The aim of this project was to increase screening activity within screening sites that are part of the Norfolk and Waveney Chlamydia Screening Programme (NWCSP). The ultimate goal was to help the NWCSP meet increasingly challenging national targets for screening 15- to 24-year-olds in Norfolk and Waveney.

The NWCSP is delivered by over 200 health and non-health screening sites across Norfolk and Waveney; however many of them return few or no screens at all each year. Six interventions were piloted, which focused on enhancing the Chlamydia Screening Office’s role in engaging, supporting and managing the large and growing number of screening venues across Norfolk and Waveney, to deliver increasing and sustainable volumes of chlamydia screening in the longer term.


  • Improved induction training for new sites coincided with a threefold increase in chlamydia screening volumes
  • Dissemination of promotional materials to pharmacies from December 2009 was followed by a 300 per cent increase in chlamydia screens returned by pharmacies
  • Chlamydia screening rates among 15- to 24-year olds increased from 3.8% in 07/08 to 16.15% in 09/10 in the Norfolk and Waveney area

Getting Started


Chlamydia is the most common sexually transmitted infection (STI) in the UK, with up to 1 in 12 sexually active 15- to 24-year-olds testing positive. If left untreated, infection can lead to ectopic pregnancy and infertility.

The National Chlamydia Screening Programme (NCSP), established in 2003, is a major long-term public health prevention and control programme that offers opportunistic screening for chlamydia across England, with the aim of:

  • Detecting asymptomatic infection in sexually active men and women under the age of 25 who would not otherwise access or be offered a chlamydia test
  • Reducing onward transmission to sexual partners
  • Preventing the consequences of untreated infection

Traditionally, opportunistic screening methods have been delivered in healthcare settings. Where possible, the NCSP aims to deliver screening through a combination of health and non-health venues to extend opportunities for young people to be tested in a variety of community-based locations.

Norfolk Primary Care Trusts (PCTs) as a consortium joined the NCSP in April 2004 and Waveney PCT joined in April 2006. Chlamydia screening across Norfolk and Waveney is managed by the local Chlamydia Screening Office (CSO), which sits within the Sexual Health Promotion Unit (SHPU) that serves both NHS Norfolk and NHS Great Yarmouth and Waveney (NHSGYW).

In 2007 the SHPU partnered with The NSMC to embark on a learning demonstration project to use social marketing to help increase the uptake of chlamydia screening amongst under-25s.

As part of the NCSP, the local CSO was tasked with meeting targets of 17 per cent (in 2008/09) and 25 per cent (in 2009/10) of 15- to 24-year-olds in Norfolk and Waveney accepting a chlamydia test. In 2007/08, just 3.8 per cent of 15- to 24-year-olds in the area were screened for chlamydia, far below that year’s national target of 15 per cent.

The SHPU was initially keen to use social marketing to increase the demand for and uptake of chlamydia screening amongst young people. In particular, boys and young men were the anticipated target audience for the project, since they are less likely to access sexual health services.

A Steering Group was formed, including the Head of SHPU, Chlamydia Screening Coordinator, Sexual Health Commissioner, and a Sexual Health Promotion Specialist, who served as the Project Manager.

As 1 of 10 learning demonstration sites, the group received free social marketing advice and support from a dedicated member of The NSMC team. Funding for the project came from existing programme budgets within the SHPU.

Are you getting it? Team



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.

Screening Kit

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.


  • 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


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


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


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.


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.



Concept testing

Based on findings from the primary research, the project team came up with a number of interventions to address screening providers’ barriers.

A stakeholder event was held in November 2008 to engage internal PCT stakeholders and frontline screening staff, feed back on the research, and test and brainstorm the intervention ideas. Following the event, five screening providers volunteered to form the Solutions Group.

The team developed and piloted the following six interventions, which focused on providing better management, support and communication to screening sites.

  1. 1.    Improved and standardised induction session for new sites

Before this project, the initial induction given to new sites when they joined the NWCSP varied in content and length from 10 minutes to 1 hour, depending on the site and the CSO member delivering the induction. The project team recognised the need to standardise the induction session so that all new sites received at least the minimum information required to successfully carry out screening, thereby ensuring quality control and consistent messaging.

The CSO team improved and standardised the induction materials to fit into a 90-minute session, which all new sites are now required to receive when they join the NWCSP. Depending on the setting, different information (like how to complete DIY versus postal kits) can be ‘bolted on’ to the generic basic material.

Desired outcomes included:

  • More confident, engaged and active screening providers
  • Better quality of screens returned (for example fewer tests incorrectly done)
  • Greater cascading of knowledge to other colleagues
  1. 2.    Sexual health communication training

One of the main barriers identified in the research was that some providers, particularly those whose main remit was not sexual health, were apprehensive about raising the issue of chlamydia screening, particularly in unrelated situations. To overcome this barrier, the Central Office of Information (COI) was commissioned, with funding from the DH, to develop a bespoke training resource to help providers build their confidence and skills in discussing sexual health issues with young people.

The resulting ‘Talking Chlamydia’ workshop was designed to complement, rather than replace, the induction session delivered to new providers, which focuses more on the practical information necessary to carry out screening. This three-hour workshop, which can be delivered as three one-hour modules, focuses on skills, confidence and behaviour around discussing chlamydia screening with young people.

Training slide

Desired outcomes included:

  • Greater willingness from providers to offer chlamydia screening to young people
  • Increased confidence and sensitivity with which providers handle discussions around chlamydia screening and sexual health
  1. 1.    Personal catch-ups from the CSO

Proactive contact with screening sites, particularly those that are medium or low screeners, on a regular basis from a designated CSO Health Advisor would demonstrate interest in and support for providers, as well as allow the CSO to gather issues arising in practice and offer tailored advice to sites. Although Health Advisors had been contacting screening sites, this had not been done in a systematic or consistent way.

To help the CSO focus their efforts on those sites that had greatest potential to screen more actively, all screening sites were analysed and segmented based on footfall (or a proxy measure) of 15- to 24-year-olds and current engagement in or ‘warmth’ towards the NWCSP.

A contact strategy was then developed to set out when and how each segment of screening sites should be contacted by the CSO. For example, those sites that needed greater handholding or encouragement and had potential to return large numbers of screens would receive more frequent and direct (face-to-face or phone) contact. Those sites that were relatively prolific screeners or who were unlikely to ever return many screens would receive less frequent and direct (email) contact.

To help the CSO implement the contact plan and manage their growing network of sites, the CSO database was enhanced with automatic prompts to remind Health Advisers to contact each site at least once a month, and extra prompts were set for GP sites when their screening volumes fell below 5 per cent of registered 15- to 24-year-olds. A new field was added to the database to record any comments, feedback or follow-on actions required. An additional function was also added to the database to automatically send each site their monthly screening volumes and positivity rates.

Desired outcomes included:

  • More awareness, engagement and confidence in the NWCSP from providers
  • Stronger management and coordination of sites by the CSO
  • Continual adjustments and improvements to the NWCSP based on feedback from providers
  1. 2.    Quarterly newsletter

To keep the profile of the NWCSP high and to create a sense that chlamydia screening is an ongoing priority, a quarterly newsletter was developed for distribution to all sites. The newsletter provided updates on the programme’s progress (like latest screening levels, quarterly/annual targets and new initiatives), dates of events and training coming up, and tips on good practice. An anonymised league table was included to show how each site was performing in relation to others and to introduce an element of competition between the sites. Recognition was also given to high or enthusiastic screeners to encourage local screening ‘champions’ who may serve as role models for other sites.

Screening newsletter

Desired outcomes included:

  • More awareness and engagement in the NWCSP from providers
  • Greater cohesion and sense of joint working from NWCSP providers
  • Increased screening activity
  1. 1.    Promotional materials to display in screening sites

Providers requested more hard-hitting, appealing promotional materials to display alongside or instead of the NCSP materials, to catch the attention of young people and clearly signpost the chlamydia screening service within sites. Pharmacists in particularly were keen to receive fresh promotional materials to advertise that they were now offering free chlamydia screening to young people.

A range of locally branded materials, including posters, flyers, shelf wobblers and dump bins, were produced by a local website design and development company that also built the NWCSP client-facing website.

'1 in 12' Poster

Desired outcomes included:

  • Greater awareness and engagement in the NWCSP from screening providers and young people
  • Increased confidence and willingness with which providers offer chlamydia screening to young people
  1. 1.    Register-based pop-up reminders

For many providers whose main remit is not sexual health, chlamydia screening often slipped their minds in the face of competing priorities. To remind providers about chlamydia screening and to help normalise the practice of offering every 15- to 24-year-old a screen, register-based pop-up reminders were piloted in 3 GP clinics between June and August 2009. Given that GPs were now being paid per screen, the pop-up reminders were promoted as a way to increase their financial return.

Desired outcomes included:

  • Higher profile of chlamydia screening amongst GPs
  • More proactive and routine screening of young people for chlamydia within GPs


In June 2009, members of the Solutions Group pretested the improved and standardised induction materials, newsletter and promotional materials (which were also pretested with young people). The Talking Chlamydia workshop was formally pretested in September 2009 with a group of seven screening providers.



The interventions were launched at slightly different times depending on how quick and easy they were to develop and implement.

In June 2009, all new screening sites began receiving the improved induction session from CSO staff, which includes a presentation on the NCSP, epidemiology of chlamydia, how to screen and the payments process, with added bolt-ons with information for processing DIY packs, postal kits and paperwork. Slides were also adapted to represent both PCTs. 

Given the news that the NCSP was negotiating with EMIS (the clinical IT system used at 60 per cent of GP sites nationally) to install pop-up reminders on GP systems about chlamydia screening, a number of non-EMIS based GP clinics in Norfolk and Waveney were approached about piloting pop-up reminders as part of this project. Three GP clinics agreed to pilot pop-up reminders between June and August 2009. However, two clinics did not respond with any feedback at the end of the pilot. The third clinic reported that although offers were made to young people, there was a low return rate, with young people refusing on the grounds that they had screened sometime previously.

After analysing various newsletter formats and gathering feedback through a questionnaire circulated to all sites asking what format and content providers wanted, a newsletter was designed by the SHPU team which focused on the NWCSP programme, but also included key information on the wider SHPU work. In July 2009, the first newsletter was distributed as hard copies and electronically to all screening sites, and then at quarterly intervals.

The Talking Chlamydia workshop was piloted by COI in October 2009 with six GPs and nurses. Since the workshop was delivered as a three-hour session at the SHPU office in Norwich, those who accepted the invitation to participate tended to have a special interest in sexual health.

A range of materials, including posters, flyers, shelf wobblers and dump bins, were offered to all screening sites, but particularly to pharmacies, from December 2009. These are branded ‘Are you getting it’, to align with the look and feel of the NWCSP client-facing website.

During the project, the CSO focused on laying the groundwork for the new systematic contact process, producing a new contact plan and enhancing their database with prompts to remind staff to contact each site personally at set intervals. However, due to staff shortages the CSO postponed carrying out systematic, targeted follow-ups with all sites until after the project ended in March 2010.

Are you getting it? Poster



With support from the London School of Hygiene and Tropical Medicine (LSHTM), a three-part evaluation plan was designed.

Annotated time-series data

Annotated time-series data was looked at, which used routinely collected screening data to assess progress made by the interventions in increasing the volume of chlamydia screens.

The findings were very promising:

  • Chlamydia screening rates among 15- to 24-year olds increased from 3.8% in 07/08 to 16.15% in 09/10 in the Norfolk and Waveney area
  • The improved induction training for new sites coincided with a threefold increase in chlamydia screening volumes
    • The dissemination of promotional materials to pharmacies from December 2009 was followed by a 300 per cent increase in chlamydia screens taking place in pharmacies during the period autumn 2009 to February 2010
    • The data also indicated that general practices (the main provider type targeted) achieved the biggest increase in the number of completed chlamydia screens between April 2009 and March 2010

Post-intervention surveys

Post-intervention surveys were conducted to explore the extent to which the improved induction sessions and Talking Chlamydia workshops were seen as appropriate and useful by attendees.

Again, there were very positive findings:

  • The sessions and workshops were rated very highly by participants for their relevance, delivery and for meeting their objectives
  • According to a self-assessment of understanding, skills and ability by participants before and after the Talking Chlamydia pilot workshop, all respondents reported improvements on all three measures 

Retrospective in-depth interviews

Retrospective in-depth interviews were planned to be conducted by telephone with screening providers to examine their experiences and views of the interventions. Unfortunately due to time and resource constraints, these were not carried out in the end.

Follow Up


The scoping research findings have been shared with various other PCTs and the primary research findings were presented to the DH Sexual Health Board in late 2008 and helped inform national strategy.

The project has been presented as a case study at various academic and practitioner workshops and was included in the Government’s response to the sexual health strategy review in June 2009. The Talking Chlamydia training resource was presented as a poster at the Sixth Annual NCSP Conference, where it was awarded the Best Poster prize. The training resource is also currently downloadable from the NCSP website for providers to access free of charge. Following the project, the DH Sexual Health Team and NCSP expressed interest in rolling out the Talking Chlamydia training in other parts of the country, as well as replicating the concept of CSOs developing a contact strategy for better managing their network of screening sites.


The most effective components of the project have been integrated into the everyday workings of the NWCSP. Based on positive feedback from the Talking Chlamydia pilot, the CSO has continued to offer this workshop locally to providers interested in, or who may benefit most from, this additional training. The quarterly newsletter to all screening sites continues to be published and distributed by the SHPU and all promotional materials are ordered by providers in all settings on a regular basis.

Lessons learned

  • The scoping stage revealed a number of competing priorities for our interventions and there was a temptation to try and address them all. It was therefore important to identify the most important issue and target the audience most in need of our attention
  • Insight work has been crucial, as demonstrated by the expansion of the target audience to include GPs and other agencies. Insight work has shown that the assumed target audience for an intervention often will not be the most important one and that there are a range of people who might be important in contributing to a specific behavioural outcome
  • Roles and responsibilities of all those involved in a social marketing project should be clearly defined and agreed when planning work
  • Commissioners, programme coordinators and managers should also be fully cognisant of the impact the project will have on people’s workloads, so that staff can dedicate time to the project from the start
  • Communication was an issue as new terminology had to be learnt. Marketing language is very different to that of public health, even though in many cases different terms mean the same thing!

Key facts

Target audience





August 2007 to March 2010


NHS Norfolk; NHS Great Yarmouth and Waveney