Pelvic inflammatory disease: causes, symptoms, and treatment

Pelvic Inflammatory Disease

Conduct a data analysis of a problem that you perceive can be improved through health education/health promotion activities.

The research shows that today, pelvic inflammatory disease represents a significant healthcare problem in the United States with serious outcomes that can be addressed to a significant extent through the use of health promotion activities. The research will also show that pelvic inflammatory disease is a fairly common condition, but one that can cause chronic pelvic pain and even infertility if left untreated. Finally, the research will show that the majority of cases of PID today are caused by infection with Chlamydia or gonorrhea and that young women in particular are at higher risk of acquiring one of these sexually transmitted diseases. An overview of this condition and its causes and costs is provided below.

a. Explain why your identified problem is a problem. Pelvic inflammatory disease (PID) is a serious syndrome of the female reproductive system (Macdonald & Brunham 1997:161). Studies have confirmed that PID is an important risk factor for ectopic pregnancy and infertility (Mcglynn, Kerr and Damberg 2000:269). By and large, PID is a preventable disease in many cases but remains an expensive public health threat. For instance, as noted below, PID can be caused by sexually transmitted diseases, especially Chlamydia and gonorrhea. There are approximately 3 to 4 million cases of Chlamydia and 2 million cases of gonorrhea reported each year in the U.S. and, not surprisingly, about one million new cases of PID are reported in the United States each year as a result (Mcglynn et al. 269). According to these researchers, "Both gonococcal and chlamydial infections may be asymptomatic, or present with vaginal symptoms (e.g., mucopurulent vaginal discharge, vaginal itching, dyspareunia, dysuria, vague lower abdominal pain), anorectal symptoms, and pharyngeal symptoms. However, both have the potential to cause pelvic inflammatory disease, the sequelae of which include ectopic pregnancy and infertility" (Mcglynn et al. 330). Moreover, fully 30% of women who contract chlamydia will develop acute PID within 6 months of an initial infection if it is left untreated or the condition becomes acute (Mckay 2006:2). In addition, it is well documented that subclinical, asymptomtic chlamydia infection in women with no previous history of PID represents a major contributor to tubal infertility (Mckay 2006:2). According to estimates provided by Patrick (1997), somewhere between 10-40% of women who contract chlamydia will develop pelvic inflammatory disease. This author also emphasizes, "This human and fiscal tragedy is preventable because cost-effective means to dramatically reduce the burden of morbidity are at hand in almost all developed nations. All that is required is the will to deploy them" (143).

In fact, while the emotional toll of this "human tragedy" is inestimable, the pragmatic aspects of "fiscal tragedy" associated with PID are more easily discernible, with the cost of PID and associated ectopic pregnancy and infertility exceeding $2.7 billion a year in the United States alone (Mcglynn et al.). Taking into consideration as well the comorbidities associated with PID, including infertility, ectopic pregnancy, and chronic pelvic pain, the direct and indirect costs of PID are estimated to be in excess of $4.2 billion a year (Mcglynn et al.). For a largely preventable disease, these costs are extraordinary and the time to act is now. In this regard, Mckay (2006) emphasizes that, "In the face of what appears to be a rising incidence of chlamydia, particularly among youth and young adults, strategies to reduce the incidence and negative outcomes of chlamydia are needed" (2). Indeed, even a small fraction of the staggering amounts of money currently being spent on PID could be well applied towards cost-effective educational initiatives targeted at populations at risk of acquired these two STDs, and these issues are discussed further below.

b. Explain how this disease/condition is caused. Pelvic inflammatory disease is typically caused by the spread of infections (most frequently the result of sexually transmitted diseases [STDs] such as Chlamydia trachomatis and Nisseria gonnorrhoea), from the vagina and endocervix to the uterus, fallopian tubes and ovaries; in most cases, PID manifests as endometritis (e.g., infection of the lining of the uterus) or salpingitis (e.g., infection of the fallopian tubes) but also as pelvic peritonitis and/or inflammation of contiguous structures in some cases (Macdonald & Brunham 1997). Other causes of PID may be related to the types of intrauterine devices used by women. According to a study by Mckay (2000), intrauterine devices (IUDs) have long been cited as the cause of pelvic inflammatory disease (PID) which can result in tubal infertility. As this author emphasizes, "Studies that indicated an association between IUDs and PID lead to the withdrawal of many IUDs from the North American market. In particular, one IUD, the Dalkon Shield, was shown to be strongly associated with PID" (Mckay 259). Fewer than one in twenty women of reproductive age in North American currently use IUDs, but their use is more common in Asia and Europe; however, the studies assessing the association between IUDs and PID have been controversial and resulted in mixed findings (Mckay). The findings of a study by Hubacher and his colleagues (2001), though, suggest that, "The use of copper IUDs is much safer than was previously thought. Nulligravid women [e.g., a women who have never been pregnant] who are not at risk for a sexually transmitted disease are appropriate candidates for the copper IUD. Contemporary copper IUDs may be among the safest, most effective, and least expensive reversible contraceptives available" (566). While the scientific community continues to investigate the connection between IUD use and PID, what is known is that chlamydia and gonorrhea are two of the most readily apparent causes of PID among certain populations, and these issues are discussed further below.

c. The distribution of the disease/condition. One expert on PID reports that the incidence of chlamydia is highest among 15- to 24-year-old females and that, "Chlamydia is a highly prevalent STI among young people and research suggests that adolescent and young adult women living in socio-economically disadvantaged areas are likely to carry a disproportionate burden of morbidity (e.g., PID, ectopic pregnancy, infertility)" Mackay 2006:1). According to O'Keeffe (2003), "Those who have sex younger are much more likely to contract a sexually transmitted disease: among the under 16s, one in seven sexually active girls tests positive for chlamydia" (26). Likewise, the Centers for Disease Control and Prevention (CDC) report that young women aged 15 to 19 years account for almost 50% of all reported cases of chlamydia among women, and women aged 20-24-year account for yet another 33% (Screening for chlamydia infection, 2008). Although 10% of teenage girls test positive for chlamydia, infection rates differ from community to community (Screening for chlamydia infection).

Therefore, interventions intended to reduce the comorbidities such as PID that are associated with chlamydia through increased physician screening should target young people in those areas with the highest incidence of chlamydia (Mckay 2006:1). Nevertheless, even these initiatives are complicated by the insidious nature of the condition, particularly among young people. According to Macdonald and Brunham, "Clinical diagnosis of PID is difficult because of the wide variation in symptoms and signs, and the high rate of asymptomatic infection, particularly among adolescents" (161). Despite the magnitude and complexity of addressing this problem, the need is clear and the potential solutions are largely cost effective, and these issues are discussed further below.

d. Explain how the disease/condition can be prevented/controlled through health education/health promotion activities. According to Mcglynn and her colleagues (2000), "The most efficacious means of reducing the risk of acquiring STDs through sexual contact is either abstinence from sexual relations or maintenance of a mutually monogamous sexual relationship with an uninfected partner. In addition, the use of latex condoms and spermicides may reduce the risk of infection with STDs" (269). A study by Ness, Randall, Richter et al. (2004) found that women who reported consistent use of condoms (i.e., using condoms between 75% to 100% of the time) experienced the lowest rates of recurrent PID, chronic pelvic pain, and infertility; by sharp contrast, women in the Ness et al. study reporting condom use at 0% to 25% of the time experienced the highest rates. Although the use of oral contraception was not found to be associated with a significantly elevated or reduced risk of PID sequelae, Ness and his colleagues emphasizes that their findings "lend strength to the literature on condom use and the prevention of PID and its sequelae" (p. 1328).

2. Identify sources of health related information you will rely on to identify a particular need as well as sources that will assist in developing the program.

The U.S. Centers for Disease Control and Prevention's Preventive Services Task Force (USPSTF) Web site at http://www.ahrq.gov/clinic/prev/chlamwh.htm. provides some useful and timely information concerning the effectiveness of various educational programs, screening and treatment protocols for the most common causes of PID.

Timely data concerning the costs and cost savings of different screening and treatment methods is available from the Centers for Disease Control at http://www.cdc.gov/nchstp/dstd/HEDIS.htm.

Additional information concerning chlamydia and effective treatment protocols is available from the Systematic Evidence Review, Summary of the Evidence, and USPSTF Recommendations and Rationale on the Agency for Healthcare Research and Quality (AHRQ) Web site at http://www.ahrq.gov/clinic/uspstfix.htm, through the National Guideline Clearinghouse at http://www.guideline.gov.

Evidence-based findings concerning chlamydia screening and treatment of PID contained in the peer-reviewed and scholarly literature.

The additional resources cited at Appendix a will also be consulted.

3. Identify a specific group of people that are being affected by the disease/condition. The screening guidelines published by the USPSTF recommend that the following specific groups of women should be routinely screened, whether or not they are pregnant, if they:

Are sexually active and aged 25 or younger;

Have more than one sexual partner, regardless of age;

Have had an STD in the past, regardless of age; and Do not use condoms consistently and correctly, regardless of age (Screening for Chlamydial infection) a. Explain any unhealthy behaviors that may be contributing to the disease/condition. Some of the unhealthy behaviors that may contribute to the incidence of PID include (1) having multiple sex partners and (2) not using condoms consistently and correctly; I addition, having had an STD in the past also increases the risk of contracting chlamydia which may result in PID (Screening for Chlamydial Infection 2001:1).

b. Explore why this group is experiencing the disease/condition, or why the disease/condition has a higher prevalence rate among the population that you have selected. Given the serious health care outcomes that can result from failing to use a condom correctly and consistently, it remains unclear why so many young unmarried people fail to use condoms. The growing body of research in this area suggests that just a small minority of adolescent females consistently use condoms (Christ, Raszka and Dillon 1998:735). These authors report that just 22%-47% of adolescent females used condoms during their first intercourse, and only 21%-33% currently used them (Christ et al.). Other studies have shown that just one in ten females had actually bought a condom, while other researchers have determined that just over one-quarter (28%) of women used condoms during their most recent intercourse, and only 17% used them more than 90% of the time (Christ et al.). A number of studies have identified reasons why adolescent females may not use condoms correctly or routinely, with the identified factors including:

Negative experience with condoms decreases the likelihood of using condoms again in the future.

There is an association between risk-taking behaviors and inconsistent condom use;

Self-efficacy theory is also relevant to effective condom use, with low self-efficacy among college students contributing to inconsistent condom use (Christ et al.).

c. Specifically, consider the 5 dimensions of access to health care (from BHS-450).

d. Tell me if there is a barrier to access that is preventing the clients from accessing health education/health promotion activities that would mitigate the problem you have identified. There are some interesting and perplexing aspects to the provision of timely and effective preventive care information to the targeted group. On the one hand, it is reasonable to suggest that lower socioeconomic members of this group would be at higher risk of contracting chlamydia or gonorrhea and their associated complications in PID. On the other hand, though, a number of studies have suggested that female college students regardless of socioeconomic status are at high risk as well, making the formulation of a "one-size-fits-all" approach inappropriate. In addition, the provision of heath promotion activities will be facilitated in the case of high school and college students where the audience and appropriate educational support services are already in place compared to community-based educational initiatives.

MODULE 2 - as evidence of progress on your final assignment submit a paper that contains the following:

1. Consider any specific factors that may influence learning in the group you have selected for your health education program. As noted above, infection rates vary from community to community, as well as from group to group, with sexually active girls under the age of 16 years representing one of the groups at highest risk. Therefore, the educational initiatives envisioned herein must be relevant and able to be comprehended by the target audience. Depending on the audience, then, the specific factors that should be addressed would include the need to openly discuss safe sex practices to emphasize the dangers involved in failing to use condoms correctly and consistently. According to Klein and Knauper (2003), "The tendency to avoid thoughts related to sexually transmitted infections (STIs) is associated with communication about safer sex practices and condom use consistency. Many STIs are more easily transmitted from male to female than vice versa. Infection rates for common STIs, such as chlamydia and herpes simplex virus, are higher among women than men" (137). Besides being biologically more susceptible to contracting certain STIs such as chlamydia than their male partners, women with untreated STIs can experience severe long-term health consequences including acute pelvic inflammatory disease (PID), difficulties with conception due to tubal infertility, pregnancy loss due to ectopic pregnancy, spontaneous abortion, premature delivery and stillbirth, and cervical lesions that may result in cervical cancer (Klein and Knauper 137). Studies have also shown that young people may be reluctant to discuss safer sex issues because they believe discussion of the topic implies mistrust, infidelity and a lack of commitment to the relationship (Klein and Knauper 138).

In addition, Klein and Knauper note that the tendency to ignore the issue altogether carries some potentially serious consequences: "Individuals may also unconsciously avoid asking questions that are too detailed because they may fear an answer that indicates their partner could pose an STI risk. Becoming aware of partner STI risk may induce individuals to worry that they have already contracted an STI and consequently need to be tested and need to suggest that their partner be tested" (138). These all-too-human reactions to what may be a clear and present danger is perhaps reflective of the extent to which these young people feel they are immortal and are somehow immune from such public health threats. In addition, broaching the subject of condom use and STI transmission might involve changes in behavior that many young people are hesitant to make. As Klein and Knauper point out, discussions of safer sex might "require refraining from unsafe sexual practices. Consequently, individuals are motivated not to discuss issues regarding safer sex practices" (138).

a. Explore whether or not there are any physical/mental / developmental considerations that must be taken into consideration when planning your program.

b. Consider such factors as age, socioeconomic status, or cultural considerations that may influence learning.

c. Address any health literacy concerns that may exist in the group you have selected. According to Mackay (2006), "Increased educational efforts are required to improve physician compliance with STD screening and treatment guidelines, as well as ensure the appropriate use of STD drugs provided. Opportunities are being missed for screening for C. trachomatis among young people, the majority of whom are seen regularly by a physician" (2). The studies to date clearly indicate that many physicians may lack basic, up-to-date factual information necessary to motivate increased chlamydia testing. Such information includes the prevalence of asymptomatic chlamydia infection among young people, its association with PID, screening procedures, and awareness of pertinent chlamydia screening guidelines. There is good reason to conclude that providing physicians with informational packages that fill important gaps in their knowledge is a perquisite to increasing physician testing (Mackay 2006:2).

2. Identify the setting in which your proposed health education/health promotion program will be implemented and supporting rationale.

The educational component of the initiative envisioned herein would take place in the schools, throughout the community and workplaces, and the screening component would take place in community-based health care settings. As noted above, the costs of treating PID each year are staggering, and there are some cost-effective educational programs available as well as low-cost screening techniques that are particularly appropriate for women who are not pregnant and who are at risk for chlamydial infection. In fact, these initiatives, including the cost of the screening, may be less than the cost of treating chlamydia and its complications such as PID in the first place (Screening for Chlamydial Infection, 2001).

3. Identify organizations, groups and/or individuals who may assist in planning, implementation or administration of your proposed health education program.

4. Consider how you would incorporate principles of community organization in the planning of your program.

a. Consider how you would communicate the need for this health education program to whose who will be involved.

5. Select an appropriate health planning model which will serve as the framework for your health education/health promotion program.

a. Explain why this model is appropriate for your health education/health promotion program.

MODULE 3 - as evidence of progress on your final assignment submit a paper that contains the following:

1. Identify the program goals and measurable objectives (remember that your objectives should be behaviorally stated).

2. Identify specific strategies that you will implement in your health education/health promotion program.

It would appear reasonable to conclude that because resources are by definition scarce, it is important to wring every bit of public health good from every available dollar. While abstinence represents the absolute best way to avoid contracting STDs such as chlamydia, many observers maintain that some of these initiatives simply do not work. For instance, O'Keeffe emphasizes that, "I'm not sure how you would teach abstinence -- the body of evidence shows it doesn't work. Abstinence messages conflict with all the other messages about sex which teenagers receive from the culture around them. And a cultural shift is very difficult to achieve" (27). Therefore, a pragmatic approach that encourages the use of condoms among the targeted group appears to represent a particularly effective strategy to prevent PID. Other strategies are also available that can be incorporated into a health promotion program aimed at reducing the incidence of PID among the targeted population. In this regard, Patrick reports that educational initiatives targeted at chlamydia frequently promote the use of condoms or suggest lower risk (non-insertive) sexual practices; recommendations to reduce the contact rate between infected an uninfected individuals such as reducing the number of sexual partners, maintaining "monogamous" relationships or, among the young, to encourage postponement of sexual involvement or abstention from high risk sexual activity altogether (144). According to this author, "These and other behavioral interventions are common elements in attempts to control bacterial and viral STDs and unwanted pregnancy. In practice, these behaviors are sometimes difficult to influence although there has been some notable success in increasing condom use in particular populations" (Patrick 144).