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.

Full article at:   http://goo.gl/PwEzsq

By:  Ricketts EJ1, Francischetto EO2, Wallace LM3, Hogan A4, McNulty CA5.

• 1Public Health England Primary Care Unit, Microbiology Department, Gloucestershire Royal Hospital, Great Western Road, Gloucester, GL1 3NN, UK.
• 2NIHR CLAHRC West Midlands Chronic Disease Theme, Institute of Applied Health Research, University of Birmingham, Edgbaston B15 2TT, Birmingham, UK.
• 3Faculty of Health and Social Care, National Institutes of Health Research Health Services and Delivery Research Programme, The Open University, Walton Hall, Milton Keynes, MK7 6AA, UK.
• 4Health Protection Agency Primary Care Unit, Personalised Medicine Consortium Integrated Biobank of Luxembourg 6, Rue Nicolas Ernest Barblé, L-1210, Luxembourg.
• 5Public Health England Primary Care Unit, Microbiology Department, Gloucestershire Royal Hospital, Great Western Road, Gloucester, GL1 3NN, UK. cliodna.mcnulty@phe.gov.uk. 
• BMC Fam Pract. 2016 Mar 22;17(1):33. doi: 10.1186/s12875-016-0430-2.

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Racial Differences in Receipt of Chlamydia Testing among Medicaid-Insured Women in 2013

OBJECTIVE:

To estimate the percentage of young, sexually active Medicaid-insured women who were tested for chlamydia by age, race/ethnicity, and history of sexually transmitted disease (STD) diagnosis.

METHODS:

We used the medical diagnostic and procedural codes from Truven Health MarketScan Medicaid claims data from 10 states in 2012 and 2013 to estimate the rates of chlamydia testing in 2013 and previous STD diagnosis (diagnosed in 2012) among Medicaid-insured women aged 15-25 years who were sexually active in 2013. We also used a logit model to assess the association between chlamydia testing and women's age, race/ethnicity, and previous STD diagnosis.

RESULTS:

Overall, among approximately 261,000 Medicaid-insured women aged 15-25 years in 2013 who were classified as sexually active, 50.2% were tested for chlamydia in 2013. The chlamydia testing rate was 45.6% for white women and 57.5% for black women. The chlamydia testing rate was 63.5% for women diagnosed as having an STD in 2012 and 46.8% for women not diagnosed as having an STD in 2012. The chlamydia testing rate was significantly (P < 0.05) associated with previous STD diagnosis, age, and race/ethnicity in our logit model.

CONCLUSIONS:

Higher chlamydia testing rates among black women can be explained in part by higher rates of previous STD diagnoses. Our finding that black women have the highest chlamydia testing rates is encouraging, as improved access to STD prevention services among racial/ethnic minorities can help to reduce racial/ethnic disparities in STDs. However, chlamydia screening remains an underused preventive health service for young women of all racial and ethnic groups.

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By:  Patel CG1, Chesson HW, Tao G.

• 1From the *Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Atlanta, GA; and †Oak Ridge Institute of Science and Education, Oak Ridge, TN. 
• Sex Transm Dis. 2016 Mar;43(3):147-51. doi: 10.1097/OLQ.0000000000000405.

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Predictors of Chlamydia Trachomatis Testing: Perceived Norms, Susceptibility, Changes in Partner Status & Underestimation of Own Risk

BACKGROUND:

It is hard to convince people to participate in chlamydia screening programs outside the clinical setting. In two earlier studies (BMC Public Health. 2013;13:1091; J Med Internet Res. 2014;16(1):e24), we identified explicit and implicit determinants of chlamydia screening behavior and attempted, unsuccessfully, to improve participation rates by optimizing the recruitment letter. In the present study, we examined the links between a number of social-cognitive determinants (e.g., stereotypical beliefs about a person with chlamydia, intentions, changes in partner status), and self-reported chlamydia testing behavior six months after the initial study.

METHODS:

The present study is a follow-up to our first study (T0). We assessed self-reported testing behavior 6 months after the first measure by means of an online questionnaire (T1; N = 269). Furthermore, at T1, we measured the social-cognitive determinants in more detail, and explored the influence of stereotypical beliefs and any changes in partner status during this six month period.

RESULTS:

In total, 25 (9.1 %) of the participants tested for chlamydia at some point during the six months between baseline (T0) and follow up (T1). Testing behavior was influenced by testing intentions in combination with changes in risk behavior. The higher the participants' own numbers of partners ever, the higher they estimated the number of partners of the stereotypical person with chlamydia. Testing intentions were most strongly predicted by perceived norms and susceptibility, and having had multiple partners in the last 6 months (R(2) = .41).

CONCLUSION:

The most relevant determinants for testing intentions and behavior were susceptibility, subjective norms and changes in partner status. We found a systematic tendency for individuals to underestimate their own risk, especially the risk of inconsistent condom use. Future research should focus on more promising alternatives to population-based interventions, such as online interventions, screening in primary care, the rescreening of positives, and clinic-based interventions. This future research should also focus on making testing easier and reducing barriers to testing, as well as using social and sexual networks in order to reach more people.

Below:  Logic Model of Predictors of Testing Intention and Behavior

Full article at:   http://goo.gl/Icj1mJ

By:    Ten Hoor GA1, Ruiter RA2, van Bergen JE3,4, Hoebe CJ5,6, Dukers-Muijrers NH7,8, Kok G9.

• 1Department of Work & Social Psychology, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands. Gill.tenHoor@MaastrichtUniversity.nl.
• 2Department of Work & Social Psychology, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands. r.ruiter@maastrichtuniversity.nl.
• 3STI AIDS Netherlands, Keizersgracht 390, 1016GB, Amsterdam, The Netherlands. JvanBergen@soaaids.nl.
• 4Department of General Practice, AMC-University of Amsterdam, P.O. Box 19268, 1000GG, Amsterdam, Netherlands. JvanBergen@soaaids.nl.
• 5Department of Sexual Health, Infectious Disease and Environmental Health, Public Health Service South Limburg, P.O. Box 2022, 6160HA, Geleen, The Netherlands. Christian.Hoebe@ggdzl.nl.
• 6Department of Medical Microbiology, Maastricht University, P.O. Box 5800, 6202AZ, Maastricht, The Netherlands. Christian.Hoebe@ggdzl.nl.
• 7Department of Sexual Health, Infectious Disease and Environmental Health, Public Health Service South Limburg, P.O. Box 2022, 6160HA, Geleen, The Netherlands. Nicole.Dukers@ggdzl.nl.
• 8Department of Medical Microbiology, Maastricht University, P.O. Box 5800, 6202AZ, Maastricht, The Netherlands. Nicole.Dukers@ggdzl.nl.
• 9Department of Work & Social Psychology, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands. g.kok@maastrichtuniversity.nl. 

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Predictors of Chlamydia Trachomatis Testing: Perceived Norms, Susceptibility, Changes in Partner Status & Underestimation of Own Risk

Background

It is hard to convince people to participate in chlamydia screening programs outside the clinical setting. In two earlier studies (BMC Public Health. 2013;13:1091; J Med Internet Res. 2014;16(1):e24), we identified explicit and implicit determinants of chlamydia screening behavior and attempted, unsuccessfully, to improve participation rates by optimizing the recruitment letter. In the present study, we examined the links between a number of social-cognitive determinants (e.g., stereotypical beliefs about a person with chlamydia, intentions, changes in partner status), and self-reported chlamydia testing behavior six months after the initial study.

Methods

The present study is a follow-up to our first study (T0). We assessed self-reported testing behavior 6 months after the first measure by means of an online questionnaire (T1; N = 269). Furthermore, at T1, we measured the social-cognitive determinants in more detail, and explored the influence of stereotypical beliefs and any changes in partner status during this six month period.

Results

In total, 25 (9.1 %) of the participants tested for chlamydia at some point during the six months between baseline (T0) and follow up (T1). Testing behavior was influenced by testing intentions in combination with changes in risk behavior. The higher the participants’ own numbers of partners ever, the higher they estimated the number of partners of the stereotypical person with chlamydia. Testing intentions were most strongly predicted by perceived norms and susceptibility, and having had multiple partners in the last 6 months (R² = .41).

Conclusion

The most relevant determinants for testing intentions and behavior were susceptibility, subjective norms and changes in partner status. We found a systematic tendency for individuals to underestimate their own risk, especially the risk of inconsistent condom use. Future research should focus on more promising alternatives to population-based interventions, such as online interventions, screening in primary care, the rescreening of positives, and clinic-based interventions. This future research should also focus on making testing easier and reducing barriers to testing, as well as using social and sexual networks in order to reach more people.

Full article at:   http://goo.gl/YDUjUQ

By:  Gill A. ten Hoor, Robert A. C. Ruiter, Jan E. A. M. van Bergen, Christian J. P. A. Hoebe, Nicole H. T. M. Dukers-Muijrers and Gerjo Kok

Department of Work & Social Psychology, Maastricht University

DOI: 10.1186/s12889-016-2689-6

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Changes in Chlamydia Control Activities in Europe Between 2007 & 2012: A Cross-National Survey

In 2012, the levels of chlamydia control activities including primary prevention, effective case management with partner management and surveillance were assessed in 2012 across countries in the European Union and European Economic Area (EU/EEA), on initiative of the European Centre for Disease Control (ECDC) survey, and the findings were compared with those from a similar survey in 2007.

Experts in the 30 EU/EEA countries were invited to respond to an online questionnaire; 28 countries responded, of which 25 participated in both the 2007 and 2012 surveys. Analyses focused on 13 indicators of chlamydia prevention and control activities; countries were assigned to one of five categories of chlamydia control.

In 2012, more countries than in 2007 reported availability of national chlamydia case management guidelines (80% vs. 68%), opportunistic chlamydia testing (68% vs. 44%) and consistent use of nucleic acid amplification tests (64% vs. 36%). The number of countries reporting having a national sexually transmitted infection control strategy or a surveillance system for chlamydia did not change notably. In 2012, most countries (18/25, 72%) had implemented primary prevention activities and case management guidelines addressing partner management, compared with 44% (11/25) of countries in 2007.

Overall, chlamydia control activities in EU/EEA countries strengthened between 2007 and 2012. Several countries still need to develop essential chlamydia control activities, whereas others may strengthen implementation and monitoring of existing activities.

Below:  EU/EEA countries with a national strategy or plan about STI control in 2012. CT = chlamydia. UK situation based on England. Adapted from ECDC Report7

Below:  Map of Europe indicating the level of chlamydia control based on the countries’ accomplishments of key indicators assessed in the survey in 2012. UK situation based on England. Adapted from ECDC Report7

Full article at: http://goo.gl/nWGa1D

By: van den Broek IV1, Sfetcu O2, van der Sande MA3, Andersen B4, Herrmann B5, Ward H6, Götz HM7, Uusküla A8, Woodhall SC9, Redmond SM10, Amato-Gauci AJ2, Low N10, van Bergen JE11.

• 1Unit of Epidemiology and Surveillance, RIVM/Centre for Infectious Disease Control Netherlands, Bilthoven, The Netherlands ingrid.van.den.broek@rivm.nl.
• 2European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden.
• 3Unit of Epidemiology and Surveillance, RIVM/Centre for Infectious Disease Control Netherlands, Bilthoven, The Netherlands Julius Centre, UMC Utrecht, Utrecht, The Netherlands.
• 4Department of Public Health, Randers Hospital, Skovlyvej, Randers, Denmark.
• 5Section of Clinical Bacteriology, Department of Medical Sciences, Uppsala University, Uppsala, Sweden.
• 6Infectious Diseases Epidemiology, School of Public Health, Imperial College London, St Mary's Campus, Norfolk Place, London, UK.
• 7Department of Infectious Disease Control, Municipal Public Health Service Rotterdam-Rijnmond, Rotterdam, The Netherlands.
• 8Department of Public Health, University of Tartu, Tartu, Estonia.
• 9HIV & STI Department, National Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK.
• 10Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.
• 11Unit of Epidemiology and Surveillance, RIVM/Centre for Infectious Disease Control Netherlands, Bilthoven, The Netherlands Department of General Practice, University of Amsterdam, Amsterdam, The Netherlands STI AIDS Netherlands, Amsterdam, The Netherlands.  

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Retesting Young STI Clinic Visitors with Urogenital Chlamydia Trachomatis Infection in The Netherlands; Response to a Text Message Reminder & Reinfection Rates

The objective of this study is to assess the effect of reminder text messages 6 months after the initial treatment on retest and chlamydia reinfection rates in young heterosexuals compared with a historical control group and to assess factors associated with both outcomes.

Heterosexual people (aged 16-23 years), testing positive for urogenital chlamydia, were offered a retest after 6 months. Participants received a text message reminder at 6 months after the initial chlamydia diagnosis. Rates of retest uptake and the result of the retest were analysed using Cox regression. Prevalence ratios (PRs) were calculated to identify factors associated with these outcomes. Furthermore, the retest rate was compared with the retest rate of a historical control group.

30.6% (253/838) of the study group returned within 5-8 months compared with 9.2% (140/1530) in the historical control group. Women and persons who were not notified for a sexually transmitted infection (STI) at inclusion were more likely to return for a retest. 20.4% (56/275) of participants had a chlamydia reinfection upon retesting. Reinfection was higher in participants reporting STI-related symptoms and in participants who were notified for an STI at retest.

A text message reminder appeared to have a clear, positive impact on the resulting retest rate. These results also indicate that retesting is necessary to identify chlamydia reinfections.

Via: http://ht.ly/SXXfr Purchase full article at: http://goo.gl/7mULPH

By: Kampman C1, Koedijk F1, Driessen-Hulshof H2, Hautvast J3, van den Broek I4.

• 1Public Health Service Twente, Enschede, The Netherlands.
• 2Public Health Service West-Brabant, Breda, The Netherlands.
• 3Department of Primary and Community Care, Radboudumc University Medical Center, Nijmegen, The Netherlands.
• 4Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, The Netherlands 

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Incidence & Predictors of Annual Chlamydia Testing among 15–29 Year Olds Attending Aboriginal Primary Health Care Services in New South Wales, Australia

For the past two decades, chlamydia has been the most commonly notified infectious disease among young people (15–29 year olds) in Australia, the United States of America and the United Kingdom and rates have increased annually in these three countries. In Australia, rates of chlamydia are three times higher in Aboriginal compared with non-Aboriginal people. Australian sexually transmissible infection guidelines recommend annual chlamydia testing for 15–29 year old females and males. This analysis will examine the incidence and predictors of annual chlamydia testing in 15–29 year olds attending four Aboriginal Community Controlled Health Services (ACCHS) in Australia.

From 2009–2011, attendance and chlamydia testing data were extracted from the patient system to calculate the number and proportion of 15–29 year olds that were tested for chlamydia and that tested positive for chlamydia by gender (male, female), age-group (15–19, 20–24, 25–29 years), Aboriginal status (Aboriginal, non-Aboriginal people) and by the four ACCHSs sites (1, 2, 3 and 4). A cohort was created to calculate the incidence rate per 100 person-years (PY) and predictors of an annual chlamydia test (a test within 12-months of a previous test/visit) by the above factors using Cox regression. Unadjusted and adjusted hazard ratios (AHR) and their 95 % confidence intervals (CIs) and p-values were calculated with significance at p < 0.05.

From 2009–2011, there were 2896 individuals who attended the four ACCHSs. Overall , 17 % (22 % of females and 10 % of males) were tested for chlamydia and 9 % tested positive (8 % of females and 14 % of males). The median time to an annual chlamydia test was 10.7 months. The cohort included 2318 individuals. Overall the incidence rate of an annual chlamydia test was 9.1 per 100 PY (11.6 in females and 5.8 in males). Predictors of an annual chlamydia test were being female, being 15–19 years old and attending ACCHS site 2.

This analysis highlights that opportunistic STI testing strategies are needed to increase annual chlamydia testing in young people; especially males.

Below:  Incidence rate and 95 % confidence intervals of chlamydia testing in females by age-group, 2009-2011

Below:  Incidence rate and 95 % confidence intervals of chlamydia testing in males by age-group, 2009-2011

Full article at:  http://ht.ly/SStqJ 

By: Simon Graham^12*, Rebecca J. Guy¹, James S. Ward³, John Kaldor¹, Basil Donovan¹⁴,Janet Knox¹, Debbie McCowen⁵, Patricia Bullen⁵, Julie Booker⁵, Chris O’Brien⁵, Kristine Garrett⁵ and Handan C. Wand¹ 

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