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Background  In the Netherlands, a national chlamydia screening program started in 2008, but the participation was low and the screening was not cost-effective. This study aimed to explore unconscious and conscious associations with chlamydia screening (16-29 year-olds). In addition, we examined whether information presented in chlamydia screening invitation letters had an effect on the evaluation of these determinants compared to a no-letter group.    Methods  An Internet survey was conducted that included self-report measures of attitude, susceptibility, severity, unrealistic optimism, subjective, moral, and descriptive norm, perceived behavioral control, outcome expectations, barriers, intention, and a response time measure to assess unconscious associations of chlamydia screening with annoyance, threat and reassurance.    Results  On the unconscious level, participants (N = 713) who received no information letter associated testing for chlamydia with annoyance and threat, but also with reassurance (all  p’s <  .001). On the self-report measures, participants showed a low intention towards chlamydia screening ( M  = 1.42, range 1–5). Subjective norm, moral norm, perceived susceptibility and attitude were the most important predictors of the intention to screen (R 2  = .56). Participants who rated their susceptibility as high also reported more risky behaviors ( p  < .001).  In the groups that received a letter (N = 735), a weaker unconscious association of chlamydia screening with annoyance was found compared with the no-letter group ( p  < .001), but no differences were found in reassurance or threat. Furthermore, the letters caused a higher intention ( p  < .001), but intention remained low ( M =  1.74). On a conscious level, giving information caused a more positive attitude, higher susceptibility, a higher subjective and moral norm, and more positive outcome expectations (all  p’s  < .001).    Conclusion  Subjective norm, moral norm, susceptibility, and attitude towards chlamydia might be crucial targets to increase chlamydia screening behavior among sexually active young people. This study shows that informational invitation letters increase the intention and the intention-predicting variables. More evidence is needed on whether screening behavior can be increased by the use of an alternative information letter adapted to the specific unconscious and conscious determinants revealed in this study, or that we need other, more interactive behavior change methods.

bmc public health

Non-participation in chlamydia screening in the Netherlands: determinants associated with young people’s intention to participate in chlamydia screening