Our study found that most youth consider both STI screening and treatment to be accessible because of easy access to healthcare or access to insurance and funding. Additionally, youth in our sample noted a preference for going to their established doctors or primary care providers for treatment services. Most notably, we found that nearly all MyVoice youth respondents indicated they would confide in their partners about an STI diagnosis, with more than half of these respondents reporting reasons such as how the diagnosis impacts their partners and that it is morally right.
While other studies report that many youth have access to general healthcare, there is limited literature on youth knowledge of included health services [9, 10]. Our study provides insight here by noting that our cohort believes STI screening and treatment services to be accessible via established or local health providers. This highlights the importance of youth having a healthcare home at sites that they routinely encounter, such as school-based health centers and federally qualified health centers. During the COVID-19 pandemic, the use of telehealth services has increased to support wider access to health services, but virtual healthcare services may not replace necessary clinical services when inequities in technology access remain [11]. Harnessing the interest and willingness of youth to seek sexual healthcare services at locations they are comfortable with is critical given that access to reproductive health services continues to decline [12], despite the growing incidence of STIs among youth [13]. Similar to our findings, access to care and insurance has previously been noted to make screening and treatment easy for youth [14]. However, our data does not support limited knowledge of health services as the primary barrier to care. Youth in our sample noted other barriers in accessing these services like cost or insurance coverage, embarrassment, and concerns about notifying their parents.
Youth concerns about confidentiality regarding an STI diagnosis note difficulty “… because it would be something that I would have to tell my parents and that would be very uncomfortable,” or “… because treatment would require health care, which would require me telling my parents.” This is consistent with existing literature that reports how perceptions of confidentiality may pose a barrier to healthcare for youth [3, 4]. Addressing youth concerns about cost and confidentiality must be considered when developing and implementing STI treatment and prevention services. Providers and health departments can encourage positive communication about sexual health between parents and their children, thus promoting safer sex practices and better health outcomes [15, 16]. In addition, providers can educate youth on the rules of confidentiality between minor patients and providers.
Despite their perceived ease of access to STI screening and treatment, actual use of these services remains low among U.S. youth. A possible explanation for this discrepancy, as noted in previous work, may be due to youth assuming that they are STI-free or generally not at risk [4]. Our study supports this conclusion, with some respondents reporting “It wouldn’t be hard for me to get tested because I know I do not have chlamydia or gonorrhea” and “No I go to the doctors often and they ask if I want to get tested but I’ve been with the same person since the last test I have no reason to get tested.” Youth must also want to, or perceive a need to, get STI screening. This barrier to use of STI screening services illustrates the need for local and federal health officials to support initiatives that emphasize—to youth and providers—the importance of regular STI screening, even in asymptomatic individuals.
Findings from our work also suggest primary care offices as the preferred location for STI screening and treatment in youth. This is congruent with previous work on STI screening amongst youth in the U.S. that indicated the majority of those who sought STI screening were evaluated at primary care physicians’ offices [4]. Youth preferences for STI screening and treatment at primary care clinics and concern for costs may require additional support and education for primary care health professionals. Furthermore, STI screening and prevention counseling for youth during their routine clinic visits will serve to increase awareness of STI screening methods and treatment options.
Our study also reports the important finding that nearly all respondents (95%) stated they would share their STI results with their partners. Common responses included “Yes because they need to know, in case they have it too. Also, they can help prevent the spread.” and “Yes it’s the most responsible thing to do. They would deserve to know.” A previous study on sexual health behaviors of U.S. college-age men similarly reported that the majority of participants were willing to disclose their STI status to their partners [17]. Our results contrast with previous data on youth concerns of STI stigma and the general misperception of youth being less willing to notify their partners [3, 4, 18, 19]. Youth willingness to confide in their sexual partners and concern about health effects on their sexual partners supports potential use of expedited partner therapy (EPT) to increase treatment of STIs. EPT—a treatment option where individuals can obtain STI medications or prescriptions for their sexual partners—may provide a useful opportunity to support youth treatment as it is quick, convenient, and respects patient privacy [20]. Clinician education on youth willingness to share STI results and use of EPT may also be beneficial to their efforts to increase screening and treatment in their patient populations. Additionally, it may address the hesitancy and uncertainty that some clinicians may face regarding the permissibility of this therapeutic measure [21]. It is important to note that youth willingness to participate in partner notification does not necessarily reflect youth behaviors. Currently, there is a gap in literature on the rates of partner notification specifically in the youth population [22]. In an Australian evaluation of individuals > 16 years diagnosed with chlamydia (median age of 27 and 24 years in males and females, respectively), 31 and 46% of heterosexual males and females notified their partners [23]. However, partner notification is increased in youth (ages 13–20 years) with higher levels of self-efficacy and in relationships with stronger emotional ties [24]. This mirrors the findings noted in adult populations, where partner notification is highest for spousal partners than for causal or commercial partners [22]. Thus, further evaluations of partner notification in youth ages 15–24 years are needed to quantify the efficacy of interventions like EPT among youth.
Though the MyVoice cohort sample recruits nationally from youth aged 14–24 years, there are some limitations. While MyVoice recruits based on benchmarks for national data on age, gender, race and ethnicity, and region of the country, respondents are not nationally representative because there is no assurance that the recruitment advertisements will reach all eligible participants. Additionally, recruitment via social media may bias the sample by including only those who use social media, limiting generalizability. Specifically, MyVoice respondents are oversampled in the Midwest region (Fig. 1) of the U.S., thereby providing data that may not necessarily reflect the perceptions and practices of youth in other parts of the country. Another limitation stems from the lack of concurrence between the time at which the survey was administered and analyzed and the onset of the COVID-19 pandemic. The majority of the cohort reported access to healthcare services at the time the survey was administered, yet youth have experienced decreased access to reproductive healthcare services during the COVID-19 pandemic [25]. To protect our respondents from having to self-report their past STI history, the open-ended questions posed to youth also asked about their theoretical behaviors. This may lead to desirability bias, as individuals may over- or under-report to conform to societal norms [26]. The other limitation of assessing theoretical behaviors is that intentions may not always lead to actions. Finally, the anonymous nature of this protocol prevented us from clarifying any unclear or missing responses. This is illustrated by our inability to discern if sexual partners were primary or casual in nature.
