This chapter provides the background discussion of sexually transmitted infections (STIs) focussing on Chlamydia trachomatis infection since the study is positioned within this area leading down to the specific research question and objectives. In addition, sexual health prevention and control strategies have been explored.

2.1 Introduction

Health has been defined by the World Health Organization (WHO) as “the science and art of preventing disease, prolonging life and promoting health through organised efforts of society” (WHO, n.d.). Sexual activity is known as an essential element of human health and well-being contributing to quality of adult partnerships and a requirement for natural creation. Yet it poses a lot of risks to health through transmission of STIs. Although syphilis, gonorrhoea and chancroid are generally considered as the main STIs, various other pathogens are transmissible including Herpes Simplex Virus type 2, Chlamydia trachomatis, Human immunodeficiency virus (HIV) Herpes Papilloma Virus, and Hepatitis B Virus (HPA, 2010)

STIs affect people of all ages with the greatest occurrence amongst those under the age of 25 years (Nicoll, 1999; Johnson, 2001; NCSP, 2009). In the UK, certain groups of populations are affected more than others thus creating sexual health inequalities (Thomson & Holland, 2003; HPA, 2010; Marmot, 2010).

The research has delved into mainly secondary literature from peer reviewed journal articles, books, health agency or governing bodies’ reports and articles to demonstrate what past researchers have established on CI. Moreover, sexual health prevention and control strategies have been explored in order to place CI in a context that engages with appropriate literature (Expert Advisory Group, 2001; Thomson, 2004; Ellis, 2004; Brabin et al., 2009; Cameron et al. 2007, 2009.

2.2 Chlamydia Infection Trends

Chlamydia trachomatis is the most widespread bacterial pathogen transmitted through infected secretions and mucous membranes of urethra, cervix, rectum, conjunctivae and throat following unprotected sexual contact with an infected partner. An infected pregnant woman can infect her baby during vaginal delivery.

Genital Chlamydial infection is currently the most common STI in the UK with prevalence’s between 2% and 12% detected in studies of women attending general practice (Fenton et al., 2001; Creighton et al., 2003; HPA, 2010). Chlamydia infection rates are disproportionately high in under 25s (Low, 2006; HPA, 2010; Land, 2010). Rate of infectivity for Chlamydia at national level for young people aged 15–24 is one in ten supporting the level of sexual activity in that group (HPA 2010; Salford NHS, 2010).

In 2001, women under 20 years of age had reported cases of 36% of Chlamydia. CI cases rose by 108% during 1998 to mid-2004 (Ryan, 2004). As reported by the Department of Health (DH), diagnosis of new Chlamydia and other STI diagnosed cases in the UK such as re-infections made in GUM showed a gradual rise in 1995-2009 (Figures 2, 3) (HPA, 2010).

STI data from laboratory reports in England, Wales and Scotland and Chlamydia nucleic acid amplification test (NAAT) data from the UK National External Quality Assurance Scheme (NEQAS).

Most people infected with Chlamydia are asymptomatic (70% females and 50% males) until a diagnostic test is performed (HPA, 2010). Chlamydia infection is significant to women’s reproductive health problems since 10-40% of those untreated infected women develop PID (Garside, 2001; Sweet & Gibbs, 2009; Pippa et al., 2010). If efficient and effective health measures are not administered, the disease has the potential of causing significant health complications to women’s well-being including persistent pelvic pain, infertility, ectopic pregnancy, PID, Chlamydial pneumonia of the newborn, neonatal conjunctivitis, pre-term labour/delivery and neonatal death (Figure 4) (Golden, et al, 2000; Simms et al., 2000, 2007; Garnett, 2008; Oakeshott et al., 2010). There is also greater risk in those with recurring and untreated infections to spread to other reproductive organs resulting in chronic pelvic pains (La Montagne, et al, 2007; Evans et al., 2009; Hosenfeld et al., 2009). Sweet & Gibbs (2009) state that CI can also facilitate HIV transmission adding to the already long-term consequences it poses.

The number of diagnosed episodes of Chlamydia infection has been rising over the past 10 years (Figures 5, 6). Because GUM clinic data is skewed towards symptomatic patients and Chlamydia is highly asymptomatic, prevalence is also used to describe the epidemiology.

Studies by Pimenta et al. (2003) and Adams et al. (2004) support findings of highest prevalence rates of Chlamydia infection in young women aged 16-24. Pimenta et al (2003) measured prevalence of Chlamydia infections in 16–24 year old females rather than just reported cases from GUM clinics (Figure 7). In Portsmouth there was a 9.8% prevalence of Chlamydia infection in 16–24 year old women, with the 18–year old women having the highest peak and Wirral had 11.2% with the 20–year old women having the highest peak (Pimenta et al., 2003). Most of these individuals from both sites would have been unaware of their infection and thus at risk of developing Chlamydial complications.

Furthermore, the economic impact of Chlamydia infections on the health service is enormous with high cost in the management of female health complications (Simms, 2006; Skinner, 2010; Land et al., 2010). UK costs to NHS are estimated at > £100 million per year (HPA, 2010). Because of the impact of CI on the health of young people, it is important to identify and treat infected patients and their partners and as a result reduce the burden of the disease on the people and health systems (Appleby et al., 2007; Adams et al., 2007; Low et al., 2009).

2.3 Chlamydia Awareness and Knowledge

Chlamydia rates of infection do vary in each region in the UK (HPA, 2010). This variation may reveal the provision of diagnostic services as much as disease prevalence. In the UK, certain groups of populations are affected more than others thus creating sexual health inequalities with young people bearing the greatest burden by being disproportionately affected by CI (Figure 8, Table 2–4) (NCSP, 2009; Marmot, 2010; HPA, 2010).

2.4 Sexual Behaviour: Chlamydia Infection

Although sex has become safer to a significant extent through the use of condoms, CI rates significantly increased in recent years in the UK predominantly from various factors like sexual risk behaviours and poor infection control. It has become a major public health concern as highlighted in the National Strategy for Sexual Health and HIV (DH, 2001). The 15–24 year age group comprises only 12% of the population but has the largest diagnosis of STI cases of almost 50% of newly acquired infections. Control of Chlamydia infection is complicated since it is asymptomatic.

The sexual behaviour of the population is an important determinant of the rates of CI and other STIs. The National Survey of Sexual Attitudes and Lifestyles II identified sexual behaviour as the risk of acquiring an STI in the young age groups (McDowall et al., 2006). The factors included low age at time of first sexual intercourse, frequent changing of partners, increased likelihood of being involved with concurrent partnerships, irregular use of condoms and the increased chances of being involved with a partner who comes from a part of the world other than UK that is regarded as high risk (Figure 9) (Johnson, 2001, Mueller, 2008; Waylen, 2009; Skinner, 2010). The young people appear to be the central part of the risk of passing on the infection to other groups of the population. Thus prevention should be mostly targeted at this core group which would result in economic benefits.

A study by Shiely et al. (2010) proved that expedited partner therapy (EPT) offer reductions in risks of recurring or continual CI in heterosexuals, and enhancing the percentage of those sex partners who obtain treatment. Thus EPT was revealed as better than standard partner referral over an extensive range of socio-demographic and behaviourally distinctive subgroups.

Behavioural interventions might be limited because choices about behaviour are controlled by local context and culture. Smedley and Syme (2000) state that, “It is clear that behaviour change is a difficult and complex challenge. It is unreasonable to expect that people will change their behaviour easily when so many forces in the social, cultural and physical environment conspire against such change.” For example, Cohen et al. (2006) study found that when adolescents were exposed to sex education classes and parent-child communication about sex, they intended to practice safer sex; however, this did not actually lead to increased condom use. Rather, situational attributes, including partner attitudes about, or the availability of, condoms played a greater role in behaviour. However, the consequences of environmental risks like poverty and discrimination might be moderated by interventions focused on the individual: “But such efforts do little to address the broader social and economic forces that influence these risks” (Smedley & Syme, 2000).

Bandura (1986, 1997, 2007) developed the self-efficacy model which offers a degree of individual self-assurance through an individual’s learning and mastering self-control thus empowering themselves in reducing risky behaviour. He suggested that individuals beliefs in their competence to conduct certain behaviours impacts on the way they engage themselves, their willpower when faced with difficulties, and their attempt in conducting these behaviours. Bandura (1986, 1997, 2001a, 2001b) further states that peoples behaviour is affected by what they believe, think and feel. Foresight d