Background
Partner notification (PN) has an essential role to play in the management of sexually transmitted infections (STIs), both for the individual (i.e. in terms of the prevention of re-infection and complications) and the community (i.e. in terms of transmission interruption) [
1],[
2]. The PN process entails four steps: 1) a health care professional discusses PN with an STI-positive patient and explains the possible infection risk for sex partners, 2) the sex partner is then identified, 3) notified, and is finally 4) tested, treated and educated [
3]. The primary strategies used to notify partners include provider referral and patient referral. Provider referral involves the provider contacting the patient’s partner(s). Compared to patient referral -- where the patient notifies his/her sex partners -- provider referral has been shown to be more effective at increasing the number of sex partners who are subsequently tested and treated [
3]-[
5].
When all 4 PN steps are carried out successfully, PN is an extremely effective tool in STI prevention, as it enables a high-risk population to be targeted, tested and treated. However, barriers at the health care professional, patient and organisational levels can disrupt the process at every step [
1]. Data about PN barriers among public health care professionals (i.e. nurses) are scarce, and most research is conducted among General Practitioners (GPs). Previous research investigating PN barriers as perceived by GPs identified several important barriers at step 1 (i.e., discussing PN with the patient), including: time pressure, lack of financial reimbursement, and provider discomfort [
6],[
7]. While GPs are generally supportive of PN, they can be unaware of, or misunderstand, their own role in PN; for example, they may assume that PN will be performed by local health care services [
6],[
8],[
9]. Most GPs prefer patient referral [
5],[
6], as provider referral is perceived as being both costly and time consuming [
2],[
5].
In the Netherlands, public health STI clinics are responsible for approximately 30% of STI care and the large majority of PN [
10]. The organisational structure and scope differs between medical (i.e., among GPs and medical specialists) and public health care (i.e., STI clinics) settings. The latter are often described as being more concerned with populations than with individuals, and with prevention and care more than with cure [
11],[
12]. There may well be different barriers to and facilitators of PN in medicine as compared to public health care, yet data on public health care professionals who perform PN in STI clinics are scarce, and any available data focuses on STI/HIV in general [
13].
This study examined the barriers to and facilitators of PN, as identified by public health care professionals, in relation to young heterosexual patients diagnosed with
Chlamydia trachomatis (Ct) who had visited an STI clinic for treatment. In the Netherlands, PN is not mandatory or enforceable by health care professionals. The role of the health care professional is to motivate and help Ct positive patients to identify and notify their sex partners. PN can be initiated when a STI test is performed, when a patient is informed about a positive test result by telephone, or when a patient visits the STI clinic for treatment. In cases where a patient agrees that the health care professional may notify his or her sex partner(s), the health care professional will telephone or send a text message. Other tasks performed by STI clinic health care professionals include sexual health consultations, STI testing, treatment, and education. Their professional role description (as part of a public health service) includes the protection of the community as a whole (i.e. sex partners). In the current study, we focused on Ct because it is the most common STI in patients younger than 25 years old, with an estimated prevalence of 17% in 2013 in the Netherlands [
14]. Young patients have consistently high rates of risky sexual behaviour and, in terms of reproductive morbidity, potentially bear the largest burden of STI sequelae [
15]. It is our intention that findings from the present study will inform a more effective PN process i.e., improve the prevention of re-infection and complications and interrupt transmission.
Discussion
The semi-structured interviews we carried out among health care professionals in national public health STI clinics in The Netherlands revealed several barriers at the health care professional, patient, and organisational levels. These barriers may hinder the PN process (in which PN is discussed with the patient and sex partner(s) are subsequently identified, notified, tested, treated and educated). Important barriers were identified as: no-shows at the treatment stage (which was the most important moment to discuss PN), a focus on curing patients, less of a perceived need to conduct PN in male sex partners, a perceived lack of commitment among patients towards sex partners, missing contact data of partner(s), unreliable sexual history, a lack of feedback on the effectiveness of the PN process and on the strategies used by health care professionals, and sub-optimal guidelines. In addition to these barriers, important facilitators of PN were identified as: feelings of being comfortable discussing sexual history and PN, one-on-one consultation, sufficient consultation time, a proactive helping style, being experienced in Motivational Interviewing, patient commitment towards sex partner(s), and having sex partners attend the clinic together with the patients
While barriers among GPs concentrated on the discussion of PN (i.e. step 1 in the PN process), barriers among STI clinic professionals were mostly related to steps 2 and 3 (see Figure
1). Public health care is complementary to medicine, and has a different scope and organisational structure. Public health care aims to protect the community; it benefits individuals by providing treatment and preventing re-infection. Public STI clinics are non-profit organisations that provide free care and employ experienced health care professionals (i.e., staff who are experienced in Motivational Interviewing and sexual consultation). Contrary to the public health scope, most of the health care professionals in this study were more committed to curing patients than to preventing STIs in sex partners. Potentially, such a curative approach is maintained as the health care professionals do not have any information on the effectiveness of PN on the community, or any feedback on the PN process and the strategies they have implemented. As a possible result, health care professionals may feel less responsible for PN and the process of contacting and notifying sex partners on behalf of the patient. Currently, almost all notifications at Dutch STI clinics appear to be carried out by patients (i.e. patient referral) and not by health care professionals, as revealed during the interviews. Patient referral has generally been observed as the most common PN practice in patients with STIs [
5]. However, its effectiveness is not known [
18], due to the frequent absence of recorded PN outcome data (i.e. data regarding whether partners are notified, tested and treated) [
2],[
18],[
19]. It is expected that patients will often fail to notify sex partners, because of the stigma surrounding STIs/HIV, and associated feelings of embarrassment or fear [
20]. Therefore, barriers and facilitators surrounding PN, as identified by Ct positive patients and their partners, should also be considered when improving PN implementation in practice. While Motivational Interviewing was mentioned as a facilitator among health care professionals, there are differences in how well such techniques are applied; differences may be related to age, experience and/or personal attitude. Almost all health care professionals in our study merely informed the client about PN, while only one health care professional discussed PN and used a more proactive helping style in order to examine and resolve problems during PN. Notably, this health care professional was asked by almost half of the patients to notify sex partner(s) on their behalf (i.e. provider referral). Provider referral has been found to be more effective [
4],[
18] and is thus important in the management of re-infections and the screening and testing of sex partners. Professionals can use email, text messages, telephone and outreach approaches such as face-to-face conversations to inform sex partners. However, provider referral is labour intensive, and a combination of different PN methods has therefore been recommended in the literature [
18].
A low level of commitment towards sex partners (on the part of the patient) has previously been identified as a barrier in the PN process [
21]. Health care professionals in our study identified low commitment as a barrier to the notification of patients’ sex partners. However, a previous study has demonstrated that young female and male patients who blamed their sexual partners for acquiring an STI infection still felt morally obliged to notify them [
20]. The notification of sex partners may be hampered by patients under-reporting the number of sex partners in an attempt to provide socially acceptable answers – or simply forgetting [
22].
The results of this study underline the fact that national and international guidelines about PN contain only general recommendations [
23],[
24]. Guidelines do not specify which motivational strategies to use, which PN procedures to follow, or which referral strategy is preferred and how exactly to implement it. This lack of specific instructions was also reported to be a barrier among GPs [
7]. Sub-optimal guidelines may lead to misconceptions about best practice, job roles, and responsibilities [
7].
A different approach towards partner management, called Expedited Partner Therapy (EPT), has recently gained attention in the literature [
25]. In this approach, partners are treated without a personal assessment. Although EPT decreases the number of PN steps necessary, and could therefore potentially optimize the PN process, some barriers identified in this study could also hamper the implementation of EPT. Examples of such barriers include a focus on curing the patient and the lack of commitment among patients towards sex partner(s). Future studies are needed to map the barriers and facilitating factors in both providers and the public regarding EPT.
Since the results of this study became clear, discussions have taken place among health care professionals about their emphasis on patient care rather than public health, and also about the absence of outcome measures to determine effectiveness. Nationally, there is an ongoing public debate about these issues, and the professional community has been informed. Currently, national PN protocols are being re-written and regional PN reporting systems have been developed, taking into account the findings presented in this study.
Recommendations
It is important to use, improve, and maintain current facilitators of PN. On the other hand, perceived barriers to PN should be tackled (see Table
1). From an organisational perspective, future efforts need to concentrate on addressing the public health care goals of public sexual health care professionals, focusing especially on their responsibility towards the community. For example, this could involve the development of PN protocols that encourage the notification of sexual, and possibly also social, networks. Furthermore, attention should focus on Motivational Interviewing, which has been shown to improve skills and behaviour of health care professionals in dealing with patients’ resistance towards PN [
26]. PN training using MI as a useful tool should therefore be included in the education of health care professionals. In addition to this, recall of sex partners is likely to increase when professionals are better trained to motivate patients to contact sex partners, or when care professionals are more proactive in helping patients in the notification process (i.e., provider referral)[
4],[
5],[
18],[
22],[
26]. Since no feedback on the effectiveness of PN outcomes and PN techniques used is available, future efforts should also include developing ways to provide feedback to staff, which in turn could have a positive effect on their feelings of responsibility, and address their feelings of being ineffective. The frequent absence of recorded PN outcome data could be tackled by implementing a centralized and standardized collection of PN data. Regional and/or national PN reporting systems shared among all stakeholders who perform PN should be developed to determine, for instance, rates of notification, test, positivity and treatment among partners. One option, which was mentioned by some of the health care professionals, and has also been identified in the literature [
27], would be to implement an internet-based PN system (i.e., e-mail and text messages) which can be used by both clients and health care professionals; this strategy would take advantage of a communication technology that is increasingly utilised [
28]. An initiative of the Public Health Care Service South Limburg is to test and implement an internet-based system called SafeFriend [
29]. Young people at risk for Ct will be motivated via their sexual and social networks (i.e. e-mail and text messages) to get tested for Ct, and offered home-based test kits. As shown in a systematic review [
5], home-based test kits improve the effectiveness of PN by increasing the number of partners tested.
Table 1
Recommendations to improve partner notification
PN Guidelines | PN guidelines should provide concrete steps for health care professionals in terms of how they can address public health goals |
PN training | Motivational Interviewing should be specifically addressed in training for PN |
Discussing PN | Organisations should encourage and facilitate inter-professional discussions on best practice regarding PN |
Feedback on PN | Information systems should be created and implemented that provide feedback on PN outcomes to health care professionals and policy makers |
Limitations
Some limitations need to be considered when interpreting the data. First due to logistical reasons, we decided to conduct the interviews in participating clinics outside South Limburg via telephone rather than face-to-face (interviews were conducted face-to-face in participating South Limburg clinics). To minimize the difference between the verbal and non-verbal communication of the interviewers, a protocol was used for each of the interviews. Data showed that there were no notable differences in the themes raised by the interviewees across the face-to-face or telephone interviews. Second, to minimize the possibility of receiving only socially desirable answers, the interviewers emphasized the confidentiality of data before and during the interview. Third, barriers and facilitators as perceived by health care professionals were studied only in relation to PN in young heterosexual people infected with Ct (i.e., the largest group of STI clinic patients in the Netherlands). Therefore, it is unknown whether results can be extrapolated to other target groups (i.e. men having sex with men, or commercial sex workers) and other STIs (e.g. Syphilis or HIV). Fourth, the experience that a health worker has (i.e. number of years working in a clinic) may play a role in the PN process. Positive and/or negative experiences over time could influence the attitudes and self-efficacy of health care professionals towards PN. Although we did not have exact data relating to employment years, all participants in the present study had at least six months PN experience in an STI clinic setting. Finally, the results of this study were not presented to the participants for confirmation. Nevertheless, at the end of each interview, participants were given the opportunity to ask questions and/or give comments concerning the interview.
Conclusion
The results of this study carried out among Dutch STI clinics provides insight into the challenges and facilitators at the health care professional, patient, and organisational levels. These applied mainly to steps 2 and 3 of PN, i.e., the identification and notification of sex partner(s). In order to overcome these barriers and maintain facilitators --and thereby optimize PN -- efforts should be made to focus more on the public health care goals of STI clinical practice, especially on the aim of protecting the community. Examples of ways in which these goals can be reached include: introducing PN protocols, providing feedback on the effectiveness of strategies used by health care professionals, and on the PN process as a whole, education in the use of Motivational Interviewing strategies, and the possible implementation of an Internet-based PN system.
Ethical approval
The Medical Ethics Committee of Maastricht University reviewed and approved this study (reference number 13-4-054).
Competing interest
The authors declare that they have no competing interests.