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 WilsonThis study was funded by a grant from the Research and Development

Department of Greater Glasgow Primary Care NHS Trust

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

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

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?”

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

Outcome Measures

Secondary measures

• Screening rates for other STI’s

• Knowledge and understanding among professionals and patients

Methods

• Controlled before-and-after intervention study

• Set in area of high deprivation

• 2 large urban health centres

Demography and Population

Population GPs Practice Nurses Practices

Health Centre A 24,566 25 9 8

Health Centre B 32,822 24 8 6

Intervention

Health adviser in health centre 6 months:

• Training and support for staff

• Development of administrative systems for partner notification

• Outreach work

Data Collected

• Laboratory computer systems• Questionnaires

– Professionals– Patients

• Case note review– Reasons for test– Partner notification outcomes

• Qualitative data– Researcher field notes– Interviews

ResultsNumbers of tests done

0

50

100

150

200

250

A <20 A 20-24 A >24 B <20 B 20-24 B>24

20002001

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

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%

Partner Notification Outcomes

21 of 24 case notes for positive tests were available:

Partner notification discussed 17

1 partner treated 11

1 partner positive 3

Declined partner notification 1

>1 partner declared 0

Other STIs

No change in rate of testing

for GC or STS at either health centre

Knowledge and Attitudes

Patient questionnaires117 of 335 completed a pre-test questionnaire asking about reasons for testing:

– Doctor/nurse advised me to 85– I asked for a test 17– Information from poster/leaflet 14– Discussion with friends 11– Information from magazine/newspaper 4– Partner has infection 2– Information from tv/radio 1– Lesson at school 0

– Other 6

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

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"

Knowledge and Attitudes

Staff questionnaires• Distributed pre- and post-intervention in

both health centres

• Response rate:

2000 2001

HCA 38% 49%

HCB 24% 26%

Qualitative Data

Major themes

• Time constraints

• Skills for sexual health work

• Staff and patient’s agendas

• Practicality of guidelines

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.”

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?”

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”

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!”

Practicality of Clinical Guidelines

“Probably general practice wasn’t considered (when the SIGN guidelines were written).”

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

Possible Reasons - 1

Most patients under 20 years are seen by GPs, not practice nurses

Possible Reasons - 1

Practice nurses were more likely to:

• Attend training

• Use the health adviser as a resource

• Carry out testing

Possible Reasons - 1

Therefore the staff best equipped to carry out opportunistic testing were least likely to see the patients most at risk.

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

What Are the Constraints on Opportunistic Testing?

General practitioners

• Time constraints

• Multiple, competing priorities

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

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

Partner Notification

Passive, 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

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

“Chlamydia may be the most important thing in the world to you,but we have to think about a lot of

other things!”