“It feels good to be told that I'm all clear”: patients' accounts of retesting following genital chlamydial infection

Abstract

Objective

To examine the meaning that people with genital chlamydial infection attribute to retesting as part of their treatment management.

Methods

Unstructured interviews with 50 heterosexual patients (40 female and 10 male) who had or had had genital chlamydia infection. Recruitment was via a genitourinary medicine clinic and a contraceptive clinic.

Results

The return visit was understood in terms of the retest. The retest occupied a pivotal position in the infection experience and was invested with symbolic significance because it provided a means by which to deal with feelings of bodily pollution. It marked the end of dirtiness that was important for the restoration of identity. It also marked the beginning of cleanness that was important in relation to sexual relationships.

Conclusion

The sociocultural construction of sexually transmitted infections shapes the individual experience of having chlamydial infection. This perspective sheds light on the meaning that individuals invest in aspects of infection management. It is important for some people to know rather than assume that their infection has been eliminated, a function that is fulfilled by the retest. When retesting is not available, individuals may use increasingly available opportunistic chlamydia testing for this purpose with consequent cost and resource implications.

The management of genital chlamydial infection in English genitourinary medicine (GUM) clinics has traditionally included a return visit and retest. Current national guidelines advise that patient follow up is an important part of infection management but that retesting is not necessary in the majority of situations.¹ However, retesting does continue to be offered in some clinics; in 2002, 41% of GUM clinics in the United Kingdom offered retesting,² and it is a recognised means by which to ensure re‐attendance.³ However, clinics are increasingly overstretched⁴,⁵ and the resource implications of retesting may be increasingly difficult to justify.

Qualitative studies of genital chlamydial infection provide valuable insight into patients' responses to infection, their anxieties and concerns, and the decisions that influence their uptake of services.⁶,⁷,⁸ This viewpoint is essential to the effectiveness of secondary prevention strategies and will inform the effectiveness of the national chlamydia screening programme. Although retesting has been identified as important for patients, particularly women,⁶ no work has been done previously on exploring the meaning that people ascribe to retesting.

This paper reports on the meaning that people with genital chlamydial infection attributed to retesting as part of their treatment management.

Methods

The primary site for this qualitative study was a GUM clinic in a medium sized district general hospital where retesting was routinely offered. A town centre family planning (FP) clinic served as a secondary site. Both clinics serve a semirural population in the Midlands region of England.

In the primary site, clinic staff identified and recruited to the study those attending the GUM clinic in relation to chlamydial infection, either at diagnosis or at the return visit. This approach was deemed most appropriate given the sensitivity of the setting and topic. Interviews were carried out on site by the researcher, either at the time of recruitment or at a later appointment. Forty four participants (34 female, 10 male) were recruited in this way, all of whom had undergone or were expecting to undergo retesting.

A further six participants (all female) were recruited via the FP clinic. Those attending the clinic, whose records indicated previous chlamydial infection in the past few months, were identified by staff and invited to participate. The purpose of this was to include those who had not been retested, although it transpired that all those recruited had been retested. This study received approval from the local research ethics committee.

Interviews were unstructured; they used a standard opening question and then a topic guide to examine the individual experience. Interviews were tape recorded and fully transcribed.

Data were analysed using a constant comparative method in accordance with the principles of grounded theory.⁹,¹⁰ Data were coded and categorised to provide a hierarchical structure of core themes and sub themes which reflected the dimensions of those core themes. Data collection continued until the point of theoretical saturation—when no new categories emerged from the data and the dimensions of emergent themes had been explored.

Results

The recruitment method necessitated opportunistic sampling. A total of 50 participants, with an age range of 16–29 years and median age of 17 years, were interviewed. All respondents identified themselves as heterosexual.

Four key themes concerned with retesting were identified from the data.

The function of the return visit

The respondents understood the purpose of the return visit solely in terms of the retest, and unanimously understood the retest as a test of cure (TOC); its function was described as establishing unequivocally that the infection had been eliminated. There was a remarkable degree of similarity in the language used by the respondents to describe the test and its purpose. The three words or phrases “make sure,” “gone,” and “clear” were repeatedly used in the explanations, either individually or in combination.

• “I've come along today for my check‐up, for them to do some more swabs to make sure that it's cleared up and gone.” (Jane)

Their explanations suggested that two things needed checking; whether the infection had been fully eliminated in quantitative terms and whether sufficient time had elapsed for it to be eliminated. The phrase “make sure” is confirmatory and there is an implicit expectation of what the outcome will be. However, it appeared to carry an additional connotation in this context that related to the treatment.

• “I had two swabs to make sure that I'm clear of it because I've had like antibiotics” (Michelle)

• “Today is a follow up from the first time that I came… it's called a test of cure, to see if the treatment's worked.” (Peter)

The purpose of the test in this respect was to confirm the effectiveness of the medication and its ability to eliminate the infection, the inference being that the medication does not always work. These descriptions were used regardless of medication type, whether it was a course of tablets or an immediate dose administered in the clinic.

• “They gave me the tablets and they gave me the tests to check whether it had all gone away.” (Isobel)

The second suggestion in the data was that elimination of infection is a fairly lengthy purpose and therefore that insufficient time may have elapsed since treatment. The purpose of the retest in this reading was to ascertain whether the end point in the process had been reached.

• “Last time I came I got given some antibiotics and so they were just checking to see if it was gone or not yet.” (Jacky)

Personal significance of the retest

For many of the respondents the retest had a personal significance that served as sufficient motivation to assure their re‐attendance at the clinic. Retesting provided the means by which to establish definitively that they were free from infection in so far as they had been tested and the test results were negative. Knowing that their treatment had been effective was particularly important for some of the respondents, who anxiously waited for their results.

• “I'm still a bit on edge, whether it has worked, whether it has gone or not.” (Helen)

• “It's been a month since I finished my tablets and I'm still worried that I could still have it…. I think I will believe it [the test of cure letter] and try and forget it. Yes yes, I wanted the test.” (Jacky)

The significance of the retest centred round the concept of bodily contamination. The diagnosis of infection commonly produced feelings of dirtiness or uncleanness, indicative of social pollution.¹¹ The retest enabled them to deal with such feelings. It served as a transitional point which was viewed in one of two ways; either as the end of dirtiness or as the beginning of cleanness.

The end of dirtiness

For several respondents the significance of the retest extended to incorporate the symbolic significance associated with the infection and provided a means by which to deal with feelings of bodily pollution. It enabled them to know that they were clear of infection and therefore clean. The retest had ritualistic significance because it marked the end point of the cleansing process and enabled them to draw a line under this episode of their life.

• “I did for a bit [feel dirty] but not now, because now I'm thinking all clear.” (Andrew)

• “I don't know in the back of my mind if I'm 100%, if they think I've got it because I've not heard that I've not…. I'm not clean from it yet.” (Beccy)

• “I need that [the letter giving the results of the test of cure] to feel that I can, it's just like closure, I just need it to say this, this and this, it's done. I couldn't have come and had my antibiotics and then never come back again.” (Jenny)

The beginning of cleanness

As well as marking the end of the infected period, the pivotal positioning of the retest means that it also marks the beginning of the clear phase and for some it was this that appeared to have greatest significance. For those who were not currently in a sexual relationship it enabled them to move on and contemplate a new relationship in the knowledge that the possibility of transmitting the infection to someone else no longer existed.

• “Another urine test, just to see that it has completely gone, and then I can start having a sex life again, when it's all gone.” (Tom)

• “I want to find out, to know that I'm clear and then if I want to start a new relationship with someone, then I'll feel more confident to do so.” (Beccy)

Within an ongoing relationship, when both partners had been treated and retested, the significance of knowing that they were both free from infection lay in the safety it afforded. The demonstrated lack of infection within that relationship enabled decisions to be made about future contraceptive usage and provided sufficient justification for cessation of condom usage.

• “C and I have been tested for lots of things and we know we've not got anything else. I think as soon as this is cleared up I don't think we'll be using condoms again. I know that everything is cleared up and we don't like using them anyway.” (Angela)

• “When we've both been cleared and we both know that we haven't got anything, if I'm on the pill we don't necessarily have to use condoms all the time, because if we both know that we're clear of everything….” (Margaret)

For most this was viewed as a positive outcome of the situation because of their dislike of condoms. However, one woman who preferred not to use hormonal contraception and another who favoured dual method usage for contraceptive effect acknowledged that the clean bill of health effectively undermined their contraceptive decision making by removing one of their main arguments for condom usage.

Confirmation of the absence of infection effectively drew a boundary around that relationship; however, it was clearly recognised that the safety this provided was contingent upon sexual exclusivity. The boundary therefore was viewed as a benchmark against which any subsequent infection that may occur within that relationship could be interpreted. As such, subsequent infection was interpreted as a visible indication of extra‐relationship sexual activity both theoretically and in reality.

• “When my partner's all clear, we're both all clear now and that if one of us got it again it means that one of us has been sleeping with someone else so we'd know.” (Anne)

• “He told me he'd had chlamydia before and he told me just before we got together that he'd come here and been cured of it, so from that point of view it shouldn't be in our relationship and it is.” (Jodie)

Discussion

One possible reason for placing high value on the test of cure relates to asymptomatic infection. As a physical manifestation of infection, symptoms serve two important functions; their presence indicates the presence of infection, while their absence indicates absence of the infection. The lack of symptoms associated with chlamydial infection makes it equally difficult for someone to make these judgments about the presence or the subsequent elimination of infection. One might expect therefore that the retest would have greater significance for those who did not experience identifiable symptoms of chlamydial infection and this is supported to some extent by the data.

The retest served a purpose that was related to, but distinguishable, from the medical rationale. While the medical purpose of retesting is to identify infection in those in whom it is present, either because it has not been eliminated or because of re‐infection, for the respondents in this study, the significance of retesting resided in not identifying infection when it was not present.

Van Gennep¹² draws attention to the way in which the life of any individual within society is marked by a series of passages from one phase of life to another. These rites of passage exist wherever there are social distinctions such that life is constructed from a succession of stages. Culturally defined significant life stages are readily apparent and marked to a greater or lesser extent by formalised rituals; however, rites of passage may accompany any change from one state to another.¹³ Rites of passage, whatever their context or purpose, are characterised by the three stages of separation, transition, and incorporation. Separation marks the detachment of the individual from a fixed point in the social structure. This leads to a liminal or transitional period, during which the state of the subject is ambiguous. Incorporation marks the consummation of the passage and entry into a new stage of life. In a comparable health context, Forss et al identify how the cervical smear which women expect to confirm their state of cervical health projects them into a liminal state when they receive a diagnosis of cellular abnormality, a situation that is “betwixt and between,”¹³ neither confirmed health nor confirmed disease.¹⁴

In terms of chlamydial infection, diagnosis of infection projects an individual from an unknown to a known infected state. This is a liminal state within which there is recognised danger both to self and to others. Danger to herself resides in her physical state of infection and her social state of otherness. As a source of infection, she also represents a potential source of danger to others. While the treatment is the pharmacological means by which the infection is eliminated, it is the test of cure, the evidence of freedom from infection that constitutes the post‐liminal rite. Retesting provides a ritualistic process that marks the transition from the state of liminality to the incorporation phase and occupies a pivotal position marking the symbolic boundary between the infected and uninfected state. It may therefore be viewed either as the end of the infected state, the end of dirtiness or the beginning of the uninfected state, the beginning of cleanness. Within either of these understandings the retest functioned as a form of ritualistic cleansing.

Key messages

• When retesting after chlamydial infection is available in genitourinary medicine clinic, the follow up visit is understood in terms of retesting

• Retesting is invested with symbolic significance, providing the means by which to deal with feelings of bodily pollution

• An imperative to know that one is clear of infection has potential resource implications for the national chlamydia screening programme

This paper highlights the symbolic significance that is attached to one aspect of infection management. This derives from the sociocultural construction of the infection; a perspective that merits consideration because it is so central to the patient experience.

There are limitations to the study. While retesting was important to men and women, the small proportion of males mean that it is not possible to comment on its relative importance to either gender. Additionally, efforts to include those who had not been retested were unsuccessful and it is therefore not possible to represent their views.

The extent to which feelings of dirtiness persist when retesting is not available and the possible impact of this on screening services is a matter of consideration. As screening becomes widespread with implementation of the national screening programme, the number of diagnoses in asymptomatic individuals will increase and the availability of retesting is likely to decrease. An emphasis of the programme is easy availability and patient initiated screening.¹⁵,¹⁶ The extent to which individuals start to use screening for retesting, to confirm that they are “clear” merits investigation because the consequent cost and resource implications may be considerable.

Abbreviations

FP - family planning

GUM - genitourinary medicine

TOC - test of cure