Journal of Public Health | Vol. 34, No. 3, pp. 411 – 420 | doi:10.1093/pubmed/fds007 | Advance Access Publication 8 March 2012
The importance of distinguishing between black Caribbeans and Africans in understanding sexual risk and care-seeking behaviours for sexually transmitted infections: evidence from a large survey of people attending genitourinary medicine clinics in England M. Gerressu 1, C.H. Mercer 1, J.A. Cassell 2, G. Brook 3, S. Dave 4 1
Centre for Sexual Health and HIV Research, University College London, London WC1E6JB, UK Brighton and Sussex Medical School, University of Brighton, Falmer, Brighton BN1 9PX, UK 3 Central Middlesex Hospital, Patrick Clements GUM Clinic, North West London Hospitals NHS Trust, Acton Lane, Park Royal, London NW10 7NS, UK 4 Institute for Women’s Health, University College London, London W1T 7DN, UK Address correspondence to M. Gerressu, E-mail:
[email protected] 2
A B S T R AC T Background In the UK, black Caribbean and African populations experience disproportionately high rates of sexually transmitted infections (STIs) and HIV. Often studies do not differentiate between these populations notwithstanding differences in STI epidemiology and sociodemographics. Methods Patterns of care-seeking behaviour for STIs were explored separately for black Caribbean (n ¼ 345), black African (n ¼ 193) and white people through a cross-sectional survey of 2824 people attending five genitourinary medicine (GUM) clinics in England. Results Black Caribbean men were least likely to use, or try to use, their general practice surgery prior to GUM clinic attendance (16.6%). Symptomatic black Caribbean and African men were least likely to delay seeking care (30.8 and 26.3%, respectively). Symptomatic black Caribbean men faced the least provider delay in accessing care (27.3%). Black Caribbean men and women were most likely, and black African men and women least likely, to be diagnosed with an STI (49.7 and 32.0% versus 26.8 and 16.3%, respectively). Among symptomatic women, black Caribbeans and, among symptomatic men, black Africans were most likely to report abstaining from sex (46.3 and 73.1%, respectively). Conclusions Our analyses highlight the importance of distinguishing between black ethnic groups and the need for future studies to ensure sufficiently large samples to permit such analyses. Keywords sexual risk, STI care-seeking behaviour, black Caribbean, African, survey
Background In the UK, black Caribbeans and Africans continue to be identified as target groups for prevention of sexually transmitted infections (STIs), including HIV, due to disproportionately high STI and HIV rates, respectively, over the last 20 years.1 – 3 Data from Britain’s national probability surveys of sexual behaviour, the National Surveys of Sexual Attitudes and Lifestyles (‘Natsal’), show that black Caribbean and black African populations report more genitourinary medicine (GUM) clinic attendance and HIV
testing, respectively, compared with other ethnic groups.4 It is unclear whether the higher prevalence of infections in
M. Gerressu , Research Fellow C.H. Mercer , Senior Lecturer J.A. Cassell , Professor of Primary Care Epidemiology G. Brook , Clinical Lead GUM/HIV S. Dave , Senior Clinical Associate
# The Author 2012, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved.
411
412
J O U RN A L O F P U B L I C H E A LTH
these communities lead to increased clinic attendance or if an increase in clinic attendance leads to more diagnoses. In a study of men attending 11 London GUM clinics,5 overall rates of gonorrhoea and chlamydia were higher among black Caribbeans and those classified as ‘black other’ compared with black Africans, even after adjusting for age and levels of residential area deprivation. This contrasted with higher HIV rates among black African men, and as such, the authors emphasized the importance of analysing black ethnic groups separately, even if group numbers are small. Despite this, many studies over the last two decades investigating ethnic variations in STI burden have not differentiated between black Caribbean and black African participants.6 – 10 Analyses of a generic ‘black’ ethnic group can lead to difficulties with interpreting data and limit their utility in guiding service provision and sexual health promotion. We present data from the largest survey to date of GUM clinic attendees across England, including data on sociodemographic characteristics, reasons for GUM clinic attendance, health-seeking behaviour and STI prevalence. The study has relatively large samples of patients from black Caribbean and African populations reflecting the burden of sexual ill-health in these groups.3 We are therefore able to consider black Caribbeans and black Africans as two distinct groups, and compare them with white clinic attendees, the largest ethnic group in the study.
Methods Population and sampling
The methods of the patient access and the transmission of sexually transmitted infections (PATSI) study have been previously published.11 In brief, all new patients attending seven GUM clinics across England were asked to complete a 22 item, self-completion, written questionnaire in English about their health-seeking behaviour and contact with services with regard to their current problem(s). The clinics were selected to represent different demographic, geographic and service configuration characteristics likely to influence sexual health need and service use. Data collection occurred between October 2004 and March 2005. Questionnaires were anonymous apart from the clinic identification number used to link the questionnaires to the clinics’ routine database for data on the patient’s gender, age, self-identified ethnicity, partial postcode and any STI diagnoses made on the day of clinic attendance. Ethical approval for the study was obtained from the South West Multi-Centre Ethics Committee (number: MREC/04/6/02).
Statistical analyses
We present data from patients attending five of the seven clinics. These included a London clinic, large provincial cities with single and multiple clinics, and a city with a substantial Asian population. Two clinics were excluded as they did not have data on ethnicity, reflecting their local demography which was nearly all of white ethnicity. The study clinics operated different access policies; however, all offered some degree of triage to identify patients needing more urgent care. For each gender, we compare proportions of responses by black Caribbean, black African and white respondents and so exclude patients of other ethnicities (n ¼ 752, including n ¼ 231 Asian and n ¼ 521 ‘other/ mixed’) from the analyses. Due to the relatively small numbers of cases, we did not look at the association of individual STIs with ethnicity and gender but grouped them into bacterial and viral STIs. Statistical significance was determined using the Chi-square statistic for categorical variables (considered as P , 0.05 for all analyses). Analyses were carried out using survey commands in STATA 10.0 to take into account of clustering by clinic.12
Results Response rates varied by clinic (range: 24.5 – 70.1%) but there was no evidence of differences between new patients who completed the questionnaires and those who did not with respect to routinely collected data on gender, age, ethnicity and STI diagnoses.11 Among the 2824 questionnaires analysed, 345 were from black Caribbean (12.5%), 193 from black African (6.8%) and 2286 from white respondents (81%). The proportions who were black Caribbean and African varied among the five clinics (range: 1.8 – 23.4%). Sociodemographic characteristics
The sociodemographic characteristics of the sample are presented in Table 1. Men were older on an average than women. White and black African respondents were similar in age while black Caribbean male respondents had a bimodal age distribution. Black Caribbean men and black African women were least likely to report they were registered with a general practitioner (GP) (men: black Caribbean 77.4% versus white 88.1% versus black African 82.3% and women: black Caribbean 95.1 versus white 94% versus black African 82.1%, respectively). Black Caribbeans were less educated, less likely to have college or work commitments when the clinic was open and less likely to report they were living with a spouse but more likely to have
Table 1 Sociodemographic characteristics by gender and self-reported ethnicity
Men Black
Women White
Caribbean
Black
Black
Black Caribbean
Black African
African
Caribbean
versus Black
versus White
(P-value)
versus White
African (P-value)
(P-value)
0.6641
0.1322
0.0091
0.2736
0.0042
0.1795
0.3122
0.2519
0.1280
0.1328
0.0069
0.0570
0.4077
0.3210
0.7507
0.1101
0.5616
0.0276
0.0486
Black
Black Caribbean
Black Caribbean
Black African
Black
African
versus White
versus Black
versus White
Caribbean
(P-value)
African (P-value)
0.0237
0.0060
Age, grouped (three
White
groups) ,25
46.0%
35.8%
32.0%
50.8%
52.6%
40.2%
25– 34
19.6%
40.4%
44.3%
24.9%
31.8%
43.5%
35þ
34.4%
23.8%
23.7%
24.3%
15.6%
16.3%
Median (lower and
27 (21, 38)
27 (23,
29 (23.5, 34)
24 (20, 34)
24 (20,
26 (22,
upper quartiles) Denominator
34) 163
1092
97
Highest educational
181 0.0011
0.0085
30)
30)
1171
92
0.0819
qualification so fara 11.0%
42.6%
55.1%
29.2%
46%
42.0%
A levels
17.1%
18.3%
17.4%
17.9%
19.9%
23.2%
GCSE
18.3%
18.1%
2.9%
14.1%
18.1%
13.0%
NVQ/other
31.7%
15.6%
21.7%
30.2%
12.2%
20.3%
No qualifications
21.9%
5.29%
2.9%
8.5%
3.8%
1.4%
Denominator
82
850
69
106
813
69
20.5%
22.9%
32.9%
171
1142
85
31.9%
13.6%
18.8%
163
1140
85
qualifications
Living with spouse Denominator
0.0242 22.6%
27.9%
31.8%
133
1029
88
Childcare responsibilitiesb Denominator
0.0284 15.5%
9.1%
8.9%
129
1028
90
Work/attend college
0.0073
0.0229
0.2738
0.1447
0.3174
0.9372
0.0218
when clinic is open Yes, every day
47.7%
67.3%
44.3%
46.9%
56.1%
Yes, some days
26.1%
19.2%
43.2%
34.8%
26.8%
38.8%
No
26.1%
13.6%
12.5%
18.3%
17.1%
14.1%
Denominator
130
1017
88
164
1128
85
Registered with a GP Denominator
0.0086
0.5510
0.4172
77.4%
88.1%
82.3%
95.1%
94.0%
82.1%
115
1003
85
165
1124
84
GCSE, General Certificate of Secondary Education; GP, general practice; NVQ, National Vocational Qualification. a
47.1%
DI ST I NG U I SH I N G BET WE EN BL AC K ET H NI C G RO U P S I N TH E U K
Degree/higher degree
Denominator excludes those under 21. Yes includes: all day every day or after school and holidays or weekends only or other.
413
b
414
J O U RN A L O F P U B L I C H E A LTH
childcare responsibilities compared with other respondents (no qualifications: men, black Caribbean 21.9 versus 2.9% black African and women, black Caribbean 8.5 versus black African 1.4%, respectively). Among men, black African men and among women, white women were more educated than other respondents. Black Africans were most likely to report they were living with a spouse (men: black Caribbean 22.6% versus white 27.9% versus black African 31.8% and women: black Caribbean 20.5% versus white 22.9% versus black African 32.9%, respectively). How respondents found out about the clinic and reasons for GUM clinic attendance
How respondents found out about the GUM clinic and reasons for attending the clinic are presented in Table 2. The two most common ways of finding out about the clinic were through a friend and through their GP surgery. Black Caribbeans were most likely to report hearing about the clinic from a friend (men: black Caribbean 35.2% versus white 19.8% versus black African 24.7% and women: black Caribbean 26% versus white 22% versus black African 27.8%, respectively). They were least likely to report finding out about it from their GP surgery (men: black Caribbean 20.9% versus white 29.5% versus black African 37.1% and women: black Caribbean 23.2% versus white 32.7% versus black African 33.7%, respectively). The three most common reasons for attending the GUM clinic were the same across genders and ethnic groups: having symptoms, being asymptomatic but wanting a check up and wanting an HIV test. Symptoms and health-seeking behaviour
Symptoms and health-seeking behaviour are reported in Table 3. Fewer black Caribbean men (16.6%) used, or tried to use, their GP before attending the GUM clinic compared with a quarter of all other respondents. About half of all respondents were asymptomatic when they attended the clinic. Black Caribbean women were most likely to report symptoms at their clinic visit (43.1%), whilst uncertainty about the presence of symptoms was most common among black Caribbean men and African women (22.5 and 19.0% respectively, P-values ,0.05 for both comparisons). The majority of symptomatic black African and Caribbean men sought care within 7 days of the start of their symptoms (73.7 and 69.2%, respectively), whereas about half of other respondents waited .7 days (from here on labelled ‘patient delay’, that is, when a patient reported waiting .7 days after the start of symptoms to seek care from any healthcare provider). Almost half of all respondents, irrespective of symptoms, experienced delay of .4
days in accessing care—at the study GUM clinic—from first contact with a health service (labelled hereon as ‘provider delay’). The exceptions were symptomatic black Caribbean men, of whom only a quarter faced provider delay. White respondents were more likely to face provider delay compared with other groups. Three-quarters of black African women and around two-thirds of black Caribbean women, white women and white men had been symptomatic for .7 days by the time they attended the GUM clinic. However, over half of the black Caribbean and African men attended the clinic within 7 days of the start of symptoms. The majority of symptomatic respondents did not report any change in their symptoms since they first tried to be seen. However, white respondents were more likely to report their symptoms had worsened compared with the other groups. White men, together with black Caribbean women, were also more likely to report their symptoms had improved. The majority of black African and black Caribbean respondents reported they would have attended clinic even if their symptoms had gone away (range: 62.5 – 72.4%), although white respondents were much less likely to report this (men 44.3 and women 44.4%) and much more likely to report they would not have gone to see anyone (men 38.5 and women 34.1% versus a range 6.9 –25% for all other ethnic groups). A substantial proportion of respondents were unsure what they would have done (range: 15.4 –21.9%). Fewer men (range: 26.9 – 47.4%) compared with women (range: 53.7 – 60.8%) reported they had sex after their symptoms started. Among men, black African men and among women, black Caribbean women were most likely to abstain (73.1 and 46.3%, respectively), whereas white men and women were least likely to abstain (52.5 and 39.2%, respectively). However, multiple sexual partners were much more likely to be reported by black Caribbean men compared with black African and white men (18.2 versus 3.8 versus 9.3%, respectively) and black African women compared with black Caribbean and white women (11.5 versus 4.5 versus 6.6%, respectively).
STI diagnoses
Previous and current STI diagnoses are reported in Table 4. Black Caribbeans were much more likely to report previous STI diagnosis/es, or that they were unsure if they had previously been diagnosed with an STI, compared with other respondents. Black Caribbeans were also most likely, while black Africans were least likely, to be diagnosed with at least one acute STI on the day of clinic attendance (men: black Caribbean 49.7% versus black African 26.8% and women:
Table 2 How respondents found out about the clinic and reasons for attending by gender and self-reported ethnicity
Men Black
Women White
Caribbean
Black
Black
Black
Caribbean
Caribbean
African
versus
versus White
versus Black
versus
African
White
(P-value)
African
White
(P-value)
(P-value)
(P-value)
(P-value)
Black
Black
Black
Black
Black
African
Caribbean
Caribbean
African
Caribbean
versus White
versus Black
(P-value)
White Black African
How respondents found out about the clinic I found it in the phone book
4.3%
11.1%
2.1%
0.0084
0.1774
0.0080
5.5%
9.3%
1.1%
0.2662
0.0816
0.0826
I found it on the internet
4.3%
12.17% 5.1%
0.0170
0.7290
0.0177
2.2%
8.2%
2.2%
0.0050
0.9859
0.1971
My GP or the nurse at the GP surgery
20.9%
29.5%
37.1%
0.0008
0.0075
0.0645
23.2%
32.7% 33.7%
0.2154
0.2204
0.8412
2.4%
1.4%
2.1%
0.4100
0.8099
0.6345
9.9%
6.9%
7.6%
0.0844
0.5956
0.8231
0%
1.2%
3.1%
0.5727
0.0578
0.1861
1.1%
0.9%
0%
0.6693
0.1143
0.4822
I picked up a leaflet
2.4%
1.6%
4.1%
0.2249
0.3495
0.1998
4.4%
2.2%
1.1%
0.0211
0.2217
0.5000
My partner told me about it
16.6%
11.8%
18.6%
0.5300
0.8052
0.0143
14.9%
8.2%
9.8%
0.0898
0.4487
0.6108
A friend told me about it
32.5%
19.8%
24.7%
0.0536
0.2009
0.2116
26.0%
22.0% 27.8%
0.4228
0.6867
0.2287
A family member told me about it
2.4%
1.8%
1.0%
0.4860
0.4888
0.5981
9.4%
3.8%
Someone else
10.4%
10.7%
11.3%
0.8552
0.7503
0.7470
15.5%
10.2% 14.1%
Denominator
163
1093
97
181
1171
Have (had) symptoms
41.7%
49.5%
46.7%
0.1681
0.5160
0.5882
44.6%
Partner has/had symptoms
12.1%
10.1%
5.5%
0.5292
0.1440
0.0546
8.3%
Partner diagnosed with an infection
12.1%
11.2%
14.4%
0.6729
0.4064
0.2057
Contacted by clinic/health advisor
1.5%
1.4%
2.2%
0.9008
0.7623
No symptoms but wanted check-up
31.8%
34.4%
36.7%
0.4854
Wanted HIV test
15.1%
15.3%
20%
0.9425
For contraception/pregnancy test/ECb
N/A
N/A
N/A
Other
12.1%
10.53% 12.22%
Denominator
132
1016
told me about it I heard about it at the Family Planning I saw an advertisement in a newspaper or magazine
2.2%
0.0457
0.1052
0.5283
0.0780
0.6280
0.2455
43.0% 39.1%
0.5496
0.5704
0.6640
12.2% 16.1%
0.4592
0.1584
0.2829
10.1%
9.9%
11.5%
0.9329
0.7213
0.7192
0.4020
3.0%
2.5%
3.4%
0.5339
0.8530
0.6521
0.1108
0.5601
43.4%
39.0% 40.2%
0.0738
0.6597
0.8533
0.5471
0.4337
14.9%
13.3% 19.5%
0.6697
0.0600
0.1852
1.2%
1.9%
0.2699
0.0829
0.3182
15.5%
16.7% 11.5%
0.7202
0.3651
0.0545
168
1125
92
Reasons for attending GUM clinica
a
90
0.4569
0.9723
0.4552
Percentages may add up to more than 100 because the question ‘Why did you come to the clinic?’ asked respondents to ‘tick all that apply’.
b
Free text description within ‘other’ option.
2.3% 87
DI ST I NG U I SH I N G BET WE EN BL AC K ET H NI C G RO U P S I N TH E U K
Clinic
415
416
Table 3 Patient and provider delay in accessing care, symptoms and sex since symptoms started by gender and self-reported ethnicity
Black
Women White
Caribbean
Black
Black
Black
Black
African
Caribbean
Caribbean
African
versus
versus White
versus Black
versus
African
White
(P-value)
African
White
(P-value)
(P-value)
(P-value)
(P-value)
0.0057
0.4310
0.2010
0.4022
0.6723
0.2714
0.4442
0.1956
0.7785
0.4357
0.3885
0.6205
0.5477
0.5716
0.8094
0.5185
0.1726
0.6333
0.7513
0.8294
0.1676
0.2490
0.3590
0.3442
0.2105
0.0392
Black
Black
Black
Black
Black
African
Caribbean
Caribbean
African
Caribbean
versus White
versus Black
(P-value)
Evidence that tried/used GP before GUM
0.0053
White
Yes
16.6%
23.5%
27.8%
26.0%
27.4%
26.1%
No
61.3%
68.5%
63.9%
64.6%
67.0%
67.4%
Unclear
22.1%
8.0%
8.2%
9.4%
5.6%
6.5%
Denominator
163
1093
97
181
1171
92
50%
51.6%
51.8%
41.2%
49.8%
45.2%
Have symptoms now No
0.4263
0.5581
0.5273
Not sure
22.5%
14.8%
16.9%
15.6%
13.4%
19.0%
Yes
27.5%
33.5%
31.3%
43.1%
36.8%
35.7%
Denominator
120
997
83
160
1120
84
Days since symptoms started when seen in the
0.0600
0.7406
0.0105
study GUM clinica 0 – 7 days
56.7%
33.3%
54.2%
33.9%
31.1%
7þ days
43.3%
66.7%
45.8%
66.1%
68.9%
76.9%
Denominator
30
303
24
56
350
26
Patient waited .7 days after start of symptoms
0.1299
0.5154
0.0102
23.1%
0.5716
before seeking any carea (patient delay) Yes
30.8%
45.1%
26.3%
44.4%
48.1%
52.4%
Denominator
26
275
19
45
310
21
Among all respondents
45.4%
52.5%
45.3%
51.8%
54.5%
45.8%
Denominator
130
1023
86
166
1140
83
50.7%
55.2%
53.6%
67
411
28
Provider delay (4 days) in access to care from first contact with health services (provider delay) 0.4883
0.9878
0.3976
Among symptomatic respondentsa
27.3%
52.1%
48%
Denominator
33
332
25
Yes, they have gotten worse
21.4%
24.9%
17.4%
30.6%
34%
21.7%
Yes, they have improved
10.7%
21.5%
17.4%
24.2%
17.7%
13.0%
No change
67.9%
53.5%
65.2%
45.2%
48.2%
65.2%
Denominator
28
325
23
62
400
23
I would not have gone to see anyone
18.7%
38.5%
19.2%
25%
34.1%
6.9%
I would still have come here
62.5%
44.3%
65.4%
53.1%
44.3%
72.4%
Not sure
18.7%
17.2%
15.4%
21.9%
21.6%
20.7%
Denominator
32
332
26
64,
408
29
Changes in symptoms since first tried to be seena
0.0391 0.4255
Hypothetical action if symptoms had gone awaya
0.2440
0.0876 0.4174
0.7914
0.0946 0.3991
0.1869
Continued
J O U RN A L O F P U B L I C H E A LTH
Men
DI ST I NG U I SH I N G BET WE EN BL AC K ET H NI C G RO U P S I N TH E U K
Denominator only includes respondents who answered yes to the question about having symptoms now (no and unsure excluded).
406, 26 33 Denominator
333
3.8% 9.3% 18.2% Yes, with more than 1 partner
38.1% 23.1% 21.2% Yes, with 1 partner
Discussion
a
11.5%
26
6.6%
67
46.1% 54.2%
4.5%
49.2%
42.3% 60.6%
52.5% 73.1%
0.2783
0.5373
0.3968
46.3%
39.2%
0.5200
0.4803
0.4599
black Caribbean 32.0% versus black African 16.3%, P , 0.05 for both, respectively). Across all groups, the most common bacterial diagnosis was chlamydia (range: 6.5 – 17.8%) while genital herpes accounted for ,2% of diagnoses. Black Caribbean men were almost twice as likely to be diagnosed with bacterial STIs compared with black African and white men (45.4 versus 26.8 versus 24.4%, respectively). Although there were fewer diagnoses a similar pattern was found among women. Viral STIs were uncommon, especially among black African men and women. However, white respondents were twice as likely to report viral STIs as black Caribbeans (11.5 versus 6.1% among men and 12.5 versus 6.1% among women).
No
Had sex since symptoms starteda
Table 3 Continued
417
Main findings of this study
We found differences in sociodemographic characteristics, STI diagnoses, service use and GUM clinic access by ethnicity and gender. Black Caribbeans were least likely to have heard about the GUM clinic from a GP surgery. Black Caribbean men in particular were significantly less likely to report this compared with black African men. This may reflect how black Caribbean men were least likely to report using, or trying to use, their GP surgery prior to GUM clinic attendance. Symptomatic black Caribbean and black African men were least likely to delay seeking care, and while symptomatic black Caribbean men faced the least provider delay in accessing care, symptomatic black African men were faced with a greater delay similar to other respondents. Black Caribbeans were most likely, while black Africans were least likely, to be diagnosed with STIs. The majority of men reported abstaining from sex since their symptoms started, unlike women. However, symptomatic black Caribbean men and black African women were most likely to report multiple sexual partners. None of the comparisons about sexual behavior while seeking care were statistically significant. Although our analysis focused on black Caribbean and black African respondents, it was interesting to note that white respondents were most likely to be diagnosed with a viral STI and report sex whilst symptomatic. They also faced more provider delay and were most likely to report that they would not attend a GUM clinic if their symptoms resolved compared with other ethnic groups. The reasons for this are unclear and need to be explored further. Differences in provider delay may reflect differences in clinics’ access policies, however, at the time of the survey, all the study clinics offered some degree of triage.
418
J O U RN A L O F P U B L I C H E A LTH
Table 4 Previous and current STI diagnoses started by gender and self-reported ethnicity Men Black
Women White
Caribbean
Black
Black
Black
Caribbean
African
versus
versus
versus
White
White
Black
White
(P-value)
(P-value)
African
(P-value)
Black
Black
Black
Caribbean
African
Caribbean
versus
versus
versus
White
Black
(P-value)
African
Black
African Caribbean
White
Black
Black
African Caribbean
(P-value)
(P-value) 0.2425
Previously
0.2773
0.3908
0.0519
0.3601
0.3310
0.1089
0.0015
0.0042
0.0024
0.5517
0.0609
0.0096
0.0322
0.3609
diagnosed with an STI No
70.3%
79.3% 82.8%
67.7%
Not sure
10.2%
4.1%
6.2%
3.0%
Yes
19.5%
16.6% 11.5%
26.1%
18.4% 17.9%
Denominator
118
1005
161
1127
5.7% 87
Diagnosed with
0.0032
0.0055
78.6% 75% 7.1% 84
0.0966
one or more acute STI(s)a Yes
49.7%
33.8% 26.8%
32.0%
28.4% 16.3%
Denominator
163
1093
181
1171
97 0.0422
Diagnosed with
0.0359
92
0.2517
one or more viral STI(s)a Yes
6.1%
11.4% 0%
6.1%
12.5% 4.3%
Denominator
163
1093
181
1171
97 0.0033
Diagnosed with
0.0160
92
0.4292
one or more bacterial STI(s)a Yes
45.4%
24.4% 26.8%
27.6%
17.2% 13.0%
Denominator
163
1093
181
1171
97
92
a
Respondents without a KC60 code were included under ‘no’. Acute STIs are defined as infectious syphilis (KC60 codes: A1, A2), uncomplicated
gonorrhoea (KC60 codes: B1, B2), complicated gonorrhoea (KC60 code: B5), chancroid/lymphogranuloma venereum (LGV)/donovanosis (KC60 codes: C1, C2 & C3); chlamydial infection (uncomplicated/complicated) (KC60 codes: C4a, C4b, C4c); uncomplicated non-gonoccocal/non-specific urethritis in males (KC60 code: C4h); complicated non-gonoccocal/non-specific infection (KC60 code: C5); herpes simplex (first attack) (KC60 code: C10a); genital warts (first attack) (KC60 code: C11a); trichomoniasis (KC60 code: C6a).
What is already known on this topic
The differences we found in age and education between black Caribbeans and black Africans have previously been described, together with other sociodemographic differences on a population level,13 and are likely to influence sexual behaviour. Previous STIs were reported by similar proportions of black Caribbean men in our study as in the Natsal general population sample.4 However, previous STIs were reported by more African women and white respondents and fewer African men in our study compared with Natsal. Greater ethnic differences have been reported among GUM clinic
patients than we observed,4,5 including substantially higher reports of previous STIs among black Caribbean attendees (83.8 men and 68.7% among women).14 In keeping with the results of other studies of GUM clinic attendees, 5,8,9,15 we found more bacterial STIs in black Caribbeans and viral STIs in white respondents. However, like us, they and other researchers reported that black Caribbeans were more likely to be diagnosed with a bacterial STI compared with black Africans.5,15,16 Higher levels of risk-taking behaviour including greater numbers of sexual partners and concurrent sexual partnerships were reported in the Natsal sample by black
DI ST I NG U I SH I N G BET WE EN BL AC K ET H NI C G RO U P S I N TH E U K
Caribbean and African men.4 In our study, symptomatic black Caribbean men were most likely to report multiple partners. Greater differences in sexual risk taking and attitudes between genders than between ethnic groups have been reported in some studies, mainly in young people.17 – 19 Our findings concur with this. Across all ethnic groups women reported more delay in seeking care and were also more likely to report they were sexually active when symptomatic compared with men. The association between ethnicity and STIs is likely to be influenced by a number of factors including sexual mixing patterns, undiagnosed disease prevalence, cultural factors and effects of discrimination.4 Assortative (same ethnicity) mixing may explain variations in STI rates between different ethnic groups.5 The increased STI risk among black Caribbean and African women compared with white women may be the result of selecting sexual partners with higher STI prevalence and/or higher risk behaviours.4 Variations in success of partner notification and patterns of clinic use by ethnicity do not appear to explain the higher gonorrhoea prevalence in black Caribbeans.20 Genetic variations based on ethnicity have not been found for chlamydia and gonorrhoea.21
What this study adds
Our data suggest a need to explore sexual health among black Africans and black Caribbeans separately. These distinctions will facilitate the development of better informed service provision, health promotion messages and interventions. Although black Caribbean men who were at highest risk of STIs were least likely to face provider and patient delay in the PATSI study, a large proportion still did, together with a high proportion of other respondents including black Caribbean women, the highest risk group among women. The substantial proportions of respondents who reported sex whilst symptomatic, or were either unsure or would not visit a GUM clinic if symptoms resolved is also of concern. Our findings suggest that provider and patient delay, the presence of asymptomatic STIs and abstinence when symptomatic need to be covered more widely during service provision and sexual health promotion. Differences in how respondents found out about the GUM clinic they attended suggest targeted information about services is also necessary. ‘Easy access to sexual health services that can provide advice, screening and treatment for STIs including HIV’ among black Caribbean and African communities as
419
recommended by the 2008 Health Protection Agency report3 (2008) continues to be a priority. Our study emphasizes the need for samples of black Caribbeans and black Africans in future GUM clinic and population studies to be large enough to detect significant associations between the determinants and outcomes of sexual health in these two populations separately, moving away from a generic ‘black’ ethnic group. After more than two decades of research, we need to differentiate between black Caribbeans and black Africans and find ways to better target education programmes and interventions to better tackle the sexual health inequalities. Limitations of this study
The paper presents secondary analyses of data from a study focused on patient access to GUM clinics11 and was not originally powered to detect statistically significant differences between ethnic groups. Therefore, although we had a relatively large number of black Caribbean and black African respondents, we still lacked the power to detect some differences as statistically significant, especially as we analysed by gender to reflect well-established gender differences in sexual behaviour reporting.22 In the six years since this study was conducted we are only aware of one study looking at black Caribbeans attending GUM clinics14 but none comparing across ethnic groups. We therefore felt it was important to take the opportunity to examine ethnic differences in a data set that took a novel approach to addressing STI transmission by including health-seeking behaviour questions in addition to issues related to service access. Socioeconomic status was not measured in the PATSI study. Although it appears to be a less powerful determinant of STI infection than ethnic group,6,9 a better understanding is required since ethnicity and socioeconomic status are interlinked.13 Although it is challenging, developing better measures of socioeconomic status will help disentangle the complex interactions between sex, geographical location, age, ethnic group and social deprivation already identified for gonorrhoea and chlamydia risk.5,7
Acknowledgements The PATSI study was funded by the Medical Research Council, with funding allocated from the Health Departments, under the aegis of the MRC/UK Health Departments Sexual Health and HIV Research Strategy Committee. Statement of independence from funders: The Medical Research Council has had no role in the collection, analysis and interpretation of data; in the writing of the
420
J O U RN A L O F P U B L I C H E A LTH
report or in the decision to submit the paper for publication. The views expressed are those of the authors and not necessarily those of the MRC or the Health Departments.
9 Monteiro EF, Lacey CJN, Merrich D. The interrelation of demographic and geospacial risk factors between four common sexually transmitted diseases. Sex Transm Infect 2005;81:41– 6. 10 Risley CL, Ward H, Choudhury B et al. Geographical and demographic clustering of gonorrhoea in London. Sex Transm Infect 2007;83:481 – 7.
Funding
11 Mercer CH, Sutcliffe L, Johnson AM et al. How much do delayed health seeking, delayed care provision, and diversion from primary care contribute to the transmission of STIs?. Sex Transm Infect 2007;83:400 – 5.
M.G. was funded by a Doctoral Research Fellowship award from the National Institute for Health Research while working on the analysis and writing of the paper. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health.
12 StataCorp. Stata Statistical Software: Release 10. College Station, TX: StataCorp LP, 2007.
References
14 Gerver SM, Anderson M, Solarin I et al. Sexual risk behaviours and sexual health outcomes of heterosexual black Caribbeans: comparing sexually transmitted infection clinic attendees and national probability survey respondents. Int J STD AIDS 2011;22:85– 90.
1 HPA. Health Protection Agency reports 2002 onwards. http:// www.hpa.org.uk/Publications/InfectiousDiseases/HIVAndSTIs/ (20th September 2011, date last accessed). 2 The UK Collaborative Group for HIV and STI Surveillance. Testing Times. HIV and Other Sexually Transmitted Infections in the United Kingdom: 2007. London: Health Protection Agency, Centre for Infections. 2007.
13 Nazroo J, Demography of multicultural Britain. In: Nazroo J. (ed.). Health and Social Research in Multiethnic Societies. London; Routledge, 2006,1 – 19.
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3 The UK Collaborative Group for HIV and STI Surveillance. Sexually transmitted infections in black African and black Caribbean communities in the UK: 2008 report. London: Health Protection Agency, Centre for Infections, 2008.
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4 Fenton KA, Mercer C, McManus S et al. Ethnic variations in sexual behaviour in Great Britain and risk of sexually transmitted infections: a probability survey. Lancet 2005;365:1246– 55.
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6 Lacey CJN, Merrick DW, Bensley DC et al. Analysis of the sociodemography of gonorrhoea in Leeds 1989 – 93. Br Med J 1997;314:1715– 18.
20 Ross JDC, Sukthankar A, Radcliffe KW et al. Do the factors associated with successful contact tracing of patients with gonorrhoea and Chlamydia differ? Sex Transm Infect 1999;75:112 – 5.
7 Winter AJ, Sriskandabalan P, Wade AAH et al. Sociodemography of genital Chlamydia trachomatis in Coventry, UK, 1992 – 6. Sex Transm Infect 2000;76:103– 9.
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