A THEORY-BASED INITIATIVE TO REDUCE THE RATES OF CHLAMYDIA TRACHOMATIS INFECTION AMONG YOUNG ADULTS IN THE YUKON.
Key Words: Chlamydia STD control Screening Social marketing Community health
Chlamydia trachomatis infection is the most common sexually transmitted infection in Canada (Patrick, 1997). Men and women infected with chlamydia are often asymptomatic and can unknowingly infect others. Undetected and untreated infection poses a significant long term health concern because chlamydia is often associated with pelvic inflammatory disease (PID), tubal infertility and ectopic pregnancy (MacDonald & Brunham, 1997). In addition to the impact on individuals, chlamydia infection and its sequelae represent a significant cost to the Yukon health care system. A study conducted for the Royal Commission on New Reproductive Technologies (1993) estimated the national annual cost of chlamydia and gonorrhoea infections to be between 71 million and 197 million dollars.
Since chlamydia infection is preventable (consistent condom use, safer sex practices, partner notification), detectable (urine testing facilitates screening of young adult males), and treatable (single dose azithromycin is highly effective), communities at particular risk have the means available to reduce infection and its attendant social and economic costs (see Patrick, 1997; Royal Commission on New Reproductive Technologies, 1993).
Of the 36,376 cases of genital chlamydia reported in Canada in 1995, Ontario, Quebec, British Columbia and Alberta (which have about 85% of Canada's population) accounted for 78% of the total (Patrick, 1997). Infection rates in these provinces varied between 104.1 and 181.6 per 100,000 population. In contrast, the Yukon, had a reported infection rate of 518 per 100,000, considerably above the national average of 122.9 per 100,000. Young people aged 15-29 accounted for about 85% of all reported cases in Canada in 1995 (Patrick, 1997) and chlamydia infection rates for the Yukon in 1996 showed a similar but slightly wider age distribution (Fig. 1).
[Figure 1 ILLUSTRATION OMITTED]
In 1997, the Health Promotion Unit of the Yukon Government's Department of Health and Social Services initiated a large scale chlamydia education and prevention program to reduce this high infection rate and its consequences. The program, called "Style: doing the right thing", included a 3-month social marketing campaign aimed at teens and young adults and a survey questionnaire administered to a sample of this intended audience both before and several months after the campaign.
This paper describes the conceptual approach and methodology of the campaign and presents findings from the pre-and post-campaign surveys of teens and young adults in this geographically large and diverse northern community.
In June, 1997, the Yukon had a population of 33,586 people (Yukon Bureau of Statistics, personal communication, 1998) including 2,286 youth aged 1519, 2,242 aged 20-24, and 2,697 aged 25-29. About 72% of these Yukoners live in Whitehorse, the largest urban centre; those outside Whitehorse live in small communities throughout the territory. The chlamydia infection rate for 15- to 29-year-olds living outside Whitehorse in 1996 was about double that for those 15-29 living in Whitehorse. The social marketing campaign described here was initially designed to increase awareness of chlamydia and its prevention and treatment in the younger 15- to 19year-old segment of this age group. By the onset of the campaign in mid-November, 1997, elements had been added that expanded the scope of the campaign to include 20- to 29-year-olds as well.
Patrick (1997) suggested that the mathematical model for the reproductive rate of an STD (R=BcD) could serve also as a conceptual model for designing public health programs to reduce the occurrence of new cases of sexually transmitted infection. Patrick describes the reproductive number (or rate) of an infection as
the mean number of new infections generated by infected persons over the lifetime of their infection (in a fully susceptible population). The phrase in brackets means that the infected person is encountering new uninfected partners who would not have been exposed except through him/her (Patrick, 1997, p. 144).
In order to control the spread of an infection (i.e., to reduce R well below 1), one must alter the three parameters listed below:
B = the probability of transmission from an infected to an uninfected partner (influenced by occurrence and type of sexual activity, infectivity of the agent, susceptibility of the individual to the infectious agent, condom use);
c = the contact rate between infected and uninfected individuals (influenced by number of partners, sexual networks or sub-groups, age of onset of sexual intercourse or other risk behaviours for infection); and
D = duration of infectivity (influenced by presence of symptoms that might influence treatment, availability and effectiveness of treatment, social support to seek treatment).
In the context of a campaign to reduce the number of people infected with chlamydia, these parameters become possible sites for intervention. One might seek to:
* reduce probability of transmission (B), e.g., by promoting safer sex practices such as regular condom use and non-insertive sexual practices;
* reduce contact rate (c), e.g., by promoting postponement of sexual intercourse among younger teens and reduction in number of partners;
* reduce duration of infectivity (D), e.g., by promoting regular testing, early treatment, and effective follow-up.
Interventions to effect these parameters could, in theory, help to reduce rates of infection with chlamydia, HIV or other STDs and perhaps also rates of unintended pregnancy. Maticka-Tyndale's (1997) review of the literature suggests that strategies to increase regular condom use (reducing B) and to improve access to diagnosis and treatment (reducing D) are likely to be most efficacious against sexually transmitted infections such as chlamydia. Patrick (1997) also emphasized the importance of strategies to reduce the duration of infection (D) through such measures as:
* Annual screening offered to all sexually active individuals aged 15-24;
* Use of the most effective screening technology such as amplified DNA technology for screening (urine testing) which has high sensitivity and greater acceptance, particularly among males (Quinn et al., 1996);
* increased access to single dose azithromycin as the antibiotic of first choice for treatment;
* Maintenance of an effective system for notification of contacts. Patrick (1997) cites evidence suggesting that over 50% of sexual partners of individuals infected with chlamydia are themselves infected (Viscidi, Bobo, Hook, & Qumn, 1993).
Based on the foregoing evidence, our social marketing campaign to reduce the chlamydia infection rate among young adults in the Yukon, sought to:
* increase awareness of chlamydia and its implications;
* increase condom use and other safer sex practices to reduce probability of infection; increase the number of individuals seeking testing for chlamydia in order to reduce duration of infection.
THEORY-BASED FRAMEWORK FOR DESIGN OF SOCIAL MARKETING CAMPAIGN
All aspects of the design in content of the campaign were influenced by Information/Motivation/ Behavioural Skills Theory (Fisher, 1997) and Social Network Theory (Kelly, St. Lawrence, Brasfield, Stevenson, & Haugh, 1991). Information on prevention and treatment of chlamydia was presented in a way that was easy to understand, pertinent to teens and young adults, and readily translatable into behaviours that could reduce the probability and/or duration of infection. A similar theory-based approach prompted our focus on messages designed to foster positive attitudes toward chlamydia testing, safer sex practices, condom use and communication about these issues. Two focus groups, one of "mainstream" youth and the other of "at-risk" teens, reviewed print promotional materials, selected examples from magazines of visual images that would appeal to their peers, and suggested revisions to the text and design of the resource materials used to communicate the campaign's messages.
1. Poster. A colourful and visually arresting graphic design was developed for the bilingual campaign poster that became widely identified with the "Style: doing the right thing" campaign. A smaller graphic on the poster featured the stylized image of a young person's face looking directly at the reader. Text was limited to a single message, "Chlamydia is the most common sexually transmitted disease in the Yukon", accompanied by phone numbers, locations and a website to obtain information, testing, the poster, and/or the "Style Kit" described below. Promotional signs on buses in Whitehorse also increased the campaign's visibility. Signs done separately in English and French contained one of the four following messages:
* "It's hard to stand up for your own rights while respecting the rights of others. Accept the challenge";
* "Manhood is a quest for inner strength and courage";
* "Chlamydia is the most common sexually transmitted disease in the Yukon. Up to 70% of women infected with this disease have no symptoms. For women, chlamydia infections can lead to infertility";
* "If you decide to get tested for HIV, the virus that causes AIDS, consider getting tested for chlamydia."
2. Style Kit. The widely distributed Style Kit featured a plastic CD case in which the graphic theme design of the enclosed bilingual campaign brochure showed through the cover to give the impression of a rock CD. This impression was reinforced by the title "Popular disease" ("maladie a la mode") and by the words "Style" and "chlamydia". Brochure panels contained brief first person stories from a young woman and a young man. This text alone communicated the campaign's key information and motivational messages. For example, the idea that people "like me" can get chlamydia is conveyed when the young woman says,
My doctor told me that chlamydia is really common among Yukon teens-about as common as teen pregnancy. I was pretty amazed when she said that because I know a lot of people my age who have got pregnant--to think the same amount of them have been infected with chlamydia and some don't even know it totally blows my mind away.
A sticker taped inside the case reinforced this point: "Most women and some men with chlamydia notice no symptoms." The Style Kit also included four different Lifestyles condoms, a card listing the types and characteristics of condoms available, and an external sticker on the back that read "Free. This item does not contain a compact disc."
3. Radio information tape. A 10-spot audio tape on chlamydia prevention and treatment was made available to a rock radio station with a large youth audience. The station aired 6 of the 15-second spots at different times each evening during the course of the campaign at key youth listening times (4 pm and 9 pm).
TIMING OF CAMPAIGN COMPONENTS
Fall 1997 -- Pre-campaign STD scenario questionnaires were administered throughout the Yukon to assess teen's and young adult's knowledge and attitudes concerning chlamydia and safer sex practices. The public school system was not used as a site for distribution of the Style Kits or other promotional materials. However, the high schools and Yukon College campuses were the primary sites for administration of pre- and post-campaign questionnaires.
Mid-November 1997 -- Phase 1 of the social marketing campaign was launched. About 2,000 Style Kits were distributed throughout the Yukon via restaurants, retailers, and other public settings where youth are likely to gather. Kits were also distributed by community nursing stations, the Communicable Disease Control Unit, AIDS offices and government agencies dealing with youth at risk. Schools were the sites for surveys but, as noted above, were not asked to be distribution sites for the Style Kits. Radio spots began and campaign posters or signs appeared on bulletin boards, sandwich boards, on buses, and in other public settings. Phase 1 ended at the end of February, 1998.
February 1998 -- Urine testing for chlamydia became available in the Yukon as a screening option.
Spring 1998 -- Post-campaign STD Scenario Questionnaires were administered throughout the Yukon as above.
PRE- AND POST-CAMPAIGN QUESTIONNAIRES: CONTENT AND ADMINISTRATION
The two-page questionnaire had 14 questions (mostly multiple choice) that assessed basic knowledge about chlamydia, sought respondents' opinions about the availability and desirability of testing and treatment for chlamydia, and asked about their attitudes toward condoms and condom use. There were no questions on respondents' sexual behaviour. Nine questions were based on a brief paragraph about Amanda and John, a mid-twenties couple, living together for three years, who stopped using birth control to have a child. She was still not pregnant 8 months later when they consulted a doctor. Following testing their doctor reported that they both had an STD that may have made it impossible for her to ever have children.
Questionnaires were administered in a class settings in public schools or Yukon College campuses by either a community health nurse, a community health representative, the Health Promotion Coordinator, or in a few cases by Yukon College instructors. Many questionnaire administrators were also involved in organizing the chlamydia social marketing campaign in their respective communities. Since they were given detailed written procedural instructions and asked to follow them, this involvement is unlikely to have biased the results. After distributing questionnaires, the questionnaire administrator read the scenario out loud, and then read the first scenario-based question which asked, "What STD are Amanda and John probably infected with?" Respondents were given time to write their answer but were asked to wait before doing the next question. In the analysis of results, those who answered "chlamydia" were deemed to be aware of or "have knowledge of" chlamydia. When all had answered, the questionnaire administrator said that the STD was chlamydia but gave no further explanation apart from stating that students should not now add to or alter their answer. Each of the main questions was similarly aloud and answered. In most cases, a 15- to 45-minute information session on chlamydia followed completion of the questionnaire.
Both the questionnaire and this subsequent session became part of the educational intervention for all respondents to the pre-campaign study. Although it was uncertain whether differences in knowledge or attitudes among post versus pre-campaign respondents could be meaningfully attributed to the campaign, efforts were made to reduce factors that would preclude this possibility. Hence, high school students did the questionnaire before they had their regular sexuality education classes for that school year and administrators were asked to give the post-campaign questionnaire to classes that had not previously done it. In addition, the spring 1998 questionnaire was administered some time after the end of the active campaign when responses would have been less likely to reflect short term recollection due to very recent exposure.
Respondents were predominantly students attending either Yukon public schools or Yukon College campuses although in a few cases other community members who were not in school were also included. Respondents were not randomly selected and our small subsample (about 4%) of the target age group for the social marketing campaign may perhaps be unrepresentative. Questionnaires were only administered in public school classes where the school administration and the classroom teacher consented. Among College students, questionnaires were only administered in classes where the instructor consented. Outside Whitehorse, questionnaires were only administered in communities where a public health nurse or a community health representative was available for this purpose.
The post-campaign questionnaire had a similar scenario and questions to the initial study with the exception that Health and Social Services was not granted permission to include questions assessing attitudes towards condoms in the version given to the public school student sample.
Given the prohibitive cost of large scale population surveys, a comparison of pre-campaign (n=366) and post-campaign (n=328) questionnaire responses is used here as one, albeit tentative, measure of the campaign's impact on chlamydia-related knowledge and attitudes in selected age groups. Age and sex distribution of the two samples is given in Table 1.
Table 1: Age and Sex Distribution of Respondents to Pre- and Post-Campaign Questionnaires on Chlamydia
Characteristics Fall 1997 Spring 1998 Pre-campaign Post-campaign Age N % N % Not stated 10 2.7 5 1.5 under 15 28 7.7 26 7.9 15 - 19 162 44.3 171 52.1 20 - 24 40 10.9 34 10.4 25 - 29 25 6.8 30 9.1 30+(*) 101 27.6 62 18.9 Sex Not stated 10 2.7 7 2.1 female 214 58.5 163 49.7 male 142 38.8 158 48.2
(*) Most respondents over 30 were community college students.
AWARENESS OF CHLAMYDIA
When asked what STD the couple in the questionnaire scenario had, 29.5% of the pre campaign versus 49.5% of the post-campaign sample responded correctly. This significant increase in post-versus pre-campaign "awareness of chlamydia" in the overall sample (p [is less than] 0.0001) was also noted for 15 to 19-year-old females both inside and outside Whitehorse, for 15- to 19-year-old males outside but not inside Whitehorse, and to a lesser extent for 20 to 24-year-olds overall (Table 2).
Table 2 Awareness of Chlamydia Among Respondents to the Pre- and Post-Campaign Questionnaires(*)
Fall 1997 Pre-Campaign Sample Respondents % Correct(*) All 366 29.5 15- to 19-year-olds female (Whitehorse) 53 22.6 female (outside Whitehorse) 36 44.4 male (Whitehorse) 37 24.3 male (outside Whitehorse) 36 41.7 20- to 24-years-old (all) 40 30.0 Spring 1998 Post-Campaign Sample Respondents % Correct All 328 49.5 p<0.0001 15- to 19-year-olds female (Whitehorse) 66 43.9 p=0.0075 female (outside Whitehorse) 18 100.0 p=0.0002 male (Whitehorse) 72 29.2 p=0.2981 male (outside Whitehorse) 15 60.0 p=0.0392 20- to 24-years-old (all) 33 45.5 p=0.0869
(*) Awareness based on correctly naming chlamydia as the STD most probably affecting the couple in the questionnaire scenario.
AWARENESS THAT PEOPLE INFECTED WITH CHLAMYDIA ARE OFTEN ASYMPTOMATIC
After they had answered the first question assessing their awareness of chlamydia, all respondents were told that the woman and man in the questionnaire scenario had chlamydia. The next question noted that the woman did not know she was infected and asked whether women infected with her STD usually have symptoms. Options were yes, no and don't really know. Among 15- to 24-year-old females, 58.3% in both pre- and post-campaign groups answered correctly that they might not usually know. Among males 15-24 years old, there was also no significant change in the percentage responding correctly (43.8% versus 46.7%, p=0.3409). Among other response options, "don't know" was slightly more frequent than the incorrect response.
KNOWLEDGE OF POSSIBLE PROTECTIVE BEHAVIOURS AGAINST CHLAMYDIA
Respondents were asked what the woman and man in the questionnaire scenario could have done to prevent themselves from getting infected with the STD they had. Although these responses do not require specific knowledge of chlamydia (i.e., they could be generic for any STD), the type and frequency of options volunteered is instructive (Table 3). Pre-campaign respondents averaged 1.32 volunteered examples per person, post-campaign 1.26. Since the question did not state that students should list all the examples they could think of, comparison of the percentages of various pre-versus post-campaign responses may be less instructive than the actual options chosen. Methods cited in the literature as most amenable to public health intervention (e.g., condom use, testing, safer sex practices) were volunteered more often than those that are less likely to be influenced by public health programs (e.g., mutually monogamous relationships or reducing number of lifetime partners). However, when asked elsewhere in the questionnaire whether they thought it was "a health risk to have many different partners during a lifetime," 89-91% of women and 74-78% of men in both samples said yes. Contrary to expectation, a lower percentage of post-campaign respondents cited condoms as a means of protection ( 51.5% versus 63.1%, p=0.0010). Consistent with expectation, a higher percentage cited testing (28.4% versus 20.5%, p=0.0139).
Table 3 Number and Percentage of Pre- and Post- Campaign Respondents Suggesting Various Chlamydia Preventive Actions(*)
Protective Behaviour Fall 1997 Spring 1998 Pre-Campaign Post-Campaign N % N % Using condoms during sex 231 63.1 169 51.5 Using safer sex practices 76 20.8 69 21.0 Get self/partner tested 75 20.5 93 28.4 before beginning sex Abstain from sex, 67 18.3 49 14.9 postpone age of first sex Reduce number of lifetime 23 6.3 32 9.8 partners Mutually monogamous 11 3.0 2 0.6 relationships
(*) Percentages total to more than 100% because more than one option could be volunteered.
OPINIONS ABOUT CONDOM USE AND AVAILABILITY
Four multiple choice questions asked for opinions about condom use. Because permission was not obtained to ask 15- to 19-year-olds these questions in the post-campaign questionnaire, they were not included in the post-campaign high school questionnaire. Pre-campaign responses from the total sample (n=366) are summarized below.
* The majority thought it was "easy to get flee condoms in your community" (54.9%) or "easy to get as long as you know where to go" (24.9%). Only 3.3% thought it was not easy; 8.2% did not know about access to condoms.
* With regard to how they think men "feel about using condoms", a majority replied that some (51.9%) or most (15.3%) men do not like using condoms; 17.2% said men are "OK with using condoms"; 13.9% did not know. In relation to how they think women feel about using condoms, 30.3% said some women and 5.2% said most women do not like using condoms; 48.6% said women are OK with using condoms, 14.5% did not know.
* Concerning whether it was easy for women to convince their sex partners to use condoms, 53.6% said sometimes hard, 4.6% always, 27.9% easy, and 12.8% did not know.
NUMBER OF CHLAMYDIA TESTS PERFORMED PRE-VERSUS POST-CAMPAIGN
A total of 794 chlamydia tests were done in the Yukon from December, 1996 to February, 1997 inclusive and 911 from December 1997 to February, 1998 inclusive. This 15% increase in testing may be attributable to the campaign although the variability and fluctuation in testing makes this possibility difficult to confirm. However, it is worth noting that an additional 2000 chlamydia "Popular Disease" CD pamphlets were distributed between late April and the end of July, 1998, after the campaign was over and around the time that the newly available urine test for chlamydia was fully implemented. Test numbers for May-August, 1998, were also higher (by about 9.2%) than for the comparable period in the previous year.
The social marketing campaign described here used current theory and knowledge about STD prevention (Patrick, 1997; Fisher, 1997; Maticka-Tyndale, 1997) to determine the goals, design, and execution of a campaign to increase awareness of chlamydia, to reduce transmission, and to increase testing. Campaigns such as this are thought to be most effective when they are presented in high profile over a brief time period (e.g. 6-10 weeks), emphasize a few focused, understandable messages that are directly pertinent to the goals and to the audience, and offer clear guidance on actions that individuals can take to achieve the goals. "Style: doing the right thing" sought to meet these criteria. The intended audience received extensive exposure to campaign materials through community networks, agencies, popular media, and social settings where young adults gather. Distribution of information, and condoms in a contemporary format (the Style Kit) was intended to reinforced the peer acceptability and social desirability of the campaigns goals. Involvement of schools in the questionnaires and subsequent education/discussion sessions provided an additional, high content interaction with over 650 teens and young adults.
The questionnaire component of the campaign provided both an educational intervention and a possible means of assessing, via a small segment of the target audience, whether post-campaign respondents were more likely to demonstrate knowledge and opinions consistent with the campaign goals. Despite the limitations of the methodology, some of the findings provide reinforcement for other qualitative measures used to assess the campaign's impact.
IMPACT ON AWARENESS OF CHLAMYDIA AND RELATED TOPICS
In order to correctly identify "chlamydia" as the STD in the questionnaire scenario, respondents would have had to recognize one or all of the clues, i.e. that both the man and woman in the couple had been asymptomatic for some time and that their STD could affect her fertility even though she was asymptomatic. Since respondents had to write in their answer, not choose it from a multiple choice list, this seemed a reasonable basis for "awareness" of chlamydia. The significant increase in correct post-campaign responses in the total sample (49.5% versus 29.5%) and in all but one of the teen subsamples suggests greater knowledge of chlamydia in the post-campaign respondents. Slight differences in age composition of the pre versus post samples are unlikely to explain this finding. Some community college and public school students among the post-campaign respondents had also done the pre-campaign questionnaire. Given that the post-test was done 3-5 months after the pre-test, the much higher awareness rate overall is salutary. It is difficult to attribute such changes exclusively to the campaign but worth noting that 53% of post-campaign respondents said they had heard of the campaign via radio, Style Kit distribution or other such venues.
Although about 58% of women and 47% of men aged 15-24 knew that people infected with chlamydia could be asymptomatic, these post-campaign percentages were not significantly greater than in the pre-campaign sample. A higher percentage of post- than pre-campaign questionnaire respondents (28.5% versus 20.5%) did cite "getting tested before beginning sex" as a preventive measure against chlamydia (Table 3). However, the percentage suggesting "safer sex practices" did not change and those suggesting "using condoms during sex" declined. Since most respondents volunteered only one answer to this question, an explanation for the less frequent citing of condom use could be that pre-campaign respondents, who were considerably less knowledgeable about chlamydia (see Table 1), were more likely to think of a common response applicable to preventing any STD (condom use, safer sex) whereas post-campaign respondents were more inclined to suggest testing, a specifically chlamydia-related message of the campaign.
IMPACT ON TEST-SEEKING FOR CHLAMYDIA INFECTION
Our focus on the accessibility and effectiveness of testing and treatment drew on existing recommendations (Patrick, 1997) which were then adapted to the circumstances in the Yukon. For example, high infection rates among 25- to 29-year-olds in the Yukon led us to recommend annual chlamydia testing for all sexually active individuals under 30 years of age (in contrast to the 15-24 age range suggested in STD goals for Canada, [Patrick, 1997]). The increase in the number of tests done in December 1996 versus December 1997 (1.5 months after the start of the campaign) suggests that the campaign may have had some impact on this goal.
CHALLENGES IN IMPLEMENTATION AND OUTCOME ANALYSIS
In their conceptual model for the implementation of STD) control programs, McIntyre & Jagosh (1998) identify evaluation as a key component in the multilevel implementation process. In our experience, a theory-based sexual health-related campaign aimed at young people is easier to "sell" when the content and evaluation measures are directed toward changes in knowledge. Asking questions about attitudes or behaviours is more sensitive. The interventions and outcome measures described here therefore reflect a balance between the demands of effective evaluation and the goal of broad community participation, acceptance and support. In the questionnaire, behavioural intentions thus stood in for actual behaviours in the questionnaires, opinions replaced actions, and some opinions (i.e., high school student's view on condoms) were not included in the post-campaign questionnaire. While evaluations based on pre-and post-intervention test scores are an important dimension for assessing the impact of some interventions, we have recognized that a social marketing campaign to influence key aspects of knowledge about chlamydia is not a controlled experiment. In our case, the questionnaire process was both a means to assess impact and a vehicle for furthering the educational goals of the campaign. While some findings provide strong evidence that the campaign influenced knowledge, further effort will be needed to ensure that this knowledge is translated into sexual health promoting attitudes and behaviour. This goal is a key element of the Canadian Guidelines for Sexual Health Education (Health Canada, 1994) and a continuing stimulus for sexual health programs in the Yukon.
ACKNOWLEDGEMENTS: Patricia Living, Health and Social Services Communications Coordinator, co-produced the social marketing campaign. Pat Mandl, Yukon Communicable Disease Control, was instrumental in planning, in promoting the initiative outside Whitehorse, and in obtaining Chlamydia urine testing technology. Dr. Jim Tousignant, Yukon Bureau of Statistics, championed the evaluation process and provided analytical advice; Ron Pearson, Director of Health Programs, Judy Pelchat, and staff in Community Nursing and in the Whitehorse Health Centre, also contributed to various aspects of the overall program. Health and Social Services also extends thanks to the Department of Education and Yukon College for allowing students to participate in the questionnaire study and to the many community agencies, businesses and individuals who supported the campaign.
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McIntyre, L. & Jagosh, J. (1998). Challenges in implementing innovative and successful sexually transmitted disease control programs: theory and practice. The Canadian Journal of Human Sexuality, 7, 321-329.
Patrick, D.M. (1997). Chlamydia control: components of an effective control strategy to reduce the incidence of Chlamydia trachomatis. The Canadian Journal of Human Sexuality, 6, 143-150.
Quinn, T., Gaydos, C., Shepherd, M., Bobo, L., Hook, E., Viscidi, R., & Rompalo, A. (1996). Epidemiologic and microbiologic correlates of Chlamydia trachomatis infection in sexual partnerships. Journal of the American Medical Association, 276, 1737-1742.
Royal Commission on New Reproductive Technologies. (1993). Proceed with Care: Final Report of the Royal Commission of New Reproductive Technologies.
Viscidi, R.P., Bobo, L., Hook, E.W., & Quinn, T.C. (1993). Transmission of Chlamydia trachomatis among sex partners assessed by polymerase chain reaction. Journal of Infectious Diseases, 168, 488-92.
Correspondence concerning this paper may be directed to Jeff Wackett, Health Promotion Unit, Department of Health and Social Services, Government of Yukon, #2 Hospital Road, Rm. 112, Box 2703, Whitehorse, Yukon, Y1A 2C6. Tel: (867) 667-8393; fax: (867) 667-8338; email: firstname.lastname@example.org.
Jeff Wackett Health Promotion Unit Health and Social Services Whitehorse, Yukon
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|Publication:||The Canadian Journal of Human Sexuality|
|Date:||Dec 22, 1998|
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