Facilitators and barriers to patient-delivered partner therapy acceptance for Chlamydia trachomatis among young African American men who have sex with women in a Southern urban epicenter

Abstract

Background:

Chlamydia trachomatis (Ct) disproportionately affects African American young people living in the Southern United States and can have negative consequences if left untreated. Patient-delivered partner therapy (PDPT) is an evidence-based practice in which individuals diagnosed with Ct can provide treatment directly to their sex partners. However, PDPT acceptance rates need improvement. Although reasons for PDPT acceptance have been explored previously, the facilitators and barriers to EPT acceptance among young southern African American men who have sex with women have not yet been examined.

Methods:

Twenty semi-structured interviews were conducted as part of a community-based Ct screening and treatment intervention among African American men ages 15–25 who had female sex partners. Participants were asked about why they did or did not accept PDPT for their sex partners. Data were transcribed and analyzed in NVivo qualitative software using an inductive thematic approach.

Results:

Participants’ decision-making was multi-faceted. Facilitators for PDPT acceptance included being able to cure their partner, convenient access to treatment, believing it was the right thing to do, having a close relationship with a partner, concern for the partner’s well-being, and the perceived severity of Ct. Barriers to PDPT acceptance were the belief that a partner did not need treatment, not having a close relationship with the partner, being unable to contact the partner, and fear of conflict.

Conclusions:

Findings had similarities to other studies, indicating some universal messaging may be warranted alongside culturally-tailored interventions for specific patient populations to increase PDPT acceptance. Implications for patient-provider communication are provided.

Short Summary:

Based on in-depth interviews, young African American men with female partners living in a major Southern city had multifaceted facilitators and barriers to patient-delivered partner therapy acceptance for Chlamydia trachomatis.

INTRODUCTION

Chlamydia trachomatis (Ct) is the most common reportable sexually transmitted infection (STI) in the United States, with more than 1.8 million cases diagnosed in 2018.¹ Ct rates have climbed across all populations in the past several years, but particular sub-groups are disproportionately burdened, including young people ages 15–24, African Americans, and those living in the Southern United States.¹ Although reported Ct cases are substantially higher among women than men, likely due in part to more women being screened, Ct rates among men have increased by 38% over the past four years.¹ Young Black men are disproportionately affected, with Ct rates far exceeding those of young men and women of other race/ethnicities.¹ The burgeoning rates of Ct are of great concern given the potential for serious health complications, particularly among young women. If left untreated Ct can lead to pelvic inflammatory disease, which in turn can cause chronic pelvic pain, infertility, and ectopic pregnancy.¹ Infected men serve as a reservoir for Ct transmission, and can suffer from urethritis, scarring of the reproductive tract, epididymitis, and possible infertility.^1,2 Ct can also increase susceptibility to HIV.¹ Due to its severity, Ct testing is recommended annually for all sexually active women under the age of 25.³ Despite this recommendation, Ct screening among young women is low,⁴ enabling the continued spread of Ct.

Expedited partner therapy (EPT) is the clinical practice of providing treatment for the sex partners of a diagnosed patient without them needing a secondary examination.⁵ This can be done by the health care provider writing prescriptions or through patient-delivered partner therapy (PDPT), in which patients are also prescribed medication to give directly to their partner(s). Recommended by the CDC and numerous other medical and public health organizations, EPT is a growing practice among health care providers^6,7 and has demonstrated effectiveness at reducing repeat Ct infection and increasing rates of partner treatment.⁸

The success of EPT, and particularly PDPT, is contingent on index patient acceptance, meaning the patient is able and willing to provide the prescription or medication to their partner(s). There is considerable variability across studies regarding EPT/PDPT acceptance. Layton and colleagues’ 2020 systematic review on PDPT for Ct in high-income countries found that although patients generally have a high perceived willingness to give PDPT to their partners (between 45%−96%), the actuality of patients providing PDPT to partners is much lower (between 24%−71%).⁹ Further, Mickiewicz and colleagues found that men were 40% less likely than women to accept EPT for their sex partners, and Black/non-Hispanic patients were 20% less likely than White/non-Hispanic and Hispanic patients to accept EPT for their sex partners.¹⁰

Several studies have examined why index patients do or do not accept EPT/PDPT for their partners. Commonly identified reasons for acceptance include benefiting a partner’s health, preventing reinfection, having a long-term or steady partner, and convenience.⁹ Conversely, patients may not accept EPT/PDPT for their partners if they have concerns about a partner experiencing adverse health effects, apprehension about not getting the prescription or medication directly from a healthcare provider, or if provision is for an ex-partner or casual partner.⁹ Despite the emergence of literature on EPT/PDPT acceptance in recent years, there is limited research focused solely on EPT/PDPT among adolescents.¹¹ Further, to the authors’ knowledge, there have been no studies examining PDPT acceptance among young African American men who have sex with women living in the Deep South, two groups facing some of the most severe Ct disparities. This paper therefore fills this gap by examining facilitators and barriers to PDPT acceptance among African American young men ages 15–25 who have sex with women living in a metropolitan area in Louisiana that has the second highest rate of Ct in the United States.¹

METHODOLOGY

Recruitment and Procedure

This qualitative study is part of a larger research project evaluating a city-wide Ct reduction program called Check It. Briefly, Check It is a community-based bundled intervention that engages young African American men who have sex with women through a modified version of the Seek, Test, and Treat model.¹² Check It recruits participants in the community venues they frequent (e.g., barbershops, recreation centers, local Historically Black Colleges and Universities [HBCUs]), offers a modest monetary incentive for them to get tested for Ct, provides free treatment at local pharmacies convenient to participants who test positive, and provides free PDPT for the participants’ sexual partners. Specific to PDPT, when a participant tests positive for Ct they are contacted by a Check It staff member to discuss their results and to encourage them to request PDPT for their recent sex partners. More information on Check It can be found elsewhere.¹³

Semi-structured interviews were conducted to learn more about participants’ experiences with Check It, and particularly with PDPT. The sample consisted of previously enrolled Check It participants who tested Ct positive who agreed to be contacted for future research during the original Check It consent process. Efforts were made to diversify interviewees based on age, college enrollment status, and Check It enrollment site. In general, interviews took place approximately one month after participants enrolled in Check It. Three Check It staff trained in effective interviewing techniques conducted the interviews. Interviewers had similar demographic characteristics as the participants as this is a known strategy to increase research participants’ comfort level in discussing sensitive subjects.¹⁴ Interviews were conducted at a locale convenient for each participant, such as a private space in the library for college-enrolled participants, a local coffee shop or restaurant, or the research team’s office. Participants were offered $50 as an incentive.

Participants provided informed consent prior to beginning the interview via a written consent form. The interview guide included questions about each stage of the Check It program. Questions specific to the current study asked if participants told each of their recent sex partners about their Ct diagnosis and offered PDPT, why or why not, and for those who did, what the interaction was like. Interviewees were recruited until saturation was reached, meaning no new information was given.¹⁵ Twenty interviews were conducted, ranging in total time from 24 to 64 minutes, with a mean time of 38 minutes. Interviews were digitally recorded and transcribed verbatim. Prior to analysis the research team had ongoing meetings to discuss each interview and to gather insights from the interviewers. This contextual information was added as notes to each interview. The study was approved by the authors’ Institutional Review Board.

Analysis

Transcripts were analyzed in NVivo 12. Two coders used an inductive thematic analysis approach.¹⁶ First, they independently reviewed all interview transcripts to generate an initial list of facilitators and barriers to PDPT acceptance. Then they collaboratively created a preliminary codebook. Next, they coded two interviews independently to assess the codebook’s functionality and completeness. Interrater agreement was examined to ensure reliability and reproducibility using NVivo analytics, taking unitization into account.¹⁷ Discrepancies were discussed until consensus was reached, resulting in minor changes to the codebook. The coders completed this process three more times prior to finalizing the codebook, at which time interrater agreement was high. Both researchers then dual coded the remaining interviews and re-coded those coded initially. Upon completing the coding process, all content associated with each code was collated and reviewed, and as appropriate some conceptually similar codes were combined and those with few endorsements were removed, resulting in a finalized set of themes. Exemplar quotes were selected to illuminate each theme.

RESULTS

Participant Characteristics

As shown in Table 1, participants (N=20) were between 15–24 years old, with a mean age of 20 (SD=2.71). Sixty percent were in high school or college. As a proxy for socioeconomic status, just under half of the participants reported that in the last 12 months they or someone they lived with received government assistance (e.g., food stamps, WIC, Section 8 housing). Most participants reported having fewer than ten lifetime female sexual partners, with approximately one-quarter having only one or two partners. No participants reported ever having a male sexual partner. Just over half of the participants indicated that they had been tested for Ct previously, with one participant reporting having been formerly diagnosed with Ct. Sixty percent requested one or more doses of PDPT for their current or former sex partners.

Table 1:

Participant characteristics (N=20)

Participant Characteristic	n or x̅	% or SD
Age	x̅ = 20.00	SD = 2.71
Currently in school	12	60.0%
Receives government-sponsored assistance	9	45.0%
Lifetime number of female sexual partners
1–2 partners	5	26.3%
4–6 partners	7	36.8%
7–9 partners	3	15.8%
10+ partners	4	21.1%
Previously tested for chlamydia	11	55.0%
Previously diagnosed with chlamydia	1	5.0%
Requested 1+ PDPT	12	60.0%

x̅ = mean; SD = standard deviation

Not all participants answered every demographic question. Valid percentages are presented.

Facilitators and Barriers to PDPT Acceptance

Several facilitators and barriers for accepting PDPT were identified as themes. They are described in more detail below and summarized in Table 2.

Table 2:

Facilitators and barriers for PDPT acceptance

PDPT Facilitators

Being able to cure partner’s Ct

Convenient access to medication

Believing it’s the right thing to do

Having a close relationship with partner

Concern for partner’s well-being

Perceived severity of Ct

PDPT Barriers

Belief partner doesn’t need treatment

Not having a close relationship with partner

Unable to contact partner

Fear of conflict with partner

PDPT Facilitators

The most common facilitator for PDPT acceptance was being able to cure a sex partner of Ct. As one participant recounted, “I told her I had the medicine for her to get cured” (#4180). Participants also discussed wanting to cure Ct among past or current partners to stop the spread of Ct infection to others. For example, “But it’s good because like, you know, I ain’t want her to be passing whatever she, you know, to- to the next person” (#4174). A few participants expressed that they wanted to cure a specific partner who they thought was either responsible for infecting them or who they thought they may have infected.

Participants also talked about the convenient access of PDPT being a facilitator. As one participant said, “Like I could just go right there and get [the medicine], for them too, they don’t have to like go anywhere, like yes. That made me try to hop on it as quick as possible” (#4212). Some participants also discussed how having the medication immediately available could ease the disclosure of having tested positive for Ct and subsequent conversation. According to one participant, “So instead of just like [laughs] bringing bad news... I got some bad news but something to clean it with, you know?” (#4712).

Several participants expressed feeling obligated to offer PDPT to their partners because they believed it was simply the right thing to do. As one participant said, “I just know that you gotta tell people, like- it’s like the right thing to do as a person” (#4714). Another participant voiced “I was like should I take this to the grave? I ain’t even gonna lie I had my thoughts, you know . . . I feel like, put myself in her shoes, you feel me, like if she found out before me and she didn’t tell me and just let me sit there, walking around with God knows what” (#4278).

Participants also discussed accepting PDPT for a partner due to being in a committed or long-term, although not necessarily monogamous, relationship. Of those, some participants talked about wanting to offer PDPT because communication was valued in their relationship. For example, after one participant told the interviewer that he had been in an eight-year relationship with his girlfriend and that they have open communication with one another, he said “We did the hiding and stuff from each other and fighting. And we, we done- we passed that level. Simple. We at the level where it’s- it’s on the future” (#4208). Another participant stated, “We like actually have good conversation, talk, like do couple shit . . . So that’s why I was more concerned for her. That’s why I told her” (#4202).

Although a primary theme among participants was the closeness of their relationship being a facilitator to accepting PDPT for their partners, a few participants discussed how not being in a close relationship made it easier to offer PDPT. One participant disclosed “Cuz it’s like it just depends on who you’re dealing with. If you dealing- there was somebody from like- like in my instance who I didn’t have no ties to it’s easy for you to be like yeah, like what’s up with this? Like I know I got this from you. But if you dealing with somebody you been in a relationship with you been knowing for some time...you don’t want to tell them that, you feel what I’m saying. That’s a hard conversation for somebody you [have sex with] cuz then how they gonna look at you afterwards?” (#4276).

Another facilitator was participants’ concern for their partners’ health. Sometimes this concern was associated with the closeness of the relationship, such as the previous quote from Participant #4202. However, there was not always a direct connection. For example, one participant said “Cuz like, you know, even though it’s like, you know, we not together like you know, I still have feelings for her. It’s not even about the feelings. It’s the fact that I care” (#4372). Another participant recounted talking with a partner he was no longer in a relationship with, “I’m saying I don’t know how long I have had it and I had sex with you so I’m trying to help you, you know” (#4098).

Participants also discussed their perceived severity of Ct as an influencing factor in their decision to accept PDPT for a partner. However, the belief that Ct was a serious health condition motivated some participants to offer PDPT, whereas the belief that Ct was inconsequential led others to offer PDPT. One participant described wanting to talk with his partner face-to-face, and said, “It was that serious to me. I was feeling like I was about to die so... I gotta get this to you ASAP” (#4372). Yet another participant asserted, “I mean, it’s nothing to address it and just see the outcome after that cuz it’s not like a death situation” (#4326).

Although not a primary theme, a few participants mentioned that no one else having to know about their partner potentially having Ct was a facilitator, especially if it could save their partner from needing to seek healthcare or could prevent embarrassment. For example, one participant affirmed “She ain’t have to go through all that I went through, you feel me?” (#4314).

PDPT Barriers

The most common reason participants discussed for not offering PDPT was the belief that their partner did not need treatment because they had already received it elsewhere or because they were not infected. Participants sometimes had information to reasonably draw this conclusion. For example, “I was supposed to give it to my- my female companion but when I told her . . . she went and got tested by her doctor” (#4278). Yet other times this belief was based on problematic assumptions. As one participant recounted, “I was uncomfortable because I didn’t know what she would say but she didn’t say anything so that’s when I assumed she already got treated for herself” (#4560). Participants’ suppositions about which partners needed treatment often related to who they believed gave them Ct. For example, one participant explained why he only chose one partner to accept PDPT for: “Nah not all of them because the majority of them, they was before the person I know I got it from, get what I’m saying? I know who I got it from so it was like why . . . imma call them and tell them?” (#4276).

Many participants discussed not wanting to give PDPT to sex partners they were not in regular contact with or did not feel close to. Some participants insinuated that offering PDPT would be emblematic of being in a more serious relationship. For example, when explaining why he chose not to give a partner PDPT, one participant said, “Yeah like we could mess around but other than that I’m not about to make it exclusive with you” (#4190). Some participants initially attempted to provide PDPT, but given their relationship status, did not persist in their efforts if challenges arose. For example, a participant who contacted his partner once but did not reach her explained he didn’t contact her again because, “It wasn’t really that deep to me, you get what I’m saying. . . . She didn’t text me back so I just left it at that” (#4276). Another barrier was the actuality or belief that a partner could not be contacted. For example, a participant explained why he didn’t request PDPT for one partner: “I don’t know where she moved out but she moved. She went ghost” (#4446).

Participants also discussed anticipating conflict with a partner as a barrier to offering PDPT. The conflict they were most often concerned about was accusations of cheating. As one participant described, “Because she always accuses me she’s like oh you’re cheating on me, you’re doing all this. I’m like no I’m not. I’m not. I never have in any relationship ever. . . . I feel so hurt and betrayed” (#4408). Another participant explained, “It’s gonna be the blame game. I’m not really- I’m not really down for the blame game and all that. . . . I’d rather not deal with it in the first place” (#4208).

DISCUSSION

This study identified numerous and often nuanced facilitators and barriers to young African American men living in the South accepting PDPT for their female sex partners. Many of the themes are similar to those established with other populations⁹ and have important implications for patient-provider communication and public health messaging. Facilitators primarily included participants’ altruistic intentions, including wanting to cure partners, to protect the broader community from infection, and to do the right thing. Ensuring partners receive treatment is one of the most common reasons why patients accept PDPT.⁹ One other study found patients’ desire to reduce the spread of Ct in the community to be a motivator for accepting PDPT,¹⁸ and two other studies have found that patients described accepting EPT as the responsible thing to do.^19,20 PDPT acceptance communication strategies could therefore appeal to patients’ sense of empathy and collective responsibility. These findings undercut problematic negative stereotypes of young African American men that permeate American society,²¹ and instead exemplify this community’s maturity, social consciousness, and regard for others.

Similar to other studies,⁹ participants also expressed that the convenience of PDPT enabled their acceptance. This may mean that PDPT could be even more effective at increasing partner treatment in comparison to the more traditional EPT method of writing a prescription. It is unclear whether patient acceptance or partner treatment differ based on providing a prescription for the partner versus the patient providing medication to the partner directly. However, a study among Check It participants found that when the intervention was adapted from providing EPT to PDPT, participants and their sex partners were more likely to complete treatment.¹³ More research is needed comparing EPT approaches.

Perceived severity of Ct was also a facilitator for PDPT acceptance, albeit there being a complex relationship. For some participants, fearing that Ct had serious consequences made them want to provide PDPT. For others, feeling that Ct had minimal health effects made it easier to do so. According to seminal health behavior theories, thinking that a health condition has negative ramifications is a pivotal determinant of health behavior. Yet there is also a delicate balance—people should feel threatened enough to elicit action, but not so endangered that they believe the consequences are inevitable.²² As such, providers should emphasize the seriousness of Ct if left untreated, paired with patients’ ability to prevent these outcomes through providing PDPT for their partners.

Participants’ impediments to providing PDPT included fear of conflict, particularly around allegations of cheating, not feeling committed to a partner, and the belief that partners did not need treatment. Relationship status has been found to influence EPT acceptance in many other studies; patients are consistently more likely to report providing EPT to current romantic partners than ex- or casual partners.⁹ Concerns about infidelity have also been previously identified.^23,24 Additionally, in their retrospective examination of patient medical records in New York City, Vaidya and colleagues found that patients’ belief that their partner had already been treated for Ct was one of the most common reasons why patients refused EPT, with 20.3% making this presumption.²⁵ The authors concluded that given the substantial number of partners who had received treatment elsewhere, overall partner treatment rates may actually be much higher than when considering EPT acceptance rates alone. Yet the current study has illustrated that while a patient’s notion that a partner has already been treated is sometimes based on direct communication, it can often be founded on assumptions or wishful thinking. Given this, providers may want to probe further when patients initially report that their partners have already been treated. To further encourage higher PDPT acceptance rates based on the barriers identified, patients could benefit from support with conflict resolution, unpacking potential suppositions about why their partners may not need treatment, and affirming the need for all partners to be treated, regardless of relationship status. For the latter, it may be worthwhile to underscore patients’ altruism and sense of decency. Helping patients to identify different and novel partner notification communication methods (e.g., phone call, text, Instagram direct message, snap chat) may be a helpful approach given that smart phone ownership and social media use are now ubiquitous among young people across gender, race/ethnicity, and socioeconomic status.²⁶

Behavioral determinants often vary by population.²⁷ Yet considering this study within the extant literature reveals that patients’ belief systems about PDPT acceptance may have more similarities than differences, indicating that some universal messaging may be warranted to increase PDPT acceptance. However, interventions that are culturally tailored and responsive to the unique needs, assets, beliefs, values, and preferences of a given population have the greatest likelihood of success.²⁸Areas for potential tailoring could include language used, visual representations, communication mediums, and how interpersonal interactions are portrayed, among others. Relatedly, in prior research with Check It participants, they responded favorably to having a medication mail-delivery option, and when participants were informed about their Ct status and encouraged to engage in PDPT by individuals they considered friendly and non-judgmental, they were more likely to treat both themselves and their partners.¹³ Yet the complexity of the facilitators and barriers identified (for example, participants having differential reactions to perceived severity and relationship closeness) demonstrates that a one-size-fits-all approach may be insufficient. Rather, individuals’ motivations should also be incorporated into interventions, as they may necessitate differing approaches.

In a similar vein, although there is now substantial literature about patients’ EPT/PDPT decision-making, little work has been done to systematically translate this research into practice. As a next step, healthcare providers’ standard of practice regarding their provision of PDPT, including patient communication and health education materials, should be assessed. One recent study examining health department websites found that EPT informational materials had little information for index patients, and what was available was inadequate in terms of readability and content.²⁹ Future research should therefore also examine how implementing new intervention strategies could increase patients’ PDPT acceptance. It must also be noted that problems with EPT/PDPT uptake among healthcare providers are well-documented and include lack of knowledge, perceptions of sub-optimal care, and legal challenges.³⁰ Addressing these provider obstacles will be necessary to increase provider uptake while also working to mitigate barriers for patients to ensure that EPT/PDPT can be a widely available and accessible treatment option.

A possible limitation of this research is its transferability, meaning its applicability beyond the current sample.¹⁵ Interviewees’ participation in the Check It program is a contextual factor that has the potential to make the present sample distinct from the general population of young African American men living in the South. Interviewees’ possible self-selection effect may also be a transferability concern, as the sample consisted of a subset of former Check It participants who agreed to be contacted for future research, and among those, who were willing to participate in the current study. However, this potential bias should have been minimized as participants were told that the study was about their experience in the overall Check It study, in which PDPT was only one part, and incentives were provided to garner wider participation. Yet it remains possible that individuals who agreed to be interviewed may have been more inclined to help others or may have been more invested in the program, their sexual health, or the sexual health of their partners. Further, because the interviewers were affiliated with the Check It study, some participants had interacted with them previously. The decision for Check It staff to serve as interviewers was purposeful because participants generally had a positive rapport with the Check It team, which was deemed especially important given the sensitivity of the interview content. Therefore, although participants seemingly provided frank accounts of their experiences, interviews may still have been subject to social desirability. Additionally, the study’s sample size was sufficient for qualitative research given saturation was reached,¹⁵ but because the sample was small, other analyses that may be of interest such as the quantification of the facilitators and barriers identified were less apropos for the study’s inductive thematic methodological approach. Future quantitative research could be done to examine the facilitators and barriers established in this study among a larger sample.

Despite these considerations, this study identified important information corroborating previous research and extending it to a new population that faces major Ct health disparities. Results demonstrate multifactorial influences on PDPT patient acceptance, yielding numerous implications for health communication messaging and patient-provider counseling.