The chlamydia knowledge, awareness and testing practices of Australian general practitioners and practice nurses: survey findings from the Australian Chlamydia Control Effectiveness Pilot (ACCEPt)

Chlamydia trachomatis (hereafter referred to as chlamydia) is the most common reportable infection in the United States (US), Europe and Australia. In 2011, around 1.4 million new chlamydia diagnoses were reported in the US, 344 491 in 24 European Union member states during 2010 and 80 800 in Australia in 2011 [1‐3]. In these countries, notifications of chlamydia are increasing steadily each year, with most cases in 15-29 year olds [1‐3]. Without treatment, chlamydia may persist for a year or longer, with an estimated 10% of young women developing pelvic inflammatory disease within a year [4, 5]. Untreated chlamydia is also an important cause of other serious reproductive morbidity including infertility and ectopic pregnancy [6, 7].

Most chlamydia infections are asymptomatic [7], and in the absence of screening they may remain undetected. Clinical guidelines in various countries recommend regular testing of sexually active women aged less than 25 years, with England extending the recommendation to include males, and Australia recently extending to males and up to age 29 years [8‐10]. Australian general practice clinics are ideally placed to conduct widespread chlamydia screening with 86% of women and 64% of men aged 16-29 years of age visiting a general practitioner (GP) at least once each year; however testing rates in this age group are low at 12.1% in women and 4.8% in men [11].

The Australian Government has funded the Australian Chlamydia Control Effectiveness Pilot (ACCEPt), a cluster randomised controlled trial of annual chlamydia testing in 16-29 year old males and females. ACCEPt aims to determine whether annual chlamydia screening in general practice can reduce the prevalence of chlamydia. Clinics are randomised to either receive a multifaceted intervention designed to facilitate increased testing or to continue with usual care. Further details about the intervention are described elsewhere [12]. Given the growth of the role of the practice nurse (PNs) (employed in around 60% of Australia’s general practices) in recent years, there is an opportunity for PNs to take a role in chlamydia testing [13, 14]. ACCEPt clinics randomised to the intervention arm can choose for PNs to become more involved in testing and management and receive PN specific education and financial incentives. Although PNs have been recognized as having the potential to play a key role in the provision of sexual health services in general practice in the UK [15, 16] to our knowledge, ACCEPt is also the first chlamydia screening trial to formally evaluate the impact of practice nurses in increasing chlamydia testing rates.

To inform the design of the ACCEPt intervention in supporting GPs and PNs to increase testing rates and to assess the scope for PN involvement in chlamydia testing in clinics, we aimed to determine the chlamydia knowledge, attitudes, awareness and testing practices of participating GPs and PNs prior to randomization and education. Although other surveys have been conducted among GPs in Australia [17‐21], none have included PNs. We also assessed if PNs demonstrated any differences in these outcomes compared with GPs which could require tailoring of the intervention.

This survey identifies some important gaps in the chlamydia knowledge and self reported practices of GPs and PNs which may contribute to low chlamydia testing rates and suboptimal management of chlamydia in young people attending Australian general practice clinics. Knowledge of the age groups at greatest risk of chlamydia, especially in men, was poor in both professions. PNs demonstrated greater knowledge and more correct testing and retesting practices than GPs, but were less likely to collect the appropriate specimens for chlamydia testing. In addition, most of the GPs indicated that they were not prescribing the recommended antibiotic treatment for pregnant women with chlamydia. The study also demonstrated that although the majority of PNs were willing to become more involved in chlamydia testing and just over half in partner notification, they identified potential barriers to increasing testing including time constraints, lack of patient knowledge and lack of formal reminder systems to facilitate repeat testing.

The survey had a number of strengths. To our knowledge this is the first survey examining PN chlamydia knowledge and practice specifically and comparing the responses of PNs and GPs. Second, because of the direct questionnaire administration method and reminders the response rates were very high, comparable with the 85% response rate achieved by Mulvey et al. [20] and a vast improvement on more recent response rates achieved in other postal chlamydia knowledge and practice surveys in Australian general practice settings [17, 19, 21]. A similar system of sending reminders to non-responders was undertaken by Hocking et al. and achieved response rates of 60% [18].

A number of limitations should also be noted. About a quarter of clinicians did not return the questionnaire. The characteristics of these non responders are not available but it is possible they were less interested in sexual health and our study findings related to knowledge and practices may be overestimated. The ability to detect significant differences between professions was hampered by the lower sample size of PNs. Also the PNs who participated in the survey reflect nurses who were selected by their clinics to be involved in chlamydia testing if randomised to the intervention arm, whereas the majority of GPs were recruited. Thus the PNs may represent a more interested group of PNs, which may account for high levels of knowledge compared to GPs. The GPs are also unlikely to be representative of all Australian GPs, with most from rural towns where many overseas trained doctors are required to work for ten years before receiving access to Medicare benefits arrangements [28]. The result is an over- representation (41%) of overseas trained GPs in the sample compared with one-third in Australia GPs overall [29]. It should be noted however, that there were no significant differences in knowledge or correct practices between GPs trained overseas compared with those trained in Australia.

GPs reported they wouldn’t offer chlamydia testing opportunistically in a range of clinical presentations, including pap smears and pregnancy, which explains the low testing rate currently seen in general practice [11], and the low uptake of chlamydia testing in antenatal screening [30]. Testing only those with symptoms or reported risk will achieve a very low testing coverage, with the baseline prevalence survey of patients attending ACCEPt clinics finding only 5% presented for STI-related reasons [31]. Previous Australian and UK research examining GPs’ chlamydia knowledge and practice also found that GPs were less likely to offer testing during asymptomatic presentations, even those related to chlamydia testing, such as pap smears [19, 21, 32‐34]. Conversely, the participating PNs in our survey thought that testing should be offered in all the asymptomatic non-sexual health scenarios presented, even in age groups outside of that recommended guidelines current at the time of the survey suggesting a greater commitment to opportunistic testing. This may be because nurses view sexual health as an integral part of holistic care and thus part of their role. PNs may also feel more comfortable discussing and offering chlamydia testing in unrelated consultations, compared with GPs, who may fear “offending” or “insulting” patients [16, 35, 36]. A reduced awareness of those age groups with the highest risk of chlamydia may also lead to missed opportunities for testing in the target age group and over testing in older age groups. It is very important that PNs are aware of the target age groups for chlamydia testing, as they are important providers of pap smears in Australian general practice and since 2006 have had the ability to undertake chlamydia testing at the time of cervical screening. Past initiatives linking chlamydia testing to pap smears have resulted in higher testing rates in older, lower risk age groups [37], and lower rates in younger women not eligible for cervical screening [38].

Inconsistencies in knowledge regarding recommended specimen collection suggest that respondents’ may be unfamiliar with guidelines for testing. Most identified acceptable specimens for asymptomatic patients and symptomatic female patients, but not for symptomatic heterosexual males and MSM. This could reflect lack of experience in STI testing for MSM due to the lower populations of MSM in rural areas or lack of awareness of patients’ sexuality due to not asking or gay men themselves not disclosing [39]. Research examining the comprehensiveness of STI testing in MSM shows that anal (and throat) swabs are the least common specimen collected [40, 41].

By far, GPs had poorer knowledge about the need for chlamydia retesting and the appropriate time frame. This explains why in general practice only a quarter of young people are currently re-testing at 3 months following a positive chlamydia diagnosis and of those tested, only 7% are retesting in 12 months [42]. Recent data from England’s National Chlamydia Screening Programme (NCSP) revealed moderate annual repeat testing rates with 18% (overall NCSP) to 26% (GUM clinics) of young people re-tested within one year, and a higher proportion of positive retests in those who tested positive at baseline [10]. Lack of clinician awareness or inconsistencies in the guidelines recommendations on the timing of retesting may explain Australian GPs poor knowledge in this area. RACGP guidelines advise repeat testing from 3-12 months following chlamydia infection, compared with other STI management guidelines recommending 3 months [9, 26]. However, within our sample, over half of the GPs (63%) who identified the need for a repeat test following chlamydia diagnosis thought that this test should be performed before 12 weeks, with just under half (44%) choosing between 1 to 5 weeks, a timeframe in which retesting may result in a false positive result due to the presence of non-viable chlamydial DNA [43]. GPs self reported treatment practices are also suggestive of unfamiliarity with current guidelines. Whilst the majority indicated that they would usually prescribe azithromycin for men or non-pregnant women, under half chose azithromycin for the treatment of chlamydia infection in pregnant women. Almost the same proportion would use amoxicillin or erythromycin, which despite being effective in treating chlamydia infection, are associated with more adverse gastro-intestinal side effects and poorer adherence than azithromycin [44].

It is encouraging to note that not only do PNs in this survey demonstrate good baseline chlamydia knowledge but they are also willing to undertake a role in all aspects of chlamydia management, including partner notification and management of recall systems for chlamydia retesting, whilst also identifying the need to undergo additional training to do so. The perceived barriers to increasing chlamydia testing were consistent with those previously identified by Australian GPs in a study by Hocking et al. [35] and GPs and PNs in the UK [15, 16, 34, 36].

In conclusion, chlamydia infection and re-infection are important health issues for young people. General practice is ideally placed to implement a successful chlamydia screening programme that may have the potential, through increasing testing, to impact on the burden of chlamydia in this population. Despite this, testing rates in general practice are poor and as this survey reveals, important gaps in chlamydia knowledge and practice and barriers to testing exist amongst clinicians. To fully support clinicians in achieving increased testing rates, these gaps and barriers must be addressed. The multifaceted ACCEPt intervention, which is tailored to each participating clinic, is appropriately designed and targeted to achieve this. Finally, PNs, with their demonstrated levels of chlamydia knowledge and willingness to offer testing opportunistically have the potential to make a significant contribution to chlamydia testing in general practice and therefore strategies to increase their involvement must be explored.