Chlamydia screening providers: Qualitative research
Summary of findings
In evaluating the potential and support needs of Providers, this research, while qualitative and based on a small sample, does indicate some differences between organisations depending on:
- Type of organisation
- Remit and level of focus on Sexual Health (SH)
- Engagement and enthusiasm of contact
- Numbers and types of Young People(YP) presenting themselves
As such, it appears these are potential indicators for understanding what is required to boost screens and to map expectations regarding targets.
1. All Providers were not actively engaged in the programme at sign up
- Whilst there was widespread recognition to rising Chlamydia rates as an issue, amongst Providers there was limited specific understanding of the NWCSP including its targets.
- Primarily most Providers had been motivated to take part in the programme as they believed it would provide a better service to the Young People (YP) they saw. Secondly the perceived ease of the kits, particularly DIY and the need for low or no involvement, was also a motivation for some to sign up.
- There was, however, varying degrees of warmth towards the programme, with some suggestion that not all Providers were involved in or happy about signing up and as such there were more ambivalent or negative.
- As warmth generally translated to performance and engagement, there is clearly some benefit in discriminating between Providers early on, in order to target warmer or to build better relationships with those cooler Providers.
2. Chlamydia Screening Office (CSO) set-up and day to day support generally works well although greater proactivity is needed to keep screening top of mind.
- For the majority of Providers the set up of the programme i.e. initial training and provision of the kits had met their needs well. However there were some (those less confident and working further away from SH) who felt the need for more up-front training. As such it will be useful to identify those that might need greater handholding at the start in order to enable them to engage as strongly as possible.
- Providers were generally positive towards the CSO on a day to day basis and felt that they offered the ad-hoc back up and support they required. That said there were some who felt less positive and cited instances where the CSO had been less reactive than they would have liked. Whilst they acknowledged staff limitations, it did not mitigate their own frustrations causing irritation and potentially undermining their commitment due to the unexpected increase in effort.
- Although provision of ad-hoc support was felt reasonable, there were perceptions of a lack of proactivity on behalf of the CSO with limited contact beyond the set-up. As such Chlamydia Screening (CS) was not kept top of mind for many Providers.
3. Sexual health discussions currently main route in to introduce screens with little evidence of face to face promotion beyond this
- Providers claimed to be raising awareness of screens typically through conversations or consultations with YP.
- However, most claimed the topic of screening would only be raised in a face to face situation when the consultation was felt related in some way i.e. contraceptive advice, smears, concerns, fears or symptoms raised by clients. It was in these situations that the provider claimed it felt most appropriate and likely to be most warmly received.
- This said, whilst contraception advice was felt to be an ‘ideal’ opener to screening, there was a minority for whom condom provision was felt contradictory to CS i.e. the YP or even the Provider felt that the YP would not be at risk if they were using condoms.
- In contrast, there was little evidence of screening being raised when the discussion was not related. Providers felt that it was or would be awkward to do this (for themselves and the YP) as well as several other barriers which impacted on their perceived ability to do this.
4. There was a disparity between provider claims of use and the CSO use of CSP marketing materials and other marketing initiatives
- There were a range of marketing efforts claimed across the different Providers in relation to CS.
- Whilst some admitted to be doing very little to promote the service, the majority claimed to use (or have used) CSP materials i.e. posters and leaflets to promote CS. In addition, a minority, more SH focussed, claimed to go beyond this and were being even more proactive i.e. producing their own materials, doing their own events, etc.
- However there does appear to be a disparity between these claims and the experiences of CSO (who felt that by contrast Providers appear to be doing very little at all to promote screening).
- This disparity between provider claims around use and CSO perceptions of use of marketing material, raises several possible issues: Provider having a high level of defensiveness about own effort levels? A potential perception gap between what Providers believe they are doing and what they are actually doing? Possibility that after materials initially displayed, they do not get monitored/refreshed thereafter without prompting? Low success in achieving screens? ‘Piggy backing’ on CSO/NWCSP initiatives?
5. Target setting polarising but useful to have as long as not measured
- Being made aware of targets was polarising. Many already had target overload in relation to their own roles and as such the addition of more targets in conjunction with limitations about ability to reach those targets did irritate.
- That said there was an acknowledgement that being made aware of targets, for example for their region (rather than on an individual basis) may help to raise the priority of the programme giving impetus to staff and themselves.
- Reaching 10 a month was attainable for some, with additional effort and support, however for others (less SH focussed), current barriers meant it was unlikely.
6. Barriers from both provider and YP persist to prevent more screens being achieved
a) Provider Barriers:
- Limited time: Either offering to screen was either simply not feasible due to time constraints or would be likely to seriously compromise the primary reason for a YPs visit to a Provider
- Limited staffing: A lack of ‘appropriate staff’ i.e. trained or same gender was felt to limit ability to maximise screening opportunities
- Propensity to prioritise: The propensity to prioritise CS largely reflected the role of SH in the Provider’s remit. Those that were primarily dealing with sexual health or those that were dealing with SH and other medical matters were warmest to CSP. For the other Providers, where SH is dealt with alongside other big life issues i.e. drugs, housing, pregnancy CS was often low priority. Lastly there were a minority for who SH was not part of their remit and therefore were unlikely to ever achieve a higher number of screens.
- Attitude and Experience of the staff: The experience, confidence and knowledge of staff also impacted on ‘willingness’ to introduce test, with those most experienced very engaged and in contrast those Providers who were less confident needing greater handholding and support.
- Lack of ongoing support: Due to a lack of on-going contact from the CSO, CS does fall lower in priorities with an underlying perception of lower urgency.
- Lack of management support: Those in very structured organisations i.e. military, prison tended to be hampered by internal structures that prevented higher rates of CS.
- Red tape from venues: There were only a few reports of this issue however it does impede efforts made on behalf of the Provider.
- GPs: GP surgeries had other issues which compounded the above barriers. The fact that GP surgeries were not paid to conduct the screens (as is not part of the Quality Outcomes Framework they work towards) meant that CS typically had a low priority (evidenced by the fact that no GPs wanted to take part in the study) in all but those surgeries with an enthusiastic and interested nurse. In addition there was some evidence that GPs wished to do their own screening in order to provide continuation of care.
b) Perception of Barriers from Young People
- Footfall: It was clear that some of the Providers did not have a high footfall of 15-24 year olds limiting the number of screens they could complete. In addition there was an acknowledgement that Males were much less likely to present as well as many of the Ethnic Minorities in the Norfolk and Waveney region.
- Attitude towards Chlamydia: It was perceived that a ‘low risk’ perception around Chlamydia prevailed amongst Young People making them unlikely to agree to a screen.
- Attitudes towards the test: The low risk barrier was perceived to be exacerbated by negative attitudes towards the test from Young People; either embarrassment (and concerns around confidentiality) and/or perception that the tests would hurt. The DIY test was felt to go some way to overcome these issues although it was felt that it could still be made easier for Young People i.e. smaller more discrete bag, simpler form.
7. There are a number of ideas suggested that may go some way to help raise screens
- Most Providers requested additional funding to help increase their resources and therefore their capacity to conduct more screens. Although this lies outside the remit of NWCSP there are potential ways that NWCSP could develop their programme to meet the needs of Providers which may in turn raise the number of screens achieved;
- Targeting those with more potential
- Greater contact and support from CSO (e.g. we are here to help you reminders, details on how the programme is doing, newsletters, website, etc)
- Additional training and support (or greater signposting to what is currently available and resources to help disseminate learnings across staff)
- More promotional materials
b) Young People
- For YP it was felt critical that general messaging around Chlamydia and its impact was conveyed. However whilst NWCSP might be able to go some way to help, remit for this activity probably lies elsewhere i.e. Government, NHS, DH, HPA
- Specific steps that NWCSP could take to target Young People specifically include: Raise awareness of how testing works; Improve the DIY kit; Offer collateral or freebies to help incentivise
- In addition it was acknowledged by some Providers that more work was needed to take the testing to Young People and their environment i.e. pubs, festivals, places of work.
The overall objective of the research was to understand what will ‘move and motivate’ screening sites to proactively offer screening to young adults to the level required to meet targets (including capacity needs and needs for building in self-reliance and sustainability).
Norfolk and Waveney is one of a number of programme demonstration areas for the National Chlamydia Screening Programme (NCSP), a major long-term public health prevention and control programme that offers opportunistic screening for Chlamydia across England.
The National Social Marketing Centre (The NSMC) are now working with and alongside the Sexual Health Promotion Unit to help them increase the uptake of Chlamydia screening amongst under 25-year-olds in Norfolk and Waveney and meet the NHS LDP targets of 17% by the end of March 2009.
To assist in this task, research was needed to understand why screening sites signed up to the NWCSP initially and, vitally, what can be done to increase the number of Young People that they screen.
Providers were not actively engaged in the programme at sign up. Whilst there was widespread recognition to rising Chlamydia rates as an issue, there was limited specific understanding of the NWCSP including its targets.
However, this research indicates what is required to boost screens and to map expectations regarding targets.
40 depth interviews – 10 face to face and 30 telephone
Data collection methodology