Chlamydia Prevelance among Female College Students in Alabama: A Social Epidemic

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Chlamydia Prevalence among Female College Students in Alabama: A Social Epidemic

Charles C. Mueller

Troy University




The prevalence of the sexually transmitted infection chlamydia in female college students aged 18 to 24 in Alabama post-secondary institutions has topped the nation's leading cause of sexually transmitted diseases from 2005 to the present. Prevalence, etiology, risk-behaviors and potential solutions to reducing the spread of Chlamydia in college and university populations will be presented.�

Chlamydia Prevalence among Female College Students in Alabama: A Social Epidemic

Sexually transmitted infections have increased on college and university campuses in Alabama in recent years. According to Trojan Brand Condom's 2010 annual ranking of sexual health resources at American Colleges and Universities, Troy State University - main campus ranked 130th as being one of the worst sexually healthy schools (Trowery & Sevin, 2010, p.

5) when compared with the 2007 rating of 94th which represents the University's lowest rating (Sperling, 2007, p. 3) Just a year later in 2008, Troy's sexual health report card dropped from 94 to 116th in the nation (Saleh & Trowery, 2008, p. 5). In 2009, Troy State University hit its all-time low of 132th (Goldstein & Trowery, 2009, p. 3). In the three year annual reports published by Trojan Condoms, demonstrates a consistently declining trend with regards to Troy University's sexual health. Perhaps one of the biggest factors is the incidence of students becoming infected with sexually transmitted infections who either go unreported, untreated, or simply fail to recognize the signs and symptoms. Young women ages 18 to 24 are often the victims of acquiring sexually transmitted infections (Kouman, Sternberg, & Montamed, 2005, p. 211).

Scope and Complexity

The incidences of chlamydial infections on the Troy University main campus have steadily increased over the past 4 years.(Trowery & Sevin, 2010, p. 2) It is estimated that 1 in every 5 women who attend Troy University have either previously had or presently have a sexually transmitted infection. ("ADPH - STD Trends," 2010, p. 6) Most commonly the STI is chlamydia. (Centers for Disease Control and Prevention [CDC], 2007, p. 1) By comparing local, state, and national prevalence of chlamydia, it allows the opportunity to address the complexities surrounding its prevalence, etiology, risk-behaviors, and key psychological theories to explain this expansion. Furthermore, by evaluating this data, it is the aim to suggest tangible solutions on how to reduce the incidences of chlamydial infections and to develop more aggressive strategies to prevent its spread and better protect the students that attend this great university. While there are numerous factors that contribute to the acquisition, inoculation, and manifestation of chlamydia, the focus will on using evidence-based-practicums coupled with empirical evidence in order to understand why chlamydia is a social epidemic.


Chlamydia is the most commonly reported sexually transmitted infection (STI) in the United States (James, Simpson, & Chamberlain, 2008, p. 529). An estimated 2.8 million chlamydial infections occur annually and approximately 48% of reported cases occur among sexually active young adults between the ages of 15 and 24 years of age. (James et al., 2008, p. 529) Chlamydial infections are asymptomatic in most sexually active women who have the highest rate for this infection.(James et al., 2008, p. 529) Risk factors for chlamydial infections include young age and age at coital debut of less than 15 years (James, Simpson, & Chamberlain, 2008, p. 529).

In a 2008 study, a total of 789 students were screened for chlamydia and gonorrhea in three states; Alabama, Mississippi, and Georgia. (James et al., 2008, p. 530) The median age was 20 years. Subjects consisted of 263 students under the age of 20 years and 526 older students. (James et al., 2008, p. 530) More than half of the students (57%) were females and 80% of students were African-American.(James et al., 2008, p. 530) Approximately 60% of students resided in Georgia, which had the lowest chlamydia prevalence among all 3 states.(James et al., 2008, p. 530) Most of the subjects (42%) attended schools with a student enrollment >10,000 followed by 34% attended schools with <5,000 students and 24% attended schools with an enrollment between 5,000 and 10,000 students (James et al., 2008, p. 530).

The prevalence of chlamydia among all the students was 9.7%. However, in Alabama and Mississippi, students under the age of 20 years had a chlamydia prevalence of 17.1% in Alabama and 16.9% in Mississippi, respectively (James et al., 2008, p. 530). Data demonstrated that students under the age of 20 years were more likely to have chlamydial infections than older students (OR 1.66; 95% CI 1.01-2.73). (James et al., 2008, p. 530) Female students under the age of 20 years were more likely to be infected than were older female students (OR 1.92; 95% CI 1.03 - 3.59) (James et al., 2008, p. 530).

Conversely, younger female students had a chlamydia prevalence of 13% compared with 8.4% among older female students.(James et al., 2008, p. 531) It was also determined that schools with a total enrollment between 5,000 and 10,000 had the highest chlamydia prevalence of 15.5%.(James et al., 2008, p. 531) Students at these schools were more likely to report chlamydia than schools with an enrollment of less than 5,000 students (OR 1.98; 95% CI 1.10 - 3.53) and are more likely to report chlamydia than with schools where there total enrollment is >10,000 students (OR 2.5; 95% CI 1.40 - 4.49).(James et al., 2008, p. 531) The chlamydia positivity among students under 20 years of age and who attended schools with a total enrollment between 5,000 and 10,000 was 21.2% (James et al., 2008, p. 531).

The National Health and Nutrition Examination Survey 2003 to 2004 and in conjunction with the American Academy of Pediatrics conducted an assessment of 838 females who were aged 14 to 19 to determine the prevalence of 5 sexually transmitted infections. (Forham et al., 2009, p. 1505) Prevalence of any of the 5 STIs was 24.1% among all and 37.7% among sexually experienced female adolescents. HPV (23 high-risk types or type 6 or 11) was the most common STI among all female adolescents (prevalence: 18.3%), followed by Chlamydia trachomatis infection (prevalence: 3.9%). (Forham et al., 2009, p. 1505) Prevalence of any of the 5 STIs was 25.6% among those whose age was the same or 1 year greater than their age at sexual initiation and 19.7% among those who reported only 1 lifetime sex partner (Forham et al., 2009, p. 1505). Further analysis revealed that chlamydia infections occurred (3.9% [95% CI: 2.2% - 6.9%]) among those who were sexually experienced.(Forham et al., 2009, p. 1507) For the individuals who reported only having 1 lifetime sexual partner, the incidence of chlamydia infections was 7.1% (95% CI: 4.1 -12.2), respectively (Forham et al., 2009, p. 1507).

According to the Centers for Disease Control and Prevention's STD Surveillance report from 2007, between 2006 and 2007, the rate of chlamydial infections in women increased from 510.8 to 543.6 per 100,000 females (Centers for Disease Control and Prevention [CDC], 2007, p. 55). Chlamydia rates for persons 15 to 19 and 20 to 24 years of age have continued to increase concurrent for all other age groups. (CDC, 2007, p. 64) For the year 2006 to 2007, the increase for those 15 to 19 was 7.7% and for those 20 to 24 was 6.6% (CDC, 2007, p. 65). In 2007, women aged 15 to 19 had the highest rate of chlamydia (3,004.7 per 100,000 population) to any other age group.(CDC, 2007, p. 65) Chlamydia rates for 15 to 19 year olds increased 6.4% from 2,824 per 100,000 population in 2006 to 3,004.7 per 100,000 population in 2007 (CDC, 2007, p. 65).

In comparison, women aged 20 to 24 in 2007 as in previous years, had the second highest rate of chlamydia (2,948.8 per 100,000 population compared to any other age / sex group. (CDC, 2007, p. 65) Chlamydia rates in women of this age group increased 5.6% from 2006 to 2007. (CDC, 2007, p. 65)

In Alabama in 2009, a total of 25,902 Alabama residents were reported with chlamydia.("ADPH - STD Trends," 2010, p. 2) This represents a 94.1% (12,554) increase compared with the number of cases recorded in 2004. ("ADPH - STD Trends," 2010, p. 3) Alabama's 2009 case rate for chlamydia was 555.6 per 100,000. (Meriweather, 2009, p. 3) This ranks Alabama's morbidity as the sixth highest in the nation. (Meriweather, 2009, p. 3) Accordingly, from 2000 to 2009, the highest number of reported cases was in African-Americans. (Meriweather, 2009, p. 4) This number of chlamydia cases has increased by 66.8% (5,526) since 2004. (Meriweather, 2009, p. 4) In looking at Alabama's total demographics, African-Americans comprised 27% of the total population. (Meriweather, 2009, p. 4)

Furthermore, they comprised 53.3 % (13,801/25,901) of chlamydia cases recorded in 2009. (Meriweather, 2009, p. 4) African-Americans had the highest incidence of chlamydial infections followed by Hispanics (119.6 per 100,000) and Whites (96.8 per 100,000). (Meriweather, 2009, p. 4) Although the number of African-American females diagnosed with chlamydia declined by 7.4% (791) from 2008 to 2009, they represented 38.0% (9,848/25,901) of the recorded cases followed by 15.3 % of African-American males (3,952/25,901), 9.4% White females (2,426/25901), and 2.8% White males (729/25901). (Meriweather, 2009, p. 4) It appears that the number of recorded cases among African-American males, White females, and Hispanic males has remained relatively consistent for the past three years. (Meriweather, 2009, p. 5)

In terms of the number of cases reported in 2009 among people aged 15 to 19 has been identical to those aged 20-24.(Meriweather, 2009, p. 5) This trend also reflects CDC emphasis on screening people ages 15 - 24 . (Meriweather, 2009, p. 5) Surprisingly, people ages 25-29 represented the third largest age group for chlamydia infections in Alabama. (Meriweather, 2009, p. 6) Moreover, African-American females comprised 39.6% (7,673/19,375) of recorded cases within this age group. (Meriweather, 2009, p. 5) The top three leading age groups for chlamydia in the state of Alabama in 2009 are: 20 to 24 (3,071.4), second is the 15 to 19 (2,922.4), and the third is the 25 to 29 (1,144.3). (Meriweather, 2009, p. 6) This represents an alarming trend among high school to post-secondary institutions.

According to the 2008 report published by the Alabama Department of Public Health and the Centers for Disease Control and Prevention, Alabama ranked 2nd among 50 states with 9.7 cases of Primary and Secondary syphilis per 100,000 persons and ranked 4th among 50 states in chlamydial infections (535 per 100,000 persons) and ranked 4th among 50 states in gonorrheal infections (210.5 per 100,000 persons. Furthermore, the numbers of recorded cases of chlamydial infections among women (785.7 cases per 100,000) were 2.9 times greater than those among men (267.9 cases per 100,000). ("ADPH - STD Trends," 2010, p. 7)

In order to correlate the prevalence of chlamydia, it becomes necessary to identify what factors or risk-behaviors contribute to increased incidence and to quantify these attributes as etiological constraints.


Chlamydia trachomatis infections are the most commonly reported notifiable disease in the United States. (CDC, 2007, p. 1) They represent the most prevalent of all sexually transmitted diseases and, since 1994, have comprised the largest proportion of all STDs reported to the CDC. (CDC, 2007, p. 1) Chlamydial infections in women usually present asymptomatic and without any acute signs of manifestation. Complications often associated with untreated chlamydial infections include: pelvic inflammatory disease or PID, which is the leading cause of infertility among women, ectopic pregnancies, and chronic pelvic pain. Chlamydia if detected is a curable STD, unlike genital herpes or HSV2, only treats systemic outbreaks and does not actually cure the disease. Moreover, as with any other inflammatory STDs, chlamydia can facilitate the transmission of the HIV infection. (CDC, 2007, p. 1) In addition, women who are pregnant with chlamydia can pass the infection onto their infants during vaginal delivery, possibly causing neonatal ophtalmia and pneumonia.(CDC, 2007, p. 1) As a result of the increased prevalence of the disease and risks associated with infections, the CDC recommends all sexually active women younger than 26 years get screened annually. (CDC, 2007, p. 1)


Studies have found that the majority of young women often initiate sexual activity during adolescents and the risks for developing a sexually transmitted infection often accompanies this initiation. (Forham et al., 2009, p. 1506) This initiation is often the result of social pressures, fear of losing a boyfriend, a fundamental need to be accepted among peers, or as an experimental trial. (Forham et al., 2009, p. 1507) As a result, women entering college for the first time as freshman have either been exposed or risks exposure due to multiple sex partners. (James et al., 2008, p. 529)

A 1995 study using the National College Health Risk Behavior survey addressed priority health risk behaviors among college students, which included sexual behaviors that lead to unintended pregnancy and STI's.(James et al., 2008, p. 529) The results of this survey concluded that 86.1% of college students have had at least 1 sexual encounter.(James et al., 2008, p. 529) Furthermore, at least two-thirds were sexually active or had sex within the last 3 months. Approximately 30% of the respondents reported condom use at their last sexual encounter and 28% reported using condoms consistently (James et al., 2008, p. 529) Therefore, the results of this survey recommend the need to develop strategies to increase awareness in reducing the transmission of STI's.(James et al., 2008, p. 530)

Despite the high-risk behaviors exhibited among students, routine chlamydia screenings is not available at most student health centers. (James et al., 2008, p. 529) Conversely, Kouman et al. conducted a randomized survey of 736 colleges and universities to evaluate the proportion of schools offering STI services and the proportion of students with access to such services.(Kouman et al., 2005, p. 212) Based upon this survey, STI services were available at 66% of colleges/universities that had a student health center and 52% of students who attended a school where chlamydia and gonorrhea testing were available (Kouman, Sternberg, & Montamed, 2005, p. 212) Although most schools with STI services test symptomatic women and men for chlamydia and gonorrhea, only 67% of schools screened sexually active women and 48% of schools screened sexually active men (Kouman et al., 2005, p. 212).

One final high-risk behavior that has been identified particularly with college students is the use of alcohol and its effects on sexual behavior. (Griffin, Umstattd, & Usdan, 2010, p. 523) Current research findings and the high frequency of both of these risky behaviors occurring at the same time support Cooper's assertion that global associations between the 2 behaviors are reliable. (Griffin et al., 2010, p. 523) It also supports the relationship between alcohol use and sexual behavior, with individuals who have consumed alcohol being more likely to have had sex. (Griffin, Umstattd, & Usdan, 2010, p. 523)

Current trends show that 42% of college-aged students binge drink (approximately 4 or more drinks for females, 5 or more drinks for males in a sitting). Significantly, over the past 30 years, binge drinking has increased among college women. (Griffin et al., 2010, p. 523) The spring 2007 American College Health Association - National College Health Assessment indicated that 3 out of 4 college students had 0 to 1 sexual partner in the past 12 months, with 58% reporting using a condom the last time they had intercourse; however, the percentage of women reporting condom use was slightly lower at 49.8%. (Griffin et al., 2010, p. 523)

Hingson et al, used previous data to speculate that 400,000 college students a year have unprotected sex after drinking, where 100,000 are too intoxicated to give consent. (Griffin et al., 2010, p. 523) In 2007, an independent study of High-Risk College Drinking Consequences revealed a high incidence of alcohol-related victimization of college-aged students, with more than 97,000 students being sexually assaulted or date raped. (Griffin et al., 2010, p. 524) Needless to say that there is a strong inverse relationship between alcohol use and sexually risky behavior. This is affluent problem on many college campuses including Troy University and is represented by various incidents that have occurred with underage consumption of alcohol and the unreported cases of sexual abuse. As with risk-behaviors, can psychology explain why people engage in high-risk behaviors and is there a causable link that explains the rationale for these actions?

Psychological Theories

Psychologist David Buss proposed the sexual strategies theory to correlate psychological mechanisms and how they relate to sexuality. (Hyde, 2007, p. 47) This theory is related to evolutionary psychology and distinguishes between short-term mating and long-term mating practices. It further identifies the problems that both women and men had in order to solve both the short-term and long-term mating. (Hyde, 2007, p. 47) Buss contends that men have evolved psychological mechanisms that allow them to select women as sexual partners who are in their 20's because women are at their peak fertility. (Hyde, 2007, p. 48) Hence, men are preprogrammed for insemination, however, Buss offers little to no explanation as to why men and women have unprotected sex. He does however; offer an insight into the reasons why men and women select mates.

Another theory that could possibly explain this disparity is to look into the behaviorist perspective, specifically the work of Albert Bandura and both his social learning theory and cognitive social learning theory. Bandura's work primarily is concentrated on personality theories and how the developmental processes could shape our decision making abilities. (Boeree, 2006, p. 1) He theorized that environment can both cause behavior and behavior can cause environment. Bandura labeled this as conceptreciprocal determination and the world and a person's behavior can cause each other. (Boeree, 2006, p. 1) A particular area of Bandura's research that has a direct correlation with controlling behavior is regarded as self-regulation. (Boeree, 2006, p. 1) Contained within self-regulation are three main areas: self-observation, judgments, and self-response. (Boeree, 2006, p. 1) In the self-observation phase operationally speaking, is defined as the way that people view themselves, their behavior, and keep tabs on it. (Boeree, 2006, p. 3) The second operational phase is known as judgment. This is where people compare what they see with a standard. His final operational step called self-response deals with the concept of reward versus punishment. (Boeree, 2006, p. 3)

The self-concept or self-esteem theory has significance to chlamydial infection prevalence and the associated high-risk behaviors. By using the concept of environment controls behavior and behavior controls environment, a paradoxical connection can be established. (Boeree, 2006, p. 1) For example, adolescent women often initiate sexual intercourse.(Forham et al., 2009, p. 1506) If her self-observational phase speaks to the fact that she is attractive and wants to engage in sexual activities, then their judgment phase encourages them to do so by the standard set by their peers. Therefore, the risk of getting pregnant and catching an STI versus the reward of the momentary sexual gratification experienced at the end of coitus. However, the inverse can also equally apply to the situation.

Potential Solutions

The chlamydia prevalence was higher in young female college students; therefore, more screening efforts and increased awareness are indicated to reducing the prevalence of chlamydial infections among active student populations. (James et al., 2008, p. 529) Another consideration with regards to decreasing the prevalence of chlamydial infections among college students is an increased effort by the schools themselves to provide better resources. Most schools provide some form of prevention education, access to prevention, proper testing, treatment and education should be a priority at schools where these services are accessible but, utilized. (Kouman et al., 2005, p. 1) The Centers for Disease Control and Prevention recommends that sex partners that have the chlamydial infections seek treatment as to prevent the spread or possibly re-infection of the initial patient. (CDC, 2007, p. 6) Concurrently, recent studies have demonstrated that many young women who have been diagnosed with chlamydia become re-infected by male partners who were not infected with chlamydia. (CDC, 2007, p. 6)

Accordingly, the American Academy of Pediatrics recommend early and comprehensive sex education, routine HPV vaccination at ages 11 to 12, and chlamydia screenings of sexually active females can lead to a decrease in chlamydial prevalence. (Forham et al., 2009, p. 1505) The Alabama Department of Public Health also encourages active screening; increased education, early treatment, and effective follow-up are key factors in reducing chlamydial prevalence. ("ADPH - STD Trends," 2010, p. 4) I concur with the evidence-based-practices on reducing the spread of chlamydia. In my opinion, the university should develop or incorporate into their Troy 101 orientation course a modified sex education program.


Both prevalence and reported cases of Chlamydia infections remain high across the age groups, racial and ethnic groups, geographic locales, and both sexes. The burden of chlamydial infections appears highest among women within the age groups of 15 to 19 and 20 to 24; racial differences also persist with the recordable cases among African-Americans remains consistently higher than those of other racial and ethnic groups. (CDC, 2007, p. 5) Future interventions articulate a high prevalence of negative sexual consequences related to alcohol use among college women should be addressed. (Griffin et al., 2010, p. 523)


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