5, when the Fisher's exact 
test was used. Inferential statistical analyses for data 
from the Community Nursing Survey on STI Screening 
Practices were not performed due to the small sample 
size (n = 20) and the low variability of data among 
respondents. 

With permission from the lead author and Toronto 
Public Health, we compared physician sexual health 
assessment frequencies and physician chlamydia testing 
frequencies from the Yukon Physician Survey on STI 
Screening Practices to published results from Toronto 
Public Health which undertook a similar survey in 
Toronto, Ontario, Canada (9). We compared Yukon 
physician data for 15 to 24-year-old patients to Toronto 
physician data for 15 to 19 and 20 to 24 year-old 
patients, since the Yukon survey categorized these age 
groups as one. We restricted this analysis to general 
practice physicians who answered the Yukon survey, since 
the Toronto survey was limited to general practice 
physicians. 

We compared the survey results of physician-reported 
chlamydia testing frequency to the number of chlamydia 
laboratory tests ordered in Yukon per year, from 2007 
to 2011. We compared the proportion of laboratory tests 
done for females to those done for males. 



Results 

Study participant characteristics 

A total of 42 physicians participated in the survey of 
53 eligible, with a response rate of 79%. 2 The majority 
(86%) of physicians practiced only in Whitehorse (which 
is representative of the territory as a whole). Almost all 
(95%) of the physicians surveyed were general practice 
physicians and 52% were female. 

Twenty community nurses participated out of 26 
eligible, with a 77% response rate. The majority (80%) 
of nurses were female and all practiced in Yukon's rural 
communities. 

How frequently is sexual health a part of the 
conversation? 

Nearly a third (29%) of physicians reported 15 to 
24-year-old female patients presenting with a sexual 
health concern more than half the time in the previous 
month, compared to just 5% of physicians who said 
the same for 15 to 24-year-old male patients (p =0.004) 
(Fig. 1). Similarly, 31% of physicians reported conduct- 
ing sexual health risk assessments on 15 to 24-year-old 
female patients at least half the time in the previous 
month, compared to 21% of physicians who reported 
the same for males (p =0.463) (Fig. 1). Just over a third 
(36%) of physicians reported testing 15 to 24-year-old 
females for chlamydia at least half the time in the past 
month, compared to 1 0% of physicians who tested 1 5 to 
24-year-old males for chlamydia (p =0.007) (Fig. 1). 

Nearly one-fifth (19%) of physicians routinely 
(76-100% of the time) asked 15 to 24-year-old female 
patients sexual health assessment questions. Only 1 
physician (2%) routinely asked 15 to 24-year-old male 
patients sexual health assessment questions. 

Unlike physicians, community nurses did not display 
differences in frequencies of patients coming in with a 
sexual health concern, conducting STI risk assessments 
and testing for chlamydia. Just 10% of nurses reported 
their female patients coming in with a sexual health 
concern or complaint at least half the time in the past 
month, conducting sexual health risk assessments at least 
half the time in the past month, and testing for chlamydia 
at least half the time in the past month among their 
female patients; 5% of nurses reported the same for males 
(Fig. 1). Only 1 nurse (5%) routinely (76-100% of the 
time) conducted STI risk assessments. 

Community nurses conducted STI risk assessments 
and tested for chlamydia less frequently in both their 
female and male patients than physicians (Fig. 1). Just 
10% of community nurses reported conducting sexual 
health assessments at least half the time among their 



Percentages are rounded to the nearest whole number in the text of this paper 
for readability, whereas they are reported to 1 decimal place in the Tables and 
Figures for precision. 



Citation: Int J Circumpolar Health 2013, 72: 21607 - http://dx.doi.org/10.3402/ijch.v72i0.21607 



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Karolina Machalek et al. 



15 to 24-year-old female patients compared to 31% of 
physicians who did the same (Fig. 1). Among males, 
just 5% of community nurses conducted STI risk assess- 
ments more than half the time compared to 21% of 
physicians who did so (Fig. 1). With regard to testing 
for chlamydia at least half the time in the past month, 
10% of community nurses did so among their 15 to 24- 
year-old female patients, compared to 36% of physicians 
who reported the same (Fig. 1). Among males, just 5% of 
community nurses reported testing for chlamydia more 
than half the time, compared to 10% of physicians who 
reported the same (Fig. 1). 

Factors associated with testing for chlamydia 

We found that physicians who tested patients for chlamy- 
dia were more likely to have patients see them with a 
sexual health concern or complaint and to have asked 
their patients about sexual health (Table I). It is interesting 
to note that the odds of physicians testing patients who 
came in with a sexual health concern or complaint were 
more pronounced for male patients than for female 
patients (Table I). At the same time, the odds of physicians 
testing patients whom they asked about sexual health were 
similar for male patients and female patients (Table I). 

We found that more physicians reported screening for 
chlamydia based on risk factors among females than 
among males (Table II). For example, 86% of physicians 
reported that "multiple sexual partners" would be a trigger 
for chlamydia screening (indicator that would prompt or 



result in laboratory testing) among females, but only 48% 
reported the same for males. Similarly, 57% of physicians 
reported screening females based on the trigger of "patient 
is known to be sexually active" compared to 19% of 
physicians who reported the same for males. We also found 
that physicians who reported testing their 1 5 to 24-year-old 
male patients for chlamydia at least half the time in 
the past month had increased odds of screening 15 to 
24-year-old males based on the trigger of "patient is known 
to be sexually active" (OR = 18.0, 95% CI = 1.5-209.3, 
p =0.022). 

In contrast to physicians, we found that equally as 
many nurses screened based on risk factors among 
females and among males (Table II). 

Notably, the majority of physicians (64%) and 
the vast majority of community nurses (90%) reported 
that screening is a standard addition to Pap testing 
among females. In total, 38% of physicians and 70% 
of community nurses reported that screening is a stan- 
dard addition to annual check-ups for females. Only 
2% of physicians reported that screening is a standard 
addition to annual check-ups for males, whereas 50% 
of community nurses reported the same for their male 
patients. 

Comparisons with other jurisdiction 

While Yukon and Toronto general practice physicians 
reported similar frequencies of asking about sexual health 
among their 15 to 24-year-old female patients, Yukon 



40 



o 35 



>■ 30 



25 



20 



S 
o 

I 15 
x: 

Q. 

*r 
° 10 
<D 
O) 

ra 
■*-» 
c 

0) 

u 

k— 

0. 




Female patients 
Male patients 



LLL 



Sexual health Sexual health Testing for Sexual health Sexual health Testing for 
concern assessment chlamydia concern assessment chlamydia 

Physicians Community Nurses 



Fig. 1. The percentage of physicians (n = 42, 2009 data) and community nurses (n = 20, 2010 data) in Yukon, Canada reporting 15-24 
year-old female and male patients presenting with a sexual health concern or complaint, conducting sexual health assessments, and 
testing for chlamydia greater than half the time as a proportion of all visits in their practice in the previous month. 



4 

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Citation: Int J Circumpolar Health 2013, 72: 21607 - http://dx.doi.org/10.3402/ijch.v72i0.21607 



Chlamydia screening practices in Yukon 



Table I. The association of patients presenting with a sexual health concern or physicians asking sexual health assessment questions 
and physicians testing for chlamydia (2009 data, Yukon, Canada) 

Tested for chlamydia 

1 5 to 24-year-old female patients 1 5 to 24-year-old male patients 



Yes a 



No a 



Yes a 



No a 



Context of patient visit 



N (%*) of physicians 
(n=42) 



OR 

(95% CI) 



N (%*) of physicians 
(n=39) 



OR 

(95% CI) 



Patient presented with a sexual health concern 
Yes b 8(19.0) 
No b 7(16.7) 



4 (9.5) 
23 (54.8) 



Physician asked sexual health assessment questions 
Yes c 10(23.8) 3(7.1) 

No c 5(11.9) 24(57.1) 



6.6 

(1 .5-28.5) 
p=0.013 

16.0 

(3.2-80.1) 
p< 0.001 



3 (7.7) 
1 (2.6) 



3 (7.7) 
1 (2.6) 



3 (7.7) 
32 (82.0) 



6 (15.4) 
29 (74.4) 



32.0 
(2.5-411.4) 
p = 0.008 

14.5 
(1.3-164.4) 
p = 0.032 



*Based on the number of physicians who answered each question; may not add up to 100% due to rounding. 
OR =odds ratio; CI = confidence interval. 

a "Yes" represents testing for chlamydia >50% of the time and "No" represents testing for chlamydia <50% of the time. 

b "Yes" represents patients presenting with a sexual health concern > 50% of the time for female patients and > 25% of the time for male 

patients; "No" represents patients presenting with a sexual health concern <50% of the time for female patients and <25% of the time 

for male patients (male cut-offs were lower than female cut-offs due to inadequate sample sizes for males in the category " >50% of the 

time"). 

c "Yes" represents physicians asking sexual health assessment questions >50% of the time and "No" represents physicians asking 
sexual health assessment questions <50% of the time. 



general practice physicians reported that they test for 
chlamydia more frequently than Toronto general practice 
physicians (Table III). Yukon general practice physicians 
had 3.7-5.6 times the odds of testing their 15 to 24-year- 
old female patients for chlamydia than Toronto general 
practice physicians (Table IV). 



Barriers to screening 

The most commonly reported barriers to discussing 
screening for physicians and community nurses were: 
patients reluctant to discuss STIs for reasons of con- 
fidentiality (not defined in the survey, but commonly 
understood to mean privacy, particularly in reference to 



Table II. Percentage of physicians (n =42, 2009 data) and community nurses (n =20, 2010 data) in Yukon, Canada, reporting triggers 
for screening (indicators for laboratory testing) for chlamydia among their female and male patients 



Physicians 
Number (%) a 



Community nurses* 
Number (%) a 





Female 


Male 


Female 


Male 


Trigger for screening 


patients 


patients 


patients 


patients 


Patient asks to be screened for chlamydia or STIs 


42 (100.0) 


31 (73.8) 


19 (95.0) 


19 (95.0) 


Patient is symptomatic 


41 (97.6) 


31 (73.8) 


16 (80.0) 


17 (85.0) 


Patient reports being a contact or is named a contact of a positive Chlamydia 


38 (90.5) 


30 (71 .4) 


18 (90.0) 


18 (90.0) 


trachomatis case 










Patient has multiple sexual partners 


36 (85.7) 


20 (47.6) 


15 (75.0) 


13 (65.0) 


Patient is young adult (aged 17-25 years) 


28 (66.7) 


10 (23.8) 


10 (50.0) 


10 (50.0) 


Patient is known to be sexually active 


24 (57.1) 


8 (19.1) 


14 (70.0) 


12 (60.0) 


Patient is being seen for birth control 


25 (59.5) 


2 (4.8) 


15 (75.0) 


13 (65.0) 


Screening is a standard addition to Pap testing 


27 (64.3) 


N/A 


18 (90.0) 


N/A 


Screening is a standard addition to annual check-ups 


16 (38.1) 


1 (2.4) 


14 (70.0) 


10 (50.0) 



*1 nurse (5.0%) noted that this question was out of the scope of practice. 

Percentages are reported to 1 decimal place in the Table, whereas they are rounded to the nearest whole number in the text. 



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Karolina Machalek et al. 



Table III. Comparison of self-reported frequencies for general practice physicians from Yukon, Canada (2009 data), and general 
practice physicians from Toronto, Ontario, Canada (2006 data), asking sexual health assessment questions and testing for chlamydia 
among their 15 to 24-year-old female patients 



Yukon general Toronto general Toronto general 

practice physicians practice physicians practice physicians 

Frequency as a proportion (for 15 to 24-year-old (for 1 5 to 1 9-year-old (for 20 to 24-year-old 

of female patients in the female patients) female patients) female patients) 

previous month (%) N (%) N (%)* N (%)* Chi-square 



Asked sexual health 
assessment 
questions 



Tested for 
chlamydia 



<25 
25-50 
51-75 
76-100 
Total 

<25 
25-50 
51-75 
76-100 
Total 



14 (35.0) 
13 (32.5) 

5 (12.5) 
8 (20.0) 

40 

17 (42.5) 

8 (20.0) 

6 (15.0) 

9 (22.5) 
40 



102 (41.5) 

50 (20.3) 
40 (16.3) 
54 (22.0) 

246 

166 (68.3) 

51 (21.0) 
14 (5.8) 
12 (4.9) 

243 



87 (35.4) 

59 (25.9) 
40 (16.3) 

60 (24.4) 
246 

150 (62.7) 
59 (23.9) 
20 (8.1) 
18 (7.3) 
247 



4.565 
(p =0.601) 



22.998 
(p< 0.001) 



'Numbers taken from Hardwick, McKay and Ashem (9) and published with permission from lead author and Toronto Public Health. 



residing in small communities), physicians/nurses not 
having enough time to discuss STIs with patients and 
physicians/nurses not having up-to-date information on 
STIs. A minority of community nurses also reported 
not having adequate training to conduct sexual health 
assessments and STI counselling (Fig. 2). 



With regard to barriers to offering screening, 25% of 
community nurses identified "testing causes patient dis- 
comfort" as a barrier to screening (this was prior to urine 
testing being introduced and widely available). Nearly 20% 
of physicians reported that they only test high-risk patients. 
A minority of physicians and community nurses indicated 



Table IV. Association of physician practice location and physician-reported frequency of testing for chlamydia as a proportion of all 
patient visits in the previous month (2009 data for Yukon, Canada; 2006 data for Toronto, Ontario, Canada) 





Number of general practice physicians reporting 
frequency of testing for chlamydia as a proportion of all 
visits in their practice in the previous month among 
15 to 24-year-old patients in Yukon and 15 to 
19-year-old patients in Toronto* 




Physician practice location 


> 75% of the time < 75% of the time 


OR (95% CI) 


Yukon (15-24) 
Toronto (15-19)* 


9 31 
12 231 
Number of general practice physicians reporting 
frequency of testing for chlamydia as a proportion of 
all visits in their practice in the previous month among 
15-24 year-old patients in Yukon and 20-24 year-old 
patients in Toronto* 


5.6 (2.2-14.3) p<0.001 


Physician practice location 


> 75% of the time < 75% of the time 


OR (95% CI) 


Yukon (15-24) 
Toronto (20-24)* 


9 31 
18 229 


3.7 (1.5-8.9) p =0.006 



'Numbers taken from Hardwick, McKay and Ashem (9) and published with permission from lead author and Toronto Public Health. 
OR =odds ratio; CI = confidence interval. 



6 Citation: Int J Circumpolar Health 2013, 72: 21607 - http://dx.doi.org/10.3402/ijch.v72i0.21607 



Chlamydia screening practices in Yukon 



Have not received adequate training to 
conduct sexual health assessments 



Have not received adequate training to 
provide effective STI counselling 



I do not have up-to-date information on STIs 



Do not have enough time to discuss STIs 
with my patients 



Patients reluctant to discuss STIs for 
confidentiality reasons 




Community Nurses 
Physicians 



0 5 10 15 20 

Percentage of physicians or community nurses (%) 



Fig. 2. Percentage of physicians (n = 42, 2009 data) and community nurses (n =20, 2010 data) in Yukon, Canada reporting barriers to 
discussing chlamydia screening with their patients. 



that they do not offer testing unless the patient is symp- 
tomatic, they are uncomfortable with conducting STI tests, 
unfamiliar with techniques for testing and do not have the 
facilities or personnel to conduct testing (Fig. 3). 

Laboratory data 

According to laboratory data, the vast majority of 
chlamydia lab tests in Yukon are conducted among 
females (average of 83% of all tests between 2007 and 
2011) (Fig. 4). Between 2007 and 2011, the number of 
tests conducted among females rose by 31% and the 
number of tests conducted among males rose by 97%. 

Discussion 

To our knowledge, this study is the first to document 
health provider STI screening practices in a northern 
Canadian jurisdiction. We found a difference among 
physicians, but not community nurses, in how sexual 
health is addressed among female and male patients 
(Fig. 1). Sexual health concerns are a more frequent 
reason for visits at physician offices among female 
patients than male patients. The frequency that sexual 
health assessment questions are being asked by physi- 
cians has relatively little difference between females 
and males compared to how frequently physicians are 
testing - testing more frequently among females than 
among males. In contrast, community nurses reported 
similar frequencies of female and male patients coming 



in with a sexual health concern, asking sexual health 
assessment questions and testing for chlamydia. Labora- 
tory data corroborate the findings from the physician 
survey, since, on average, 83% of chlamydia lab tests are 
done for females (Fig. 4). This may point to a degree of 
routine chlamydia screening during Pap testing or annual 
check-ups among females, since 64% of physicians 
reported screening as a standard addition to Pap testing 
and 38% reported screening as a standard addition to 
annual check-ups among females (Table II); screening 
for chlamydia as a standard addition to Pap testing and 
during annual check-ups has been observed among 
clinicians elsewhere (9). Interestingly, more physicians 
reported conducting sexual health assessments than 
testing for chlamydia among male patients (Fig. 1). 
This may highlight the lack of routine screening among 
males, in contrast to females, as only 2% of physicians 
reported that screening is a standard addition to annual 
check-ups for their male patients (Table II). For those 
physicians who asked males sexual health assessment 
questions and did not test males for chlamydia, it may 
be that physicians identified them as low risk and did 
not proceed to testing or physicians may have treated 
them on suspicion of STI rather than proceed to testing; 
for example, 74% of physicians reported that they would 
screen male patients if they asked to be screened for 
chlamydia or if they were symptomatic, compared 



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Karolina Machalek et al. 



Unfamiliar with techniques for testing 



Do not have the faciliites, personnel and/or 
supplies to conduct STI testing 



I am uncomfortable conducting STI tests 



Testing causes patient discomfort 



Do not offer testing unless patient is 
symptomatic 



I only test high risk patients 




Community Nurses 
Physicians 



0 5 10 15 20 25 30 

Percentage of physicians or community nurses (%) 



Fig. J. Percentage of physicians (n = 42, 2009 data) and community nurses (n =20, 2010 data) in Yukon, Canada reporting barriers to 
offering chlamydia screening to their patients. 



to 100% and 98% of physicians, respectively, who 
reported they would test female patients if they asked 
to be screened or if they were symptomatic (Table II). 



Most importantly, what we found is, physicians that 
tested for chlamydia had a similar rate of conducting 
STI risk assessments among female and male patients 



5000 



4500 



4000 



>• 3500 
o 



■o 2500 

E 

m 

■S 2000 



1500 



1000 



500 



2007 




I Males 
I Females 



Fig. 4. Number of chlamydia laboratory tests conducted in Yukon, Canada for females and for males, 2007-1 1. Numbers of lab tests by 
sex were imputed for 2010, calculated based on the total number of chlamydia lab tests for 2010 and an average proportion of tests for 
males and females between 2009 and 2011. 



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Chlamydia screening practices in Yukon 



(Table I). In other words, if the question is asked about 
sexual health, physicians are more likely to test for 
chlamydia in both females and males - we termed this 
relationship "Ask and Test." This underscored the 
importance of conducting STI risk assessments, as 
recommended by the Canadian Guidelines on STIs (4). 
We also found that the odds of a sexual health concern 
triggering testing for chlamydia were higher among males 
than among females (Table I). This may be due to the 
fact that females present with a greater variety of sexual 
health concerns than males (e.g. requesting contracep- 
tion), whereas for males, the primary reason for coming 
in with a sexual health concern is likely due to STI. 
We found that more physicians reported screening for 
chlamydia based on risk factors among females than 
among males (Table II). Risk factors may be more 
apparent with a female patient requesting contraception, 
since she has implicitly informed her provider that she 
either is or intends to become sexually active, and may 
be at risk for STIs. In our survey, 60% of physicians 
reported "patient being seen for birth control" as a 
trigger for chlamydia screening among female patients. 
For male patients, there is no similar trigger that provides 
information about risk. These distinctions would likely 
have an effect on the sex differences noted in patients 
presenting with a sexual health concern, risk assess- 
ment and testing frequencies. It may also be the case 
that physicians put more value on screening females 
than on screening males due to the greater and more 
frequent health consequences of undetected and un- 
treated chlamydia in females (PID, chronic pelvic pain, 
ectopic pregnancy and infertility); however, we did not 
survey the reasons for these differences. Further research 
should investigate the reasons for these discrepancies. 

Importantly, physicians who did report testing young 
male patients for chlamydia more than half the time 
had increased odds of screening males based on the 
risk factor of being sexually active. This suggests that 
correctly applying risk factors is associated with testing 
for chlamydia. 

When we compared our survey results to those of a 
similar survey conducted in Toronto, Ontario, Canada, 
by Toronto Public Health, we found that general practice 
physicians in Yukon were equally likely to conduct sexual 
health risk assessments but more likely to test their 15 to 
24-year-old female patients for chlamydia than general 
practice physicians in Toronto (Tables III and IV). These 
self-reported results from surveys of physician screening 
practices may indicate that Yukon physicians likely screen 
for chlamydia more frequently, at least among 15 to 24- 
year-old females, than physicians in Toronto, and poten- 
tially elsewhere. These data also support the hypothesis 
that Yukon's chlamydia testing rates (frequency of testing 
for chlamydia) may be higher than other jurisdictions, 
which may be leading to increased reported rates of 



chlamydia, due to the detection of more cases through a 
higher screening rate. This comparison of screening rates 
based on survey data has been corroborated by Yukon 
laboratory data comparisons to other jurisdictions, which 
we have reported elsewhere (19). Briefly, we compared 
Yukon laboratory data on testing volume (number of 
chlamydia laboratory tests performed as a proportion 
of the population) and positivity (percentage of tests that 
were positive) to 2 other Canadian jurisdictions with 
available data: Saskatchewan, Canada and British Co- 
lumbia Centre for Disease Control (BCCDC), in British 
Columbia, Canada. Average chlamydia testing volume in 
Yukon between 2000 and 2011 was 10.9%; average 
chlamydia positivity in Yukon between 2000 and 2011 
was 5.5% (19). Average testing volume in Saskatchewan 
between 2000 and 2007 was 4.1%, and average positivity 
in Saskatchewan between 2000 and 2007 was 8.9% (20). 
Average chlamydia positivity at BCCDC was approxi- 
mately 6% in 2010 (21). Based on these comparisons 
of laboratory data, Yukon appears to have conducted 
a greater number of chlamydia tests as a proportion of 
the population than Saskatchewan (10.9% in Yukon 
versus 4.1% in Saskatchewan). At the same time, despite 
the apparently higher testing rates in Yukon, the percen- 
tage of tests that were positive was on par or lower 
in Yukon than BCCDC and Saskatchewan (5.5% in 
Yukon versus approximately 6% at BCCDC and 8.9% in 
Saskatchewan). These laboratory data comparisons, 
although limited, appear to support the results of the 
physician survey and suggest that Yukon's chlamydia 
testing rates may be higher than other jurisdictions. This, 
in turn, may account for some of the increased reported 
rates of chlamydia in Yukon due to the detection of more 
cases through a higher screening rate. 

Our research indicates that community nurses have 
different asking and testing patterns than physicians in 
Yukon. Community nurses did not report differences 
between the percentage of patients coming in with a 
sexual health concern, asking sexual health assessment 
questions and testing for chlamydia (Fig. 1). These data 
suggest that in the context of rural Yukon and for 
community nursing practice, STI risk assessments and 
chlamydia testing may only be taking place during visits 
that are specific to a sexual health concern or complaint. 
As a result, patients who do not present with a complaint 
but may be at risk for chlamydia may not be identified. 
The survey data also indicate that chlamydia testing 
rates are reportedly lower for community nurses than for 
physicians (Fig. 1). These data may point to a degree of 
under-screening in rural Yukon, where community nurses 
predominantly practice, compared to urban Yukon, 
where physicians predominantly practice, which may 
suggest that reported chlamydia rates in rural Yukon 
are actually lower than expected, despite the fact that 
they are on the whole higher than rates in Whitehorse, the 



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urban capital (3). A recent study from the United States 
also found a similar discrepancy between testing rates 
in urban and rural environments, and found that the 
frequency of self-reported HIV testing decreased sub- 
stantially as the residential environment became progres- 
sively more rural (22). 

Data from the community nursing survey on triggers 
for chlamydia screening show that equally as many nurses 
screen based on risk factors among females and among 
males, in contrast to physicians. These data suggest that 
the majority of nurses know the risk factors for screening, 
but this knowledge may not be translating into practice. 
During a knowledge exchange session with the com- 
munity nurses to try to explain the survey results, barriers 
to discussing and offering screening were highlighted 
as a reason for this discrepancy. It was suggested that 
nurses do not necessarily have the time to conduct sexual 
health assessments and chlamydia screening when a 
young patient comes to clinic since their time in clinic 
is primarily occupied by acute cases (e.g. a broken arm) 
and there may not be a good or right opportunity for 
broaching the subject with patients; however, only 10% 
of community nurses identified lack of time as a barrier 
to discussing chlamydia screening in the survey (Fig. 2). 
The knowledge exchange session also identified the diffi- 
culty of getting young patients, especially males, to come 
into clinic and the difficulty in broaching the subject with 
patients, since 15% of nurses identified patients reluctant 
to discuss STIs for reasons of confidentiality, possibly 
due to patients' perceived lack of privacy as a result 
of residing in small communities (Fig. 2). There may be 
other factors that this survey did not identify specific to a 
rural environment that may be leading to low asking and 
testing patterns among community nurses. Further re- 
search should investigate such factors. Importantly, the 
differences between the results of the physician and 
community nursing survey indicate that the context of 
practice has an effect on opportunities for discussing and 
offering chlamydia and STI screening, and the need to 
specifically target interventions designed to increase 
opportunities for testing in each context and to each 
type of health care provider. 

Strengths and limitations 

Strengths of this study included the high response rate of 
the study participants, which makes it likely that our 
study results are generalizable to the study population 
(primary health care providers in Yukon). However, a 
limitation of the study is the lack of generalizability to 
other populations. The small sample size was a limitation 
in being able to undertake inferential analyses, especially 
among data specific to community nurses. As the original 
survey instrument was designed for a large urban popu- 
lation in Toronto, despite it being adapted to the Yukon 
context, it may not have served to fully illuminate the 



contextual differences in barriers to assessment and 
screening in Yukon's unique northern rural communities. 

Additionally, there is a potential for bias in self- 
reported data. Providers may have recalled their practice 
habits differently than what they actually do, and may 
have sought to provide the "socially desirable" response. 
At the same time, however, we do have laboratory data 
to substantiate reports from the physician survey - the 
overall percentage of tests done for females and males 
(Fig. 4) appears to support physician-reported data 
(Fig. 1). Further dividing the laboratory data by provider 
type would provide another test for internal validity; 
unfortunately, this kind of analysis of laboratory data was 
not available. 

This survey also assessed supports either utilized or 
required (not reported in this article), which has allowed 
us to take immediate action to improve supports to 
health care providers in Yukon. A Chlamydia Reduction 
Strategy Working Group has been formed at the Depart- 
ment of Health and Social Services, Government of 
Yukon which has utilized the survey results to design 
health provider education, including making screening 
guidelines easily available, providing additional training 
opportunities and reminding physicians and nurses 
to "ask and test" (e.g. through a quarterly surveillance 
newsletter sent out to all health care providers in Yukon). 
This practice-based survey has allowed us to improve 
professional education in the area of STIs and at the 
same time contribute to a body of research on the factors 
that are associated with STI risk assessments 
and STI testing. 

Conclusions 

This survey provides valuable information on health 
provider screening patterns in Yukon. We found that 
screening patterns vary between physicians and commu- 
nity nurses, and that there is a relationship between 
conducting STI risk assessments and testing for chlamy- 
dia, as well as the importance of applying risk factor 
knowledge to practice. We also identified some barriers 
to discussing and offering screening, which should be 
addressed and mitigated. We have some evidence which 
suggests that chlamydia testing rates may be higher 
among patients seen by physicians in Yukon in compar- 
ison to Toronto, Canada. Our laboratory data compar- 
isons with Saskatchewan, Canada (20), and BCCDC, 
Canada (21), which we have reported elsewhere (19), also 
suggest that Yukon's chlamydia testing rates may be 
higher than those in other jurisdictions; however, data are 
limited. 

Canadian Guidelines on STIs recommend conducting 
sexual health risk assessments for sexually active youth 
less than 25 years of age, which is a known risk factor for 
STIs. According to our survey results, only about 19% 
of physicians in Yukon conduct sexual health assessments 



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Chlamydia screening practices in Yukon 



routinely among females in that age group, and only 2% do 
so among males. Similarly, only 5% of community nurses 
routinely conduct sexual health assessments among fe- 
males and males in that age group. These data point to the 
need to start the conversation around sexual health for 
health care providers with their patients, as health provi- 
ders may be missing important risk factor information 
that may place patients at risk for STIs. More consistent 
application of optimal screening methods with support 
to "start the conversation" around sexual health may assist 
in overcoming barriers to screening and in addressing 
Yukon's high rate of chlamydia. 

Acknowledgments 



The authors thank the following individuals for their assistance 
and contribution to this research: all physicians and community 
nurses who participated in the surveys; Community Nursing staff, 
in particular Sue Lightford, Colleen Hemsley, Ron Melanson and 
Michael Caron; Yukon Communicable Disease Control staff, in 
particular Brenda Jensen. 

The authors gratefully acknowledge Toronto Public Health, 
in particular Deborah Waddington, for permission to adapt their 
survey instrument for this study, and for permission to utilize their 
data comparisons in our study. The authors also gratefully acknowl- 
edge Dr. Linda Hoang at the British Columbia Centre for Disease 
Control Public Health Microbiology and Reference Laboratory and 
Dr. David Vickers at the University of Saskatchewan for providing 
laboratory data comparisons referenced in this paper. The authors 
would also like to acknowledge Dr. Amy Greer at the Public Health 
Agency of Canada and University of Toronto for her assistance in 
our understanding of Yukon chlamydia laboratory data. 

Conflict of interest and funding 

The authors have not received any funding or benefits from 
industry or elsewhere to conduct this study. 

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"Karolina Machalek 

Department of Health and Social Services 

Government of Yukon 

305 Jarvis Street, 2nd Floor (HP 305) 

Whitehorse, Yukon Y1A 2H3 

Canada 

Email: Karolina. Machalek@gov.yk.ca; 
Karolina. Machalek@phac-aspc.gc.ca 



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