Background
The Chlamydia Intervention Randomised Controlled Trial (CIRT)
Methods
Analysis
Results
COHERENCE (was the purpose of the intervention to increase chlamydia screening and thus reduce chlamydia infections, onward transmission and sequelae clear?) Table 2
COGNITIVE PARTICIPATION (Staff engaged in the training and their role in implementation in practice) Table 3
Barriers to cognitive participation
COLLECTIVE ACTION (work undertaken to drive the intervention forward and sustain it) Table 4
BARRIERS: (to collective action)
REFLEXIVE MONITORING (appraisal of the new procedures and practices in use and its impact, and making refinements) Table 5
BARRIERS to reflexive monitoring
Discussion
Intervention components facilitating normalisation of chlamydia screening into general practice
Strengths and limitations
Comparison with existing literature
Conclusion
Staff role | High screening rates | Number of staff | Low screening rates | Number of staff |
---|---|---|---|---|
Doctor | Randomised | 10 | Randomised | 10 |
Not contactable/left practice/died | 3 | Not contactable/left practice/died | 2 | |
Refused | 2 | Refused | 4 | |
Interviewed | 5 | Interviewed | 4 | |
Nurse | Randomised | 16 | Randomised | 16 |
Not contactable/left practice/died | 10 | Not contactable/left practice/died | 9 | |
Refused | 0 | Refused | 3 | |
Interviewed | 6 | Interviewed | 4 | |
Receptionist | Randomised | 6 | Randomised | 9 |
Not contactable/left practice/died | 0 | Not contactable/left practice/died | 2 | |
Refused | 2 | Refused | 4 | |
Interviewed | 4 | Interviewed | 3 |
About the workshop and value of inviting the whole team:
“The support raised my awareness and it gave me different ways of approaching young people… I feel by including the reception teams that changed the surgery’s approach, I think it does one good to have one’s awareness raised” (Nurse 04388)
Value of explaining epidemiology of chlamydia and how to perform the test:
“I think it’s just having someone explain to you who needs what test… urine tests, swab tests, … and then what they actually practically do with it,… how long it will take for the results, … how it gets to the patient” (General Practitioner 04380) “That’s one of the things, because you get ideas about how you could manage it within this practice… being told what I can do, then I’ve got to go and try and embrace that, and get everybody else involved.” (Nurse 03028)
A receptionists view:
“I just think it’s (chlamydia screening invitations) more for a nurse more than receptionists but I suppose it’s a good idea for us to be aware a bit more. It’s just confidentiality isn’t it? (Receptionist 04417) |
How screening was promoted after the training:
“It’s prompted us to have the kits and things on our desks…so we have greater awareness, to kind of dish it (the screening tests) out.” (General Practitioner 04380) “We have posters around the surgery and cards that L (a staff member) will give them, we offer a condom service here, the c-cards, they will attach on (to the) cards (information) about the chlamydia service to those (patients) when they come for the free condoms,… and just generally in … consultations.” (Nurse 04254)
Advantage of practitioners who are decision makers in general practice being at the training:
“A couple of the lady doctors have come to a couple of the talks… and that always helps if you’ve actually got a GP there at that time.” (Nurse 04243)
Value of being given possible scripts in the workshop to use with patients:
“You just say something like: “We are a chlamydia screening surgery would you like one of these tests, we offer them to everybody under 25”…. so yes, yes that definitely helped” (General Practitioner 03730)
“Let’s check your blood pressure; and you know you’re in the age group for a chlamydia screen have you had one in the last 12 months?” (Non clinical 71)
“You just say something like: “We are a chlamydia screening surgery would you like one of these tests we offer them to everybody under 25” it did (using the script) so yes yes that definitely helped” (General Practitioner 321)
Value of doing test immediately in the surgery:
“Well I think we’ve begun to realise (by) talking to the chlamydia support team and talking amongst ourselves, that probably they (the tests) only ever really get done, if you actually make the person go and do the swab there and then and then bring it back” (General Practitioner 03730)
Barrier, lack of interest in sexual health by all medical staff:
“I’m the only, you know, GP who’s actually interested in gynaecology in this practice and two of the other female doctors aren’t interested in doing it (or) taking over from me in that respect when I, … retire or whatever, … I think you know (it’s) quite a general attitude,… not everyone (GPs) is interested in that (screening) or feels it’s important or relevant.… Whereas the nurses, a lot of them … are well-qualified in family planning … and they’re more approachable, you know people find it easier to talk to nurses often, than a ….male older doctor.” (General Practitioner 03029)
Barrier: A practitioner talking about targets set nationally and not for individual general practices:
“No there is no credible (target)… because first of all (they Public Health England) decide that a group of people in an area has got a certain type of infection, (and) promiscuity etc. and you say the average of the whole country is like that. (But) here it’s totally different from the practice in town, how can you (set) the same target for me and B practice (in town) you cannot do that” (General Practitioner 03867)
Barrier: lack of confidentiality in reception area:
"Because it's such a small practice, and because of confidentiality the problems of that (chlamydia screening) in a small practice, … and knowing everyone." (Receptionist 04417) |
Value of computer prompts:
“Definitely (computer) pop ups, that that’s key almost, I think that that’s the biggest influence it’s had on me is pop ups, so it’s just automatic, because you know you’re looking there (the computer screen) anyway and then you see (the prompt to) offer chlamydia and you think ah yeah.” (Nurse 03897)
Value of repeated contact from the Chlamydia Support Team:
“Well they (the Chlamydia Support Team) just kept on with it, so they’ve kept contacting us, they’ve kept the interest going, kept coming up and it’s not just lets visit once and clear off, you know they’ve been on several occasions and that’s good” (General Practitioner 04250)
Value of ongoing awareness raising in practice:
“I’ve brought it up at a couple of meetings since then, and also introduced the little (chlamydia patient invitation) cards and things into reception… and said look… you really have to think about it. And as a new receptionist has come in; I’ve said (to her) you know (be) aware that these little chlamydia cards could also be attached to a prescription for the pills, or you know contraceptive type of prescriptions, or anybody coming to the (reception) hatch who looks to be in that sort of age group.” (Nurse 04346)
Receptionist involvement:
“Most of our screening is done sort of across the counter at the front desk, where and when we see a lot of new patients registering from the university which is quite local to us. We offer chlamydia screening routinely to that particular age group.” (Receptionist 04430)
Barrier, perceived confidentiality issues:
“She (the chlamydia support worker) told us that (get the patient to complete screen in practice there and then) but the practice isn’t big enough to do that, because there is only one toilet… that leads right out into the waiting room area and people would see people coming out with a packet… and they wouldn’t like to do that.” (General Practitioner 03920)
“For one I would feel that I wouldn’t have the time,… so it would depend on how busy we were. And two I wouldn’t think it would be appropriate, it’s the sort of thing that somebody could complain about (if) you’re not keeping things confidential. So I would only ask if I knew there was no one behind them, even if it’s a woman coming in for a smear.” (Receptionist 04207)
Barrier, lack of ability or will to develop a computer prompt:
Well I suppose we could have done [developed a prompt] but there’s only three (practices) who have ours (computer system) they know (how) to deal with all those (other) sorts of computers but wouldn’t have known what to do (with ours).” (General Practitioner 03920)
“Because there are thousands of them, people ignore them. We have a little box at the bottom with lists of prompts that this patients (is) due their blood pressure check, their thyroid check, (lists 3 others), cervical smears and … just as a general practitioner if I’m very honest with you I ignore them.” (General Practitioner 04205)
“I think in reality probably half of time we just ignored it and thought I haven’t got time for that, but the other times it did trig your memory and you did it. We just changed to (a new computer) system a few months ago, and I don’t know whether it’s available on that, but we certainly don’t have it (any prompts) at the moment.” (General Practitioner 03730)
Barrier, some receptionists uncomfortable discussing chlamydia screening:
“I wouldn’t be comfortable sort of saying to a young person, when there’s a lot of say older people behind them, “would you want to do a chlamydia test” I just wouldn’t do it, so I don’t think it’s changed here in how we deal with the patients” (Receptionist 04207)
Barrier: concern that patient will not welcome chlamydia screening offer:
“I don’t think it’s appropriate to talk about these things (chlamydia screening), especially if you want to have a good relationship with your patients, it is just incredibly difficult.” (General Practitioner 03867)
Barrier, staff uncomfortable raising screening in non-sexual health consultation:
“I do however do quite a lot of telephone triage. Its slightly more difficult to think about chlamydia when you’re dealing with people with other health issues, be it sort of tonsillitis or you know whatever other issue they’ve got, it’s not always as easy on the phone to suddenly launch into sexual health question.” (Nurse 04346)
Barrier, problems with access to chlamydia swabs:
“Checking that nobody’s got any outdated swabs in their surgery, or you know the NAATS tubes, which sounds simple, but everybody (staff say) “I haven’t got any out of date ones” and then the following week you’ll get..a result back (from the lab) saying tube out of date, couldn’t do the test.” (Nurse 04388) “I think perhaps we have had (some) difficulty getting hold of the packs. I think if it (were)….a bit smoother ordering the packs and that sort of thing, … that would make us do more” (Nurse 04254) |
Testing data from the NCSP helps them to reflect on their testing rates and efforts:
“(Name of CSW) certainly comes, and if our rates start dropping off, she starts sending us little emails “don’t forget chlamydia screens!”. (General Practitioner 04250)
The more tests you do the easier it becomes:
“You know it’s a bit like getting a wheel turning, you know as I said, you get more confident, you get more aware and it just becomes part of your daily work.” (Nurse 04543)
By doing tests staff realise patients welcome being asked:
“So it’s not… a taboo subject… this is what we do in the surgery, it’s standard practice “would you like a pack?” (As) Opposed… to the nurses being uncomfortable about it, (or) the young person feeling uncomfortable about it. It’s … built in, very much this is what we do, this is what we offer, are you interested and we haven’t had any negative feedback from that at all.” (Nurse 04353)
Offering the test was quick:
“I think it you can do it… within a minute, it doesn’t take a lot of time” (Nurse 04254)
“It’s just a question of being organised really and keeping some (kits) available” (General Practitioner 03029)
Value of putting a specific patient prompt for the next consultation:
“I try and I do it as often as possible… if I do forget, if I know I’m bringing them back in, I’ll put a little alert on for myself to try and remember to do it the next time” (Nurse 04346) “even without the kind of financial incentive, I think if we recognise that it was a valid thing to do. I think given the initial potential training with regard to helping us to acknowledge that as an important thing to do. The logistics of this is, how you can do it, then I think we could have kind of just gone and flown with it as a result” (General Practitioner 04387)
Barrier, time
“It’s a ten minute appointment, its sometimes just not possible to even go there; we don’t even bother raising it because there’s just not enough time, because you’re running twenty minute late already” (General Practitioner 04380) “It does lengthen the consultation because you’ve got to be prepared” (General Practitioner 03730)
Barrier, other priorities:
“Because … when we discussed it and I mentioned that about reaching the targets and things and everyone just said we can’t do everything, and just you know do what you can, but we weren’t going (to) have a massive drive on this.” (Nurse 3177) |
Key determinants of success
|
Actions needed to facilitate them
|
---|---|
Attendance at workshop of all general practice staff | When workshops are organised ask and encourage all staff to attend. |
Attendance at workshop by key staff able to drive forward screening | Ensure correct staff whose role it is to undertake, facilitate or lead screening attend the workshop. |
Increased confidence to offer screening through using scripts and practice, so normalised into routine practice | Using scripts in the training, and encouragement post training – stressing that the process of offering tests will increase confidence and positive feedback from patients. |
Provision of resources for flexible use | Ensure that resources provided are in a format that can be adapted for individual general practice needs. |
Use of computer prompts | Raise this in training and when and how they are going to be used, and who is going to set them up. |
Tests are performed in the general practice before the patient leaves | Stress importance in training and plan how this can be attained in each general practice. |
Encouragement of reflective practice post workshop led by “chlamydia champion” | Encourage action planning and agree staff roles going forward. General practice lead to follow up with communications about successes and testing rates and sexual health news in general practice. |
Feedback on screening efforts | Feedback general practice screening rates on a regular basis, and identify individual in the general practice to this to other staff. |
Barriers
|
Tools to overcome barrier
|
Forgetting to offer chlamydia screen | Using computer prompts and posters, and identify individual to take this forward. |
Not wishing to offer chlamydia screening in non-sexual health consultations | Staff changing the way they offer a chlamydia screen by stating that they are testing everyone aged between 15 and 24, and having a general prompt for all ages. |
When sexual health is a low priority in the general practice | Ensure individual responsible for deciding if general practice will prioritise chlamydia screening attends the training. Having a designated general practice lead to drive screening. Ensure lead and general practice keep screening as a priority, and send around reminders and forward newsletters to all staff. |
Perception of time involved in offering chlamydia screen, and monitoring screening rates | Use the scripts; stress that staff report that using them increases confidence and fluency in making the offer. Making sure there are posters to refer to, kits easily accessible and invitation cards available to give to patients. Suggest audits as part of professional development of all staff. |
Patients not returning the chlamydia test | Feeding back that other general practice staff ask the patient to do the test prior to leaving the general practice, and this is what patients want too. |
Ongoing perception that patients may be irritated if they are offered screening | Stress patients views in the training, lead to facilitate ongoing discussions in general practice around feedback from patients. |
Lack of privacy in reception area to give out invitation cards | Stress in training that offer should be made to all in age group so not seen as judgemental by staff; and teach receptionists to use script saying "we are offering this test to all 15–24 year olds, read about it on this card." |
Targets being too high for general practices with very low screening rates | Stress importance in the workshop training of discussing realistic screening rates for individual general practices with numbers and actions needed to attain them. |