1. Missed Opportunities: The Health Adviser as a link between Genitourinary Medicine and Primary Care in the management of Chlamydia Bruce Armstrong, Sue Kinn, Anne Scoular and Phil Wilson This study was funded by a grant from the Research and Development Department of Greater Glasgow Primary Care NHS Trust

2. Background Rising incidence of genital Chlamydia Debate about a screening programme Under 25’s most at risk This group make poor use of existing sexual health services

3. Background Primary care is likely to be a common setting for screening For any screening programme to work there must be good links between primary care and GUM Current links are quite passive

4. Study Aims To investigate a model for collaboration between primary care and GUM and to answer the research question: “Does the presence of a health adviser, in a general practice setting, improve the awareness, diagnosis and treatment of Chlamydia at the community level?”

5. Outcome Measures Primary measures Screening rate for Chlamydia in under 25 year olds Screening rate for Chlamydia in under 20 year olds Partner notification outcomes

6. Outcome Measures Secondary measures Screening rates for other STI’s Knowledge and understanding among professionals and patients

7. Methods Controlled before-and-after intervention study Set in area of high deprivation 2 large urban health centres

8. Demography and Population Population GPs Practice Nurses Practices Health Centre A 24,566 25 9 8 Health Centre B 32,822 24 8 6

9. Intervention Health adviser in health centre 6 months: Training and support for staff Development of administrative systems for partner notification Outreach work

10. Data Collected Laboratory computer systems Questionnaires –Professionals –Patients Case note review –Reasons for test –Partner notification outcomes Qualitative data –Researcher field notes –Interviews

11. Results

12. Screening Rates In Health Centre A 11% of the total increase was in <20s 43% of the total increase was in 20-24s 46% of the total increase was in >24s 79% of tests were done by practice nurses 90% of <20s were seen by GPs

13. Positive Results Health centre A –In 2000: 16 of 152 = 10% –In 2001: 24 of 335 = 7% In health centre B –In 2000: 17 of 336 = 5% –In 2001: 21 of 374 = 5%

14. Partner Notification Outcomes 21 of 24 case notes for positive tests were available: Partner notification discussed17 1 partner treated11 1 partner positive3 Declined partner notification1 >1 partner declared0

15. Other STIs No change in rate of testing for GC or STS at either health centre

16. Knowledge and Attitudes Patient questionnaires 117 of 335 completed a pre-test questionnaire asking about reasons for testing: –Doctor/nurse advised me to85 –I asked for a test17 –Information from poster/leaflet14 –Discussion with friends11 –Information from magazine/newspaper4 –Partner has infection 2 –Information from tv/radio 1 –Lesson at school 0 –Other 6

17. Knowledge and Attitudes 75% of respondents had heard of Chlamydia before having the test 97% reported that the doctor or nurse had discussed the condition with them

18. Knowledge and Attitudes Patients’ Comments "I agree that screening should be available on request/randomly” "I think it should be a regular test for both men and women by their GPs” " I am pleased the nurse mentioned the test because I wouldn't have thought about it otherwise” " I would never have thought about getting a test for Chlamydia"

19. Knowledge and Attitudes Staff questionnaires Distributed pre- and post-intervention in both health centres Response rate: 20002001 HCA 38%49% HCB24%26%

20. Qualitative Data Major themes Time constraints Skills for sexual health work Staff and patient’s agendas Practicality of guidelines

21. Time Constraints “… If I'm running late and a 25 year old comes in for a repeat prescription of the pill, so I know they’re sexually active, I think thank god, quick blood pressure, pill and out … in an ideal world I would love to sit there with time to spend with every one of them. It’s painfully hard, it just can’t happen.”

22. Skills for Sexual Health Work “I don’t have a particular problem about (discussing sexual health with patients). I just think … I’m already running fifteen minutes late, am I going to open up a whole can of worms here?”

23. Staff and Patients’ Agendas “Patients sometimes come in to me quite disgruntled because they’ve come to the general practitioner with a sore throat and ended up with a cervical smear”

24. Practicality of Clinical Guidelines “ Thank god they’re not something we have to adhere to rigidly, because if they were we’d be here twenty-four hours a day!”

25. Practicality of Clinical Guidelines “Probably general practice wasn’t considered (when the SIGN guidelines were written).”

26. Why the Decrease in Percentage of Positive Results? Increase in testing activity Largest proportion of increase was in patients at low risk Small increase in patients under 20 years

27. Possible Reasons - 1 Most patients under 20 years are seen by GPs, not practice nurses

28. Possible Reasons - 1 Practice nurses were more likely to: Attend training Use the health adviser as a resource Carry out testing

29. Possible Reasons - 1 Therefore the staff best equipped to carry out opportunistic testing were least likely to see the patients most at risk.

30. Possible Reasons - 2 Practice nurses offer opportunistic testing to patients attending for cervical screening (i.e. female patients over 20 years) Other methods of introducing opportunistic testing are less well developed

31. What Are the Constraints on Opportunistic Testing? General practitioners Time constraints Multiple, competing priorities

32. What Are the Constraints on Opportunistic Testing? Practice nurses Time constraints (but more likely to offer testing than GPs) Less likely to see patients under 20 years

33. What Are the Constraints on Opportunistic Testing? Treatment room nurses See patients in the age group most at risk But do not have authority to initiate opportunistic testing

34. Partner Notification P assive, despite the presence of a health adviser in the health centre, due to: Time constraints Some practices having no follow up systems Under recording of sensitive discussions Lack of information about partners from other practices

35. Conclusions Training and support from a health adviser does not improve detection rates for Chlamydia trachomatis in the absence of changes to constraining factors. These include: Lack of time for opportunistic sexual health consultations Lack of robust systems for sexual health work

36. “Chlamydia may be the most important thing in the world to you, but we have to think about a lot of other things!”