Vol.3, No.1, 64-74 (2013) Open Journal of Preventive Medicine
http://dx.doi.org/10.4236/ojpm.2013.31009
Chlamydia prevention in Sweden—A case study of
potential key factors in successful response
Charlotte Deogan1, Cecilia Moberg2, Lene Lindberg1, Anna Månsdotter1
1Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden; *Corresponding Author:
2Department of Neurobiology, Care Science and Health, Karolinska Institutet, Stockholm, Sweden
Received 12 June 2012; revised 15 July 2012; accepted 23 July 2012
ABSTRACT
Background: Af ter a continuous increase of Chla-
mydia trachomatis (chlamydia) in Sweden, a
general reduction in reported cases was seen in
2009. However, the number and decrease of
chlamydia cases varied largely between geo-
graphical regions. Aim: The aim of the present
study was to identify potential key factors of
successful r egional prev ention of chl amydia an d
other sexually transmitted infections (STIs).
Methods: A multiple case study was performed
including seven Swedish counties. Data was
collected via surveys and interviews with key
informants, county council registry data, survey
data on condom use, and surveillance data on
reported cases of chlamydia. In a case compar-
ison, factors of prevention structure and pre-
vention activities were identified and rated as
strengths or weaknesses compared to standard
preventive measures. Potential key factors were
identified by examining prevention strengths
corresponding to high condom use and de-
crease of chlamydia cases. Results: Differences
were found in prev entio n struc ture and a ctiv ities
across counties. Identified potential key factors
were; adequate investments in STI prevention,
suitable organizational structure, strong leader-
ship, managing regional STI-networks, research
connection, multiple local collaborations with
health care and community, high testing coverage
and strategic risk approach. Conclusions: This
study shows that greater consideration to struc-
tural factors of chlamydia prevention may benefit
the outcom es of STI -prev ention activities.
Keywords: Chlamydia; STIs; Prevention;
Prevention Structure; Case Study
1. BACKGROUND
The most frequently reported sexually transmitted in-
fection (STI) in several countries including Sweden, is
Chlamydia trachomatis (chlamydia). Chlamydia is most
common among 15 - 29 years old, who account for 89%
of all Swedish cases (2010). The number of reported
cases increased steadily from 1997 onwards and reached
a peak of approximately 47,000 reported cases in 2007
(of which 57% were female) [1]. Since then, a reduction
has taken place with considerable regional differences
[2], which suggest that the preventive response differs
across geographical regions.
In 2009, the Swedish National Board of Health and
Welfare developed a new Action Plan for Chlamydia
Prevention 2009-2014 focusing on adolescents and young
adults [2]. The national action plan (NAP) generally
aimed to strengthen prevention with inter-sectorial col-
laboration and a mix of strategies. In Sweden, County
Medical Officers (CMO) are responsible for the preven-
tion and control of communicable diseases in each of
Sweden’s 21 counties and regions, whereas STI-coordi-
nators are responsible for the particular coordination of
preventive efforts of STI at the regional level. The NAP
recommendations for the regional areas focus on im-
proved counseling and partner tracing and increased
availability and accessibility to health care services. Fur-
thermore, schools and youth centers are mentioned as the
main arenas for effective prevention, and uniform com-
munication and information is underlined. To enable a
successful preventive result, the NAP emphasizes the
importance of effective collaboration between sectors
and arenas as well as improved interaction within the
health care sector [2].
Several studies have explored possible risk factors for
acquiring a STI. Strong risk factors for chlamydia and
other STIs include a young age at first sexual intercourse,
multiple lifetime sexual partners, and a history of other
STIs. Furthermore, health risk behaviours such as smok-
ing, drinking and substance use have shown to affect the
risk of STIs by association with sexual risk behaviour
[3-5].
The evidence base of effective STI-prevention is lim-
ited. Reviews have identified some characteristics of

C. Deogan et al. / Open Journal of Preventive Medicine 3 ( 2013) 64-74 65
effective interventions [6,7] but sufficient evidence for
policy and guidelines is still lacking. A study from Aus-
tralia on HIV/AIDS showed that cross-sectional partner-
ships or collaboration, commitment and active involve-
ment of all key stakeholders and favourable resource
allocation are key factors of successful prevention [8].
Other Australian studies emphasize adequate allocation
of resources as critical for effective prevention of HIV [9]
and stress the importance of policy and prevention stra-
tegies regarding different patterns of spread of disease
[10]. Collaboration, competencies in the organization and
clear leadership have also been further described as im-
portant factors for improved HIV prevention services
[11] as well as availability and accessibility to informa-
tion, health care, testing and counseling [12,13]. Re-
garding chlamydia, more women than men are diag-
nosed because of higher testing rates among women [1].
Thus, targeting men to get tested could be of particular
importance. Quality assurance regarding staff qualifica-
tion and allocated time has been shown to determine the
effectiveness of partner tracing [14]. A gender considera-
tion in this context is that more men than women are
diagnosed through the partner tracing procedure. More-
over, consistent use of behavioural counseling may po-
tentially have an effect on sexual attitudes, [13,15] and
has been found to promote healthy behaviors [16] as well
as reduce maladaptive behaviors such as HIV risk tak-
ing [17]. Condom is still the only contraceptive method
that provides protection against HIV and other STIs. Free
distribution or low-cost provision of condoms in combi-
nation with information, and education or counseling
may be an effective way to reduce chlamydia, consider-
ing the price sensitivity of the target group [18,19].
In summary, the evidence base of successful STI pre-
vention entails a range of activities aiming to promote
sexual- and reproductive health by reduced risk behavior
and increased awareness, testing and condom use. Al-
though most of the evidence presented above is included
as recommendations in the NAP, comprehensive knowl-
edge on the implementation at the regional level is lack-
ing and there is insufficient understanding of the effec-
tiveness of different components in the prevention mix.
2. Aims
The overall aim of the present study was to identify
potential key factors of successful regional prevention of
chlamydia and other STIs in Sweden.
Therefore, the specific aims were to:
 Map out the preventive response in seven Swedish
counties in terms of structure and activities;
 Perform a case comparison of the counties to examine
strengths and weaknesses compared to the standard
preventive measures;
 Identify potential key factors of successful chlamydia
prevention by examining strengths corresponding to
high proportion of condom use and decreased number
of chlamydia cases.
A conceptual model is presented in Figure 1, on
which the framework of the case study was based.
3. Methods
3.1. Case Selection
In 2006, a new mutant variant of Chlamydia tra-
chomatis bacteria (nyCT) was discovered, which was not
identified by the nucleic acid amplification diagnostic
tests (NAATs) vastly used in Sweden. Out of Sweden’s
21 counties and regions, seven used the Becton Dickin-
son ProbeTec that detected the new variant. Hence this
was used as selection criteria and the study was restricted
to those counties, in the following named county A-G
[20]. The counties were geographically distributed across
the country, with varying population size (ranging from
127 thousand inhabitants in county B to 332 thousand in
county E by December 2009), and varying proportions of
youths (ranging from 17.9% in county A to 21.9% in
county F by December 2009) [21].
3.2. Data Collection
The different sources for data collection were for pre-
vention: survey, interviews and County Council records
(2006-2009), for condom use: survey (2009), and for
reported cases of chlamydia: national surveillance regis-
ters (2006-2009). Generally, the prevention of chlamydia
and other STIs in Sweden is targeting youth (up to 18
years of age) and young adults (18 - 29 years of age).
3.2.1. Survey
In April 2010, a survey1 was sent by e-mail to two key
informants in each county: STI-coordinators and CMOs.
In some cases, surveys were passed on to colleagues
within the Units for Communicable Disease Control
(county CDC units) resulting in answers from STI-coor-
dinators (all counties), four CMOs (counties B, E, F &
G), and two CDC unit nurses (counties A & D).The in-
formants were selected for holding strategic positions in
STI prevention from which they could take an overall
view of the case. Before the questionnaires were sent out,
the informants were informed by letter about the study
and its aims. The questions in the survey considered
prevention factors of structure corresponding to: pro-
gram- and County Council investments, organizational
structure, leadership, role in regional network, compe-
tencies, research connections, collaborations, regional
action plans and implementation of NAP; and activity
1The survey is available as supplemental material.

C. Deogan et al. / Open Journal of Preventive Medicine 3 ( 2013) 64-74
66
Figure 1. Conceptual model.
corresponding to: testing characteristics, testing coverage,
partners tracing, risk approach, information efforts, in-
ternet based communication, outreaching activities and
condom distribution.
3.2.2. Interview
Following the retrieval and reading of the completed
surveys (received from all counties), telephone inter-
views with the 13 key informants were conducted during
the period from April to June 2010. An additional five
persons were interviewed based on recommendations by
the original informants (1 CDC unit nurse in county C, 4
counselors in STI-, dermatology- and venereology clinics
in counties A, C, E and F). The purpose of this step was
to further explore the preventive efforts and their imple-
mentation based on the same factors (structures and ac-
tivities) as in the questionnaires. The answers from the
interviews, which were audio recorded and ranged in
length between 30 - 45 minutes, were condensed by
county in a written document for all informants to read
and comment on. This lead to a few additions and cor-
rections in all cases, after which all informants, except
one in county A that could not be reached after repeated
attempts, approved.
3.2.3. County Council Records
The survey and interview data regarding prevention
factors was complemented with County Council data
regarding program investments from the governmental
grant for prevention of STI (obtained from the counties’
applications, decisions and follow-ups, and from state-
ments of accounts on implemented projects), and County
Council investments in STI prevention (obtained from
County council records).
3.2.4. Indicators of Successful Prevention
Successful preventive response was indicated by high
proportion of condom use (2009) and decreased number
of chlamydia cases (2006-2009) for each county. The
first indicator was measured by condom use at latest
vaginal intercourse among youth and young adults 15 -
29 years, retrieved from a large survey study on young
people, sex and health by Gothenburg University (Ung-
KAB) [22]. The survey was sent to a random selection of
15,000 (15 - 29 years) individuals across Sweden of
which 77.5% answered the question on condom use at
last intercourse (n 11,625). The second indicator was
retrieved from the annual number of reported cases of
chlamydia, provided by the Swedish Institute for Infec-
tious Disease Control (SMI).
3.3. Case Study Methodology
The study was performed by the multiple case study
method. Generally, this involves the use of multiple
sources and techniques in the data gathering and analys-
ing process in order to explore and generate understand-
ing of a phenomenon based on a restricted number of
cases [23]. Hence, the method was judged suitable for
the current study aiming at exploring several prevention
factors in connection to indicators of preventive success,
among a selection of seven cases (counties), by various
data sources.
3.4. Analysis
A single researcher performed the interviews while the
analysis was done by two researchers to improve robust-
ness. Each county was initially treated as a single case
in the analyses of prevention data. Then, a cross-case
search for patterns was applied to identify deviations
from the norm of performance in prevention activities
and structure [24].
In effect, a framework based on evidence from re-
search was applied to the data from surveys and inter-
views in order to enable a rating system from 1 - 5 for
each prevention factor. The rating was data-based,
meaning it was solely and consistently based on a com-
parison with other cases in the study. The performance of
the majority of counties was referred to as the standard
(3), whereas deviations were referred to as strengths
(rating 4 - 5) and weaknesses (rating 1 - 2). Hence, the
weakest performance on a prevention factor was given 1
while the strongest was given 5. For example, in program
investment, county F was identified with the highest in-
vestment (5) while county B was found to have the sec-
ond highest investment (4). Regarding testing character-
istics, county B illustrated good accessibility with a cam-
paign (4) while county F showed similar performance
but with a more extensive strategic plan for testing, and
was hence rated highest (5). Potential key factors for suc-
cessful prevention were finally identified by strengths (4
- 5) corresponding to a high proportion of condom use
and a decrease in number of reported chlamydia cases.
The study was approved by the Research Ethics
Committee at Karolinska Institutet in March 2010 (Dnr:
2010/239-31/4).

C. Deogan et al. / Open Journal of Preventive Medicine 3 ( 2013) 64-74 67
4. RESULTS
4.1. Strengths and Weaknesses in
Chlamydia Prevention
The summarised results of the analyses of prevention
data from survey and interviews for each county are pre-
sented in Table s 1 (structure) and 2 (activities).
County A—On the structural level most factors (7 of
10) were found below the standard, with weaknesses
regarding structure of organization, leadership, compe-
tencies, research connection, collaborations, regional
action plan and implementation of NAP. Concerning
activities, 2 of 8 factors were on a standard level while
weaknesses (6 of 8) regarded testing coverage, partner
tracing, risk approach, information efforts, internet based
communication and outreaching activities. No strengths
were found.
County B—Most of the structural factors (7 of 10)
were identified on a standard level, although identified
strengths (2 of 10) concerned high program investment
and a regional action plan. On the other hand, one weak-
ness was found to be a saving package in the County
Council. Regarding activities, factors of strength (4 of 8)
were testing characteristics, information efforts, out-
reaching activities and condom distribution. Weaknesses
(3 of 8) were found for testing coverage, partner tracing
and risk approach, whereas regarding internet based
communication, the county corresponded to standard
preventive measures.
County C—Most structural factors (6 of 10) were
identified on a standard level, one strength was identified
(County Council investment), while weaknesses (3 of 10)
were recognized in program investment, competencies
and research connection. Also for activities, the majority
was on a standard level (7 of 8). The exception was the
weakness of restricted information efforts.
County D—Regarding structural factors, the county
was mainly in line with standard (8 of 10) with strength
in implementation of NAP and a weakness regarding
organization structure. Concerning activities, strengths
Table 1. Structure of prevention: strengths (4, 5) and weaknesses (1, 2) compared to standard (3) in seven Swedish counties (A-G).
Cases
Data A B C D E F G
Program
investment (3) Rather high (4) Low (1) (3) (3) High (5) Rather low (2)
County council
investment (3) Saving package (1) Favourable (4)(3) (3) High (5) Tight budget (2)
Organization
structure STI-group meet ≤3 times/year (1)(3) (3)
STI-group meet
≤4 times/year (2)
STI-group meet
6 - 8 times/year
(4)
STI-group meet
≥6 times/year,
Network
meetings (5)
(3)
Leadership STI-coordinator
20% (1) (3) (3) (3) Good leadership (4)
Strong &clear
leadership (5)
No STI-coordinator,
Good leadership (2)
Role regional
network (3) (3) (3) (3) Responsible (4)Responsible (4) (3)
Competencies Little training (1)(3) Restricted
training (2) (3) (3)
Extensive MI
training, High
education to
health care &
school staff (4)
Extensive MI training,
High education to
health care & youth
contexts, Innovative
training (5)
Research
connection None mentioned (1) (3)
None
mentioned,
Systematic
evaluation (2)
(3) Strong & broad
(5) Strong (4) (3)
Collaborations ≤3 regional agents
(2) (3) (3) (3)
≥5 regional
agents (4)
≥7 regional
agents (5) ≤2 regional agents (1)
Regional action
plan No measurable goals (2)
Extensively
developed,
Measurable
goals (4)
(3) (3) (3)
Extensively
developed,
Measurable
goals, In line
with NAP (5)
From 2009 (1)
Implementation
of NAP Not actively (1)(3) (3) Continuously (4)(3) Extensively (5)
Actively from 2009
(2)

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68
Table 2. Activities of prevention: strengths (4, 5) and weaknesses (1, 2) compared to standard (3) in seven Swedish counties (A-G).
Cases
Data A B C D E F G
Testing
characteristics (3)
Paid by central
account, Good
accessibility,
Campaign (4)
(3)
Paid by test
taking unit,
Rather poor
accessibility, No
campaign (1)
(3)
Paid by central account,
Good accessibility,
Extensive strategy (5)
(3)
Testing
coverage
Low
male/female
ratio & test per
case (2)
Low male/female
ratio, test/case &
test/100000
inhabitants (1)
(3) (3)
High male/female
ratio, test/case &
test/100,000
inhabitants (5)
High male/female ratio
& test/case & moderate
test/100,000
inhabitants (4)
No
male/female
ratio, low
test/case &
test/100,000
inhabitants (1)
Partner tracing
Decentralized,
Little quality
assurance (1)
Decentralized,
Moderate quality
assurance (2)
(3)
Centralized,
Quality assured,
1 year back in
time, Research
(4)
(3)
Centralized, Quality
assured, 1 year back in
time Research (5)
(3)
Risk approach MI for risk
patients (2) Poor MI use (1) (3) (3)
Strategies,
Consistent MI use
some clinics (4)
Risk assessment tools
& strategies, Consistent
MI use (5)
(3)
Information efforts Little (1) Extensive (4) Restricted
(2) (3) (3)
Extensive through
variety of channels (5) (3)
Internet based
communication None (1) (3) (3) Several online activities (4) Little (2) A range of online activities (5) (3)
Outreaching
activities Some (2) Extensive (4) (3) (3) (3) Extensive in range of settings (5) Few (1)
Condom
distribution (3) Extensive & systematic (5) (3) Few (2) (3) Extensive (4) No data (1)
were found (2 of 8) regarding partner tracing and inter-
net-based communication. Four factors were on standard
level, while testing characteristics and condom distribu-
tion were identified as weaknesses.
County E—The distribution of strength and standard
factors on a structural level was equal for the county (5
of 10 respectively). Strengths included the organization
structure, leadership, the managing role in the regional
network, research connection and collaborations. Con-
sidering activities, 5 out of 8 factors corresponded to the
standard preventive measures, whereas testing coverage
and risk approach were judged as strengths, and internet
based communication as a weakness.
County F—The county was defined the strongest case
with all structural (10 of 10) and activity factors (8 of 8)
identified as strengths. Seven out of ten structural, and
six out of eight activity components were rated at highest
level (5) for possible strengths.
County G—The identified strength in structural factors
for the county was competencies while other factors
were on the standard level (3 of 10) or identified as
weaknesses (6 of 10). Concerning activities, most factors
corresponded to the standard level (5 of 8), while testing
coverage, outreaching activities and condom distribution
(3 of 8) were rated as weaknesses.
In summary, county F was the only county identified
with strengths in all prevention factors and county E was
the only county found to hold only strengths and com-
ponents at standard level with the exception of internet
based communication. On the other hand, county A was
the only county without classified strengths, with only
weaknesses besides standard preventive measures. Also
county G had more weaknesses than strengths identified
along with factors on the standard level.
4.2. Indicators of Preventive Success
Figure 2 shows the proportion of condom use by
county. In counties C, E and F, the use of condom at last
intercourse among youth and young adults were 29%,
26.5% and 27.6%, respectively, while in other counties
the use was lower, spanning from 17.8% - 23.0%.
Figure 3 shows variations in number of reported cases
of chlamydia between counties. During the period from
year 2006 to 2007, most counties (A, D, E, F & G) ex-
perienced an increase, whilst during 2008 to 2009, most
counties experienced a decrease (A, C, D, E, F & G).
Regarding the whole period (2006-2009), county F had

C. Deogan et al. / Open Journal of Preventive Medicine 3 ( 2013) 64-74 69
Figure 2. Proportion of condom use at last vaginal intercourse by county in 2009
(Source: UngKAB).
Figure 3. Number of reported cases of chlamydia per 100,000 inhabitants from
2006 to 2009 (Source: Swedish Institute of Infectious Disease Control).
the strongest decrease in reported number of chlamydia
cases by 21.03%, whereas counties A, B, D and E had
moderate decreases (5.55%, 7.05%, 5.28% and 9.84%).
The conclusion is that two counties (E and F) fulfil the
indication of successful prevention based on the com-
bined consideration of high proportion of condom use
and decreased number of reported chlamydia cases.
4.3. Key Factors of Successful Prevention
of Chlamydia
The identification of potential key factors of success-
ful prevention against chlamydia and other STIs is based
on assessed prevention strengths 2006-2009 (county F
held strengths in all factors, and county E held strengths
or standard preventive measures except for internet based
communication) in relation to the indicator of successful
prevention (counties E and F illustrated high condom use
(2009) as well as a reduction of chlamydia cases (2006-
2009)). Counties E and F were also the counties with the
highest proportions of young people compared to other
counties (21% - 22% versus 18% - 19%).
County F deviated from the rest of the counties with a
combination of high investments via the governmental
grant (program investment) and high investments in, not
only STI prevention, but also general public health and
health care issues via the County Council. This generated
a need-based and flexible resource allocation where the
CMO and the STI-coordinator had the possibility to ini-
tiate prevention activities where and when a need was
identified.

C. Deogan et al. / Open Journal of Preventive Medicine 3 ( 2013) 64-74
70
Strengths in collaboration and organization were evi-
dent for counties E and F, as well as in their position as
responsible of managing the regional networks for STI
prevention that all counties are involved in. Both coun-
ties also represented strengths regarding the number of
collaborating partners, and regarding research and per-
formance of research projects. Concerning leadership
and competencies, four counties including E and F had
STI-coordinators in full time position, which in all cases
were recognised as a crucial prerequisite for the coordi-
nation and structured implementation of activities. Addi-
tionally, counties E and F showed favourable testing
coverage, with the highest ratios of tested males versus
females, high number of tests per case and high number
of tests per 100,000 inhabitants of 15 - 29 years old
(2008 and 2009). County F had also the highest number
of tests per positive case (2008 and 2009).
Contrasting counties E and F, E had a more traditional
approach while F applied more innovative activities re-
garding, for example, information and communication
efforts. County F differentiated itself by the use of ap-
proaches such as theatre shows, and information tours at
youth clubs, while the majority of counties use strategies
such as information by outreach to schools. It could be
that this, in combination with other outreaching activities,
maintained the awareness of the issue among youth in
the region. County F provided also a range of online
platforms for communication with the target group via
information sites for events and competitions, condom
sites for information and distribution, online tools for
booking appointments and internet-based testing possi-
bilities.
Two counties, A and G appeared to be characterized
by several weaknesses. County A stands out in that it
performed few prevention activities together with weak-
nesses on the structural level such as having little col-
laboration, less than three STI-groups meetings per year
and a limited engagement by a STI-coordinator. The
weaknesses were combined with low condom use, but
also with a decrease of reported chlamydia cases (5.55%
from 2006 to 2009). When assessing this situation, it
must be considered that county A had the most signifi-
cant decrease in testing of all counties (19.63% from
2008 to 2009). County G had weaknesses such as poor
investments, collaboration and testing coverage. Fur-
thermore, up until year 2009 the county had neither a
STI-coordinator nor a regional action plan. The identi-
fied weaknesses were correlated with low condom use
and increased number of reported chlamydia cases
(4.27% from 2006-2009).
County B received high ratings in prevention activities,
but experienced a moderate decrease in reported chlamy-
dia cases (2006-2009). This county receives high num-
bers of tourists and young seasonal employees during the
winter season, which contributes to a high proportion of
cases in individuals residing outside the county, poten-
tially not targeted by the prevention activities in the
county.
County D was found to correspond to the standard
preventive measures in structure and strengths of partner
tracing and internet-based communication were found in
activities. This was combined with a moderate decrease
in chlamydia cases [24]. County D is the largest of the
counties with long distances between towns and clinics,
which has been responded to by a system of telephone
based partner tracing.
County C experienced a slight increase in reported
cases, despite prevention efforts similar to other counties
and the highest condom use of all (29.0%). This should
also be considered in the light of having the highest pro-
portion of individuals stating that religion affects their
everyday life very much, 4.6% compared to 2.4% in
Sweden in general [22].
5. DISCUSSION
Main Findings
The present study was performed to identify potential
key factors of successful chlamydia prevention by a mul-
tiple case study, analysing the differences between
Swedish counties in prevention efforts (2006-2009),
condom use (2009) and decrease of reported chlamydia
cases (2006-2009). To the authors’ knowledge, it is the
first study to explore this area. Identified potential key
factors were: adequate program- and County Council
investments, suitable organizational structure, strong
leadership, managing regional networks, research con-
nection, multiple local collaboration, high testing cov-
erage and strategic risk approach. In all, counties with
strengths in preventive measures were E and F, counties
with weaknesses were A and G, and counties with stan-
dard preventive measures were B, C, D.
More specifically, high investments in primary and
secondary prevention, legitimate and clear leadership
and collaboration with multiple cross-sectional regional
agents, and scientific foundation for action seemed vital.
Furthermore, comprehensive testing with high ratios of
tested men versus women, high numbers of tested per
positive case and of tested per 100,000 inhabitants were
identified as important. Finally recognised as successful
was implementing a broad mix of efforts simultaneously,
including targeting risk individuals in testing and coun-
seling, and potentially using innovative approaches like
internet-based communication and health care services.
Investment levels in STI prevention activities in
county F were significantly higher per capita than in the
other counties and increased investments have been
made from the County Council. Considering the high

C. Deogan et al. / Open Journal of Preventive Medicine 3 ( 2013) 64-74 71
proportion of condom use and reduction in chlamydia
cases in this county, this highlights availability of re-
sources as a key factor in an active response comple-
mentary to increasing needs in the population. Earlier
research states that a good balance between spending on
prevention, health promotion, and treatment care is fa-
vourable [7,9]. In the case of county F, this may be re-
flected by the program investment (prevention) and
spending by County Council (traditionally testing, treat-
ment and partner tracing).
Counties E and F received funding from and were re-
sponsible for the governmental grant for the regional
networks, which may entail a possible synergetic effect
regarding leadership, capacity and knowledge. However,
whether this brings positive effects or whether the latter
was a factor in them being assigned the responsibility is
unknown.
The organizational structure in county F indicates that
many local agents and multiple institutions in collabora-
tion may benefit the outcome of activities. Further, a
strong leadership and clear goals were identified, and
also expressed by informants, as strengths. This supports
evidence concerning the importance of building and sus-
taining partnerships including NGO’s, health care practi-
tioners and researchers [8].
Accessibility to testing and quality-assured partner
tracing with trained partner tracers were important stra-
tegies for all counties although the execution varied in
terms of county covering policies. The situation in county
F indicates that actively attempting to target risk groups
with risk assessment tools and consistent behavioural
counseling methods at the time of testing, may be effec-
tive [8] along with quality-assured partner tracing [25],
centralized to a limited number of trained partner tracers.
The fact that county E and F show high numbers in test-
ing volumes, testing ratio of males versus females and
number of tests per case indicates that they have suc-
ceeded in reaching risk groups. This, in combination
with their high condom use and decrease in reported
chlamydia cases indicates that a targeted and compre-
hensive testing profile is a sound approach and that men
are then included in testing to a greater extent. In coun-
ties C, D and G, testing is paid for by the specific
test-taking unit, which could be questioned as contradic-
tory with the aim of establishing a sustainable and vol-
ume-independent testing profile.
Counties C, D and F use the internet as a platform for
communication with the target group in many of their
activities regarding information, condom distribution and
testing. Previous studies highlight the preventive poten-
tial of internet-based communication with target groups
that seek health information online, specifically on sex
and sexuality in general, [26] and for chlamydia testing
[27,28].
Regional differences in population size of young
people across counties confirm that prevention efforts in
county E and F were well suited to the target group of
chlamydia and other STIs, that county B despite fine
prevention efforts failed to reach the large group of sea-
sonal employees, that county A managed to compensate
weak prevention efforts with low proportion of young
people, and that county C had high condom use and a
slight decrease in chlamydia cases despite standard pre-
vention measures.
6. LIMITATIONS
The study does not consider the effectiveness of cer-
tain prevention factors, but merely relates the results to
current evidence on effective STI prevention. Nor does it
attempt to clarify the causal link between prevention
structure, prevention activities, condom use and reported
cases of chlamydia. Another evident limitation is the
general difficulties regarding the outcome of chlamydia
since the spread of infectious disease will ultimately de-
pend on many different factors.
Condom use as a risk measurement of STI was con-
sidered a suitable indicator of successful prevention. It is
worth noting that previous studies have shown that con-
dom use among Swedish adolescents and young adults is
relatively low (20%) compared with Finland (48%) and
Norway (55%) [29] and other European countries. The
UngKab survey was not powered with the aim of detect-
ing between-counties differences of condom use, and the
variation in numbers of respondents between counties
may be due to differences in population size as well as in
response rate. This weakness was, however, considered
acceptable considering that there is no other currently
available data that could serve as an indicator of condom
use by county in Sweden.
The decrease in number of reported chlamydia cases
was considered the ultimate indicator of chlamydia pre-
vention. However, this is merely an indicator of preva-
lence (and incidence) of disease. While the true inci-
dence can only be identified if general screening is in
place, the number of reported cases largely depends on
surveillance systems and the fulfilment of reported cases
may vary between laboratories, health care staff and
counties. It should also be noted as limitation that all
cases with a decrease in reported cases was considered
noteworthy. In the analysis, based on the combined con-
sideration of high proportion of condom use and de-
creased number of chlamydia cases, the two counties (E
and F) with a decrease greater than 9% were concluded
to constitute the joint indication of successful prevention.
However, the only county with a statistically significant
decrease (p < 0.05) during the study period was F. Fur-
thermore, nationally covered data on age- and sex-spe-
cific testing volumes and frequencies are not available

C. Deogan et al. / Open Journal of Preventive Medicine 3 ( 2013) 64-74
72
due to the characteristics of the current reporting systems
in Sweden.
In the analysis, preventive factors were regarded as
equal, given the same value regardless of whether, for
example, a quality assured and well-functioning partner
tracing is more decisive for success than condom distri-
bution. It should also be noted that comprehensive data
on the quality and quantity of sexual education activities
in schools have not been taken into consideration. Given
the health promotion evidence for such interventions,
[19] one cannot exclude a possible distorting impact on
the results.
It must be acknowledged, as a potential limitation, that
county F’s CMO was involved in the development of the
National Action Plan for chlamydia prevention 2009
together with the Swedish National Board of Health and
Welfare. This indicates that county F has had the oppor-
tunity to regionally implement the NAP ahead of time in
comparison to the other counties. Moreover, it is quite
probable that participation in the national goal setting
and planning facilitate regional strategy setting and im-
plementation [2].
The study generally supports a link between on the
one hand preventive strengths and on the other hand high
condom use and decreased chlamydia cases. However,
the situation in counties B, C and D displays that the
present case study application is not sufficient for a
deeper understanding of the underlying complex regional
characteristics such as seasonal migration, geographic
distances and other demographic/cultural factors.
Nevertheless, the advantage of the case study method
is its applicability to contemporary, situational cases, based
on multiple sources of data which reinforce findings
through triangulation [30]. In this study, survey and in-
terviews among key informants, and regional and na-
tional registry data, regarding seven counties were used.
Rich amounts of data for analysis and conclusion is a
strength, while the risk of missing vital components in
the mass of data and of failing to clearly structure analy-
sis and conclusion is a weakness. Considering the het-
erogeneity of the studied cases and the extensive sources
of information used, the present study is likely to add
knowledge on potential key factors in regional preven-
tion of chlamydia and other STIs. Despite several limita-
tions, we suggest that it provides insight into current ac-
tivities as well as into development needs.
7. CONCLUSION
This study concludes that Swedish counties implement
a range of similar prevention efforts in the area of chla-
mydia and other STIs, but that the scope and systemati-
zation of implementation differs. The national as well as
the regional action plans show little concern for the
structure of prevention. Greater consideration to struc-
tural factors, such as adequate investments, suitable or-
ganizational structure, strong leadership, regional net-
works, research connection and multiple local collabora-
tion may therefore benefit the outcomes of prevention
activities. However, in order to confirm our findings,
further studies of successful prevention mix are required
and research bridging the gap between STI-prevention
and infectious disease epidemiology should be encour-
aged.
8. ACKNOWLEDGEMENTS
The financial support of The Swedish National Board of Health and
Welfare is gratefully acknowledged.
REFERENCES
[1] (2012) Swedish Institute of Infectious Disease Control
[Online].
http://www.smittskyddsinstitutet.se/statistik/klamydiainfe
ktion/
[2] Swedish National Board of Health and Welfare (2012)
National action plan for chlamydia prevention.
http://www.socialstyrelsen.se/Lists/Artikelkatalog/Attach
ments/8402/2009-126-180_2009126181.pdf
[3] DuRant, R.H., Smith, J.A., Kreiter, S.R. and Krowchuk,
D.P. (1999) The relationship between early age of onset
of initial substance use and engaging in multiple health
risk behaviors among young adolescents. Archives of Pe-
diatrics & Adolescent Medicine, 153, 286-291.
[4] Hansen, B.T., Kjaer, S.K., Munk, C., et al. (2010) Early
smoking initiation, sexual behavior and reproductive
health—A large population based study of Nordic women.
Preventive Medicine, 51, 68-72.
doi:10.1016/j.ypmed.2010.03.014
[5] Deogan, C., Cnattingius, S. and Månsdotter, A. (2012)
Risk of self-reported Chlamydia trachomatis infection by
social and lifestyle factors—A study based on survey data
from young adults in Stockholm, Sweden. European
Journal of Contraception and Reproductive Health Care,
in Press. doi:10.3109/13625187.2012.729624
[6] Ellis, S. and Grey, A. (2004) Prevention of sexually
transmitted infections (STIs): A review of reviews into
the effectiveness of non-clinical interventions. Evidence
briefing. Health Development Agency, London.
http://www.nice.org.uk/nicemedia/documents/prevention
_stis_evidence_briefing.pdf
[7] National Institute for Health and Clinical Excellence
(2007) Public health intervention guidance 3. One to one
interventions to reduce the transmission of sexually
transmitted infections (STIs) including HIV, and to re-
duce the rate of under 18 conceptions, especially among
vulnerable and at risk groups. National Institute for
Health and Clinical Excellence, London.
http://www.nice.org.uk/Guidance/PH3/Guidance/pdf/Eng
lish
[8] Bernard, D., Kippax, S. and Baxter, D. (2008) Effective
partnership and adequate investment underpin a success-

C. Deogan et al. / Open Journal of Preventive Medicine 3 ( 2013) 64-74 73
ful response: Key factors in dealing with HIV increases.
Sexual Health, 5, 193-201.
doi:10.1071/SH07078
[9] Griew R. (2008) Policy and strategic implications of
Australia’s divergent HIV epidemic among gay men.
Sexual Health, 5, 203-205. doi:10.1071/SH08003
[10] Farley, C., Grulich, A., Imrie, J. and Pitts, M. (2008) In-
vestment in HIV prevention works: A natural experiment.
Sexual Health, 5, 207-210.
doi:10.1071/SH08017
[11] Miller, R.L., Bedney, B.J. and Guenther-Grey, C. (2003)
Assessing organizational capacity to deliver HIV preven-
tion services collaboratively: Tales from the field. Health
Education & Behavior, 30, 582-600.
doi:10.1177/1090198103255327
[12] Sylvan, S. and Hedlund, J. (2009) Efficacy of partner
notification for Chlamydia trachomatis among young
adults in youth health centres in Uppsala County, Sweden.
Journal of the European Academy of Dermatology and
Venereology, 23, 517-522.
doi:10.1111/j.1468-3083.2008.03080.x
[13] Lin, J.S., Whitlock, E., O’Connor, E. and Bauer, V. (2008)
Behavioural counseling to prevent sexually transmitted
infections: A systematic review for the US. Preventive
Services Task Force. Annals of Internal Medicine, 149,
497-508.
[14] Löfdahl, M., Rydevik, G., Blaxhult, A. and Hermann, B.
(2008) Chlamydia infection among Swedish women.
Contact tracing and reporting routines must be improved.
Läkartidningen, 105, 3116-3120.
[15] Kamb, M.L., Fishbein, M., Douglas, J.M., et al. (1998)
Efficacy of risk-reduction counseling to prevent human
immunodeficiency virus and sexually transmitted dis-
eases. Journal of the American Medical Association, 280,
1161-1167.
[16] Petersen, R., Albright, J., Garrett, J.M. and Curtis, K.M.
(2007) Pregnancy and STD prevention counseling using
an adaptation of motivational interviewing: A randomized
controlled trial. Perspectives on Sexual and Reproductive
Health, 39, 21-28. doi:10.1363/3902107
[17] Outlaw, A.Y., Naar-King, S., Parsons, J.T., Green-Jones,
M., Janisse, H. and Secord, E. (2010) Using motivational
interviewing in HIV field outreach with young African
American men who have sex with men: A randomized
clinical trial. American Journal of Public Health, 100,
146-151. doi:10.2105/AJPH.2009.166991
[18] Scmeidl, R. (2004) School-based condom availability
programs. The Journal of School Nursing, 20, 16-21.
doi:10.1177/10598405040200010401
[19] Oakley, A., Fullerton, D., Holland, J., France-Dawson, M.,
Kelley, P. and McGrellis, S. (1995) Sexual health educa-
tions interventions for young people: A methodological
review. British medical Journal, 310, 158-162.
doi:10.1136/bmj.310.6973.158
[20] Velicko, I., Kühlmann-Berenzon and Blaxhult, A. (2007)
Reasons for the sharp increase of genital chlamydia in-
fections reported in the first months of 2007 in Sweden.
Eurosurveillance, 12, E5-E6.
[21] (2011) Statistics Sweden [Online]
http://www.scb.se/default____2154.aspx
[22] UngKAB09 (2009) Department of Social Work, Gothen-
burg University.
[23] Yin, R.K. (2009) Case study research. Design and meth-
ods. SAGE Publications, Inc., Thousand Oaks.
[24] Stake, R.E. (2006) Multiple case study analysis. The
Guilford Press, New York.
[25] Carré, H., Boman, J., Gardén, B. and Nylander, E. (2008)
Improved contact tracing for Chlamydia trachomatis with
experienced tracers, tracing for one year back in time and
interviewing by phone in remote areas. Sexually Trans-
mitted Infections, 84, 239-242.
doi:10.1136/sti.2007.028068
[26] Hassan, A. and Fleegler, E.W. (2010) Using technology to
improve adolescent health care. Current Opinion in Pedi-
atrics, 22, 412-417.
doi:10.1097/MOP.0b013e32833b5360
[27] Rainton, N., Odegard, O.R., Helgheim, A. and Moghad-
dam, A. (2007) Detection of chlamydia infection of an
internet-based commercial product. Tidskr Nor Laege-
foren, 127, 2080-2082.
[28] Stenqvist, K., Lindqvist, A., Almerson, P., Jonsson, L. and
Lander, R. (2010) Chlamydia test via internet a good al-
ternative to testing in clinics. Läkartidningen, 107, 350-
353.
[29] (2012) Norwegian Ministry of Health.
http://helsedirektoratet.no/english/ publications/ung ass-coun
try-progress-report-norway-january-2008---december-200
9/Publikasjoner/ungass-conuntry-progress-report-norway-
2009.PDF
[30] Malterud, K. (2001) Qualitative research: Standards,
challenges and guidelines. Lancet, 358, 483-488.

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SUPPLEMENTAL MATERIAL
Survey
1) Organization, contact person, email, phone number
2) Is the national action plan actively implemented?
-Is there already existing activities that are in line with
the national action plan?
3) What preventive measures aimed at STI/chlamydia
have been implemented from 2006-2009 in the county?
-How long have the efforts been ongoing?
-What organizations are responsible of the efforts?
-Scope/extent of each activity? Target groups/popula-
tions? Geographic restriction/area limitation?
-Is there condom distribution? (Scope, what arenas
and who is responsible?)
-Is there testing via internet? What proportions of the
tests taken in the county are taken via the Internet?
-Are there outreaching activities?
-Are there reoccuring campaigns or other activities to
promote testing?
-Has the work been evaluated in reference to the ac-
tion plan?
4) Describe the organization and structure of the pre-
ventive work.
-Collaboration at planning level?
-Collaboration in implementing activities?
-Are there targets/goals for prevention activities? How
are the goals formulated?
-Is there a regional steering group? What functions/
professions/mandates are included? How often does the
group meet?
-Are there regional steering documents? (Please attach
them to the questionnaire or provide the website)
-At what level are results reported? Are the effects of
efforts measured or evaluated?
5) Are seminars or information sessions offered in-
ternally in the organization regarding STI-development?
If so, is it offered to;
-Health care staff?
-School staff?
-Other staff that work with the target group?
-(Please specify the scope of the sessions)
6) How much resources were allocated to prevention
activities during 2006-2009? How would you describe
the economic situation in the county council?
-What positions would you say allocate their time to
prevention activities?
-What tasks are included in these positions?
-Scope of the positions (full/part time)?
-Material, PR?
7) What are the routines regarding testing?
-Methods, techniques?
-Is there a standardized guide for testing? (Who should
be tested? What type of test is recommended for men
versus women?)
-Are laboratory notifications and clinical notifications
control-checked for double samples? If clinical notifica-
tion is missing, is it asked for?
8) What are the routines regarding contact tracing?
-Who performs contact tracing?
-According to guidelines?
-Are contacts traced 1 year back in time?
-Average time/patient?
-Is counseling offered? If so, what kind of counseling?
Individually or in group?
-Is there specific training for contact tracers and if so,
how is the training performed, by whom and for how
long time?
-Are there any actions taken if contact tracing is not
performed?
9) What is your opinion of the National Action Plan?
10) What do you think about the chlamydia develop-
ment in your county? In your opinion, what are the un-
derlying reasons for the development?