Experiences of screening women and men for chlamydia
General practitioners, and particularly the PNs, described their experiences of chlamydia screening as being almost exclusively with women, which reflects the national testing figures for Scotland showing that 73% of tests were conducted with women [
10]. Participants perceived there to be a higher attendance at general practice by women compared to men, driven by contraception consultations, cervical smear tests (Pap tests) or breast screening, and this was cited regularly by both the GPs and PNs as underlying their perceived greater opportunity for, and thus experience of, opportunistic screening of women. Perceptions of low attendance by young men were cited by both GPs and PNs as a major reason for their lower experience of screening male patients for chlamydia. Practice Nurses, far more than the GPs, reported very few occasions of interacting with young men, even during times when screening was being encouraged by the Health Boards.
My experience of screening young men has probably been part of the opt-in enhanced service, that ran over, I think, a two-year period, and has now ceased. During that time, we were opportunistically asking people if they wanted to be screened, and that was people aged from 15 to 24, as I recall. During that time, I didn’t approach any young men, because I don’t think it’s an age group that I actually see very often, in my particular field. (PN3, Female, SIMD3, 12.2%)
The few occasions mentioned tended to be for specific clinic attendance, such as an asthma clinic, but such clinics were not consistently available across the practices represented by the participants as they depended on patient need across practices. GPs, who saw more men than the PNs, gave their views on why they did not screen as many men as women:
I suppose [pause] - I guess one of the reasons for the differences that we see more young female patients then we see young men, we have more interaction with them, they come in for their contraceptive pill and they generally consult more frequently. We don’t see that in many 20 year old men in and about the place so that would probably explain the difference in my testing rates between the two groups. (GP4, Male, SIMD5, 10.2%)
However, when participants were asked to describe the percentage of their practice list that were young men under 25 years, and to reflect on the frequency of the visits these young men may make over a 12 month period, it often prompted GPs to reassess their perceptions of men’s low attendance, whilst PNs continued to assert that they had few opportunities to interact with young men.
I: ok. In terms of the proportion of young people on the list, would you say it’s kind of high or low?
R: Yes, we’ve got a lot of young people. [pause]. Hmm, yeah, I mean I suppose yeah they are here. (GP2, Male, SIMD5, 9.6%)
I: OK, so you have about 1 in 10 on your list are young men.
R: As much as that? But I would say personally I can’t remember the last time I gave a guy a bottle, probably about six months ago, a urine test for chlamydia.
I: Mm-hmm, mm-hmm. Do you see many young men at all?
R: No, no.
(PN5, Female, SIMD2, 10.5%)
Experiences of screening for chlamydia were strongly linked to the nature of the patient-led consultation, with many believing it easier to raise issues of sexual health with patients when attending for related issues. There was a common belief from both GPs and PNs that women are exposed more, or are used to, health-related messages pertaining to sexual and reproductive health as well as being more used to routine screening (e.g., cervical screening).
I think women are easier to talk to about things like that, especially younger women, and especially you’ve got them in for things like smears and stuff, you know, and sometimes when they come in for things like that they tend to open up a bit more about other things, especially to a woman who again they can maybe relate to being a bit like their mum, if you see what I mean! [laugh] (PN6, Female, SIMD5, 12.8%)
Many GPs described their reluctance to initiate conversations around sexual health with men. Descriptions of such encounters by GPs were often characterised as ‘difficult’, ‘awkward’ and ‘challenging’. As a consequence, any tests they conducted with men were largely driven by the men self-reporting symptoms, which would then lead to STI conversations and investigation.
It can be a bit awkward. It’s sort of how you gauge it. (GP6, Female, SIMD1, 13.7%)
Fewer nurses offered such comments, perhaps reflecting their infrequent contact with young men. Such embarrassment and discomfort was not always a key factor in failing to raise the issue of screening with men, particularly for those based at practices in areas of higher deprivation, who were not confident that chlamydia was a high priority for their patients.
… most of the young men I see are not coming in for sore knees, they’re coming in for methadone prescriptions and often quite complicated consultations…(GP10, Male, SIMD2, 11.2%).
Both GPs and PNs spoke of being uneasy with ‘unsolicited health care intervention’ and with making health promotion ‘leaps’.
I'd go out of my way to avoid randomly bringing up new things because we've got enough staff to deal with it and I'm always running 15 or 20 minutes late anyway. The fewer new unsolicited healthcare intervention the better [laughs] and we've got all the QOF [Quality Outcomes Framework] stuff to do. We're already bugging people enough…(GP4, Male, SIMD5, 10.2%)
However, when probed, participants admitted they asked unsolicited questions about smoking or alcohol, including to patients seeking advice for sports-related injuries.
These ‘leaps’ were justified by GPs because they were part of the practices’ contractual issues and related to financial incentives. The fewer PNs who spoke about these issues were related to the infrequency with which they interacted with men in their practice, but, like GPs, they still spoke more generally of ever present time pressures within the practice environment.
I think it’s just that there’s so much else going on in general practice at the moment that, you know, sort of screening the young male population just isn’t on the agenda. (GP8, Female, SIMD5, 16.1%)
I: What do you think might be the barriers of such an approach?
R: The cost. [pause] And the QOF, I mean that’s increased our workload year on year since I started doing this job so one more little thing. (PN6, Female, SIMD5, 12.8%)
Participants spoke of chlamydia screening being higher in their practice when payments were offered but witnessing, and participating in, a subsequent reduced concern once there was no longer a financial incentive for the practice.
We used to do it [screening] a bit more when it was run by the Health Board…we would get a payment for every test done, so probably its dropped a bit since that was withdrawn. (PN2, Female, SIMD5, 6.5%)
Although this PN worked at an affluent and low percentage practice, in terms of men registered, there seemed to be a real focus on payment and time-concerns, and little attention paid to the low percentages of young men registered. Such a focus was mirrored in the views of a PN from an affluent and higher percentage practice. She reflected on this payment period and suggested that in her practice there were so few positive infections identified that the £10 payment per screen was ‘quite a lot of money to be spent on health, to reassure somebody’ (PN3, Female, SIMD3, 12.2%). Thus, their views coalesced around similar issues: payments and time.
Barriers and facilitators
Design and recruitment facilitators
The facilitators of an Internet-based approach to screening young people for chlamydia identified by participants focused on ease of access and convenience, as well as the importance of anonymity and confidentiality.
The easier it is for them, the better, probably. The more convenient it is for them, the better. (GP3, Female, SIMD5, 42.9%)
Almost every participant spoke of the anonymous or confidential nature of an Internet-based screening approach as being vital if it is to appeal to young people. For PNs in particular, this was borne out of their reflections of the potential for no anonymity in GP attendance, in particular the potential to ‘bump into’ someone.
I think they’re [young people] always concerned about the anonymity of things and GP practice, you go the doctors and you bump into your next door neighbour or your mother’s friend… (PN8, Female, SIMD2, 12.0%)
Confidentiality issues were raised by around half of all participants in relation to the type of data that would be accessed from registers for this approach; it was acceptable for age and date of birth data to be accessed but not detailed medical records. Most made the point that registers are being used for screening programmes, such as for cervical and bowel cancer. Four GPs and two PNs pondered whether some people may get annoyed at receiving an unsolicited screening letter, which might have a knock-on effect to practices.
Six GPs and two PNs mentioned practical issues that would need to be considered for an Internet screening approach so as not to become barriers, including who sends screening invitation letters and the accuracy of address information for young people. One GP believed there would need to be a ‘very small step between the screening invitation and actually being able to do the test’ (GP9, Male, SIMD4, 10.9%).
Most participants spoke with ease about targeting particular populations for health education or screening offers, often referring to examples within their own practice such as previous efforts to screen for chlamydia or to reach out to young smokers on their practice list. The approach of targeting particular sub-populations, based on age, was not questioned. Although one GP did question whether men may face scrutiny by partners relating to infidelity if there was a lack of understanding that all young men were being offered screening.
…if the young man lives with a partner, and if the partner sees ‘chlamydia screening’, she needs to be told that it’s purely screening, and not that her partner’s been cheating around, and someone has asked for the partner to be tested, in case he’s got an infection because of his infidelity. (GP7, Male, SIMD1, 14.0%).
This underscores the importance of ensuring these processes are thought through carefully if they are not to become barriers to screening.
Socio-cultural barriers
Participants were often keen to stress that an Internet screening approach could be successful if young people considered testing as a normal thing to do. Half of all participants believed that normalisation of testing could be assisted by a nation-wide marketing campaign to kick start it, but also the need for such a campaign to continue so as to help keep momentum by keeping the service in young people’s minds.
…we didn’t have a screening process for cervical cancer when I was younger. So the first time I had one here I was like, oh why am I getting this? But now it’s…I expect it every three years and it’s not something that fazes me when it comes through the door. So again I think it’s… it would then become a bit more engrained that this is part of your health like having your blood pressure checked and things like that. (PN7, Female, SIMD5, 13.9%)
For some, such a widespread awareness of the screening taking place for all age-eligible young people may lead to relationships not becoming jeopardised by the screening letter arriving in the post.
Participants also stressed perceived barriers pertaining to gender-related issues, including perceptions among young people that chlamydia is a ‘woman’s disease’, associated with infertility and promiscuous women. Consequently, these participants believed that such young people fear the stigma of attending for a STI test where they can be seen and identified as promiscuous. No participant spoke about men in this way, but some did mention the embarrassment men may feel asking for a STI test. Support for the Internet approach therefore rested on the anonymity of the approach and non-clinic attendance. Young men were described as reluctant in general to discuss issues relating to their sexual health, although some went on to widen their thoughts on this to the issue of youth’s low perception of risk for STIs.
…the ostrich sort of thing - let's not think about it. it'll not happen, sort of thing (PN8, Female, SIMD2, 12.0%).
Participants also described women as more likely to be at ease with screening offers, given their experiences of cervical screening, but also with other regular medical intrusions in their lives due to contraception appointments. Reproductive health conversations were perceived to occur more often with women, and as such respondents questioned whether an approach that included men without an accompanying educational element might not ultimately reach men.
if you’ve got somebody who’s already got their awareness raised, and who’s thinking, “I probably ought to get this screening done, but I’m too embarrassed to go and talk to a GP about it.” If you’ve got somebody in that situation then, obviously, I think doing it on the Internet would be good. (GP10, Male, SIMD2, 11.2%).