Chlamydia and Social Factors in Omaha

Alicia Luis, Al Muhannad, Kenadee Roepke, and Sarah Schissel

Introduction

According to Get Checked Omaha (2016), Omaha has been ranked as having one of the highest chlamydia rates of all major U.S Cities. Omaha also ranked 12th nationally in the 2007 “Big Cities Health Inventory” for Chlamydia incidence rates, (Get Checked Omaha, 2016). Our research project will be centered in identifying the contributing factors to why Omaha’s chlamydia rates are at an all time high in the U.S. Another aspect of the project will be looking into how different age groups have access to testing in different areas in Omaha affects the rates of chlamydia in different age groups. Our conclusions will be drawn from interpreting information from The Charles Drew Health Center, Creighton Community Health Center, Douglas County Health Department STD Clinic, Get Checked Omaha, Methodist Hospital Renaissance Health Clinic, OneWorld Teen & Young Adult Health Center, and Planned Parenthood. Our group will look into how many clinics are accessible according to different areas in Omaha (Central, North, South, and West). With the research done, more people can find out about the different techniques organizations use to deliver information about chlamydia to educate the residents of specific areas and how that can relate to the high rates of chlamydia in Omaha.

Methodology

To begin our research project, our research group collected and discussed the importance of each sociological scholarly articles, in total sixteen, that were relevant to our research project. Everyone selected different clinics to visit, and individually visited clinics all around Omaha to collect our secondary data. The clinics that were visited were the following: The Charles Drew Health Center, Creighton Community Health Center, Douglas County Health Department STD Clinic, Methodist Hospital Renaissance Health Clinic, pic-2OneWorld & Young Adult Health Center, and Planned Parenthood. The image to the left shows a map where we pinpointed all six different clinics that were visited. The secondary data consisted of flyers and brochures that were either in the waiting area or had to personally ask for. The website for all the clinics that were visited were also analyzed. Afterwards the important themes to the secondary data were discussed and selected and began to code our data. Afterwards, we visited and analyzed the map that included locations to get free or low-cost testing and treatment from Get Checked Omaha. Afterwards we visited the CDC website to figure out which racial groups were the most susceptible to Chlamydia infection in Nebraska.

Findings

When looking through Get Checked Omaha’s website, they provided a graph that showed chlamydia cases by age group (2015). From analyzing this graph, the most susceptible and pic-3-1vulnerable groups are first twenty to twenty four year olds, then fifteen to nineteen, and finally twenty five to twenty nine year olds. The age groups above or below these ages are significantly lower. Analyzing the secondary data, it was found that there were five common themes among all of our data. These themes include gender, symptoms, illustrations, prevention, and services. Our data consists of collected brochures from six different health clinics and hospitals in the Omaha area. We decided to eliminate Creighton Community Health Center from our research because they only provided one sheet of information. They had provided one sheet of paper from the CDC which normally is a two page fact sheet. The first page doesn’t include enough information for the reader to be informed of chlamydia. This shows the unprofessionalism that Creighton Community Health Center has towards its visitors.

Gender

In our research we found one of the main themes throughout our data was gender. This is an important theme. It is important that each gender, male and female, know what they can expect to experience if they have chlamydia. Throughout the data collected from Planned Parenthood, OneWorld, Douglas County Health Center, Methodist Hospital and Charles Drew Health Center, we found the occurrences of gender throughout. The theme of gender also correlates with the other themes, such as symptoms and illustrations.

In all of the data besides the Charles Drew Health Center and Methodist Hospital, the symptoms were separated by gender. Methodist Hospital only gave brochures with information for males, but this can be explained by the fact that it was a male asking for the information. The Charles Drew Health Center was abnormal in the fact that, while it was a male asking for the information, they only gave a brochure with information for women and what to do if they had chlamydia while pregnant. This information does not help the male gender with being able to better their well being.

Throughout the data, another thing we noticed pertaining to gender is the use of illustrations. More often it was found that they would use pictures of women instead of men. This can be a problem, because it may make men feel uncomfortable asking for help if they think it is normally a problem pertaining to women. Psychologically, it can make a man feel worse for having it and feel rather abnormal. The reason behind having more illustrations of women rather than men, is that women could be seen as more comforting. Seeing a woman on a brochure may cause the patient to be more relaxed  and feel more at ease with getting help. Another reason behind having more illustrations of women rather than men, is that generally, chlamydia affects more women than men.

In the data, it was also noticed that gender and illustrations coincided with the use of diagrams. This is very beneficial. When it comes to anatomical diagrams of the reproductive system, it is important for both males and females to have the correct diagram. It is also important to have these gender specific diagrams, because patients need to be aware of how parts of their body are being affected.

Symptoms

Throughout our research we found that most clinics say most of the same things about symptoms. The data we found was that most people don’t have symptoms or the symptoms they do have make them think it is a urinary tract infection. The symptoms vary between genders but are mostly the same with burning while peeing, pain it the pelvic region, and possible bleeding and/or a yellow white discharge. Some symptoms are different among genders because of their anatomical differences like for example males may experience pain or swelling in the testicles.

Most teens and young adults are too scared to get tested or may think it’s not necessary to get tested. They may be scared of what people might say or may be frightened that their if parents will find out. This can be very dangerous, because often after someone has unprotected sexual intercourse, they may not experience any symptoms of chlamydia and thus they may believe it’s not necessary to get checked. According to a brochure provided from Planned Parenthood, 75% of women and 50% of men are asymptomatic. When males and females do experience symptoms, the most common symptoms are the following: pain in the lower abdomen, pelvis, testicles, and vagina, pain occurrences during sexual intercourse, and also abnormal discharge or bleeding.

        Some of the flyers and brochures that were collected did not have information about symptoms on them to inform people. The STI sheet (picture to the right) and the Teens pic 4 (1).PNGand STDs flyer did not include this information. It is important to have information about symptoms in all flyers and brochures. It is especially important to have information about symptoms in the teen flyers because they are among one of the most vulnerable groups. Having information about symptoms would help encourage teens to get tested, because they could be more likely to know if they have chlamydia. In the flyers that did indicate the symptoms some of them categorized them by gender such as; STD facts, the CDC fact sheet, the Methodist hospital flyer, and the Planned Parenthood flyer. This can help with knowing your symptoms specifically based on if you are male or female, and it could give you more information to be prepared with.

Illustrations

The illustrations are a vital part on getting the word out about chlamydia, to show how pic 5.PNGstigma affects everyone, especially the people who don’t get tested just because they don’t want to be judged. Most of the brochures that we picked up from different clinics had some sort of illustrations, these illustrations were used to lighten up the mood (as shown in the picture), and to make it more appealing for young adults to pick them up.

The illustrations also showed different models from different races, to show that chlamydia is not only for one race but for everybody to be careful from, this would create a larger audience and a better chance of more people to get tested than just a specific audience. An observation made was that more flyers had more pictures of minorities. The reason behind this is that chlamydia affects minorities the most.

Only one clinic, Methodist, didn’t have any type of brochure to give out, they do all of the testing that a normal clinic would do. The problem is that no one knows about them, and even if they did, they would have to walk in and ask to get tested by themselves. This can actually prevent them from even walking in to begin with.

Prevention

The way prevention for chlamydia is advised can differ between age groups. In the brochures and flyers that were directed towards teenagers were more straightforward to pic-6advise, “Don’t have sex.”  They did not include much information about prevention or non at all sometimes. In fact, they wrote the pronunciation to chlamydia as “Kla-MID-ee-uh” in one of the teen brochures. This makes it reasonable as to why they would not include explicit content on there, such as information advising about non-monogamous relationships or talk about any symptoms at all. However, they did incorporate advice if you do happen to have sex. This covered, “Use condoms correctly, talk to your partner, don’t have sex under the influence, and get checked.” Although they did include this information, they were very brief about it. This is bad, because teenagers are the second most vulnerable group. This can in return cause lack of awareness for these teenagers.

An interesting finding is that the teenager flyers and brochures worded the information in a manner to be understood by really young readers. The young adult and adult ones used wording that fits the general public. They included more information such as the effective way to use condoms and alternatives to use latex free condoms in case of having an allergy to latex. They include more explicit content such as advising to be in a monogamous relationship with someone who has tested negative to a sexual transmitted disease test. This is really useful information, because often times people get in a relationship with someone new but are afraid to ask about them being tested before.

About half of the flyers and brochures didn’t include methods of prevention. This is not acceptable, because not everyone who seeks information about chlamydia is worried about having it. There are possibilities of someone wanting to know about the possible threats to having sexual intercourse, and how to avoid from getting sexually transmitted diseases such as chlamydia. That is why it is important to include more information than just abstinence. Abstinence is not the answer, well not a reasonable one. If abstinence was the answer for everyone then we wouldn’t have such high rates of chlamydia incidence in Omaha.

Services

Services was an important theme to touch base on. There are a lot of services available to the public through all of these clinics. The Women’s Fund of Omaha began the Adolescent Health Project in which they distributed funds to the following eight organizations: Charles Drew Health Center,Douglas County Health Department, Nebraska AIDS Project, Nebraska Urban Indian Health Coalition, North Omaha Area Health, OneWorld Community Health Centers, Planned Parenthood of the Heartland, and United Way of the Midlands. The project includes a cutting-edge media campaign. Their goal was to increase availability of free sexually transmitted disease testing and Treatment in Omaha.

Douglas County offers testing & treatment for chlamydia. They offer “Express Testing” for chlamydia for fast results. They also offer confidential counseling about risk reduction, partner notification, and disease information available. The fact that they are willing to discuss about partner notification is very important. There should be more awareness about the willingness to notify all possible partners you have had unprotected sex while having the disease. They also offer free condom distribution and education about the use of them. Best of all, they also offer free screening and treatment for those who are twenty four years and younger. If you are twenty five years or older it costs fifteen dollars.

OneWorld Teen & Young Adult Health Center offers confidential STD testing and treatment. This is important, because a lot of teens might be afraid to seek a healthcare provider, because they believe they have to go with a parent to get checked and treated. Testing includes a urine test and a pelvic exam if you find necessary. They now have included behavioral health counseling where they are open to talk about anything worrying you. They have free STD Testing for young adults under the age of twentyfive. They distribute free condoms, dams, and lube at their clinic.

The Charles Drew Health Center has a new Adolescent Health Project. They are similar to OneWorld. They provide comprehensive sexually transmitted disease testing and treatment at low or no cost. They give free rapid result testing. They have incorporated a behavioral health service component for individuals fifteen through twenty four years of age. They also have walk-ins available depending on their availability. Planned Parenthood tests for chlamydia using a urine sample. They provide counseling and confidential testing for STDs. They provide STD prevention, including condoms, female condoms, dental dams, and a hepatitis B vaccine. Other clinics such as Methodist Hospital Renaissance Health Clinic does not make a big emphasis in STD awareness. They will only provide testing and treatment if needed.

Finally, we looked at the map provided by Get Checked Omaha (2016). This map includes pic-7the locations where teenagers and young adults can receive free or low-cost testing. There are thirty five total locations that are pinpointed in this map. Out of these thirty five locations, there are only three locations that do not offer free testing and their prices range from ten dollars to twenty five dollars. There are three locations listed under South Omaha, four locations listed under Midtown, six locations in West Omaha, two listed under Council Bluffs, two listed under colleges, and eighteen under North Omaha. The question that came up was, Why are there so many locations in North Omaha compared to the rest?

The CDC provided a database where you could create a chart to look at the rate of pic-8chlamydia per 100,000 by race and ethnicity. To create our chart, our query criteria was restricted to only chlamydia in Nebraska, included all genders, race/ethnicity, and from years 2010-2014. The results were grouped by race and ethnicity.

In the chart and table shown below, the results show that Black or African Americans have a much higher rate than any other race or ethnicity. Black or African Americans have a pic-1rate of 1,597.15 per 100,000 cases. American Indians or Alaska Natives have a 593.92 rate per 100,000 cases. Third comes Hispanics who have a rate of 320.37 per 100,000 cases. Fourth are the Asians or Pacific Islanders with a 157.95 rate per 100,000 cases. Not so far behind is the White race with a 143.87 rate per 100,000 cases. It is now reasonable why there are more locations available in North Omaha.

pic-9

Analysis

The findings in the data collected relate back to the “Gender and Age Disparities in the Prevalence of Chlamydia Infection Among Sexually Active Adults in the United States,” scholarly article by showing that everyone is susceptible to getting Chlamydia. It was also found that groups without access to testing were more at risk because without testing, there is no treatment. As a result of no treatment, the infection will keep passing on to everyone that the infected person has sexual contact with. Nothing in the data collected expressed any concern about the correlation with alcohol and drug use with testing positive as the scholarly article found as well.

The “A Novel Public Library-Based Sexually Transmitted Infection Screening Program for Younger High-Risk Groups in Omaha, Nebraska, USA,” scholarly article was about being tested for both Gonorrhea and Chlamydia. It focused on the communities of North Omaha in Douglas County. Some things that had stopped them from getting tested in the past were lack of insurance, no transportation, etc. Through the study they had a program where the community was able to get tested in libraries. Through their research they found that this attracted both younger people and more blacks, while less Hispanics came versus a traditional clinic. In our data we found that finding information about where to get tested can be hard if you do not have transportation and or have access to the internet. This is especially true in low income neighborhoods and families. To find proper information about chlamydia, we had access to both. It also relates with the data found on there being more clinics located in North Omaha.

The “Young Women’s Decisions to Accept Chlamydia Screening: Influences of Stigma and Doctor-Patient Interactions,” scholarly article is about interviews done towards a group of women in Dublin and Galway Ireland. These interviews asked these women how they felt about being offered a test for chlamydia and by who they would want the test from. The women were worried about being stigmatized and especially if they were young and lower socioeconomic backgrounds. They would also prefer to be given a test by a female nurse or doctor their own age. It was found that if professionals want women to get tested for chlamydia they need to work on reducing the stigma to getting tested. In the data collected, it was shown that women are more often showed in illustrations than men and in the scholarly article it showed that women are the ones that are most stigmatized for having Chlamydia.

The “Gonorrhea and Chlamydia Infection Among Women Visiting Family Planning Clinics: Racial Variation in Prevalence and Predictors,” scholarly article was about testing of white and black women in a family clinic in Missouri. They wanted to find out the differences between the two groups. The majority of the women sampled were white and half of the women were between ages eighteen and twenty one. It was discovered that the younger you are the higher the risk you are at. White women who were just at the clinic for family planning were less likely to be found infected than black women who were just there for family planning. Overall, black women are at a much higher risk of being infected with Chlamydia than whites. This relates back to our research because it shows how certain minorities are more at risk for getting infected with chlamydia like it is herein Omaha.

The “Addressing the Increasing Burden of Sexually Transmitted Infections in Rhode Island,” scholarly article shows how the rates of STI’s are dramatically increasing across the U.S., including Rhode Island. The most commonly reported STI is chlamydia. In 2012, there were 1.4 million cases reported to the CDC. During the time span of 2008-2012, there was a 25% and 11% increase among men and women. The majority of cases were in males more commonly among gay and bisexuals. The CDC suggested that schools increase the talk about “safe sex.”. This is relative to our research because in Omaha chlamydia is one of the fastest growing STDs like Rhode Island.

The “Gender and Age Disparities in the Prevalence of Chlamydia Infection Among Sexually Active Adults in the United States,” scholarly article described how age and gender could affect chlamydia. Adults younger than twenty five were slightly affected more than those twenty five or older. It also occurred more frequently in females than males. Commercial sex workers, homosexual men, and injection drugs users are at higher-risk to get chlamydia. This relates to our findings from the graph provided by Get Checked Omaha. The most susceptible and vulnerable groups are first twenty to twenty four year olds, then fifteen to nineteen, and finally twenty five to twenty nine year olds and this correlates with the findings from this scholarly article.

In the “Impact of Cervical Cancer Screening Guidelines on Screening for Chlamydia,” scholarly article, they assessed the impact of not doing routine cervical cancer screening on the rates of chlamydia screening in women aged fifteen to twenty one. There are an estimated 2.8 million new cases of chlamydia infections annually in the U.S. In 2009 the changed the age for screening to twenty one or at least three years after beginning intercourse. Doing this caused there to be less screening therefore increasing more chlamydia because those who are infected do not know they are infected and therefore infecting others. Getting screened helps so you know if you have Chlamydia without having symptoms. This relates to our findings by seeing that Omaha has created projects to help increase the access to free screening so that people will get screened and treated sooner.

The “Behavioral and Community Correlates of Adolescent Pregnancy and Chlamydia Rates in Rural Counties in Minnesota,” scholarly article discussed how co-occurring community risk factors, specific to rural communities, may suggest new strategies and partnerships for addressing sexual health issues among rural youth. Minnesota’s pregnancy and chlamydia infection rates among females fifteen to nineteen year old females were compared across eighty seven counties. They both were higher in rural areas. They are also higher among the American Indian and Latino sub-groups in those rural areas. This article relates with our research findings within the rates for each ethnicity and race. It was secondly prevalent in Native Americans and thirdly for Hispanics. This also shows how the minorities are more common of getting chlamydia as seen in our findings.

The “Bridging the Gap: Using School-Based Health Services to Improve Chlamydia Screening Among Young Women,” Scholarly article was about an implemented chlamydia screening program that was targeted at young women in a school-based setting. They required that 80% of the clients who received their service to be tested for chlamydia. A population of 3026 clients screened for chlamydia and only 5.6% tested positive. They found that African American, Pacific Islander, or Asian were more likely to test positive than White clients. Their overall results showed that they were able to identify and treat a significant amount of asymptomatic infections in a population that otherwise may have not been reached if they hadn’t implemented these programs. They suggest that their should be programs such as theirs implemented in other areas where women seek care so that more asymptomatic women can be treated in time. This relates back to our findings by comparing this program to the Adolescent Health Project in Omaha.

The scholarly article “The Potential Influence of a Social Media Intervention on Risky Sexual Behavior and Chlamydia Incidence,” was about how they developed a community Facebook page that aimed to reduce Chlamydia rates among residents of a Midwestern county for ages 15–24 years. The research included 966 people who accessed their website and completed a questionnaire. Afterwards they tracked the numbers of Chlamydia testing and positive cases among the target population prior and during their intervention. A Statistical analysis showed a reduction in the number of 15-17 year olds who tested positive for Chlamydia. In addition, 74% percent of participants reported the site impacted their decision to reduce their number of sexual partners is consistent with findings. This relates back to our research by comparing the media campaign from the Adolescent Health Project to theirs.

The “Chlamydia screening of adolescent and young adult women by general practice physicians in Toronto, Canada: Baseline survey data from a physician education campaign,” scholarly article talked about how they surveyed 251 practice physicians. A 90.6% physicians said they would be very likely to recommend Chlamydia testing for 15-24 year old patients in different contexts or types of visit. In the total, a 22% reported doing assessments 76-100% of the time with 15-19 year old female patients in the past month; a comparable 24% did so with 20-24 year olds. Results also showed that female physicians are more likely to perform chlamydia testing. A common barrier discussed was not having enough time. This relates back to our research by supporting the Adolescent Health Project because their aim is so that more people have access since hospitals don’t do a good job by themselves.

In the “Identifying Relationships Between High-Risk Sexual Behaviors and Screening Positive for Chlamydia and Gonorrhea in School-Wide Screening Events,” scholarly article, they discussed about how they gathered data from 8 school-wide screening events conducted biannually at a high school. They had a total of  869 adolescents between ages 14 and 20 who attended an education session and completed a sexual health questionnaire. 86.54% said they were sexually active and 69% consented to urine chlamydia and gonorrhea screening. Results showed that out of the 69%, 46 tested positive for chlamydia and/or gonorrhea. Results of the tests showed that females were more likely to test positive than males. They couldn’t tell if race played a role because of the demographics. This relates back to our research from the brochures collected since it showed pictures of more women since women are more likely to be affected.

The “”Pee-in-a-Pot”: acceptability and uptake of on-site chlamydia screening in a student population in the Republic of Ireland.” study talks about how we need to implement different strategies for chlamydia screening, so that young people are not hesitant to be screened. The strategy was to hand out small specimen bags containing a urine container, pen and information card. They just had to write their mobile number and date of birth. You could also get your specimen bag from the toilet area, so it was private. About 1,200 specimens were received, 7% of them was positively diagnosed. The study also interviewed the participants, all of them were excited on how private the testing was, where they were anonymous and packets were easily accessible. This study relates back to the clinics that offer confidential testing, when you visit a clinic like Charles Drew or OneWorld, they will not make it obvious that you are there to be tested whereas when you visit a STD oriented clinic, it’s obvious. Also, they maintain everything confidential so you do not need your parents to come along with you even if you are under 18.

The “Prevalence of Chlamydia trachomatis Genital Infection Among Persons Aged 14-39 Years — United States, 2007-2012.” study shows statistics about how young people under the age of twenty five and non-Hispanic Blacks have more occurrence of chlamydia than others. The study also mentions that not having multiple partners does not eliminate a person from the infection. This study relates back to our research, because the most susceptible ages for chlamydia are those between fifteen and twenty four. Also, African Americans were more prevalent to contracting chlamydia in Nebraska.

The “Promoting chlamydia screening with posters and leaflets in general practice – a qualitative study,” research article discussed how effective is the use of promotions and leaflets in influencing young man (ages 15-24) to chlamydia screening. Out of the 25 practices visited, 16 of them only used promotional leaflets for chlamydia. The doctors and nurses said that older people felt offended by the leaflets and asked to remove them from their faces. The research found out that young patients are less likely to read posters than older patients. This study relates back to our research in a way because sometimes we had to ask for their leaflets or any kind of informational flyer for chlamydia since they didn’t have them in their waiting area.

The “Pilot study of a brief intervention based on the theory of planned behaviour and self-identity to increase chlamydia testing among young people living in deprived areas.” study tries to implement a theory to understand the reasons why socio-economically deprived young people do or don’t get screened for chlamydia, called (theory of planned behavior). They created two study groups (intervention and control group). The intervention group was shown a video that tried to motivate them that getting tested is a “win-win” situation, and to show them that family are supportive in this matter. There was no discussion in this group, but the control group had discussion. At the end, when asked if they would have the chlamydia test, 57% of the intervention group said yes compared to 40% of the control group. This study relates back to our research with the Adolescent Health Project because their campaign is aimed to increasing testing in Omaha.

Conclusion

In conclusion, we have found that not one flyer, brochure, covers the amount of information needed in order to fully educate the reader about Chlamydia. This in return can show that flyers and brochures don’t help prevent chlamydia rates from rising, and in fact may be the reason why chlamydia rates are high in Omaha. If there isn’t proper information being delivered, then we have a problem. If teenagers and young adults are the most vulnerable groups according to Get Checked Omaha, it must indicate that their lack of awareness plays a role. Our findings indicate that most clinics offer a variety of services that are available for these vulnerable groups which might indicate why chlamydia rates in Omaha are high. Also, our findings indicate that there are more testing locations available to the Black and African American communities in North Omaha. If these vulnerable groups have access to free testing and treatment at many locations, then why wouldn’t they be tested? If they did not have access to such services, then maybe less people would be getting tested. This is especially relevant because not just anyone gets tested for chlamydia to begin with, because in more cases than less, is it asymptomatic. If there were to be less free services available to the teenagers and young adults, it would probably then lead to less people being reported and less contributing to the number of incidence rates of chlamydia in Omaha.

It is then speculated that beginning from the ages twenty five and older, they have less rates because they may feel unmotivated to get tested because they have to pay for such services, but that is just another hypothesis. To be able to prove that the incidence rates would decrease if there were less free services to the teenagers and young adults, there would need to be future research to focus on that. Perhaps for future research, an organization in Omaha can start providing free screening for ages twenty five and older and see what that leads to. Maybe after all Omaha isn’t as dirty as the stigma says, maybe other cities just don’t have enough free resources and therefore people are unmotivated to get tested for chlamydia which then would be reasonable why their incidence rates are not as high as they are here in Omaha. There is still future research to be done to be able to know all this.

 

References

Balfe, M., Brugha, R., O’donovan, D., O’connell, E., & Vaughan, D. (2010, September 19). Young women’s decisions to accept chlamydia screening: Influences of stigma and doctor-patient interactions. BMC Public Health, 10(1). doi:10.1186/1471-2458-10-425

Beydoun, H. A., Dail, J., Tamim, H., Ugwu, B., & Beydoun, M. A. (2010, October 15). Gender and Age Disparities in the Prevalence of Chlamydia Infection Among Sexually Active Adults in the United States. Journal of Women’s Health, 19(12), 2183-2190. doi:10.1089/jwh.2010.1975

Booth, Amy R., et al. (2014, September). “Pilot study of a brief intervention based on the theory of planned behaviour and self-identity to increase chlamydia testing among young people living in deprived areas.” British Journal Of Health Psychology 19(3), 636-651. doi: 10.1111/bjhp.12065

Braun, R. A., & Provost, J. M. (2010). Bridging the Gap: Using School-Based Health Services to Improve Chlamydia Screening Among Young Women. American Journal of Public Health, 100(9), 1624–1629. http://doi.org/10.2105/AJPH.2009.186825

Chan, P. A., Maher, J., Poole, D., Alexander-Scott, N., Ducharme, R. B., Yates, G. Flanigan, T. P. (2015). Addressing the Increasing Burden of Sexually Transmitted Infections in Rhode Island. Rhode Island Medical Journal (2013), 98(1), 31–34.

Charles Drew Health Center, Inc. (2015). “HIV/AIDS and STD Testing” Retrieved from http://charlesdrew.com/medical-services/std-screening/

Delair, S. F., Lyden, E. R., O’Keefe, A. L., Simonsen, K. A., Nared, S. R., Berthold, E. A., & Watanabe-Galloway, S. (2015). A Novel Public Library-Based Sexually Transmitted Infection Screening Program for Younger High-Risk Groups in Omaha, Nebraska, USA. Journal of Community Health J Community Health, 41(2), 289-295. doi:10.1007/s10900-015-0095-0

Douglas County Health Department. (2013). “Sexually Transmitted Disease Clinic.” Retrieved from http://www.douglascountyhealth.com/services-a-clinics/sexually-transmitted-disease

Einwalter, L. A., Ritchie, J. M., Ault, K. A., & Smith, E. M. (2005, September). Gonorrhea and Chlamydia Infection Among Women Visiting Family Planning Clinics: Racial Variation in Prevalence and Predictors. Perspectives on Sexual and Reproductive Health, 37(3), 135-140. doi:10.1363/3713505

Freeman, Elaine, et al. (2009, January). “Promoting chlamydia screening with posters and leaflets in general practice – a qualitative study.” BMC Public Health 9, 383-391

Get Checked Omaha. (2015).  “Sexually Transmitted Diseases in Omaha Have Reached Epidemic Levels.” Retrieved from http://getcheckedomaha.com/stds-in-omaha/

Get Checked Omaha. (2015).  “Where To Go” Retrieved from http://getcheckedomaha.com/testing-locations/

Jones, K., Baldwin, K. A., & Lewis, P. R. (2012). The Potential Influence of a Social Media Intervention on Risky Sexual Behavior and Chlamydia Incidence. Journal Of Community Health Nursing, 29(2), 106-120. doi:10.1080/07370016.2012.670579

Kozhimannil, K. B., Enns, E., Blauer-Peterson, C., Farris, J., Kahn, J., & Kulasingam, S. (2015). Behavioral and Community Correlates of Adolescent Pregnancy and Chlamydia Rates in Rural Counties in Minnesota. Journal of Community Health, 40(3), 493–500. http://doi.org/10.1007/s10900-014-9962-3

McKay, D. A., & Ashem, M. (2007). Chlamydia screening of adolescent and young adult women by general practice physicians in Toronto, Canada: Baseline survey data from a physician education campaign. Canadian Journal Of Human Sexuality, 16(3/4), 63-75.

OneWorld Community Health Centers, Inc. (2016). “OneWorld Teen & Young Adult Health Center.” Retrieved from https://www.oneworldomaha.org/tayahc/

Planned Parenthood Federation of America Inc. (2016). “STD Testing, Treatment & Vaccines in Omaha, NE.” Retrieved from https://www.plannedparenthood.org/health-center/nebraska/omaha/68134/northwest-health-center-2447-90380/std-testing-treatment

Ruffin, M., Sen, A., & Ursu, A. Ananda Sen, (2015, August). Impact of Cervical Cancer Screening Guidelines on Screening for Chlamydia, Ann Fam Med;13(4):361-363. Retrieved from http://www.medscape.com/viewarticle/848548

Salerno, J, Darling-Fisher, C., Hawkins, N. M., & Fraker, E. (2013). Identifying Relationships Between High-Risk Sexual Behaviors and Screening Positive for Chlamydia and Gonorrhea in School-Wide Screening Events. Journal Of School Health, 83(2), 99-104. doi:10.1111/josh.12004

Torrone, E., Papp, J. & Weinstock, H. (2014, September 26). “Prevalence of Chlamydia Trachomatis Genital Infection Among Persons Aged 14-39 Years — United States, 2007-2012.” MMWR: Morbidity & Mortality Weekly Report 63(38);834-838

US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for HIV, STD and TB Prevention (NCHSTP), Division of STD/HIV Prevention, (2016). “Sexually Transmitted Disease Morbidity for selected STDs by age, race/ethnicity and gender 1996-2014.” CDC WONDER Online Database.

Vaughan, Deirdre, et al. (2010, January): “Pee-in-a-Pot”: acceptability and uptake of on-site chlamydia screening in a student population in the Republic of Ireland.” BMC Infectious Diseases, 10, 325-333. doi: 10.1186/1471-2334-10-325

Women’s Fund of Omaha. (2016). “Adolescent Health Project” Retrieved from http://www.omahawomensfund.org/leading-change/adolescent-health-project/