Overcoming the barriers to chlamydia screening in general practice– a qualitative
study
Elaine Freemana, Rebecca Howell Jonesb, Angela Hoganc, Isabel Oliverd, William FordYounge, Philippa Beckwithf, Sarah Randallg, Cliodna A M McNultyc
a) Primary Care Research Co-ordinator, Gloucestershire Research & Development Support
Unit, Gloucestershire Hospitals NHS Foundation Trust, Great Western Road, Gloucester
GL1 3NN
b) Health Protection Agency, Centre for Infections, HIV and STI Department
Colindale, London. NW9 5EQ
c) Health Protection Agency Primary Care Unit, Microbiology Department, Gloucestershire
Royal Hospital, Great Western Road, Gloucester GL1 3NN
d) Health Protection Agency South West, The Wheelhouse, Bond’s Mill, Stonehouse, GL10
3RF
e) General Practitioner, Broken Cross Surgery, Waters Green Medical Centre,
Macclesfield, Cheshire, SK1 6JL
f)
Service User Member, Student, Cardiff University
g) Consultant Community Gynaecologist/Reproductive Health Care, Ella Gordon Unit, St
Mary’s Hospital, Portsmouth PO3 6AD
Running title: Optimising chlamydia screening in general practice
Word count: Abstract 250; Main text 3608
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Abstract
Background: There is low uptake of chlamydia screening in general practices registered with
the English National Chlamydia Screening Programme.
Aims: We aimed to explore staff’s attitudes towards and behaviour around chlamydia
screening, and how screening could be optimised in general practice.
Design: Qualitative study with focus groups and interviews.
Setting: General practices in seven NCSP areas.
Methods: 25 focus groups and 12 interviews were undertaken with a purposively selected
diverse group of high and low chlamydia screening practices in 2006-08. Data were
collected and analysed using a framework analytical approach.
Results: Higher screening practices had more staff with a greater belief in the patient and
population benefits of screening, and as screening had become a subjective norm it was part
of their every day practice. Many staff in the majority of other practices were uncomfortable
raising chlamydia opportunistically and time pressures meant that any extra public health
issues covered within a consultation were determined by QOF targets. All practices would
value more feedback, and training with chlamydia screening coordinators. Practices
suggested that use of computer prompts, simplified Request forms and more accessible kits
could increase screening.
Conclusion: To facilitate increased screening general practice staff need greater belief in the
value of chlamydia screening and their ability to offer it, and an increased profile of
chlamydia in the practice. This could be attained through greater interaction, training and
feedback with their screening coordinators, combined with simpler forms, computer
reminders, targets or QOF points and greater visibility of screening in the practice.
Key Words
Chlamydia trachomatis; Primary care; Genital; Qualitative; Focus groups; Screening
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Introduction
The National Chlamydia Screening Programme (NCSP) introduced throughout all English
Primary Care Trusts in 2008 aims to reduce prevalence of chlamydia through an
opportunistic rather than re-call approach used by the NHS cervical screening
programmes.1-3 As over 60% of the NCSP target at-risk population consult their GP
annually, an opportunistic screening in general practice could be successful.4Thus far
however, screening rates in general practice remain low, with the majority screening less
than 5% of their 16-24 year old population.1 This has led some to criticise the strategy of
opportunistic screening.2 Modelling suggests that to substantially reduce prevalence,
chlamydia screening will need to reach over 50% of 16-24 year olds annually, though
lower screening rates will have a lesser effect.5 Several studies have indicated that the
success of introducing chlamydia screening in general practice will be determined by
professional attitudes, manpower, workload, time pressures and financial constraints.6-8 We
have found that chlamydia screening co-ordinators report that general practices with a staff
champion and with an interest in sexual health or young people, attain the highest
chlamydia screening rates.6 No studies have explored the attitudes and behaviour of
practice staff within the NCSP.
We aimed to explore with general practice staff, their knowledge of the screening
programme and strategies they have used within the current NCSP, to opportunistically
screen 16 to 24 year olds attending their practice for genital chlamydia. We also aimed to
explore how practice staff felt the current screening programme could be optimised within
primary care.
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Methods
Practice Selection
We used stratified criterion based (purposive) sampling9 to select practices registered with
the English Chlamydia Screening Programme with a range of chlamydia screening rates.
General practices in the seven NCSP areas, where there was significant screening being
undertaken in general practice, were ranked by the total number of chlamydia screens
(disaggregate data) in the six months prior to practice selection. We conducted 25 focus
groups10 at general practice locations between November 2005 and April 2007 and 12 semistructured interviews at two practices in 2008. At visits practice population data was used to
determine each practice’s annual screening rates per 100 patients registered aged 16-24
years. Practices were then defined as high screening practices 10% and above, medium
between 3% to 9% and low screening practices if less than 3%.
Focus group practice selection and participants
Practices were invited by telephone by one of the researchers, then letter (from CMcN) with
information sheets and consent forms to take part in a focus group exploring their approach
to chlamydia screening. We aimed to randomly select two high screening practices from the
top six screening practices. However in four areas with very few high screening practices we
selected the two highest screening practices. Practices were excluded if they undertook
chlamydia research, or the practice included a NCSP steering group member. We then
purposively selected two lower screening practices that were in a similar geographical area
to the high screening practices. Two high and six low screening practices declined to
participate in focus groups due to time constraints, or shortage or changes of staff. Practices
were asked if at least one member of each category of staff could attend the focus group;
this included doctors, practice managers, nurses, health care assistants and administrative
staff.
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Interview practice selection and participants
In 2008 we visited low screening practices in a further PCT screening area. Three of six
practices responded to a letter inviting them to participate in semi-structured interviews. We
visited the first two practices that responded, to explain the study fully and to invite all staff to
participate.
Ethics
Ethical approval was obtained for focus groups from MREC [04/MRE10/41] and for
interviews from Warwickshire NREC Ref:08/H1211/57; local research governance approval
was obtained from the relevant Trusts. The practices received a payment of £25 per
participant for focus groups and £20 in gift tokens for each interview. All health care practice
staff were assured of anonymity and gave informed consent.
Focus group and interview content
CMcN, EF and RHJ undertook the one hour focus groups. The discussion schedule was
developed by the project steering group members who included a service user, and was
based on previous research exploring strategies used in primary care.6, 11-14 The moderators,
(EF, CMcN, RHJ) encouraged respondents to speak candidly about their experiences of
chlamydia screening. The topic areas discussed were: their views of the screening
programme; factors which determined their screening rates; strategies used by staff to
identify and approach their target population; strategies used by different staff in
consultations related to and unrelated to sexual health in men and women (Appendix 1). The
acceptability and feasibility of potential strategies were explored in subsequent focus groups.
The interviews were undertaken by AH and used a questionnaire schedule based on the
results of the focus group analysis and aimed to determine GP surgery staff’s behaviour,
intention and beliefs about offering chlamydia screening based on the Theory of Planned
Behaviour (TPB) (Appendix 2).15 Interviews lasted for 20-40 minutes.
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Data analysis
Data collection and analysis occurred concurrently and we continued through purposive
sampling enriching the data.16 Focus groups and interviews were audio-taped, transcribed
and checked against the audio tapes by a researcher present at data collection. We planned
a ‘Framework’ analytical approach,17 as it allows the researcher to systematically reorganise,
appraise and reappraise transcriptions, to develop ideas and theories behind the
phenomena of interest, in this case strategies used to promote and remaining barriers to
chlamydia screening. A detailed analysis of the focus group transcripts was first undertaken
by EF and CMcN, working first independently and then together, to explore strategies used
by practice staff to promote chlamydia screening and attitudes to screening. EF and CMcN
used QSR NVivo software (QSR International PTY Ltd. Melbourne) to identify a coding
framework. This coding framework was based on barriers to screening identified in previous
research and emerging themes identified in the focus groups, and discussed in detail by the
project steering group. We also explored factors within social cognitive theories that have
been found in recent systematic reviews to be important in predicting clinicians’ intention.18
These included personal attitude towards screening and the beliefs about the consequences
of not screening and rewards for screening; social influences and moral norms; and belief in
self-efficacy and other external factors. Focus group (EF) and interview (AH) transcripts
were then analysed in detail line by line, and by word search, and quotations which
illuminated the themes were identified and imported into Microsoft Word. The relationship
between the practice screening rates (high, medium and low) and these themes was further
examined.
Results
We recruited six high, ten medium and nine low screening practices for the focus groups
and two low screening practices for the interviews. These included practices in English
inner-city, urban, rural and suburban locations, some with high ethnic practice populations,
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and mix of social class. Seventy-two GPs, 46 nurses, 23 receptionists/ administrators, 8
practice managers and 7 other staff participated in the focus groups (2- 20 staff, median
6/focus group). Of 14 staff approached to participate in the interviews, 12 staff agreed (5
general practitioners, 3 nurses, 1 receptionist, and 2 health care assistants and one
manager). One nurse was on leave, and one practice manager declined.
Practice chlamydia screening rates ranged from 0% to over 30%, but in all screening
programme areas the majority of practices had screened less than five percent of their 16-24
year olds.
Personal attitudes of staff (Box 1)
Belief in and awareness of screening: Staff in the six higher screening practices reported the
short and long-term benefits of chlamydia screening for the individual patient. Most staff in
lower screening practices and some staff in other practices were not convinced of its public
health importance. Lower screening practice staff focused on other disease areas that they
thought were higher priority, which were usually determined by Quality Outcome Framework
(QOF) targets. Several staff thought that screening would be more appropriate in
genitourinary clinics.
Very few staff in any of the practices considered screening men an important part of the
NCSP. As a result none had a systematic approach to screening men, and only considered
chlamydia if a man was symptomatic. High screening practices recognised that young men
attended for travel vaccinations, asthma checks and sports injuries, but only a minority of
staff used these opportunities to raise chlamydia screening. Most of the practices in medium
and low screening practices thought that their young male population did not visit the
surgery, or did not see the nurses who led chlamydia screening. All practices were surprised
by Salisbury’s findings that a high proportion of young men visit their general practice
annually.5 Some staff reported that men were not motivated to accept screening.
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Factors influencing personal attitude
Almost all practices reported little contact with their local chlamydia co-ordinator subsequent
to an explanatory visit; one high-screening practice reported that the co-ordinator had
updated them with knowledge and skills training. Some practice staff had received a
newsletter, although not all staff had seen it. Lack of feedback about individual and overall
patient’s results from the NCSP was considered a negative driver to screening. Conversely,
two health care workers were motivated by feedback from doctors about positive patients
they had screened at routine health checks. No practices knew how many 16-24 year olds
were registered, or had internal practice or coordinator generated screening targets. The
majority of practices reported that if chlamydia was included in the Quality Outcome
Framework priorities they would consider it more important, and develop a much more
systematic approach to screening. A minority of practices said extra QOF targets would put
additional pressure on staff.
Subjective norms (Box 2)
In the higher screening practices chlamydia had a high profile; all staff thought that
chlamydia screening was an important part of their daily practice and several doctors,
practice nurses, support staff and receptionists were involved and supported each other.
Receptionists played a key role in a few practices by flagging notes to remind clinicians to
offer a test. Some high practices routinely offered screening at new patient health checks,
travel vaccinations, or young people clinics.
In medium and low screening practices screening had not become the norm; usually they
had a single individual with a personal belief in screening who championed and tried to
promote screening, but either other members of the team were not fully supportive, were
unaware of the NCSP, or did not consider chlamydia important enough to screen
opportunistically. There was no whole practice commitment to screening and the majority of
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the practice staff had other priorities; clinicians’ undertook screening very infrequently with
the majority undertaken in symptomatic patients or in sexual health consultations.
Factors influencing subjective norm
The high profile of screening was maintained in higher screening practices by a champion
who had an interest in sexual health or young people and who was supported by their
colleagues. In contrast the champion in low screening practices often showed frustration of
the lack of commitment or knowledge of their colleagues. Several practices reported that
their initial motivation had decreased when the pivotal screening champion had left or started
working part time.
Most practices reported the importance of maintaining the high profile of screening by
reminders or regular practice meetings and ongoing support from NCSP coordinators. Some
clinical staff and receptionists in two high screening practices said that patient’s age on the
computer record, reminded clinicians to offer screening. Although two practices did include
chlamydia screening in new patients’ health checks, none of the practices had chlamydia
screening specifically included in any other consultation templates. Most staff thought that
computer alerts or tagged notes would raise the profile and remind clinicians to
opportunistically offer screening. Five GPs in the low screening practices thought they
already had too many QOF related reminders. All practices reported that offering screening
would be easier if patients were made more aware of screening through increased use of
leaflets and posters; this is covered in more detail in a separate paper.19
Perceived behavioural controls (Box 3)
Clinicians’ self-belief that they were comfortable raising sexual health issues was a key
factor in how often staff offered screening. Staff who were comfortable raising chlamydia did
so more often, and in the high screening practices in any consultation. This was not just
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restricted to doctors and nurses; two health care assistants reported that they had been
trained and were enthusiastically offering chlamydia screening at new patient checks.
Some staff in all practices felt uncomfortable discussing sexual health issues with some
patients, as they thought it could cause offence. Consequently medium and low screening
practices usually only offered chlamydia screening in consultations related to sexual health.
Staff found raising chlamydia screening was even more difficult if a parent was present. In
medium and low practices chlamydia screening was not offered at new patient checks, or
offered by health care assistants, who reported insufficient training in this area. Although
receptionists were involved in two practices, the majority of medium and low screening
practices reported their receptionists were not trained appropriately or had insufficient time.
Although they reported that receptionists could distribute discrete leaflets or cards, many
thought that their reception area was not confidential enough for discussions with patients.
In all practices clinicians’ behaviour was influenced by time pressures, therefore many
clinicians were reluctant to extend consultations or just forgot to discuss chlamydia. Staff
reported that coordinators needed a greater understanding of the barriers in general practice
to implementing the programme. Many staff reported that as screening kits were not readily
accessible they used the standard local laboratory request forms or didn’t screen. Staff also
reported that the screening request forms were difficult for some patients and time
consuming for staff to complete; a few screening practices (one high and one low) saved
time by offering self-screening kits without a consultation. Staff reported that as there were
no computer Read codes to record if they had offered chlamydia screening and if the patient
had agreed or declined, it would be difficult to audit screening offers and uptake.
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Discussion
Key findings
Chlamydia screening rates were still very low in the majority of these general practices, even
though they were registered with the NCSP. Chlamydia screening had become a part of
every day practice (a subjective norm) in only the minority of practices where all staff had a
personal belief in the importance of chlamydia screening. This whole team approach was
key to attaining higher rates. In most other practices it had not become the accepted norm to
undertake screening; as chlamydia was not included in the QOF it was considered a low
priority. Staff missed many opportunities for screening the target population, and only offered
screening when they remembered, usually at contraception consultations. None of the
practices had a systematic approach to screening men as they were unaware this was part
of the NCSP. In all practices some staff still felt uncomfortable discussing chlamydia in
consultations unrelated to sexual health and this perceived behavioural control limited the
amount of screening. Some general practices were working in isolation from their screening
co-ordinator and wanted more education, feedback of individual results and screening rates
and understanding of the pressures on practice staff. Staff suggested computer reminders,
feedback about positives and targets, may motivate practices to screen greater numbers.
Other work in this area
A USA primary care questionnaire survey also showed that greater perceived knowledge
about chlamydia, greater confidence in how to screen and feeling comfortable to screen
were associated with greater screening activity by clinicians.2 0 In our previous work
screening co-ordinators reported that practices with a champion and a whole team approach
were more likely to have higher chlamydia screening rates.11 Chlamydia coordinators
working with low screening practices reported that they provided practices with on-going
support and patient follow-up, but they were frustrated at the lack of enthusiasm and
negative feedback from some general practice staff.11 It appears that both sides are
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dissatisfied with the relationship as the staff in this study reported insufficient ongoing
support and lack of feedback from the coordinators. Although men are happier attending
general practice for screening than other healthcare settings,21 our study and others show a
widespread lack of practice awareness that chlamydia screening programmes include men.
Most health staff in a US study did not routinely screen men,22 and 88% of staff thought that
it was more important for them to spend their time testing women.22
Although the Quality Outcomes Framework has improved quality of care, GPs report that it
has increased their workloads.23 The practice staff we interviewed reported that the demands
of the QOF system meant that extra demands on them that fell outside QOF were a lower
priority. Incentive based targets were suggested by some practice staff, but a Local
Enhanced Service (LES) may not be effective without other behavioural interventions. In a
London PCT practices paid a Local Enhanced Service (LES) to facilitate sexual health
services, diagnosed eight times more chlamydia infections than non LES practices, but a
third of the LES practices made no chlamydia diagnoses despite being paid the retainer
fee.24
Most of the practice staff in our study report the need for more specific training on how to
raise chlamydia in consultations unrelated to sexual health. Several types of educational
approaches have successfully increased screening by breaking down these barriers
influencing behaviour.25 These have included a video on communication skills for sexual
history taking, internet based modules to emphasise the benefits of screening, and academic
detailing by a health advisor.25 In the US an electronic flag was successfully used to cue
health care providers to offer chlamydia screening to adolescent mothers.26 In California a
multifaceted approach used many of the strategies highlighted by our practice staff, including
identifying a champion, team building, a flow chart to identify barriers and solutions for
changing practice, promotional materials and monthly meetings to feedback progress on
performance indicators.25
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The Theory of Planned Behaviour is used to explain human behaviour15 and has been
used to design interventions to change GPs’ intentions when implementing evidence–
based practice.27 Multifaceted interventions aim to address the different components of
this model, that is personal attitude (whether a person is in favour of chlamydia screening);
subjective norm (the social pressures on a clinician to screen) and perceived behavioural
controls (whether the clinician feels able to screen due to lack of personal ability or
external barriers).15 Pavlin et al have shown using Ajzen’s Theory of Planned Behaviour
that many of the behaviour changes needed for patients to accept screening are similar to
those needed by staff.28 That is encouraging the personal attitudes of patients to be more
in favour of screening through awareness that it has long term effects; by encouraging
patients to see chlamydia screening as a social norm; by encouraging women to feel able
to have a chlamydia tests by easier access to, and understanding of tests.
Strengths and weaknesses
This is the first qualitative study in the UK involving general practices in the established
National Chlamydia Screening Programme. Our qualitative methods enabled us to probe
answers to fully understand the behavioural issues around chlamydia screening with a
diverse group of practices, and therefore, the study findings are likely to be transferable to
the majority of general practices involved in chlamydia screening programmes. The focus
group setting may have inhibited some practice staff from expressing their views in the
presence of more senior staff, however all types of staff did express their opinion. The
additional interviews allowed us to collect extra data within a setting where all staff were able
to express their opinions unhindered by other staff and the findings were very similar.
Implications of the research
The aim to screen 17% of 15-24 year olds in 2009 and 20101 may be difficult with the current
pressures on GPs even with the combination of approaches we have identified in this work.
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All practice staff need to have a greater personal belief in chlamydia screening through
increased awareness of its short and long term benefits, and being given targets or
incentives. Practice staff need to be made aware of the importance of screening men and be
shown evidence that will change their perception that men are not motivated to accept
screening. The perceived behavioural controls reducing screening need to be broken down
through training tailored to general practice on exactly how to broach and offer screening
within the time constraints of a busy surgery. So that staff remember to screen and sustain
screening offers, it needs to become a recognised part of everyday practice (a subjective
norm). This could be better attained through a whole practice approach as seen in our more
successful practices, and computer reminders to encourage clinicians to offer screening at
all consultations.
The lack of quality contact between practice staff and co-ordinators needs to be addressed
and both sides need to be aware of the other’s roles and priorities. The coordinators need to
play a greater role over a longer period of time to help change practice staff’s personal
attitudes to screening, increase staff’s confidence in raising chlamydia in consultations
unrelated to sexual health, setting targets, feeding back screening rates and maintaining
education. Policy makers should be aware of the effect of QOF on practice behaviour and
commitment to screening and consider QOF based targets to further motivate practices.
Future priorities for research
It is important to determine the value of any structured intervention that includes the
strategies we have identified (Box 6) within a controlled trial. More qualitative work is needed
with patients to determine whether the perceptions of staff, that patients in low screening
practices do not wish to be offered screening in non-sexual health consultations, are
confirmed by patients attending for such consultations.
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Funding
The study was funded by the Medical Research Council Grant No. G0500126 and Health
Protection Agency Research & Development Grant No. 105042.
Ethics
Ethical approval was obtained for focus groups from MREC [04/MRE10/41] and for
interviews from Warwickshire NREC Ref:08/H1211/57
Competing interests
Dr Cliodna McNulty writes the HPA Diagnosis of Chlamydia Quick Reference Guide for
General Practices.
Isobel Oliver, William Ford-Young are members of the English National Chlamydia
Screening Advisory Group and Sarah Randall was a former member.
Authorship
All the authors contributed to the design of the study and had input into the paper.
E Freeman, R Howell-Jones and C McNulty undertook the focus groups and detailed
analysis. Angela Hogan undertook the interviews and interview analysis. E Freeman and C
McNulty wrote the paper.
Acknowledgements
Our grateful thanks to all the practice staff for their willing participation in the focus groups
and to MRC for funding the study. Thanks to Lynsey Emmett and the NCSP for providing us
with screening data. Thanks are due to Sue Starck, Allison Bates and Jiyoon Knight for
transcribing the focus groups and to Mark Walker for his help in the data collection. Thank
you to Jill Whiting for organising the focus groups and steering group meetings and for help
with the grant application and ethical approval.
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Box 1: Personal attitude of staff towards screening:
1 Higher screeners recognised the individual patient benefits of screening:
Well, we got involved originally because we were concerned that our under 25s sexually
active were perhaps contracting chlamydia and we weren’t detecting it and weren’t treating
it, … so that’s why we’re quite keen to get involved in that.” FG1 respondent 2 high
screening practice
“we know it’s important, and when people are coming in to the young persons clinic then it is
time to, to remind then really …want to maintain as healthier young persons population as
we can really in the practice really in terms of potential, l hits in terms of a screening service
its probably very high if you compare it with breast screening or cervical screening or the one
of the other …screening programmes, actually and its so easily treatable and the swab is
easily done and you know the effects of non treatment can be so devastating its, it’s a really,
worthwhile thing to be doing I think it’s more mildly motivated about it isn’t it I think it is
absolutely good practice, it almost seems bad practice not to be talking about it.” FG6
respondent 2 medium screening practice
2 Low screeners were not convinced of the benefits and had not engaged in
screening:
“You would need to produce the evidence that there are a large significant group of people
out there who had chlamydia who had been damaged and we needed to do something
about it and that would motivate us. A study that says it’s bloody obvious you should be
doing this. That won’t motivate most practices. .. the only thing that will motivate them is
paying some money for it.” Interview 01/07 male GP low screening practice
3 Several staff were unsure of the public health benefit beyond the individual:
“There’s no doubt about individual health benefit… but in terms of any public health
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impact because it is just a disaster. Ok, when you have …X people in your target population,
and in one year only XX people get tested, there is no public health benefit in that.
We don’t see populations we see individuals, and so our enthusiasm comes from
actually seeing individual, … As a GP it’s much more, single individuals that fires you up
than actually saying our population screening programme” FG5 respondent 5 high
screening practice
4 Several staff in low screening practices thought that chlamydia screening may be
more appropriate in other health care settings:
“Whether we are the best set up to offer that sort of service within general practice. I’m not
sure whether it would be better in the GU clinics as well.” Interview 01/05 nurse low
screening practice
Personal attitudes to screening men:
5 Most practices rarely considered screening men:
“I mean I don’t think I’ve ever given a male a urine sample and I’ve never done one [a
chlamydia screen] in six years they’ve always been female.” FG26 practice nurse low
screening practice.
“To be fair, I’m only [testing women], its only really coming up when you’re getting your men
that are presenting with symptoms.” Interview 02/012 female GP low screening practice.
6 Many staff reported they rarely saw men:
“And its very, very rare, as nurses we would see a male under the age of twenty-five, [an]
asthma check it’s the only thing that I can think of that they come to see us, or for removal of
sutures” FG22 nurse low screening practice
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7 Some staff reported that men were not motivated to accept screening:
“Its getting to the young boys as well, because they are rather lethargic about it, no that’s
the wrong word really but they are not quite as forthcoming as the girls …”
“I don’t think they see it as so much of a problem, I’ve had quite a few of them say ‘ its not
really my problem is it?’ and I [say] take a leaflet, and have a read of it, do what you think.”
FG 2 respondents 1& 5 medium screening practice
Factors effecting personal attitudes:
8 Practices reported that they needed ongoing contact with their coordinator:
“We had meeting but it was quite a long time ago. It’s up to them to be proactive but I
personally haven’t got time to be chasing co-ordinators” FG23 Female GP low screening
practice
“[If the NCSP are] very keen to get it [screening] into general practice, you don’t go into a
general practice once and say here you go, … I think its drip, drip, drip approach that works
and we would say we haven’t retained [it]… getting the figures back every quarter is
interesting because, that wakes us up .. and we think I want to do some more; then it may
not last more than a week, but it’s an effect, this reinforcement really matters.” FG5
respondent 6 male GP high screening practice
9 Feedback could increase motivation to screen:
“Some how being in this programme seems very distant in a way… this is arms length sort
of screening programme you are not sort of engaging in it, you’re not involved in it, you don’t
get to see the results you’re not really seeing patients.” FG5 respondent 3 high screening
practice
“… it would be helpful for us to have some incentive to carry on doing it…it takes time and
effort and it’s taking us away from other areas of work … I think to keep the motivation going
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its essential to have feedback on how well we’re doing which we haven’t had otherwise you’ll
just, you know what’s the point, really don’t know where you are …”. “ What else can we do
to keep motivation … contact with the people who are running it I think even if we weren’t
getting paid for it, if we were getting some feedback to say, well you’ve screened 100%
patients 10% were positive, and you’ve saved 10% of people from pelvic inflammatory
disease and that’s an incentive enough.” FG24 nurse and female GP low screening practice
10 Targets could increase motivation to screen:
“The last co-ordinator would help [us by] having an incentive to get certain numbers done. It
would also help to have graphs where we are [in relation to] other local practices. We hate
being at the bottom end [of a league table].” FG19 senior partner low screening practice
11 Motivation lost as LES not funded:
“because we didn’t get the funding so maybe the loss of motivations there. I think in
essence I’m reliant on the whole of the rest of the team to refer people to me if it’s relevant
and I think because funding is not there the GP’s have stopped directing them towards
me…” FG17 nurse low screening practice
12 Most practices reported that including chlamydia in the Quality Outcome
Framework would raise its priority:
“if the government was to make it one of the main targets for GP’s to reach like they did for
vaccinations then yes … it would become officially a priority; our duty in a way, but also
because you know I think that Doctors in primary care have to do what they are told they
have to do.” FG19 male GP low screening practice
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Box 2: Social influences in the practice
1 In higher screening practices it was normal practice to offer most patients
screening:
“well I think it’s just, I mean, I really enjoyed seeing young people I suppose …enthusiasm is
quite important because I mean fortunately [within] the practice [screening] is just another
thing to do wasn’t it, we first decided to do it - but actually embraced it really…” FG3
respondent 2 high screening practice
2 Receptionist involvement in high screening practices:
“[receptionists] check the ages [and] if they’ve got time and people are coming in for their
appointment [they] just say would you like to read that [leaflet] while you’re waiting.” FG3
respondent 4 high screening practice
3 High screening practices routinely offered screening at new patients health check,
travel immunisations and young people’s clinics:
“I try to implement that in my new patient check ... get all the patients to take part if [they’re]
under 25’s, both male and females.” FG9 health care assistant high screening practice
“… sometimes we’ve got 19 year olds who might be travelling … and we would use this
opportunity as well to test.” FG5 respondent 5 high screening practice
“We see plenty of sports injuries ...I tend to ask those people because its imprinted on my
brain somewhere, they’re at that age, because they look at me [as if to say] what on earth
are you talking about this for.” FG12 respondent 4 high screening practice
4 Low and medium screening practices often had a single person interested in
screening but they were not supported by the whole team:
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“I’m [the nurse] the only one that has actually been involved in the screening. To be honest
with you I’ve got the impression when the new contract came in that the doctors weren’t
bothered whether I did it or not. They obviously want us to be doing the things that are
earning the money… I find as a nurse it can be quite demoralising to have an expertise that
you can’t use. It was me that went to the chlamydia training. But because of the way the
surgery is [run] the uptake has been quite low.” FG17 respondent 1 nurse low screening
practice
5 Low screening practices suggested screening would increase if it was the norm and
all the practice were involved and supportive:
I think the thing is it’s to offer it as a general thing, as much as testing for glucose and
cholesterol and demystify it a bit, for it not to be seen as some dirty word and for it to be
seen as a general testing as other things are.” Interview 01/04 health care assistant low
screening practice
“I think if it became the norm, if it became know that if you go to the doctor or whatever then
you’ll automatically going to be offered it, the same way that you might be offered the flu
vaccination. ... I think you’ve got to get everybody on board about it and I think sometimes
the receptionists … might feel a bit difficult about it, I don’t know if disapproval is the right
word, but we do occasionally when we get the younger ones [patients] some people
[staff/receptionists] find it difficult to come to terms with the fact that we are seeing sexually
active kids as they call them ... It would be useful to get all the staff together and just discuss
the whys, the wherefores, the reasons, the benefits behind it and all the rest of it.” Interview
female nurse 02/011 low screening practice
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6 In many low and medium practices chlamydia screening had not become the norm:
“I think mines a bit ad hoc actually the screening programme ….. I know I definitely don’t
offer screens for women who are coming in for contraception ……..I’ve only offered to one
young mum that I can remember.” FG19 male GP low screening practice.
7 Lower screening practices only thought of chlamydia in consultations related to
sexual health:
“I would definitely consider dong it sometimes, but not for everyone. So if I have someone
who is sexually active who is 20 that comes in with their toe I wouldn’t always do it.”
Interview 01/06 female GP registrar low screening practice
“I guess if they are coming in with related problems like contraception and/ or low mood but
you can talk about relationships they’re the kind of consultations where I may well mention it
[chlamydia].” Interview 01/06 female GP registrar low screening practice
“I wouldn’t offer without consulting the doctor. … Only going by situations that I had this
morning – which somebody that had had unprotected sex, then yes obviously I would agree,
but again it’s through the doctor, I wouldn’t just do it off my own back.” Interview 01/01 health
care assistant low screening practice
Strategies that would raise the profile of chlamydia screening in the practice:
8 Raising chlamydia at practice meetings:
“One must have a lead GP with a senior nurse who is very passionate about chlamydia
screening, who have monthly meetings to make sure that that’s on the agenda”. FG19 senior
partner low screening practice.
9 Practices thought that chlamydia screening co-ordinators should visit more often to
maintain the profile of screening:
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“One visit to explain the scheme is not sufficient to keep it maintained and I think what my
experience in general practice is that people take it on but to keep it going is another
matter…unless, unless you actually give the resources to training and support and send
advisers…” FG3 respondent 5 high screening practice
10 Use of computer templates at consultations attended by at risk group:
“We do have an understanding of the importance of it, but there’s so much person can cope
with, so if you have templates for a fifteen year old check when it comes up on the template,
we can add it to that, [it] would be a good idea.” FG25 respondent 1medium screening
practice
“If you give them [the nurses] a really good protocol to follow they will do it……if it is a nurse
led thing it will work very well.” Interview 01/03 female GP low screening practice
11 Most respondents reported that computer reminders/alerts would be helpful:
“Well, if it was embedded in our software. Obviously we get pop-ups for everything else.
We’ve found that pop-ups have been helpful for the other QOF stuff, very, very helpful.”
FG1 respondent 1 high screening practice
“Yes [computer prompts] would be useful it may be you are doing something totally different
and it’s a reminder, isn’t it basically, so yeah it would be useful.” Interview 01/01 health care
assistant low screening practice
12 Some respondents were aware that you could get prompt fatigue:
“On the computer everything’s flashing up as it is. I think that a prompt that only invites those
who haven’t already been invited so you’re not going over the same ground.” FG18 Female
GP low screening practice
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“As we have lots of other prompts going on at the same time, what we don’t want is prompt
fatigue or you just tend to ignore them all.” FG18 male GP low screening practice
“we’ve got too many prompts and when we were talking earlier about alerts on the screen
we try to keep those to things that are really top very vital top level priority.” FG23 female
GP low screening practice
13 Staff thought that some patients would not welcome opportunistic screening:
“Even “As there are 70% asymptomatic they obviously [think] why am I getting all this, you
know and they get offensive but I, feel that way, they might take offence, why are you asking
me that, do you think?” FG15 respondent 1 nurse practitioner and 2 male GP low screening
practice
“I Just feel that it’s [offering screening opportunistically] is a bit overpowering for the patient
really, some patients would be a little bit frightened about going to the doctor in case they
had to have chlamydia screening, you know they have to think about it.” Interview 02/10
female practice manager low screening practice
14 Staff suggested that more leaflets and advertising may make screening more
acceptable to patients:
“I think we should have more handouts available to that age range, so that patients are
aware. Otherwise young people will be frightened to come in at all, if they are going for a
sore knee and then they are pounced on about having chlamydia screening.” Interview 02/10
practice manager low screening practice
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Box 3: Behavioural controls
Belief in self efficacy
1 Most staff in high screening practices were happy discussing chlamydia:
“Everybody does, [chlamydia screening] I think we all do a little bit so there is some
consistency and I think most of us…[are] fairly comfortable dealing with that age group that
aren’t too embarrassed to offer them a leaflet and then [a screening test]” FG11 respondent
1 high screening practice
“I’ve done a STIF course; yeah six or seven of us, have done it.. in three lots , but it was
good and so when we came back we fed it back to everybody else - that’s heightened
awareness really.” FG21 two female GPs medium screening practice
“I try to implement that in my new patient check I’m pleased with it because I’ve had the
doctors come to back to me a few times and said the new patients have come back positive,
and they’ve been able to deal with that.” FG9 health care assistant high screening practice
2 Some staff in all practices were not comfortable raising chlamydia screening in
most consultations:
“I do find it more difficult to speak about sexual matters particularly if they come about
something completely unrelated, if they come about contraception or something else it’s
easier. I think if they come for an ear infection, I wouldn’t dream bring it up. It’s not
necessary, [it] depends on what the consultation is about really, its just not appropriate.”
FG10 respondent 1 medium screening practice
3 Some staff thought that offering an opportunistic screen may cause offence:
“Patients can sometimes think you are prying a little bit so everything has to be worded
carefully...” Interview 01/04 health care assistant low screening practice
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“You’ll offend a few people especially at the younger age.” Interview 01/02 male GP low
screening practice
4 Staff less likely to offer screen if a parent is present:
“[If they] turn up with a parent, it is difficult sometimes to discuss things. They don’t even get
smoking cessation ... they’re not going to say yes to a chlamydia test.” FG4 respondents 2 &
3 low screening practice
”If you’ve got them coming along for you know their tonsillitis and they’re of that age group
and they’ve got their parents, I don’t care what anybody says, I’m going to find it difficult to
delve into their sexual history with them. If people come along sort of to commence things
like the pill with their parents then we always have a frank conversation, because I think well
they’ve obviously got a good relationship because they’ve come along anyway. So we
always touch on chlamydia and the screening aspect.” Interview 02/12 female GP low
screening practice
5 Many staff (especially if not GPs) in low screening practices reported that they
would need more training if they were to offer screening:
“With the right training I think (I would offer opportunistic chlamydia screening).. I would think
maybe just a sort of an hour’s tutorial on how to go about it, and a few facts really.”
Interview 01/04 health care assistant low screening practice.
“I really think it’s better to be discussed in the appointment, the consultation personally. …
I would need further information, I think I would need training, I’d want to talk about it.”
Interview 02/09 female receptionist low screening practice
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“It would be difficult and I think they need to come and have a meeting about it, it’s no good
us just saying [do it]. They need to come and be taught what’s going on, and be involved,
and feel they’re part of it.” FG13 respondent 2 medium screening practice
“Some education, first of all so that I know what I am on about… How to approach the
subject, especially with the younger age group… And the availability of the packs in the loos
and things like that.” Interview 01/08 nurse low screening practice
6 Lack of privacy in reception areas, training and time, for receptionists to be
involved:
“I don’t think it will work …not at all” “From the confidentiality point of view, they have very
busy time, I don’t think its receptionists’ responsibility to talk [to patients] informing them
about chlamydia I think that’s our job” FG14 respondents 1 & 2 medium screening practice
“As receptionists there’s no way we would ask questions, if they [patients] did ask questions,
we’d say it’s best to discuss it with a nurse.” FG8 respondent 1 low screening practice
7 Leaflets would be appropriate at reception:
“I think reception are very busy what with one thing and another. But I think definitely having
leaflets on the desk.” Interview 01/03 female GP low screening practice
8 Lack of time was considered a major barrier to screening:
“You could pick them up at the family planning clinics when you’re fitting coils and those
sorts of things, that would work, but if you’ve got to hit a target of 15-30% I think you’re not
going to do it just opportunistically. … I think in a busy practice you might find it difficult
because it’s not the sort of thing you can just say by the way can I check your blood
pressure. You would probably need to set up a formal call or recall system.” Interview 01/07
male GP low screening practice
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“It’s time for us, ….. you know a bit of work explaining and counselling them, so it’s time. …
Then if it’s positive it’s going to result in more consultations.” Interview 01/02 male GP low
screening practice
“I think in a busy practice you might find it difficult because it’s not the sort of thing you can
just say by the way can I check your blood pressure. There’s got to be some explanation
around it, I wouldn’t feel uncomfortable doing it but it would be the time constraints that
would stop me doing it I think.” Interview 01/07 male GP low screening practice
9 Some practice staff reported that coordinators lacked understanding of how general
practice worked:
“I think you can learn about chlamydia I think, you cannot learn about British general
practice, it is not the same as Canadian general practice and I think appointing somebody
who’d never worked in primary care was a real disadvantage… I just think a lack of
understanding about general practice how it works, how it functions, just a missed
opportunity, I just feel that they [the co-ordinators] have failed to embrace the willingness of
general practice to be involved” FG5 respondent 3 male GP high screening practice.
10 Easy availability of screening kits would save time:
“If the nurse and both doctors rooms had a box with them [screening kits] in and it was next
to us with the forms and they’re on hand you’re far more likely to give them out. Especially if
you’ve got things in the waiting room highlighting it again. It would save me running out and
getting it and running back in.“ Interview 02/012 female GP low screening practice
“I think having a coordinator [within the practice] like X has be useful I think because she’s
been to the update and she’s come back and … reminded us all …so all the doctors are
aware where everything is so they’ve not got to interrupt surgery. Everybody knows where
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all the swabs, where all the test kits and all the forms are and they can go and help
themselves and offer it to everybody really.” FG21 GP medium screening practice
11 Packs left in reception area:
“We just left [packs] on the desk at the reception and there was quite a lot taken really, we
were quite surprised. We left them on the desk in a big basket with a poster about it all.” FG8
respondent 1 low screening practice
12 Several staff reported it would be useful to be able to record screening offers:
“we haven’t got a marker on our computer ... we don’t record if we offered it so we haven’t
got a marker for that at the moment and … if we put on an offered chlamydia, but declined
chlamydia screening that would be a good thing cos it shows it’s been offered but we haven’t
done that so we’ve offered it to more people than would be recorded and some people have
said no.” FG 17 respondent 1 low screening practice
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Box 6: Structured approach to maximise screening
Change personal attitude towards screening

Inform all staff of the importance of chlamydia screening in the short and longer term

Increase awareness of the importance of chlamydia screening in men

Recognise or reward practice staff when they attain screening targets

Audit leaflets and packs given out, attendance by young people, uptake of screening

Develop screening targets based on consultations with practice 15-24yr old population

Feedback of screening activity and positivity results to all staff
Influence subjective norm

Make chlamydia screening part of normal every day practice

Make chlamydia screening a greater priority for the whole practice team

Develop templates for chlamydia screening, for consultations by 15-24yr olds including
family planning, travel, new patient checks

Develop computer prompts to remind clinicians and/or receptionists to offer screening

Identify a ‘champion’ for chlamydia screening who can maintain the profile of chlamydia
and feedback progress from the coordinator
Influence perceived behavioural control

Enable staff to feel comfortable raising chlamydia in all consultations

Enable staff to offer chlamydia in a timely manner without extending consultation time

Enable non clinical staff to feel comfortable to offer a screening leaflet or card and raising
chlamydia with the at risk population

Develop Read codes for screening offers, acceptance and refusals

Simplify screening request forms

Make screening kits easily accessible
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Table: Practices involved
Mean (minimum-maximum):
Percentage of
Number of
Number of
Chlamydia
Number of
Number of
16-24 yr olds (as
screens in 6
screens per 100
screening rate
participating
registered
% of total practice
months prior
16-24 yr olds per
classification
practices
16-24 yr olds
population)
to focus group
year (%)
Focus Groups
High
6
879 (359 -1198)
9.9 (8.2-12.4)
75 (25-180)
16 (10-32)
Medium
10
681 (270 -1190)
9.9 (5.0-13.8)
19 (6-38)
6 (3- 8)
Low
9
837 (415 -1302)
9.9 (8.6-12)
6 (0-13)
1 (0- 2)
Medium
1
1030
9
10
4
Low
1
237
8
0
0
Interviews*
*Interview practices are new to the National Chlamydia Screening Programme; therefore only three months’
data available
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Appendix 1: Focus Group Questions
1. Would you tell me about your practice? (Probe: What are the characteristics of this practice (e.g.
training R&D) What ethnic groups do you serve?)
2. Does your practice population have any groups that you consider to be more at risk from chlamydia?
(Ask for examples, students, prostitutes.)
3. How has the screening programme been for you? How long have you been involved with chlamydia
screening? What made you decide to participate in the screening programme? Who does the
screening in your practice (P/N or GP)? How does your practice target individuals to come for
screening? (If they do young person clinics ask about success)
3a. For high screeners: What do you think makes a successful screening practice? What advice would you
give to practices that are not screening so successfully? What would you recommend to other
practices?
4. What has been done in your practice to encourage uptake of chlamydia screening? (If needed probe:
What else do you think is needed to encourage screening in your practice? – Check posters and
leaflets, LES)
5. What strategies are your practice using to identify and approach different patient groups, including
those most at risk? Have you recently adopted these strategies? Has your testing rate increased as a
result of these strategies? (Cover computer prompts and patient templates)
6. How have any barriers to discussing sexual health issues with young people been overcome? Do you
screen at all consultations not just those related to sexual health?
7. Can you tell me about any differences in approach to screening between males and females in the
practice? (If males worse, how can this be improved? Include staff and patients)
8. Do you have any testing targets within your practice? (Do you have any idea of how many tests you
need to do to reach the 50% target?)
9. What are the implications of the new GP contract in relation to chlamydia screening? From 2007 your
PCT is supposed to be offering testing to 18% of those in the target age group? What do you think
about this? Is this attainable in your practice?
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10. (Or if low screeners) what do you think are the reasons for your practice being less successful
screeners than others in your area?
11. Are your receptionists involved in chlamydia screening?
12. In some areas, all of the screening is managed by receptionists. What do you think about this? Some
practices have self-collection kits. What do you think would be the uptake and return by patients here?
13. What do you think about the specimen collection methods used locally and the request forms? (Probe:
Could they be improved?) Do you always use the screening form in asymptomatic patients?
14. What do you think about the leaflets? (Probe: Could they be improved?)
15. What other things outside your practice need to be addressed to increase the number of screens?
16. What are the attitudes of other organisations to screening, for example, neighbouring practices (LMC,
PCT, colleges, schools, StHA, laboratory contraceptive clinics, any other young peoples clinic?
17. How does your practice get involved with treatment and partner notification of patients who are
screened?
18. Have you historically always tested for chlamydia or is this new to you? (Probe: Are you in phase 1 or 2
screening programme?)
19. How do you maintain your staff’s motivation for screening chlamydia?
(only ask if have been screening for 1 year or more)
20. (Check with coordinator to see if appropriate question for the practice.) We are aware that screening
has fallen in some areas since remuneration has ceased. What do you think about this? Has your
practice seen a drop in the numbers of young people being screened for chlamydia?
21. Have we missed anything?
Questions for group or key worker
20. Tell me how often you see your co-ordinator or have contact with her? What support do you get from
your local coordinator?
21. What training in sexual health have your staff had overall. Did your staff need additional training to
introduce the programme? What training and support have you and your staff had?
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Appendix 2: Interview Questions
1. BACKGROUND:
1.1 Your Job: GP/ Practice Manager/ Practice administrator-receptionist/practice nurse/ other
1.2.The Practice: list size?
1.3 The Practice: Number of GP Principals?
1.4 Location: urban, semi urban, rural.
2. RECORDING chlamydia screens
2.1 Does your practice have any means for collecting data on the number of opportunistic chlamydia
screens offered to people aged 15–24 years old?
Please explain how this is captured and if the practice currently reviews this information?
-Electronic-?
-Paper?
-How shared/with whom/what for?
2.2 Can you estimate (or have you any way of determining) the current proportion of people aged 15–24
who have ever been sexually active and have been offered a chlamydia screen in the past year within the
practice as a whole? (Y/N, what number, or %)
2.3 Would you be able to estimate the number or percentage of those aged 15–24 years who have been
offered a chlamydia screen in the practice as a whole?
Intervention

Do you have any concerns regarding chlamydia screening?

Do you think that opportunistic screening for chlamydia would be worthwhile?

What do you need to convince you that screening is worthwhile?

Which computer system do you use in your practice?

Do you use templates for appointments in your practise?

Do you think prompts to remind staff to discuss chlamydia screening with patients would be
beneficial? Templates? Pop-up computer prompts?

Is there someone in the surgery that can develop these?
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
Would you be happy for junior members of staff such as receptionists or HCA’s to broach the
subject of chlamydia screening? If it is a handout leaflet rather than discussing openly?

One of the interventions we are considering is introducing a chlamydia champion within GP
surgeries. Do you think this is a good idea? What qualities do you think this person would need?

Could they be a junior member of the team?

Do you think it would be feasible to add chlamydia screening onto you practice meeting agenda?

Who would develop milestones for chlamydia screening within your practice (team meeting/senior
partner/practice manager?)

How do you think we should feedback information to practices about screening?

What information would you want?

Do you have regular practice education sessions?

What training do you think you would need to improve chlamydia screening at your practice?

Are there any other ways you think we facilitate team-working in practice?

What is the best way to get everyone positively committed?

Where do you consider the best place to advertise chlamydia screening in your practice so it is
easily visible to young people? Waiting room? Reception? Back of toilet doors?

Do you have a focal point for leaflets?

How could we assess how many leaflets are being picked up by young people?

How can we develop targets in GP practice?

What is the best way to get survey replies from GP’s?

What incentive would be most beneficial?

Have you ever replied to a computer survey eg SurveyMonkey or SNAP

Would email be better than paper?

Do you think QoF points would encourage you to undertake opportunistic screening?

Are there any other ways you think GP’s and medical practises can be encouraged to do more
opportunistic chlamydia screening?
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