Increasing chlamydia screening tests in general practice: a modified Zelen prospective Cluster Randomised Controlled Trial evaluating a complex intervention based on the Theory of Planned Behaviour

Building an Opt-Out Model for Service-Level Consent in the Context of New Data Regulations

The General Data Protection Regulation (GDPR) was introduced in 2018 to harmonize data privacy and security laws across the European Union (EU). It applies to any organization collecting personal data in the EU. To date, service-level consent has been used as a proportionate approach for clinical trials, which implement low-risk, routine, service-wide interventions for which individual consent is considered inappropriate. In the context of public health research, GDPR now requires that individuals have the option to choose whether their data may be used for research, which presents a challenge when consent has been given by the clinical service and not by individual service users. We report here on development of a pragmatic opt-out solution to this consent paradox in the context of a partner notification intervention trial in sexual health clinics in the UK. Our approach supports the individual’s right to withhold their data from trial analysis while routinely offering the same care to all patients.

Electronic Health Record Reminders for Chlamydia Screening in an American Indian Population

OBJECTIVES

Indian Health Service (IHS) screening rates for Chlamydia trachomatis are lower than national rates of chlamydia screening in the Southwest. We describe and evaluate the effect of a public health intervention consisting of electronic health record (EHR) reminders to alert health care providers to screen for chlamydia at an IHS facility. We also conducted an awareness presentation among health care providers on chlamydia screening.

METHODS

We conducted our intervention from November 1, 2013, through October 31, 2015, at an IHS facility in the Southwest. We implemented algorithms that queried database values to assess chlamydia screening performance in 6 clinical departments. We presented data on the screening performance of clinical departments and health care providers (de-identified) in the awareness presentations. We re-queried database values 1 and 2 years after implementation of the EHR reminder intervention to evaluate before-and-after screening rates, comparing data among all patients and among female patients only.

RESULTS

We found small, sustained relative increases in chlamydia screening rates during the 2012-2015 evaluation period: 20.8% pre-intervention to 24.9% and 24.2% one and two years postintervention, respectively, across all patients; 32.3% preintervention to 36.6% and 35.6% one and two years postintervention, respectively, among female patients. Increases in clinical department-specific screening rates varied and were most prominent in internal medicine (35.8% preintervention to peak 65.8% postintervention). The 1 clinic (obstetrics-gynecology) that did not receive an awareness presentation showed a consistent downward trend in screening rates, although absolute rates were consistently higher in that clinic than in other clinics.

CONCLUSIONS

Awareness presentations that offer feedback to health care providers on screening performance, heighten provider awareness of the importance of chlamydia screening, and promote development of novel provider-initiated screening protocols may help to increase screening rates when combined with EHR reminders.

Increasing Vaginal Chlamydia Trachomatis Testing in Adolescent and Young Adults

OBJECTIVE

The Centers for Disease Control and Prevention recommend testing for Chlamydia trachomatis in sexually active female patients <25 years old using nucleic-acid amplification tests (NAAT) from a vaginal swab. Our providers were typically testing using the less sensitive urine NAATs. We aimed to increase the percentage of urogenital C trachomatis NAATs performed by using vaginal swabs in adolescent female patients ages 10 through 20 years from 1.4% to 25%.

METHODS

We implemented 3 interventions at 3 pediatric practices over 12 months including education, process standardization, and cross-training. We used statistical process control to analyze the effect of interventions on our primary outcome: the percentage of urogenital C trachomatis tests performed with a vaginal swab. Our balance measure was the total number of urogenital C trachomatis tests.

RESULTS

There were 818 urogenital C trachomatis tests performed: 289 before and 529 after the first intervention. Of urogenital C trachomatis tests in the preintervention time period, 1.4% were performed by using vaginal swabs. We surpassed our aim of 25% 6 weeks after the first intervention. We noted sustained improvement after the second intervention, with an average of 68.3% of tests performed by using vaginal swabs for the remaining postintervention period. There was no difference in the overall number of urogenital C trachomatis tests pre- and postintervention.

CONCLUSIONS

Using quality improvement methodology and implementing easily replicable interventions, we significantly and sustainably increased use of vaginal swabs. The interventions standardizing processes were associated with a higher impact than the educational intervention.

How to increase chlamydia testing in primary care: a qualitative exploration with young people and application of a meta-theoretical model

Objective

The objective of this study was to explore young people’s perspectives barriers to chlamydia testing in general practice and potential intervention functions and implementation strategies to overcome identified barriers, using a meta-theoretical framework (the Behaviour Change Wheel (BCW)).

Methods

Twenty-eight semistructured individual interviews were conducted with 16–24 year olds from across the UK. Purposive and convenience sampling methods were used (eg, youth organisations, charities, online platforms and chain-referrals). An inductive thematic analysis was first conducted, followed by thematic categorisation using the BCW.

Results

Participants identified several barriers to testing: conducting self-sampling inaccurately (physical capability); lack of information and awareness (psychological capability); testing not seen as a priority and perceived low risk (reflective motivation); embarrassment, fear and guilt (automatic motivation); the UK primary care context and location of toilets (physical opportunity) and stigma (social opportunity). Potential intervention functions raised by participants included education (eg, increase awareness of chlamydia); persuasion (eg, use of imagery/data to alter beliefs); environmental restructuring (eg, alternative sampling methods) and modelling (eg, credible sources such as celebrities). Potential implementation strategies and policy categories discussed were communication and marketing (eg, social media); service provision (eg, introduction of a young person’s health-check) and guidelines (eg, standard questions for healthcare providers).

Conclusions

The BCW provided a useful framework for conceptually exploring the wide range of barriers to testing identified and possible intervention functions and policy categories to overcome said barriers. While greater education and awareness and expanded opportunities for testing were considered important, this alone will not bring about dramatic increases in testing. A societal and structural shift towards the normalisation of chlamydia testing is needed, alongside approaches which recognise the heterogeneity of this population. To ensure optimal and inclusive healthcare, researchers, clinicians and policy makers alike must consider patient diversity and the wider health issues affecting all young people.

Effects of primary care antimicrobial stewardship outreach on antibiotic use by general practice staff: pragmatic randomized controlled trial of the TARGET antibiotics workshop

Objectives

To determine whether local trainer-led TARGET antibiotic interactive workshops improve antibiotic dispensing in general practice.

Methods

Using a McNulty–Zelen-design randomized controlled trial within three regions of England, 152 general practices were stratified by clinical commissioning group, antibiotic dispensing rate and practice patient list size, then randomly allocated to intervention (offered TARGET workshop that incorporated a presentation, reflection on antibiotic data, promotion of patient and general practice (GP) staff resources, clinical scenarios and action planning, 73 practices) or control (usual practice, 79 practices). The primary outcome measure was total oral antibiotic items dispensed/1000 patients for the year after the workshop (or pseudo-workshop date for controls), adjusted for the previous year’s dispensing.

Results

Thirty-six (51%) intervention practices (166 GPs, 51 nurses and 101 other staff) accepted a TARGET workshop invitation. In the ITT analysis total antibiotic dispensing was 2.7% lower in intervention practices (95% CI −5.5% to 1%, P = 0.06) compared with controls. Dispensing in intervention practices was 4.4% lower for amoxicillin/ampicillin (95% CI 0.6%–8%, P = 0.02); 5.6% lower for trimethoprim (95% CI 0.7%–10.2%, P = 0.03); and a non-significant 7.1% higher for nitrofurantoin (95% CI −0.03 to 15%, P = 0.06). The Complier Average Causal Effect (CACE) analysis, which estimates impact in those that comply with assigned intervention, indicated 6.1% (95% CI 0.2%–11.7%, P = 0.04) lower total antibiotic dispensing in intervention practices and 11% (95% CI 1.6%–19.5%, P = 0.02) lower trimethoprim dispensing.

Conclusions

This study within usual service provision found that TARGET antibiotic workshops can help improve antibiotic use, and therefore should be considered as part of any national antimicrobial stewardship initiatives. Additional local facilitation will be needed to encourage all general practices to participate.

Clinical education alone is sufficient to increase resistance training exercise prescription

A large body of evidence demonstrates that resistance training has been ineffective for improving walking outcomes in adults with neurological conditions. However, evidence suggests that previous studies have not aligned resistance exercise prescription to muscle function when walking. The main aim of this study was to determine whether a training seminar for clinicians could improve knowledge of gait and align resistance exercise prescription to the biomechanics of gait and muscle function for walking. A training seminar was conducted at 12 rehabilitation facilities with 178 clinicians. Current practice, knowledge and barriers to exercise were assessed by observation and questionnaire prior to and immediately after the seminar, and at three-month follow-up. Additionally, post-seminar support and mentoring was randomly provided to half of the rehabilitation facilities using a cluster randomised controlled trial (RCT) design. The seminar led to significant improvements in clinician knowledge of the biomechanics of gait and resistance training, the amount of ballistic (t = -2.38; p = .04) and conventional (t = -2.30; p = .04) resistance training being prescribed. However, ongoing post-seminar support and mentoring was not associated with any additional benefits F(1, 9) = .05, p = .83, partial eta squared = .01. Further, improved exercise prescription occurred in the absence of any change to perceived barriers. The training seminar led to significant improvements in the time spent in ballistic and conventional resistance training. There was no further benefit obtained from the additional post-seminar support. The seminar led to improved knowledge and significantly greater time spent prescribing task-specific resistance exercises.

Improving STD Screening Rates on a University Campus

Gonorrhea and chlamydia infections have a high incidence among young adults. To increase screening rates among individuals aged 25 years of age and younger on a university campus, this quality improvement project was implemented to improve providers' knowledge of CDC guidelines through education. Education was provided to providers and staff members at a health clinic on a private residential university campus through informational sessions to increase knowledge of guideline-directed screening for gonorrhea and chlamydia. This education was coupled with a multifaceted approach for provider-reminder interventions: flagging patients in the EHR system that fall within the age group (25 years of age and younger) to generate an alert, patients completing a questionnaire while in the exam room, and identification of a project champion. Screening rates were evaluated during pre- and post-implementation phases to determine if a change in practice occurred among providers. Post-intervention revealed the average number of patients screened for gonorrhea and chlamydia was 65.85% (349/530). This change represented a marked increase from pre-intervention screening of 2% (11/405). The testing rate increased during the post-intervention phase to 17.86% (65/364), up from 7.90% (32/405) pre-implementation. Provider education on guideline-directed screening for gonorrhea and chlamydia increased screening among providers at a university health clinic. This intervention, combined with provider-reminder interventions, increased screening of patients, leading to an increased testing rate for gonorrhea and chlamydia.

Expanding syphilis testing: a scoping review of syphilis testing interventions among key populations

INTRODUCTION

Syphilis is an important sexually transmitted infection (STI). Despite inexpensive and effective treatment, few key populations receive syphilis testing. Innovative strategies are needed to increase syphilis testing among key populations. Areas covered: This scoping review focused on strategies to increase syphilis testing in key populations (men who have sex with men (MSM), sex workers, people who use drugs, transgender people, and incarcerated individuals). Expert commentary: We identified many promising syphilis testing strategies, particularly among MSM. These innovations are separated into diagnostic, clinic-based, and non-clinic based strategies. In terms of diagnostics, self-testing, dried blood spots, and point-of-care testing can decentralize syphilis testing. Effective syphilis self-testing pilots suggest the need for further attention and research. In terms of clinic-based strategies, modifying default clinical procedures can nudge physicians to more frequently recommend syphilis testing. In terms of non-clinic based strategies, venue-based screening (e.g. in correctional facilities, drug rehabilitation centres) and mobile testing units have been successfully implemented in a variety of settings. Integration of syphilis with HIV testing may facilitate implementation in settings where individuals have increased sexual risk. There is a strong need for further syphilis testing research and programs.

Qualitative impact assessment of an educational workshop on primary care practitioner attitudes to NICE HIV testing guidelines

Background

In 2013, Public Health England piloted the ‘3Cs (chlamydia, contraception, condoms) and HIV (human immunodeficiency virus)’ educational intervention in 460 GP surgeries. The educational HIV workshop aimed to improve the ability and confidence of staff to offer HIV testing in line with national guidelines.

Aim

To qualitatively assess the impact of an educational workshop on GP staff’s attitudes to NICE HIV testing guidelines.

Design & setting

Qualitative interviews with GP staff across England before and after an educational HIV workshop.

Method

Thirty-two GP staff (15 before and 17 after educational HIV workshop) participated in interviews exploring their views and current practice of HIV testing. Interview transcripts were thematically analysed and examined, using the components of the theory of planned behaviour (TPB) and normalisation process theory (NPT) as a framework.

Results

GPs reported that the educational HIV workshop resulted in increased knowledge of, and confidence to offer, HIV tests based on indicator conditions. However, overall participants felt they needed additional HIV training around clinical care pathways for offering tests, giving positive HIV results, and current treatments and outcomes. Participants did not see a place for point-of-care testing in general practice.

Conclusion

Implementation of national HIV guidelines will require multiple educational sessions, especially to implement testing guidelines for indicator conditions in areas of low HIV prevalence. Additional role-play or discussions around scripts suggesting how to offer an HIV test may improve participants’ confidence and facilitate increased testing. Healthcare assistants (HCAs) may need specific training to ensure that they are skilled in offering HIV testing within new patient checks.

Increased Gonorrhea Screening and Case Finding After Implementation of Expanded Screening Criteria-Urban Indian Health Service Facility in Phoenix, Arizona, 2011-2013

BACKGROUND

Gonorrhea screening is recommended for women at risk and men who have sex with men; expanded screening is encouraged based on local epidemiology. In response to a substantial increase in gonorrhea cases at an urban medical center serving American Indians, gonorrhea screening of all sexually active patients aged 14 to 45 years was initiated in March 2013. We describe gonorrhea screening coverage and case finding before and after implementation of expanded screening.

METHODS

In March 2013, provider training, electronic health record prompts, and bundled laboratory orders were implemented to facilitate gonorrhea screening of all sexually active patients aged 14 to 45 years. We assessed the proportions of patients screened and testing positive for gonorrhea in the 2 years before (March 2011-February 2012 [indicated as 2011], March 2012-February 2013 [2012]) and 1 year after (March 2013-February 2014 [2013]) expanded screening measures.

RESULTS

Gonorrhea screening coverage increased from 22% (2012) to 38% (2013); coverage increased 50% among females and 202% among males. Screening coverage increased in nearly all clinics. Gonorrhea case finding increased 68% among females in 2013 (n = 104) compared with 2012 (n = 62), primarily among women aged 25 to 29 years. No corresponding increase in gonorrhea case finding occurred among males. Most increased case finding occurred in the emergency department.

CONCLUSIONS

After introduction of expanded gonorrhea screening, there was a significant increase in gonorrhea screening coverage and a subsequent increase in gonorrhea case finding among females. Despite increased screening in all clinics, increased case finding only occurred in the emergency department.

Qualitative interviews with healthcare staff in four European countries to inform adaptation of an intervention to increase chlamydia testing

OBJECTIVE

To determine the needs of primary healthcare general practice (GP) staff, stakeholders and trainers to inform the adaptation of a locally successful complex intervention (Chlamydia Intervention Randomised Trial (CIRT)) aimed at increasing chlamydia testing within primary healthcare within South West England to three EU countries (Estonia, France and Sweden) and throughout England.

DESIGN

Qualitative interviews.

SETTING

European primary healthcare in England, France, Sweden and Estonia with a range of chlamydia screening provision in 2013.

PARTICIPANTS

45 GP staff, 13 trainers and 18 stakeholders.

INTERVIEWS

The iterative interview schedule explored participants' personal attitudes, subjective norms and perceived behavioural controls around provision of chlamydia testing, sexual health services and training in general practice. Researchers used a common thematic analysis.

RESULTS

Findings were similar across all countries. Most participants agreed that chlamydia testing and sexual health services should be offered in general practice. There was no culture of GP staff routinely offering opportunistic chlamydia testing or sexual health advice, and due to other priorities, participants reported this would be challenging. All participants indicated that the CIRT workshop covering chlamydia testing and sexual health would be useful if practice based, included all practice staff and action planning, and was adequately resourced. Participants suggested minor adaptations to CIRT to suit their country's health services.

CONCLUSIONS

A common complex intervention can be adapted for use across Europe, despite varied sexual health provision. The intervention (ChlamydiA Testing Training in Europe (CATTE)) should comprise: a staff workshop covering sexual health and chlamydia testing rates and procedures, action planning and patient materials and staff reminders via computer prompts, emails or newsletters, with testing feedback through practice champions. CATTE materials are available at: www.STItraining.eu.

Computer-generated reminders delivered on paper to healthcare professionals: effects on professional practice and healthcare outcomes

BACKGROUND

Clinical practice does not always reflect best practice and evidence, partly because of unconscious acts of omission, information overload, or inaccessible information. Reminders may help clinicians overcome these problems by prompting them to recall information that they already know or would be expected to know and by providing information or guidance in a more accessible and relevant format, at a particularly appropriate time. This is an update of a previously published review.

OBJECTIVES

To evaluate the effects of reminders automatically generated through a computerized system (computer-generated) and delivered on paper to healthcare professionals on quality of care (outcomes related to healthcare professionals' practice) and patient outcomes (outcomes related to patients' health condition).

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, six other databases and two trials registers up to 21 September 2016 together with reference checking, citation searching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We included individual- or cluster-randomized and non-randomized trials that evaluated the impact of computer-generated reminders delivered on paper to healthcare professionals, alone (single-component intervention) or in addition to one or more co-interventions (multi-component intervention), compared with usual care or the co-intervention(s) without the reminder component.

DATA COLLECTION AND ANALYSIS

Review authors working in pairs independently screened studies for eligibility and abstracted data. For each study, we extracted the primary outcome when it was defined or calculated the median effect size across all reported outcomes. We then calculated the median improvement and interquartile range (IQR) across included studies using the primary outcome or median outcome as representative outcome. We assessed the certainty of the evidence according to the GRADE approach.

MAIN RESULTS

We identified 35 studies (30 randomized trials and five non-randomized trials) and analyzed 34 studies (40 comparisons). Twenty-nine studies took place in the USA and six studies took place in Canada, France, Israel, and Kenya. All studies except two took place in outpatient care. Reminders were aimed at enhancing compliance with preventive guidelines (e.g. cancer screening tests, vaccination) in half the studies and at enhancing compliance with disease management guidelines for acute or chronic conditions (e.g. annual follow-ups, laboratory tests, medication adjustment, counseling) in the other half.Computer-generated reminders delivered on paper to healthcare professionals, alone or in addition to co-intervention(s), probably improves quality of care slightly compared with usual care or the co-intervention(s) without the reminder component (median improvement 6.8% (IQR: 3.8% to 17.5%); 34 studies (40 comparisons); moderate-certainty evidence).Computer-generated reminders delivered on paper to healthcare professionals alone (single-component intervention) probably improves quality of care compared with usual care (median improvement 11.0% (IQR 5.4% to 20.0%); 27 studies (27 comparisons); moderate-certainty evidence). Adding computer-generated reminders delivered on paper to healthcare professionals to one or more co-interventions (multi-component intervention) probably improves quality of care slightly compared with the co-intervention(s) without the reminder component (median improvement 4.0% (IQR 3.0% to 6.0%); 11 studies (13 comparisons); moderate-certainty evidence).We are uncertain whether reminders, alone or in addition to co-intervention(s), improve patient outcomes as the certainty of the evidence is very low (n = 6 studies (seven comparisons)). None of the included studies reported outcomes related to harms or adverse effects of the intervention.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that computer-generated reminders delivered on paper to healthcare professionals probably slightly improves quality of care, in terms of compliance with preventive guidelines and compliance with disease management guidelines. It is uncertain whether reminders improve patient outcomes because the certainty of the evidence is very low. The heterogeneity of the reminder interventions included in this review also suggests that reminders can probably improve quality of care in various settings under various conditions.

Chlamydia and HIV testing, contraception advice, and free condoms offered in general practice: a qualitative interview study of young adults' perceptions of this initiative

BACKGROUND

Opportunistic chlamydia screening is actively encouraged in English general practices. Based on recent policy changes, Public Health England piloted 3Cs and HIV in 2013-2014, integrating the offer of chlamydia testing with providing condoms, contraceptive information, and HIV testing (referred to as 3Cs and HIV) according to national guidelines.

AIM

To determine young adults' opinions of receiving a broader sexual health offer of 3Cs and HIV at their GP practice.

DESIGN AND SETTING

Qualitative interviews were conducted in a general practice setting in England between March and June 2013.

METHOD

Thirty interviews were conducted with nine male and 21 female patients aged 16-24 years, immediately before or after a routine practice attendance. Data were transcribed verbatim and analysed using a thematic framework.

RESULTS

Participants indicated that the method of testing, timing, and the way the staff member approached the topic were important aspects to patients being offered 3Cs and HIV. Participants displayed a clear preference for 3Cs and HIV to be offered at the GP practice over other sexual health service providers. Participants highlighted convenience of the practice, assurance of confidentiality, and that the sexual health discussion was appropriate and routine. Barriers identified for patients were embarrassment, unease, lack of time, religion, and patients believing that certain patients could take offence. Suggested facilitators include raising awareness, reassuring confidentiality, and ensuring the offer is made in a professional and non-judgemental way at the end of the consultation.

CONCLUSION

General practice staff should facilitate patients' preferences by ensuring that 3Cs and HIV testing services are made available at their surgery and offered to appropriate patients in a non-judgemental way.

Exploring why a complex intervention piloted in general practices did not result in an increase in chlamydia screening and diagnosis: a qualitative evaluation using the fidelity of implementation model

BACKGROUND

Chlamydia trachomatis (chlamydia) is the most commonly diagnosed sexually transmitted infection (STI) in England; approximately 70% of diagnoses are in sexually active young adults aged under 25. To facilitate opportunistic chlamydia screening in general practice, a complex intervention, based on a previously successful Chlamydia Intervention Randomised Trial (CIRT), was piloted in England. The modified intervention (3Cs and HIV) aimed to encourage general practice staff to routinely offer chlamydia testing to all 15-24 year olds regardless of the type of consultation. However, when the 3Cs (chlamydia screening, signposting to contraceptive services, free condoms) and HIV was offered to a large number of general practitioner (GP) surgeries across England, chlamydia screening was not significantly increased. This qualitative evaluation addresses the following aims: a) Explore why the modified intervention did not increase screening across all general practices. b) Suggest recommendations for future intervention implementation.

METHODS

Phone interviews were carried out with 26 practice staff, at least 5 months after their initial educational workshop, exploring their opinions on the workshop and intervention implementation in the real world setting. Interview transcripts were thematically analysed and further examined using the fidelity of implementation model.

RESULTS

Participants who attended had a positive attitude towards the workshops, but attendee numbers were low. Often, the intervention content, as detailed in the educational workshops, was not adhered to: practice staff were unaware of any on-going trainer support; computer prompts were only added to the female contraception template; patients were not encouraged to complete the test immediately; complete chlamydia kits were not always readily available to the clinicians; and videos and posters were not utilised. Staff reported that financial incentives, themselves, were not a motivator; competing priorities and time were identified as major barriers.

CONCLUSION

Not adhering to the exact intervention model may explain the lack of significant increases in chlamydia screening. To increase fidelity of implementation outside of Randomised Controlled Trial (RCT) conditions, and consequently, improve likelihood of increased screening, future public health interventions in general practices need to have: more specific action planning within the educational workshop; computer prompts added to systems and used; all staff attending the workshop; and on-going practice staff support with feedback of progress on screening and diagnosis rates fed back to all staff.

The Ballseye programme: a mixed-methods programme of research in traditional sexual health and alternative community settings to improve the sexual health of men in the UK

Background

Sexually transmitted infection (STI) diagnoses are increasing and efforts to reduce transmission have failed. There are major uncertainties in the evidence base surrounding the delivery of STI care for men.

Aim

To improve the sexual health of young men in the UK by determining optimal strategies for STI testing and care

Objectives

To develop an evidence-based clinical algorithm for STI testing in asymptomatic men; model mathematically the epidemiological and economic impact of removing microscopy from routine STI testing in asymptomatic men; conduct a pilot randomised controlled trial (RCT) of accelerated partner therapy (APT; new models of partner notification to rapidly treat male sex partners of people with STIs) in primary care; explore the acceptability of diverse venues for STI screening in men; and determine optimal models for the delivery of screening.

Design

Systematic review of the clinical consequences of asymptomatic non-chlamydial, non-gonococcal urethritis (NCNGU); case–control study of factors associated with NCNGU; mathematical modelling of the epidemiological and economic impact of removing microscopy from asymptomatic screening and cost-effectiveness analysis; pilot RCT of APT for male sex partners of women diagnosed withChlamydia trachomatisinfection in primary care; stratified random probability sample survey of UK young men; qualitative study of men’s views on accessing STI testing; SPORTSMART pilot cluster RCT of two STI screening interventions in amateur football clubs; and anonymous questionnaire survey of STI risk and previous testing behaviour in men in football clubs.

Settings

General population, genitourinary medicine clinic attenders, general practice and community contraception and sexual health clinic attenders and amateur football clubs.

Participants

Men and women.

Interventions

Partner notification interventions: APTHotline [telephone assessment of partner(s)] and APTPharmacy [community pharmacist assessment of partner(s)]. SPORTSMART interventions: football captain-led and health adviser-led promotion of urine-based STI screening.

Main outcome measures

For the APT pilot RCT, the primary outcome, determined for each contactable partner, was whether or not they were considered to have been treated within 6 weeks of index diagnosis. For the SPORTSMART pilot RCT, the primary outcome was the proportion of eligible men accepting screening.

Results

Non-chlamydial, non-gonococcal urethritis is not associated with significant clinical consequences for men or their sexual partners but study quality is poor (systematic review). Men with symptomatic and asymptomatic NCNGU and healthy men share similar demographic, behavioural and clinical variables (case–control study). Removal of urethral microscopy from routine asymptomatic screening is likely to lead to a small rise in pelvic inflammatory disease (PID) but could save > £5M over 20 years (mathematical modelling and health economics analysis). In the APT pilot RCT the proportion of partners treated by the APTHotline [39/111 (35%)], APTPharmacy [46/100 (46%)] and standard patient referral [46/102 (45%)] did not meet national standards but exceeded previously reported outcomes in community settings. Men’s reported willingness to access self-sampling kits for STIs and human immunodeficiency virus infection was high. Traditional health-care settings were preferred but sports venues were acceptable to half of men who played sport (random probability sample survey). Men appear to prefer a ‘straightforward’ approach to STI screening, accessible as part of their daily activities (qualitative study). Uptake of STI screening in the SPORTSMART RCT was high, irrespective of arm [captain led 28/56 (50%); health-care professional led 31/46 (67%); poster only 31/51 (61%)], and costs were similar. Men were at risk of STIs but previous testing was common.

Conclusions

Men find traditional health-care settings the most acceptable places to access STI screening. Self-sampling kits in football clubs could widen access to screening and offer a public health impact for men with limited local sexual health services. Available evidence does not support an association between asymptomatic NCNGU and significant adverse clinical outcomes for men or their sexual partners but the literature is of poor quality. Similarities in characteristics of men with and without NCNGU precluded development of a meaningful clinical algorithm to guide STI testing in asymptomatic men. The mathematical modelling and cost-effectiveness analysis of removing all asymptomatic urethral microscopy screening suggests that this would result in a small rise in adverse outcomes such as PID but that it would be highly cost-effective. APT appears to improve outcomes of partner notification in community settings but outcomes still fail to meet national standards. Priorities for future work include improving understanding of men’s collective behaviours and how these can be harnessed to improve health outcomes; exploring barriers to and facilitators of opportunistic STI screening for men attending general practice, with development of evidence-based interventions to increase the offer and uptake of screening; further development of APT for community settings; and studies to improve knowledge of factors specific to screening men who have sex with men (MSM) and, in particular, how, with the different epidemiology of STIs in MSM and the current narrow focus on chlamydia, this could negatively impact MSM’s sexual health.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Service evaluation of an educational intervention to improve sexual health services in primary care implemented using a step-wedge design: analysis of chlamydia testing and diagnosis rate changes

Background

Providing sexual health services in primary care is an essential step towards universal provision. However they are not offered consistently. We conducted a national pilot of an educational intervention to improve staff’s skills and confidence to increase chlamydia testing rates and provide condoms with contraceptive information plus HIV testing according to national guidelines, known as 3Cs&HIV. The effectiveness of the pilot on chlamydia testing and diagnosis rates in general practice was evaluated.

Methods

The pilot was implemented using a step-wedge design over three phases during 2013 and 2014 in England. The intervention combined educational workshops with posters, testing performance feedback and continuous support. Chlamydia testing and diagnosis rates in participating general practices during the control and intervention periods were compared adjusting for seasonal trends in chlamydia testing and differences in practice size. Intervention effect modification was assessed for the following general practice characteristics: chlamydia testing rate compared to national median, number of general practice staff employed, payment for chlamydia screening, practice urban/rurality classification, and proximity to sexual health clinics.

Results

The 460 participating practices conducted 26,021 tests in the control period and 18,797 tests during the intervention period. Intention-to-treat analysis showed no change in the unadjusted median tests and diagnoses per month per practice after receiving training: 2.7 vs 2.7; 0.1 vs 0.1. Multivariable negative binomial regression analysis found no significant change in overall testing or diagnoses post-intervention (incidence rate ratio (IRR) 1.01, 95 % confidence interval (CI) 0.96–1.07, P = 0.72; 0.98 CI 0.84–1.15, P = 0.84, respectively). Stratified analysis showed testing increased significantly in practices where payments were in place prior to the intervention (IRR 2.12 CI 1.41–3.18, P < 0.001) and in practices with 6–15 staff (6–10 GPs IRR 1.35 (1.07–1.71), P = 0.012; 11–15 GPs IRR 1.37 (1.09–1.73), P = 0.007).

Conclusion

This national pilot of short educational training sessions found no overall effect on chlamydia testing in primary care. However, in certain sub-groups chlamydia testing rates increased due to the intervention. This demonstrates the importance of piloting and evaluating any service improvement intervention to assess the impact before widespread implementation, and the need for detailed understanding of local services in order to select effective interventions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3343-z) contains supplementary material, which is available to authorized users.

Tools to overcome potential barriers to chlamydia screening in general practice: Qualitative evaluation of the implementation of a complex intervention

BACKGROUND

Chlamydia trachomatis remains a significant public health problem. We used a complex intervention, with general practice staff, consisting of practice based workshops, posters, computer prompts and testing feedback and feedback to increase routine chlamydia screening tests in under 25 year olds in South West England. We aimed to evaluate how intervention components were received by staff and to understand what determined their implementation into ongoing practice.

METHODS

We used face-to-face and telephone individual interviews with 29 general practice staff analysed thematically within a Normalisation Process Theory Framework which explores: 1. Coherence (if participants understand the purpose of the intervention); 2. Cognitive participation (engagement with and implementation of the intervention); 3. Collective action (work actually undertaken that drives the intervention forwards); 4. Reflexive monitoring (assessment of the impact of the intervention).

RESULTS

Our results showed coherence as all staff including receptionists understood the purpose of the training was to make them aware of the value of chlamydia screening tests and how to increase this in their general practice. The training was described by nearly all staff as being of high quality and responsible for creating a shared understanding between staff of how to undertake routine chlamydia screening. Cognitive participation in many general practice staff teams was demonstrated through their engagement by meeting after the training to discuss implementation, which confirmed the role of each staff member and the use of materials. However several participants still felt unable to discuss chlamydia in many consultations or described sexual health as low priority among colleagues. National targets were considered so high for some general practice staff that they didn't engage with the screening intervention. Collective action work undertaken to drive the intervention included use of computer prompts which helped staff remember to make the offer, testing rate feedback and having a designated lead. Ensuring patients collected samples when still in the general practice was not attained in most general practices. Reflexive monitoring showed positive feedback from patients and other staff about the value of screening, and feedback about the general practices testing rates helped sustain activity.

CONCLUSIONS

A complex intervention including interactive workshops, materials to help implementation and feedback can help chlamydia screening testing increase in general practices.

Interventions to Improve Sexually Transmitted Disease Screening in Clinic-Based Settings

BACKGROUND

The asymptomatic nature and suboptimal screening rates of sexually transmitted diseases (STD) call for implementation of successful interventions to improve screening in community-based clinic settings with attention to cost and resources.

METHODS

We used MEDLINE to systematically review comparative analyses of interventions to improve STD (chlamydia, gonorrhea, or syphilis) screening or rescreening in clinic-based settings that were published between January 2000 and January 2014. Absolute differences in the percent of the target population screened between comparison groups or relative percent increase in the number of tests or patients tested were used to score the interventions as highly effective (>20% increase) or moderately effective (5%-19% increase) in improving screening. Published cost of the interventions was described where available and, when not available, was estimated.

RESULTS

Of the 4566 citations reviewed, 38 articles describing 42 interventions met the inclusion criteria. Of the 42 interventions, 16 (38.1%) were categorized as highly effective and 14 (33.3%) as moderately effective. Effective low-cost interventions (<$1000) included the strategic placement of specimen collection materials or automatic collection of STD specimens as part of a routine visit (7 highly effective and 1 moderately effective) and the use of electronic health records (EHRs; 3 highly effective and 4 moderately effective). Patient reminders for screening or rescreening (via text, telephone, and postcards) were highly effective (3) or moderately effective (2) and low or moderate cost (<$1001-10,000). Interventions with dedicated clinic staff to improve STD screening were highly effective (2) or moderately effective in improving STD screening (1) but high-cost ($10,001-$100,000).

CONCLUSIONS

Successful interventions include changing clinic flow to routinely collect specimens for testing, using EHR screening reminders, and reminding patients to get screened or rescreened. These strategies can be tailored to different clinic settings to improve screening at a low cost.

A qualitative study exploring the acceptability of the McNulty-Zelen design for randomised controlled trials evaluating educational interventions

Background

Traditional randomised controlled trials evaluating the effect of educational interventions in general practice may produce biased results as participants know they are being evaluated. We aimed to explore the acceptability of a McNulty-Zelen Cluster Randomised Control Trial (CRT) design which conceals from educational participants that they are in a RCT. Consent is obtained from a trusted third party considered appropriate to give consent on participants’ behalf, intervention practice staff then choose whether to attend the offered education as would occur with normal continuing professional development.

Methods

We undertook semi structured telephone interviews in England with 16 general practice (GP) staff involved in a RCT evaluating an educational intervention aimed at increasing chlamydia screening tests in general practice using the McNulty-Zelen design, 4 Primary Care (PC) Research Network officers, 5 Primary Care Trust leads in Public or sexual health, and one Research Ethics committee Chair. Interviews were undertaken by members of the original intervention evaluation McNulty-Zelen design RCT study team. These experienced qualitative interviewers used an agreed semi-structured interview schedule and were careful not to lead the participants. To further mitigate against bias, the data analysis was undertaken by a researcher (CR) not involved in the original RCT.

Results

We reached data saturation and found five main themes;

Support for the design: All found the McNulty-Zelen design acceptable because they considered that it generated more reliable evidence of the value of new educational interventions in real life GP settings.

Lack of familiarity with study design: The design was novel to all. GP staff likened the evaluation using the McNulty–Zelen design to audit of their activities with feedback, which were to them a daily experience and therefore acceptable.

Ethical considerations: Research stakeholders considered the consent procedure should be very clear and that these trial designs should go through at least a proportionate ethical review. GP staff were happy for the PCT leads to give consent on their behalf.

GP research capacity and trial participation: GP staff considered the design increased generalisability, as staff who would not normally volunteer to participate in research due to perceived time constraints and paperwork might do so.

Design ‘worth it’: All interviewees agreed that the advantages of the “more accurate” or “truer” results and information gained about uptake of workshops within Primary Care Trusts (PCTs) outweighed any disadvantages of the consent procedure.

Discussion

Our RCT was evaluating the effect of an educational intervention to increase chlamydia screening tests in general practices where there was routine monitoring of testing rates; our participants may have been less enthusiastic about the design if it had been evaluating a more controversial educational area, or if data monitoring was not routine.

Implications

The McNulty-Zelen design should be considered for the evaluation of educational interventions, but these designs should have clear consent protocols and proportionate ethical review.

Trial registration

The trial was registered on the UK Clinical Research Network Study Portfolio database. UKCRN9722.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-015-0356-0) contains supplementary material, which is available to authorized users.

Supporting general practices to provide sexual and reproductive health services: protocol for the 3Cs & HIV programme

OBJECTIVES

Sexually transmitted infections, HIV and unplanned pregnancies continue to be a major public health problem in England, especially in young adults. Strengthening the provision of free condoms, HIV testing, chlamydia screening and contraception within primary care will contribute to reducing poor sexual and reproductive health outcomes. Recent research demonstrated the benefit for general practices of educational support visits based on behaviour change theory. Public Health England (PHE) has piloted an educational training programme to improve the delivery of sexual health services and HIV testing within general practice.

STUDY DESIGN & METHODS

The 3Cs & HIV programme used practice based workshops to improve staffs' awareness and skills in order to increase opportunistic offers of chlamydia testing, provision of contraceptive service information and free condoms (the '3Cs') to 15-24 year olds and HIV testing according to national guidelines. The programme was based on the theory of planned behaviour and has been implemented using a stepped wedge design. Process evaluation, testing and diagnosis data, plus qualitative interviews were all used in the evaluation. The primary outcome measures were chlamydia testing and diagnosis rates. Secondary outcome measures were HIV testing and diagnoses rates within each practice and rates of consultations where long acting reversible contraceptives had been discussed.

CONCLUSION

A key strength of the 3Cs & HIV programme has been the evidence base underpinning the development of the resources and the formal process evaluation of its implementation. The programme was designed to encourage sustainable relationships between general practice staff and local sexual health services as well as the knowledge, awareness and behaviours cultivated during the programme.

Developing and testing accelerated partner therapy for partner notification for people with genital Chlamydia trachomatis diagnosed in primary care: a pilot randomised controlled trial

Background

Accelerated partner therapy (APT) is a promising partner notification (PN) intervention in specialist sexual health clinic attenders. To address its applicability in primary care, we undertook a pilot randomised controlled trial (RCT) of two APT models in community settings.

Methods

Three-arm pilot RCT of two adjunct APT interventions: APTHotline (telephone assessment of partner(s) plus standard PN) and APTPharmacy (community pharmacist assessment of partner(s) plus routine PN), versus standard PN alone (patient referral). Index patients were women diagnosed with genital chlamydia in 12 general practices and three community contraception and sexual health (CASH) services in London and south coast of England, randomised between 1 September 2011 and 31 July 2013.

Results

199 women described 339 male partners, of whom 313 were reported by the index as contactable. The proportions of contactable partners considered treated within 6 weeks of index diagnosis were APTHotline 39/111 (35%), APTPharmacy 46/100 (46%), standard patient referral 46/102 (45%). Among treated partners, 8/39 (21%) in APTHotline arm were treated via hotline and 14/46 (30%) in APTPharmacy arm were treated via pharmacy.

Conclusions

The two novel primary care APT models were acceptable, feasible, compliant with regulations and capable of achieving acceptable outcomes within a pilot RCT but intervention uptake was low. Although addition of these interventions to standard PN did not result in a difference between arms, overall PN uptake was higher than previously reported in similar settings, probably as a result of introducing a formal evaluation. Recruitment to an individually randomised trial proved challenging and full evaluation will likely require service-level randomisation.

Trial registration number

Registered UK Clinical Research Network Study Portfolio id number 10123.

Tailored interventions to address determinants of practice

BACKGROUND

Tailored intervention strategies are frequently recommended among approaches to the implementation of improvement in health professional performance. Attempts to change the behaviour of health professionals may be impeded by a variety of different barriers, obstacles, or factors (which we collectively refer to as determinants of practice). Change may be more likely if implementation strategies are specifically chosen to address these determinants.

OBJECTIVES

To determine whether tailored intervention strategies are effective in improving professional practice and healthcare outcomes. We compared interventions tailored to address the identified determinants of practice with either no intervention or interventions not tailored to the determinants.

SEARCH METHODS

We conducted searches of The Cochrane Library, MEDLINE, EMBASE, PubMed, CINAHL, and the British Nursing Index to May 2014. We conducted a final search in December 2014 (in MEDLINE only) for more recently published trials. We conducted searches of the metaRegister of Controlled Trials (mRCT) in March 2013. We also handsearched two journals.

SELECTION CRITERIA

Cluster-randomised controlled trials (RCTs) of interventions tailored to address prospectively identified determinants of practice, which reported objectively measured professional practice or healthcare outcomes, and where at least one group received an intervention designed to address prospectively identified determinants of practice.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed quality and extracted data. We undertook qualitative and quantitative analyses, the quantitative analysis including two elements: we carried out 1) meta-regression analyses to compare interventions tailored to address identified determinants with either no interventions or an intervention(s) not tailored to the determinants, and 2) heterogeneity analyses to investigate sources of differences in the effectiveness of interventions. These included the effects of: risk of bias, use of a theory when developing the intervention, whether adjustment was made for local factors, and number of domains addressed with the determinants identified.

MAIN RESULTS

We added nine studies to this review to bring the total number of included studies to 32 comparing an intervention tailored to address identified determinants of practice to no intervention or an intervention(s) not tailored to the determinants. The outcome was implementation of recommended practice, e.g. clinical practice guideline recommendations. Fifteen studies provided enough data to be included in the quantitative analysis. The pooled odds ratio was 1.56 (95% confidence interval (CI) 1.27 to 1.93, P value < 0.001). The 17 studies not included in the meta-analysis had findings showing variable effectiveness consistent with the findings of the meta-regression.

AUTHORS' CONCLUSIONS

Despite the increase in the number of new studies identified, our overall finding is similar to that of the previous review. Tailored implementation can be effective, but the effect is variable and tends to be small to moderate. The number of studies remains small and more research is needed, including trials comparing tailored interventions to no or other interventions, but also studies to develop and investigate the components of tailoring (identification of the most important determinants, selecting interventions to address the determinants). Currently available studies have used different methods to identify determinants of practice and different approaches to selecting interventions to address the determinants. It is not yet clear how best to tailor interventions and therefore not clear what the effect of an optimally tailored intervention would be.

Practice nurse chlamydia testing in Australian general practice: a qualitative study of benefits, barriers and facilitators

Background

Chlamydia infection is a significant public health issue for young people; however, testing rates in Australian general practice are low. Practice nurses (PNs) could have an important role in contributing to increasing chlamydia testing rates. The Australian Chlamydia Control Effectiveness Pilot (ACCEPt), a large cluster randomised control trial of annual testing for 16 to 29 year olds in general practice, is the first to investigate the role of PNs in maximising testing rates. In order to assess the scope for PN involvement, we aimed to explore PN’s views in relation to involvement in chlamydia testing in general practice.

Methods

Semi structured interviews were conducted between June 2011 and April 2012 with a purposive sample of 23 PNs participating in ACCEPt. Interview data was thematically analysed using a conventional content analysis approach.

Results

The participants in our study supported an increased role for PNs in chlamydia testing and identified a number of patient benefits from this involvement, such as an improved service with greater access to testing and patients feeling more comfortable engaging with a nurse rather than a doctor. An alleviation of doctors’ workloads and expansion of the nurse’s role were also identified as benefits at a clinic level. Time and workload constraints were commonly considered barriers to chlamydia testing, along with concerns around privacy in the “small town” rural settings of the general practices. Some felt negative GP attitudes as well as issues with funding for PNs’ work could also be barriers. The provision of training and education, streamlining chlamydia testing pathways in clinics and changes to pathology ordering processes would facilitate nurse involvement in chlamydia testing.

Conclusion

This study suggests that PNs could take a role in increasing chlamydia testing in general practice and that their involvement may result in possible benefits for patients, doctors, PNs and the community. Strategies to overcome identified barriers and facilitate their involvement must be further explored.

The SPORTSMART study: a pilot randomised controlled trial of sexually transmitted infection screening interventions targeting men in football club settings

Background

Uptake of chlamydia screening by men in England has been substantially lower than by women. Non-traditional settings such as sports clubs offer opportunities to widen access. Involving people who are not medically trained to promote screening could optimise acceptability.

Methods

We developed two interventions to explore the acceptability and feasibility of urine-based sexually transmitted infection (STI) screening interventions targeting men in football clubs. We tested these interventions in a pilot cluster randomised control trial. Six clubs were randomly allocated, two to each of three trial arms: team captain-led and poster STI screening promotion; sexual health adviser-led and poster STI screening promotion; and poster-only STI screening promotion (control/comparator). Primary outcome was test uptake.

Results

Across the three arms, 153 men participated in the trial and 90 accepted the offer of screening (59%, 95% CI 35% to 79%). Acceptance rates were broadly comparable across the arms: captain-led: 28/56 (50%); health professional-led: 31/46 (67%); and control: 31/51 (61%). However, rates varied appreciably by club, precluding formal comparison of arms. No infections were identified. Process evaluation confirmed that interventions were delivered in a standardised way but the control arm was unintentionally ‘enhanced’ by some team captains actively publicising screening events.

Conclusions

Compared with other UK-based community screening models, uptake was high but gaining access to clubs was not always easy. Use of sexual health advisers and team captains to promote screening did not appear to confer additional benefit over a poster-promoted approach. Although the interventions show potential, the broader implications of this strategy for UK male STI screening policy require further investigation.

Provision of chlamydia testing, and training of primary health care staff about chlamydia testing, across four European countries

Background

The objectives of this study were to describe and compare chlamydia testing provided by general practitioners (GPs) in four selected European countries with well-developed primary health care systems and high reported chlamydia rates; we aimed to compare contrasting countries where chlamydia testing is provided by GPs (England, Sweden) with countries where primary care chlamydia testing is absent or very limited (France, Estonia).

Methods

For data generation a structured questionnaire was developed and secondary data sources were searched. The questionnaire developed by the research team allowed a systematic approach to analysing chlamydia care (including testing in general practice) and the gathering of relevant data.

Results

There were no significant differences in the burden of the disease or the type of general practice care provision in the study countries. In all four countries, testing for chlamydia (with nucleic acid amplification test, NAAT) is available in the public sector, a substantial proportion (>60%) of young people aged 16–25 years visit their general practitioner (GP) annually, and reimbursement for chlamydia testing costs to the relevant parties (GPs in England, Sweden and Estonia; and patients in France) by the national health insurance system or its equivalent.

In countries where chlamydia testing is provided by GPs (England, Sweden) a national strategy or plan on STI control that specifically mentions chlamydia was in force, chlamydia care guidelines for GPs were in place and STI management was more firmly established in the GP residency training curriculum, either formally (England) or informally (Sweden), than in the other countries.

Conclusion

Future research on the effectiveness of chlamydia screening (also in the context of general practice care) and program provision should reflect national needs and the prevention of complications.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2458-14-1147) contains supplementary material, which is available to authorized users.

Prevalence of chlamydia in young adulthood and association with life course socioeconomic position: birth cohort study

BACKGROUND

Few estimates are available of chlamydia prevalence in the general population. Existing studies have limited scope to explore potential selection bias or associations with socioeconomic position.

METHODS

We examined the prevalence of Chlamydia trachomatis infection and associations with life-course socioeconomic position in the Avon Longitudinal Study of Parents and Children in England. Chlamydia infection was measured through nucleic acid amplification test of urine specimens.

RESULTS

4864 (51%) of those invited attended the clinic (mean age 17.8; SD 0.37 years). (60%) provided a urine specimen. Prevalence was 1.0% (95% CI 0.6 to 1.6) among participants reporting sexual activity. Risk of infection was strongly associated with life course social disadvantage and with recent sexual behaviour. After adjustment for other measures of disadvantage and for sexual behaviour the strongest risk factors for infection were lower maternal educational attainment (OR 9.1 (1.1, 76.7)) and lower participant educational attainment at age 11 (OR 5.0 (1.5, 16.5)). Both clinic attendance and agreement to test were lower amongst the disadvantaged. Adjustment for selective participation based on detailed information on non-participants approximately doubled prevalence estimates. Prevalence was higher in sexually active women (1.4% (0.7 to 2.4) than men (0.5% (0.1 to 1.3)).

CONCLUSIONS

Chlamydia prevalence in this general population sample was low even after adjustment for selective participation in testing. These estimates of prevalence and patterns of association with socioeconomic position may both reflect recent screening efforts. Prevalence was higher amongst the disadvantaged who were also less likely to engage in testing. Our results reveal the importance of monitoring and addressing inequalities in screening programme participation and outcomes.