Introduction

Twenty million new sexually transmitted infections (STIs) occur annually, making STIs a significant public health concern in the U.S. Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) are the two most commonly reported STIs with 1,422,976 cases of CT and 334,826 cases of NG in 2012 [1]. The total direct cost of these infections was $516.7 million for CT and $162.1 million for NG in 2010 [2]. Though STIs affect individuals of all ages and racial/ethnic groups in the U.S., adolescents, young adults, and Blacks are particularly at a high risk [1]. Individuals aged 15–24 years carry half the burden of these infections while they account for only 27 % of the sexually active population [1]. Many of the adolescents and young adults with CT and NG are asymptomatic and unaware of infection. Untreated CT and NG can lead to serious long-term health consequences such as pelvic inflammatory disease and infertility especially for adolescent girls and young adult women; in addition, untreated NG can lead to blood and joint infections that may become severely debilitating to both men and women [3–5]. Moreover, epidemiologic and clinical studies have shown that both CT and NG infections can facilitate the transmission of human immunodeficiency virus (HIV) infection [6].

Currently, the Centers for Disease Control and Prevention (CDC) recommends annual chlamydia screening for all sexually active women age 25 and under, as well as yearly gonorrhea screening for at-risk sexually active women and men who have sex with men [7]. Nucleic acid amplification tests for CT and NG allow for sensitive (>95 %), specific (>99 %) and noninvasive testing ideal for rapid screening [8, 9]. Despite CDC recommendations and the availability of effective treatment, less than half of people who should be screened are tested for CT and NG [10]. Reasons for this are most likely multifactorial, including being asymptomatic, lacking health insurance, being unable to pay even subsidized fees, and lack of transportation to and from testing centers, especially in high risk groups [7, 11, 12]. Furthermore, traditional testing facilities are mainly designed for adults and have been described as uncomfortable and intimidating among youth who also report significant confidentiality barriers as a reason not to get tested [13].

In recent years, an increasing number of community-based programs have been developed to address the aforementioned barriers to STI screening among the hard-to-reach segments of the population. According to a recent systematic review of outreach STI screening programs, 32 % of the studies reviewed included both CT and NG screenings while 40 % focused exclusively on CT screening [14]. Most of the programs in these published studies are aimed at adolescent and young adults (52 %), men who have sex with men (24 %), and sex workers (8 %) [14]. The conclusion was that outreach programs located in existing neighborhood venues such as community centers, shelters, parenting centers, sports clubs and schools were more successful than screening programs on the streets and in open public areas [14]. There were no public library screening programs described.

STI prevention and control is an important part of public health practice especially for a community with high STI rates such as Douglas County, Nebraska, in which the city of Omaha is located. One fourth of Nebraska residents reside in Douglas County, the state’s most populous county with an estimate of 543,244 residents in 2014 [15]. Douglas County, Nebraska has had CT and NG infection rates consistently above the state and U.S. national averages [16]. In 2012, rates of NG were 158.3 per 100,000 population in Douglas County compared to 77.6 per 100,000 in Nebraska and 107.5 per 100,000 in the U.S. [1, 16]. Rates of CT for that same year were 617.6 per 100,000 population in Douglas County compared to 366.2 per 100,000 in Nebraska and 457.6 per 100,000 in the U.S. [1, 16]. In 2013, CT and NG infections were highest among the 20–24 year olds, accounting for 31 and 39.9 % of the cases, respectively [17]. That same year, Blacks had more NG infections than Whites with 58.2 and 26.4 % respectively. The CT infection rate was 37.9 % in Blacks and 33.8 % in Whites [17].

A recent focus group study conducted in the area of highest STI prevalence within Douglas County, North Omaha, which includes historically Black neighborhoods. This study revealed that confidentiality was a major barrier to seeking testing for STI, followed by fear of being judged and knowing about the diseases and outcomes [18]. Another important barrier identified was not knowing where the testing locations were within the county and believing that the participant’s area of the city (North Omaha) had no testing sites available [18]. In order to address some of these barriers, in 2010, the Douglas County Health Department (DCHD) developed an innovative community-based CT and NG screening program located in public library branches that has expanded since its inception to cover ten branches throughout metropolitan Omaha.

Public libraries are usually located throughout urban and rural areas, often near town centers, schools and/or universities and are frequently associated with community education. Access to public libraries is free and open to a wide segment of the community. To our knowledge, there are no published studies on health screening programs based in libraries. An STI screening program within a library is likely to attract a very diverse section of the community with socio-demographic and clinical characteristics that may be different from a hospital, clinic or community event-based STI testing site. Our hypothesis was that the DCHD novel public library-based screening program would reach a high-risk population that would otherwise not readily seek care at the traditional DCHD STI clinic. The primary aim was to evaluate the effectiveness of the library-screening program compared to the traditional DCHD clinic in terms of its reach to the target population. The second aim was to identify demographic and clinical factors predictive of CT and NG infections.

Methods

This study is a retrospective review of records of patrons who participated in DCHD-sponsored urine testing for CT and NG in ten Omaha, Nebraska public library branches (Benson, Millard, Florence, South Omaha, Saddlebrook, Swanson, Sorensen, W. Dale Clark, Charles B. Washington and Willa Cather Libraries) from June 2010 through April 2014. Encounter records during the same time period from the DCHD traditional STI clinic located in east central Omaha were also reviewed. The University of Nebraska Medical Center Institutional Review Board approved the study.

First, we present an overview on how the data were originally obtained in the DCHD library-screening program: a trained DCHD STI specialist is posted regularly at each of the ten library branches and obtains urine samples from interested library patrons. Participants completed a questionnaire that requested socio-demographic information such as gender, age, race, ethnicity, zip code, presence of symptoms at the time of screening and contact information for result reporting. Survey data was transcribed into two database systems used at DCHD. The same demographic and clinical data were retrieved for the DCHD traditional clinic clients using the existing medical records.

Statistical Methods

Using SAS v9.3, descriptive statistics were used to summarize variables, such as age, gender, race, ethnic group, zip code and presence of symptoms. Only the first visit of each participant to the library or DCHD screening site was considered part of the dataset to be analyzed. Chi square and Fisher exact tests were used to examine the potential associations of categorical variables with CT and NG infections. Student’s t test was used for continuous variables. Univariate analysis and multivariable logistic regression were used to identify predictors of dichotomous outcomes and to provide a quantified value for the strength of the association after adjusting for other variables. A p value of <0.05 was considered statistically significant.

Results

During the 2010–2014 period, the DCHD recorded a total of 2321 tests (1160 for CT and 1161 for NG) performed in the library screening programs. Among these, 377 tests had a missing value for the type of disease (NG or CT); therefore, they were excluded from further analysis. There were 977 first-time participant encounters in the library-screening program (976 tested for both chlamydia and gonorrhea and one additional participant tested only for chlamydia). During the same five-year period, the traditional STI clinic recorded 11,620 tests performed among 4871 first encounter participants. The library branch with the most participants was the Washington Library, located in North Omaha (70.5 %) followed by the W. Dale Clark Library, located downtown (9.3 %).

Table 1 summarizes demographics of participants in the library screening program and the traditional clinic. The library screening program participants were significantly younger than the traditional clinic patients (average age 25.3 vs. 30.3 years). Approximately 70 % of the library program participants were 24 years and younger compared to about 40 % of the traditional clinic participants. Among Black participants, the library program was more commonly used than the traditional site (65.8 vs. 37.0 %). Additionally, the proportion of Hispanic participants was significantly lower for the library than for the clinic (6.1 vs. 11.5 %).

Table 1 Demographics: library versus traditional clinic 2010–2014
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Table 2 shows the CT and NG test results among the participants of the library program and the traditional clinic. Among library participants, 9.9 % had a positive test result for CT and 2.7 % had a positive test result for NG. Among the traditional clinic participants, 11.3 % had a positive CT test result and 5.3 % had a positive NG test result. The percent positives for CT and NG were significantly lower among library program participants than the clinic participants (p = 0.0393 and p = 0.0004 respectively).

Table 2 Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) Results: library versus traditional clinic 2010–2014
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Table 3 shows that traditional clinic participants were much more likely to report any symptoms compared to the library program participants. Overall, 16.0 % of the library program participants reported symptoms compared to 60.7 % of the traditional clinic participants. Among those who tested positive for NG, 34.6 % of the library participants reported at least one symptom while 59.7 % of the traditional clinic participants reported at least one symptom. Among those who tested positive for CT, 23.9 % of the library participants reported at least one symptom while 59.9 % of the traditional clinic participants reported at least one symptom. We performed univariate analysis for factors associated with a positive CT and NG test among the library program participants and traditional clinic patrons. At the library, younger individuals (p = 0.0001) and those who reported symptoms (p = 0.001) were more likely to test positive for CT, while Black participants (p = 0.0126) and those who reported symptoms (p = 0.0007) were more likely to test positive for NG. At the traditional clinic we found that for CT, younger age (p < 0.0001), Black race (p < 0.0001) and Hispanic ethnicity (p = 0.0008) were significantly associated with a positive test. For NG, younger age (p = 0.0003), male gender (p = 0.0039), Black race (p = 0.0001), Hispanic ethnicity (p = 0.0002), and presence of symptoms (p = 0.0001) were all significantly associated with a positive test.

Table 3 Symptom reporting: library versus traditional clinic 2010–2014
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In Table 4, we reported the multivariate logistic regression results to identify factors independently associated with library use for STI screening. Younger clients were more likely to be screened at the library compared to the traditional clinic. The youngest age group (≤19 years) and the next youngest group (20–24 years) were 6.1 and 1.3 times more likely to be screened than oldest age group (>24 years) at the library. The odds of being screened at the library versus the traditional clinic were 1.3 times higher for women than men. The odds of being screened at the library versus the traditional clinic were 3.4 times higher for Blacks than Whites and 2.1 times higher for individuals from other racial/ethnic groups than Whites. Hispanics were less likely than non-Hispanics to be screened at the library compared to the traditional clinic (OR = 0.6). Asymptomatic clients were 12.4 times more likely to be tested at the library.

Table 4 Likelihood of being screened at the library versus the traditional clinic
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Discussion

In recent years, community-based screening programs have received more attention as important venues to reach out to high-risk groups [14]. This study is the first of its kind to describe a free public educational resource, libraries, as a venue for STI screening in a vulnerable high-risk segment of the population. The study results supported our hypothesis that the novel DCHD library STI screening program reached a younger, mostly Black population that is not as well captured by traditional DCHD clinic-based screening programs. This racial and ethnic breakdown could be explained by the fact that the library with the most participants was the Charles B. Washington branch located in North Omaha, where Blacks are predominant with as much 50 % of the local residential population according to 2010 census data [19]. In addition to being one of the first library branches in the DCHD non-traditional testing program, screening is offered more frequently at the Washington library than other sites because of the higher STI rates among Blacks in the Douglas county area, with 42.9 % of those diagnosed with CT and 69.2 % of those diagnosed with NG in Douglas County in 2012 residing in North Omaha [15]. Prevalence studies in the U.S. have shown that half of the newly acquired STIs are in the adolescent 15–19 and young adult 20–24 category [13]. The library program is targeting this key high-risk demographic by effectively screening the younger age group; 70 % of the library program participants were 24 years and younger compared to about 40 % at the traditional clinic. Our review of published literature found one community-based program that targeted a similar population; a NG and CT screening program among adolescents in a family court setting in Philadelphia, Pennsylvania [14, 20]. In this setting, almost 13.9 % of females and 7 % of males were found to be positive for NG, CT or both, and 100 % of females and 93 % of males were confirmed to be treated [20]. That study showed the utility of a non-traditional venue, such as family court, as an important setting for STI screening in the high-risk adolescent group and effective treatment outcomes. In our study, the overall treatment rates of participants who tested positive in both the library and the DCHD programs were not linked and were kept on a separate database so we cannot compare the treatment outcome of our two groups to other studies.

Our review could not determine, however, the popularity of this unique program from a participant’s point of view, as the surveys were not designed to assess participant’s feelings about the library setting as a STI screening site. We can hypothesize that being within a walking distance, being open after school with no membership fees for access, and offering no cost, confidential STI screening are all factors that could contribute to making the library venue particularly appealing to the adolescent 15–19 age group. Further studies are needed to more accurately assess these incentives. Though the numbers were small, the library is also more likely to capture the <15 year-old demographic more often than the traditional site for the same previously stated reasons with 73 (~7.5 %) being screened at the library compared to eight (~0.2 %) at the traditional site in the same period. Of note, only two participants <15 were positive for CT and 1 for NG, small numbers, but that raise a concern as to need for sexual education in that age group or assessment of social circumstances that might lead to infection at such young age.

Our study found lower infection rates among patrons of the community-based screening program compared to the traditional clinic. The CT infection rate was 9.9 % at the library and 11.3 % at the DCHD, while the NG infection rate was 2.7 % at the library and 5.3 % at the DCHD. Regardless, all of these rates are higher than national prevalence of 1.5 % overall (5.9 % in Blacks) for CT in the period 2005–2008 in all age groups [21] and an estimated prevalence of 0.8 % of NG in a 2010 survey of women 15–24 years of age in the U.S. [22]. This study also found a similar pattern of risk factors as the U.S. national data which indicate that CT and NG rates were highest in the 15–24 years age group among women, while in men they were highest in those aged 20–24 years [1]. Adolescent (≤19 years) and young adults (20–24 years) were about 2–5 times more likely to be diagnosed with CT or NG compared to those older than 24 years of age. The adjusted risk was highest among young adult women (20–24 years) who were approximately five times more likely to be diagnosed with CT compared to women older than 24 years of age.

There were interesting patterns of race/ethnicity risk distributions. Among men, Black patrons were more likely to test positive for both CT and NG compared to White patrons after adjusting for age, ethnicity, presence of symptoms and testing sites. This is consistent with 2012 CDC surveillance data that show rates of CT were eight times that of White men, while rates of NG in Black men were 16.2 times the rates in White men [23]. As for NG infection, Black women were more likely to have a positive diagnosis than White women. This is also consistent with 2012 CDC data where NG rates among Black women were 13.8 times rates among White women [23]. Among women, race was not significantly associated with a positive diagnosis of CT, but Hispanic ethnicity was associated with double the risk of CT diagnosis. 2012 CDC data showed that rates of CT among Hispanic women were two times the rates among White women [23].

When comparing testing venues in terms of presence of symptoms, the proportion of symptomatic patrons at the library site was significantly smaller (16 vs. 60 %) than the clinic setting. This finding had the potential limitation of comparing symptom self-reporting of the library client surveys to the DCHD traditional clinic clients whose self-reported symptoms were discussed with and entered into the medical chart by care providers. Additionally, participants in the library program could not get an immediate physical examination. Those with significant symptoms may then have chosen to go to a traditional clinic site to be fully evaluated. However, our results show that non-traditional testing sites can target sexually active young adults who would otherwise not get screened because most are asymptomatic. Previous studies have also demonstrated that young, healthy populations may not be routinely offered, or seek, STI testing during primary care health maintenance visits, highlighting the value and ongoing public health need for STI-focused testing and treatment venues [14, 24].

Interestingly, in the library-screening program there were at least 184 participants that had submitted surveys within the five-year period of our study and had been previously screened at the library. This means that the library screening was not a one-time event and some participants may be choosing this venue as part of their sexual health maintenance. Further studies are needed to characterize this group of participants and to review the rates of positive screens within that group, as well as the reasons they choose the library versus a traditional clinic. Are these participants coming in because they are symptomatic, have no insurance, or prefer the convenient neighborhood location? It would be important to assess their view of the library screening as part of sexual health maintenance and treatment for STIs. The DCHD traditional clinic also had a significant number of participants with repeat STI screens, with 939 participants that used the facilities more than once during the five-year study period. The somewhat central metropolitan location of the clinic within Douglas county and low cost STI screening and treatment could contribute to making it an appealing option, especially for the uninsured. Further studies should be conducted to understand the healthcare seeking behavior of this group as well.

Conclusion

Most library patrons screened for STIs were asymptomatic and infection rates were higher than national averages, underscoring the need for routine screening in at risk groups. Public libraries branches are useful venues for STI screening and attract a young, mostly Black population in the Omaha metropolitan area.