Are you getting it? – Chlamydia screening learning demonstration site

Secondary research

The project team began by reviewing existing data and literature to define the issue, provide initial audience insights, analyse the behaviour and provide ideas for the intervention. Relevant behavioural theories were considered to understand factors that influence human behaviour. Young people’s lifestyles and media usage were also explored to develop a rounded view of the target audience.  

Analysis of NWCSP resources and screening figures revealed that while over 200 venues across Norfolk and Waveney had signed up to offer free chlamydia screening to young people on behalf of the NWCSP, most of these sites were returning few or no screens.

Stakeholder consultations

As part of the initial scoping work, the project team carried out informal stakeholder consultations. The Department of Health (DH) and NCSP members were approached to understand what the national guidance, strategies and priorities were. Other CSO leads from across the country were contacted to learn what approaches had or had not worked in increasing chlamydia screening rates, and why.

Seven screening providers in Norfolk and Waveney were also interviewed over the phone to explore their experiences with chlamydia screening, the barriers they faced and any suggestions they had for improving their experiences of offering screening.

Target audience

Given limited resources for the project, the team decided to focus on one rather than multiple target audiences. Although this was initially anticipated to be young people, there was news that the DH was planning a national advertising campaign promoting chlamydia screening to young people. The team therefore decided to focus their local resources on screening providers rather than young people, thereby maximising routine opportunities for screening through the existing large network of screening sites.

Behavioural goal

The behavioural goal was for existing screening providers to actively offer chlamydia screening to 15- to 24-year-olds.

Primary research

Since there was little research into what providers’ barriers and motivators were to actively offering chlamydia screening, and other programme areas faced similar challenges engaging with frontline staff, The NSMC secured £20,000 funding from the DH for primary research. A research agency was commissioned to carry out in-depth telephone and face-to-face interviews with 40 NWCSP screening providers. The purpose of this research, which took place in summer 2008, was to understand what the primary barriers were with regard to screening and what could be done to increase the number of young people sites screened.

 Insights

• Low awareness of annual targets and NWCSP performance to date meant that providers neither felt urgency to offer screening, nor that they were part of a larger initiative
• Some providers perceived a lack of interest and support from the CSO once they signed up to the programme, which sometimes led to cynicism and the assumption that there was no real need for screening
• For providers whose main remit was not sexual health, chlamydia screening often fell to the back of their minds. Screening was also often only offered when a young person presented for a sexual health related reason

Exchange

Screening providers faced several real and perceived barriers when offering chlamydia screening. These included:

• Limited time and/or staffing
• Anxieties about raising the issue of screening (particularly in an unrelated consultation)
• Limited specific understanding of the NWCSP, including its targets

Perceived benefits the team would aim to promote to screening providers include:

• Providing a better service to young people
• Being part of an important national initiative
• Professional development and networking opportunities
• Earlier diagnosis and treatment of chlamydia
• Free screening kits and other collateral
• Payment per screen

Theory

The Theory of Planned Behaviour (TPB) suggests that attitude, subjective norms and perceived behavioural control can influence providers’ screening behaviour. This project therefore needed to:

• Promote attitudes that favour screening
• Encourage providers to see screening as a socially approved behaviour
• Help providers develop the confidence and skills to effectively offer screening to young people

Segmentation

Using findings from the primary research, screening providers were segmented into four main groups according to provider type, as well as current screening activity and ability and motivation to screen.

1. Engaged and motivated – These sites were those where sexual health was a key focus of service provision to young people, like sexual health services, family planning clinics and GP surgeries that had an enthusiastic sexual health lead. These providers tended to have the highest numbers of young people in the target age group presenting for treatment in a number of closely related areas. Since these types of provider were already experienced and proactive, they had potential to act as spokespeople for the NWCSP and were likely to need less support and resources, which could be diverted to providers who needed more of both.
2. Interested but restricted – This category of provider may have capacity to increase screens, but time available to screen was minimal given other issues and priorities. Whilst staff were positively inclined towards screening, they typically experienced limitations around their knowledge and expertise in matters of sexual health. For this type of provider, greater levels of support would be instrumental in enabling them to engage more proactively with the programme and increase screening levels.
3. Low interest – These sites were generally those where screening was seen as beneficial but ancillary to their primary service provision. They were currently more resistant as they felt they did not have the time or resources to dedicate to this service and typically had low interest or experience in this area. However, it was at least on their radar and they generally conceded that they could be more proactive, given greater support. Information in relation to the ‘bigger picture’ in terms of infection levels and how their personal contribution was important might persuade them into striving for higher screening levels.
4. Low priority – These tended to be providers (like hostels and some outreach services) where other life issues (like drug and substance abuse, mental health problems and homelessness) experienced by young people they were in contact with dominated service provision. Often, limited and non-specialist resources were another barrier. This type of provider was unlikely to want or be able to engage with the programme beyond the minimum effort, but if the message was right, may increase their efforts. Additional coaching and support may help and as long as performance expectations were not too high, these providers could be valuable in helping to raise the profile of the screening programme.

The team chose to target core providers (namely GPs and pharmacies) who were interested but restricted or who had low interest, as they had greatest potential to increase screening, but needed greater handholding and encouragement.

Strategy

In order to meet the project’s aim of increasing screening activity within screening sites, a strategy was developed that focused on enhancing the CSO’s role in engaging, supporting and managing the large and growing number of screening venues across Norfolk and Waveney. With increasingly challenging targets to meet, small CSO teams were unlikely to have the capacity to provide screening, treatment and partner notification. It was therefore vital to build the capacity of the whole system, particularly within existing local clinical services.

This strategy aligned with national guidance from the NCSP for CSOs to play a stronger role in managing and developing frontline services to generate testing opportunities.