The chlamydia knowledge, awareness and testing practices of Australian general practitioners and practice nurses: survey findings from the Australian chlamydia control effectiveness pilot (ACCEPt)

Chlamydia-related knowledge, opinion to opportunistic testing, and practices of providers among different sexually transmitted infections related departments in hospitals in Shenzhen city, China

BACKGROUND

Chlamydia trachomatis (CT) infection could lead to seriously adverse outcomes if left untreated. This study aimed to determine CT-related knowledge, opinion to testing, and practices of providers among different sexually transmitted infections (STI) related departments in hospitals in Shenzhen city, China, and also to explore the differences in these responses.

MATERIALS AND METHODS

From 1st April 2018 to 15th April 2018, a cross-sectional study was conducted in Shenzhen and 64 of 66 hospitals agreed to participate in this study. In the hospital sites, all the providers from the department of obstetrics and gynecology, department of dermatology and venereology, department of urology, and anorectal surgical department were recruited. A structured paper-based questionnaire was used to obtain data on CT-related information.

RESULTS

A total of 355 providers from 64 hospitals participated in the current study. Compared to providers from the department of dermatology and venereology, those from the department of obstetrics and gynecology (OR = 0.31, 95% CI 0.16-0.62), department of urology (OR = 0.32, 95% CI 0.16-0.65), and anorectal surgical department (OR = 0.25, 95% CI 0.09-0.71) were less likely to identify that "Be in a long-term mutually monogamous relationship with a partner who has been tested and has negative STI test results." is an appropriate way for a sexually active person to reduce risk of getting CT. Also, those from the department of obstetrics and gynecology (OR = 0.45, 95% CI 0.23-0.87) were less likely to identify that "Use latex condoms the right way every time you have sex" is another appropriate way. A high proportion of providers agreed that all sexually active patients attending to their department should be screened regularly (77.1%), and they are willing to offer opportunistic CT screening (96.0%). Only 11.4% of respondents correctly identified that the appropriate time frame of the CT retesting is three months.

CONCLUSIONS

Providers among STI-related departments in hospitals showed a very high willingness to offer opportunistic CT screening. However, this study showed important gaps in providers' knowledge and practices in China, targeted training in CT-related knowledge and practice is urgently needed.

Chlamydiae from Down Under: The Curious Cases of Chlamydial Infections in Australia

In Australia, the most researched and perhaps the most successful chlamydial species are the human pathogen Chlamydia trachomatis, animal pathogens Chlamydia pecorum and Chlamydia psittaci. C. trachomatis remains the leading cause of sexually transmitted infections in Australians and trachoma in Australian Indigenous populations. C. pecorum is globally recognised as the infamous koala and widespread livestock pathogen, whilst the avian C. psittaci is emerging as a horse pathogen posing zoonotic risks to humans. Certainly not innocuous, the human infections with Chlamydia pneumoniae seem to be less prevalent that other human chlamydial pathogens (namely C. trachomatis). Interestingly, the complete host range for C. pecorum and C. psittaci remains unknown, and infections by other chlamydial organisms in Australian domesticated and wildlife animals are understudied. Considering that chlamydial organisms can be encountered by either host at the human/animal interface, I review the most recent findings of chlamydial organisms infecting Australians, domesticated animals and native wildlife. Furthermore, I also provide commentary from leading Australian Chlamydia experts on challenges and future directions in the Chlamydia research field.

Incomplete recording of Indigenous identification status under-estimates the prevalence of Indigenous population attending Australian general practices: a cross sectional study

BACKGROUND

Australian Aboriginal and Torres Strait Islander (Indigenous) peoples face major health disadvantage across many conditions. Recording of patients' Indigenous status in general practice records supports equitable delivery of effective clinical services. National policy and accreditation standards mandate recording of Indigenous status in patient records, however for a large proportion of general practice patient records it remains incomplete. We assessed the completeness of Indigenous status in general practice patient records, and compared the patient self-reported Indigenous status to general practice medical records.

METHODS

A cross sectional analysis of Indigenous status recorded at 95 Australian general practices, participating in the Australian Chlamydia Control Effectiveness Pilot (ACCEPt) in 2011. Demographic data were collected from medical records and patient surveys from 16 to 29 year old patients at general practices, and population composition from the 2011 Australian census. General practitioners (GPs) at the same practices were also surveyed. Completeness of Indigenous status in general practice patient records was measured with a 75% benchmark used in accreditation standards. Indigenous population composition from a patient self-reported survey was compared to Indigenous population composition in general practice records, and Australian census data.

RESULTS

Indigenous status was complete in 56% (median 60%, IQR 7-81%) of general practice records for 109,970 patients aged 16-29 years, and Indigenous status was complete for 92.5% of the 3355 patients aged 16-29 years who completed the survey at the same clinics. The median proportion per clinic of patients identified as Indigenous was 0.9%, lower than the 1.8% from the patient surveys and the 1.7% in clinic postcodes (ABS). Correlations between the proportion of Indigenous people self-reporting in the patient survey (5.2%) compared to status recorded in all patient records (2.1%) showed a fair association (r = 0.6468; p < 0.01). After excluding unknown /missing data, correlations weakened.

CONCLUSIONS

Incomplete Indigenous status records may under-estimate the true proportion of Indigenous people attending clinics but have higher association with self-reported status than estimates which exclude missing/unknown data. The reasons for incomplete Indigenous status recording in general practice should be explored so efforts to improve recording can be targeted and strengthened.

TRIAL REGISTRATION

ACTRN12610000297022 . Registered 13th April 2010.

Application of the COM-B model to barriers and facilitators to chlamydia testing in general practice for young people and primary care practitioners: a systematic review

Background

Chlamydia is a major public health concern, with high economic and social costs. In 2016, there were over 200,000 chlamydia diagnoses made in England. The highest prevalence rates are found among young people. Although annual testing for sexually active young people is recommended, many do not receive testing. General practice is one ideal setting for testing, yet attempts to increase testing in this setting have been disappointing. The Capability, Opportunity, and Motivation Model of Behaviour (COM-B model) may help improve understanding of the underpinnings of chlamydia testing. The aim of this systematic review was to (1) identify barriers and facilitators to chlamydia testing for young people and primary care practitioners in general practice and (2) map facilitators and barriers onto the COM-B model.

Methods

Qualitative, quantitative, and mixed methods studies published after 2000 were included. Seven databases were searched to identify peer-reviewed publications which examined barriers and facilitators to chlamydia testing in general practice. The quality of included studies was assessed using the Critical Appraisal Skills Programme. Data (i.e., participant quotations, theme descriptions, and survey results) regarding study design and key findings were extracted. The data was first analysed using thematic analysis, following this, the resultant factors were mapped onto the COM-B model components. All findings are reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results

Four hundred eleven papers were identified; 39 met the inclusion criteria. Barriers and facilitators were identified at the patient (e.g., knowledge), provider (e.g., time constraints), and service level (e.g., practice nurses). Factors were categorised into the subcomponents of the model: physical capability (e.g., practice nurse involvement), psychological capability (e.g.: lack of knowledge), reflective motivation (e.g., beliefs regarding perceived risk), automatic motivation (e.g., embarrassment and shame), physical opportunity (e.g., time constraints), social opportunity (e.g., stigma).

Conclusions

This systematic review provides a synthesis of the literature which acknowledges factors across multiple levels and components. The COM-B model provided the framework for understanding the complexity of chlamydia testing behaviour. While we cannot at this juncture state which component represents the most salient influence on chlamydia testing, across all three levels, multiple barriers and facilitators were identified relating psychological capability and physical and social opportunity. Implementation should focus on (1) normalisation, (2) communication, (3) infection-specific information, and (4) mode of testing. In order to increase chlamydia testing in general practice, a multifaceted theory- and evidence-based approach is needed.

Trial registration

PROSPERO CRD42016041786

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0821-y) contains supplementary material, which is available to authorized users.

Barriers and Facilitators of Partner Treatment of Chlamydia: A Qualitative Investigation with Prescribers and Community Pharmacists

Chlamydia trachomatis is the most frequently-notified sexually transmitted infection in Australia. Effective and timely partner treatment of chlamydia is essential to reduce overall prevalence and the burden of infection. Currently in most of Australia, the only avenue for partner treatment of chlamydia (“standard partner therapy”) is a tedious, and often inconvenient, process. The barriers and facilitators of standard partner therapy, and newer models of accelerated partner therapy (APT), need to be identified in the Australian setting. Additionally, the potential role of community pharmacists need to be explored. Semi-structured interview guides for two key stakeholder groups (prescribers and pharmacists) were developed and piloted. Eleven prescribers (general practitioners, sexual health clinicians and nurse practitioners) and twelve pharmacists practicing in the Perth metropolitan region were interviewed. Key reported barriers to standard partner therapy were lack of or delayed chlamydia testing. Key facilitators included ability to test and educate sexual partner. Key barriers for APT included prescribers’ legal responsibility and potential for medication-related adverse effects. Healthcare provider consultation and chlamydia testing were seen as potential facilitators of APT. Pharmacists were receptive to the idea of expanding their role in chlamydia treatment, however, barriers to privacy must be overcome in order to be acceptable to prescribers and pharmacists.

Correlates of sexually transmissible infection testing among a sample of at-risk young Australians

Annual chlamydia testing is recommended for all sexually active Australians aged 15-29 years; however, the testing rate is below recommended levels. Three surveys at a Melbourne music festival were conducted over 2012-14 to identify correlates of sexually transmissible infection (STI) testing among young people at risk of STIs. In total, 3588 participants were recruited; 72% reported having sex in the past year. Based on sexual behaviours, 38% of sexually active participants were classified as at risk of contracting STIs. In the past year, at-risk participants had significantly higher odds of reporting a STI test (37%) than participants classified as not at risk (24%) (OR=1.9; CI=1.6-2.3). Among at-risk participants, correlates of STI testing in the past year included being aged 20-24 years, visiting a GP, higher knowledge levels, earlier sexual debut and reporting more than five lifetime partners. Testing rates in our sample did not meet levels required to reduce chlamydia prevalence. However, the testing rate was higher in at-risk participants than participants who were not at risk. Future programs aiming to increase chlamydia testing should improve knowledge and promote the importance of testing after risk exposure, particularly among 16- to 19-year-olds.

Exploring why a complex intervention piloted in general practices did not result in an increase in chlamydia screening and diagnosis: a qualitative evaluation using the fidelity of implementation model

BACKGROUND

Chlamydia trachomatis (chlamydia) is the most commonly diagnosed sexually transmitted infection (STI) in England; approximately 70% of diagnoses are in sexually active young adults aged under 25. To facilitate opportunistic chlamydia screening in general practice, a complex intervention, based on a previously successful Chlamydia Intervention Randomised Trial (CIRT), was piloted in England. The modified intervention (3Cs and HIV) aimed to encourage general practice staff to routinely offer chlamydia testing to all 15-24 year olds regardless of the type of consultation. However, when the 3Cs (chlamydia screening, signposting to contraceptive services, free condoms) and HIV was offered to a large number of general practitioner (GP) surgeries across England, chlamydia screening was not significantly increased. This qualitative evaluation addresses the following aims: a) Explore why the modified intervention did not increase screening across all general practices. b) Suggest recommendations for future intervention implementation.

METHODS

Phone interviews were carried out with 26 practice staff, at least 5 months after their initial educational workshop, exploring their opinions on the workshop and intervention implementation in the real world setting. Interview transcripts were thematically analysed and further examined using the fidelity of implementation model.

RESULTS

Participants who attended had a positive attitude towards the workshops, but attendee numbers were low. Often, the intervention content, as detailed in the educational workshops, was not adhered to: practice staff were unaware of any on-going trainer support; computer prompts were only added to the female contraception template; patients were not encouraged to complete the test immediately; complete chlamydia kits were not always readily available to the clinicians; and videos and posters were not utilised. Staff reported that financial incentives, themselves, were not a motivator; competing priorities and time were identified as major barriers.

CONCLUSION

Not adhering to the exact intervention model may explain the lack of significant increases in chlamydia screening. To increase fidelity of implementation outside of Randomised Controlled Trial (RCT) conditions, and consequently, improve likelihood of increased screening, future public health interventions in general practices need to have: more specific action planning within the educational workshop; computer prompts added to systems and used; all staff attending the workshop; and on-going practice staff support with feedback of progress on screening and diagnosis rates fed back to all staff.

Service evaluation of an educational intervention to improve sexual health services in primary care implemented using a step-wedge design: analysis of chlamydia testing and diagnosis rate changes

Background

Providing sexual health services in primary care is an essential step towards universal provision. However they are not offered consistently. We conducted a national pilot of an educational intervention to improve staff’s skills and confidence to increase chlamydia testing rates and provide condoms with contraceptive information plus HIV testing according to national guidelines, known as 3Cs&HIV. The effectiveness of the pilot on chlamydia testing and diagnosis rates in general practice was evaluated.

Methods

The pilot was implemented using a step-wedge design over three phases during 2013 and 2014 in England. The intervention combined educational workshops with posters, testing performance feedback and continuous support. Chlamydia testing and diagnosis rates in participating general practices during the control and intervention periods were compared adjusting for seasonal trends in chlamydia testing and differences in practice size. Intervention effect modification was assessed for the following general practice characteristics: chlamydia testing rate compared to national median, number of general practice staff employed, payment for chlamydia screening, practice urban/rurality classification, and proximity to sexual health clinics.

Results

The 460 participating practices conducted 26,021 tests in the control period and 18,797 tests during the intervention period. Intention-to-treat analysis showed no change in the unadjusted median tests and diagnoses per month per practice after receiving training: 2.7 vs 2.7; 0.1 vs 0.1. Multivariable negative binomial regression analysis found no significant change in overall testing or diagnoses post-intervention (incidence rate ratio (IRR) 1.01, 95 % confidence interval (CI) 0.96–1.07, P = 0.72; 0.98 CI 0.84–1.15, P = 0.84, respectively). Stratified analysis showed testing increased significantly in practices where payments were in place prior to the intervention (IRR 2.12 CI 1.41–3.18, P < 0.001) and in practices with 6–15 staff (6–10 GPs IRR 1.35 (1.07–1.71), P = 0.012; 11–15 GPs IRR 1.37 (1.09–1.73), P = 0.007).

Conclusion

This national pilot of short educational training sessions found no overall effect on chlamydia testing in primary care. However, in certain sub-groups chlamydia testing rates increased due to the intervention. This demonstrates the importance of piloting and evaluating any service improvement intervention to assess the impact before widespread implementation, and the need for detailed understanding of local services in order to select effective interventions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3343-z) contains supplementary material, which is available to authorized users.

Do Australian general practitioners believe practice nurses can take a role in chlamydia testing? A qualitative study of attitudes and opinions

BACKGROUND

Chlamydia notifications continue to rise in young people in many countries and regular chlamydia testing is an important prevention strategy. Although there have been initiatives to increase testing in primary care, none have specifically investigated the role of practice nurses (PNs) in maximising testing rates. PNs have previously expressed a willingness to be involved, but noted lack of support from general practitioners (GPs) as a barrier. We sought GPs' attitudes and opinions on PNs taking an expanded role in chlamydia testing and partner notification.

METHODS

In the context of a cluster randomised trial in mostly rural towns in 4 Australian states, semi structured interviews were conducted with 44 GPs between March 2011 and July 2012. Data relating to PN involvement in chlamydia testing were thematically analysed using a conventional content analysis approach.

RESULTS

The majority of GPs interviewed felt that a role for PNs in chlamydia testing was appropriate. GPs felt that PNs had more time for patient education and advice, that patients would find PNs easier to talk to and less intimidating than GPs, and that GPs themselves could benefit through a reduction in their workload. Although GPs felt that PNs could be utilised more effectively for preventative health activities such as chlamydia testing, many raised concerns about how these activities would be renumerated whilst some felt that existing workload pressures for PNs could make it difficult for them to expand their role. Whilst some rural GPs recognised that PNs might be well placed to conduct partner notification, they also recognised that issues of patient privacy and confidentiality related to living in a "small town" was also a concern.

CONCLUSION

This is the first qualitative study to explore GPs' views around an increased role for PNs in chlamydia testing. Despite the concerns raised by PNs, these findings suggest that GPs support the concept and recognise that PNs are suited to the role. However issues raised, such as funding and remuneration may act as barriers that will need to be addressed before PNs are supported to make a contribution to increasing chlamydia testing rates in general practice.

The views of general practitioners and practice nurses towards the barriers and facilitators of proactive, internet-based chlamydia screening for reaching young heterosexual men

BACKGROUND

Chlamydia trachomatis is a common bacterial sexually transmitted infection (STI), which disproportionately affects young people under 25 years. Commonly, more women are offered screening than men. This study obtained the views of general practitioners and practice nurses towards Internet-based screening and assessed levels of support for the development of proactive screening targeting young heterosexual men via the Internet.

METHODS

Semi-structured telephone interviews with 10 general practitioners and 8 practice nurses, across Central Scotland. Topics covered: experience of screening heterosexual men for chlamydia, views on the use of the Internet as a way to reach young men for chlamydia screening, beliefs about the potential barriers and facilitators to Internet-based screening. Transcripts from audio recordings were analysed with Framework Analysis, using QSR NVivo10.

RESULTS

Experiences of chlamydia screening were almost exclusively with women, driven by the nature of consultations and ease of raising sexual health issues with female patients; few practice nurses reported seeing men during consultations. All participants spoke in favour of Internet-based screening for young men. Participants reported ease of access and convenience as potential facilitators of an Internet-based approach but anonymity and confidentiality could be potential barriers and facilitators to the success of an Internet approach to screening. Concerns over practical issues as well as those pertaining to gender and socio-cultural issues were raised.

CONCLUSIONS

Awareness of key barriers and facilitators, such as confidentiality, practicality and socio-cultural influences, will inform the development of an Internet-based approach to screening. However, this approach may have its limits in terms of being able to tackle wider social and cultural barriers, along with shifts in young people's and health professionals' attitudes towards screening. Nevertheless, employing innovative efforts as part of a multi-faceted approach is required to ensure effective interventions reach the policy agenda.

Chlamydia trachomatis Infection: Screening and Management

OBJECTIVE

To review current criteria and rationale for Chlamydia trachomatis screening, testing methods, and treatment of infection.

METHODS

Review of the literature.

RESULTS

C. trachomatis urogenital infections are an important public health problem. Screening for C. trachomatis in women age 25 and younger and men and women of any age at increased risk allows for the early treatment of disease, avoiding morbidity such as pelvic inflammatory disease, ectopic pregnancy, and chronic pelvic pain, and reducing health care costs.

CONCLUSION

Current screening recommendations are not being implemented satisfactorily. Home-based methods of screening are acceptable and may improve universal screening rates.

The chlamydia knowledge, awareness and testing practices of Australian general practitioners and practice nurses: survey findings from the Australian chlamydia control effectiveness pilot (ACCEPt)

Background

ACCEPt, a large cluster randomized control trial, aims to determine if annual testing for 16 to 29 year olds in general practice can reduce chlamydia prevalence. ACCEPt is the first trial investigating the potential role of practice nurses (PN) in chlamydia testing. To inform the design of the ACCEPt intervention, we aimed to determine the chlamydia knowledge, attitudes, and testing practices of participating general practitioners (GPs) and PNs.

Methods

GPs and PNs from 143 clinics recruited from 52 areas in 4 Australian states were asked to complete a survey at time of recruitment. Responses of PNs and GPs were compared using conditional logistic regression to account for possible intra cluster correlation within clinics.

Results

Of the PNs and GPs enrolled in ACCEPt, 81% and 72% completed the questionnaire respectively. Less than a third of PNs (23%) and GPs (32%) correctly identified the two age groups with highest infection rates in women and only 16% vs 17% the correct age groups in men. More PNs than GPs would offer testing opportunistically to asymptomatic patients aged ≤25 years; women having a pap smear (84% vs 55%, P<0.01); antenatal checkup (83% vs 44%, P<0.01) and Aboriginal men with a sore throat (79% vs 33%, P<0.01), but also to patients outside of the guideline age group at the time of the survey; 26 year old males presenting for a medical check (78% vs 30%, P = <0.01) and 33 year old females presenting for a pill prescription (83% vs 55%, P<0.01). More PNs than GPs knew that retesting was recommended after chlamydia treatment (93% vs 87%, P=0.027); and the recommended timeframe was 3 months (66% vs 26%, P<0.01). A high proportion of PNs (90%) agreed that they could conduct chlamydia testing in general practice, with 79% wanting greater involvement and 89% further training.

Conclusions

Our survey reveals gaps in chlamydia knowledge and management among GPs and PNs that may be contributing to low testing rates in general practice. The ACCEPt intervention is well targeted to address these and support clinicians in increasing testing rates. PNs could have a role in increasing chlamydia testing.