This study determined the level of awareness and knowledge of chlamydia among young people who were approached in a variety of community settings and offered opportunistic screening. The survey data revealed a high awareness of chlamydia, which contrasts with other survey work, which reports levels of awareness of chlamydia in men and women to be around 50-60% [30–34]. These studies were with clinical populations but poor knowledge has also been reported among non-clinical populations, including medical students, other university students and school pupils, [35–37]. Nevertheless, whilst awareness was high, knowledge decreased as questions became increasingly focussed, so that the majority of respondents knew they could not catch chlamydia from toilet seats but few knew chlamydia could cause conjunctivitis.
The participant observation data, specifically the recorded observations made during the initial approach to young people, revealed gender differences in the degree of certainty of having heard of chlamydia: women immediately reported having heard of chlamydia; in contrast, men were unsure and required prompting that it was a STI before recognising it and confirming awareness. This lack of recognition among men could have implications for social marketing approaches, as men may not instantly recognise chlamydia as an STI or consider it to be personally relevant. These gender differences could have implications for how young people are approached and offered chlamydia screening. However, conveying information will involve more than information provision as stigma and embarrassment may reduce participation in screening .
Gender differences in awareness extended to knowledge of symptoms of chlamydia. The survey revealed that a third of men and women were unaware of the asymptomatic nature of chlamydia infection. Almost half of men agreed with the statement 'I'd only be concerned about chlamydia if I had symptoms'. Poor knowledge could lead to increased risk behaviour , and negatively impact screening uptake as young people who are better able to assess their own personal risk are more likely to take up a screening offer . However, as reported elsewhere,  learning of the asymptomatic nature of chlamydia was central to young people's willingness to be screened in this study, which reveals the modifiable nature of their knowledge and the importance of this for subsequent participation. Others have noted the tendency for those who develop minor symptoms to delay care seeking , and poor knowledge of the potential implications of chlamydia infection for fertility , which places greater importance on ensuring that young people are aware of key aspects of chlamydia infection. Participation in screening and uptake of repeat testing are vital for early detection and treatment of asymptomatic infections [11, 40].
This Scottish study population is not exposed to chlamydia screening as part of a national screening programme, thus our data are not necessarily generalisable to other populations. Nevertheless opportunistic screening guidelines in Scotland (SIGN Guideline 109) recommend screening as part of routine care in the same clinical settings as the NCSP in England: community contraception services, general practice, community pharmacies and termination of pregnancy services . Despite the NCSP in England, poor knowledge of the issue is still present [25, 35].
There are other limitations to this study. We used a convenience sample for the survey, and it was difficult to undertake purposive sampling for the qualitative study. Despite the care taken by the researcher to ensure a consistent approach to all age-eligible users it is possible that there was selection bias. In addition, recall and social desirability biases may have been introduced, with respondents perhaps selecting firm responses in the presence of their peers rather than answer 'Don't know'. There could also have been conferring between participants when completing their questionnaires. It is possible that responses to some questionnaire items could have been influenced by the information contained within the study literature (leaflets and posters) as well as the nature of the consent procedure - for example, the leaflet detailed female symptoms and the questionnaire asked for knowledge of female symptoms. A questionnaire-based study which does not provide such prior information about chlamydia could introduce less bias to findings. These issues could bias the study and the results should be interpreted in light of this. We did not ask participants for information on their level of education, so we do not know how far this might have affected responses to questionnaire items on knowledge. However, as noted above, poor knowledge has been reported among young people recruited across a range of settings [35–37], and this study found little setting-effect on knowledge of symptoms. A strength is the qualitative data confirming the questionnaire responses, including the gender differences in knowledge. Rigorous recording of the outcome of each approach made to young people was included in fieldnote diaries, which revealed a high participation rate. The sample size and variety of community settings used are also strengths.
Whilst the inclusion of men in screening has been widely encouraged [41–43], this study shows that their knowledge continues to be lower than that of women's, with little changing from earlier studies. Better ways to inform young men of the key features of the infection are vital if screening rates among men are to improve. The implications of poor knowledge for disease control are significant unless there is an improvement in young people's understanding of this infection. To improve chlamydia detection and treatment innovative strategies have been developed, including postal testing kits either mailed proactively from general practice lists or made available on the Internet for young people to request a kit and/or log-on to receive a diagnosis [29, 44, 45]. Despite these innovations, uptake remains poor. In order to maximise gains from interventions to improve detection and treatment, interventions are also required to increase young people's understanding of chlamydia, their assessment of personal risk and to change health behaviours.