Chlamydia Outreach Advice Screening and Treatment (COAST)
As part of England’s National Chlamydia Screening Programme, COAST (Chlamydia Outreach Advice Screening and Treatment) is an innovative, nurse-led scheme designed to make the detection and treatment of chlamydia a simple and straightforward process.
Established and funded by North East Lincolnshire Care Trust Plus and NHS North Lincolnshire, COAST offers free chlamydia screening and treatment to 15- to 24-year-olds living in Northern Lincolnshire. Designed with young people in mind, COAST offers screening at over 100 sites and the option to order a freepost DIY testing kit online or by text. The COAST team send results by text, email or mail, and offer to notify sexual partners on behalf of those who test positive. A branded promotional campaign and incentives are used to raise awareness and encourage young people to get tested.
In its first year, North East Lincolnshire screened 7.5 per cent of its 15- to 24-year-old population (higher than the 4.9 per cent average for England) and North Lincolnshire screened 3.8 per cent. By year three (2009/10), screening rates had increased to 26.4 per cent in North East Lincolnshire (exceeding that year’s target of 25 per cent), and 20.6 per cent in North Lincolnshire. Work is now underway to meet the 2010/11 government target of 35 per cent.
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 have serious long-term consequences, including ectopic pregnancy and infertility.
In 2003, the England Department of Health (DH) set up the National Chlamydia Screening Programme (NCSP) to ensure that all sexually active young people under 25 are aware of chlamydia, its effects, and have access to free and confidential testing services. The NCSP is made up of local screening programmes and responsibility for delivering the programme lies with individual Primary Care Trusts (PCTs).
In 2006, North East Lincolnshire Care Trust Plus (NELCTP) and NHS North Lincolnshire (NHSNL) decided to collaborate and establish one chlamydia screening programme that covers all of Northern Lincolnshire. A budget of £282,255 per year was assigned to the new programme using Choosing Health funding. In 2010 the team is made up of the coordinator for the programme, three health advisors and three administrator support positions.
As coordinator of the new programme, Paul Watson was given the freedom to develop the service from scratch by the two PCTs. With challenging government targets to screen 15 per cent of all 15- to 24-year-olds living in Northern Lincolnshire for chlamydia in its first year (increasing to 17 per cent in 2008/09, 25 per cent in 2009/10 and 35 per cent by 2010/11), Paul decided to take a social marketing approach to ensure that the programme was tailored for young people.
“For me the thing was always going to be – this has got to work for young people. I’ve got to fit the service around them, rather than expect them to fit into a service.” Paul Watson (COAST Coordinator)
Paul began by consulting local service providers, such as Choices (which provides health, sexual health and wellbeing services to young people) to capture their experiences about how best to engage with young people. He also set up a steering group with representatives from public health, health promotion, young peoples’ services, schools, youth centres, the Youth Offending Team, the Drug Intervention Programme, pharmacies and GPs.
The steering group decided that primary research was needed to develop appropriate and effective interventions to engage with young people and encourage them to take up chlamydia screening. Based on assessments of work conducted elsewhere, the team set a six month timescale to research and develop the new screening programme, with the aim of offering testing from 1 April 2007.
Research began with assessments of data on chlamydia screening from the area and elsewhere. This highlighted that amongst 15- to 24-year-olds, uptake of chlamydia screening was particularly low amongst males. Although the programme is aimed at all 15- to 24-year-olds, the steering group decided to develop interventions specifically targeted at males in this age group. Screening sites and service providers were also recognised as important stakeholders and were therefore established as the secondary target audience that the programme would need to engage.
Having consulted with local service providers in the area about how best to engage with young people, three focus groups were conducted in a variety of settings, including community cafes, drop-ins and local further education (FE) colleges. This research helped the project team understand young people’s lives, including their attitudes towards the sensitive issue of chlamydia screening. It was within one of these focus groups that a 15-year-old girl came up with the name for the new programme: COAST (Chlamydia Outreach Advice Screening and Treatment).
Between late 2006 and early 2007, 30 one-to-one interviews were also conducted with students from Barton on Humber and North Lindsey College to establish the most effective methods of getting the chlamydia screening message across and encouraging young people to use the service.
The research identified a number of perceived and actual barriers to screening, such as:
- Lack of knowledge about screening sites
- Belief that screening involves an embarrassing examination, or is expensive
- Fear of testing positive and having to tell previous partners
- Worry that others would find out about the test when the results are delivered
A key insight was that peace of mind was an important motivator for young people to get tested, but without a service that meets their needs, this was not enough in itself. Young people said they wanted a “cool”, nurse-led service that did not involve any "men in white coats". They wanted one point of contact for advice, screening and treatment, and treatment had to be quick, easy and offered “where we are, when we are”. Text messaging was the preferred way of receiving test results, and since young people worried about informing previous sexual partners if they tested positive for chlamydia, they wanted support in this area.
With the benefit of being able to create the screening programme from scratch, the steering group were able to use these findings and insights to build a programme that was flexible and met the needs of young people in the area. Screening needed to be offered in a variety of settings to reach a wide range of young people. In addition to healthcare settings, screening should be available in non-health venues where young people spent their time, such as colleges, youth centres and sports clubs.
Representatives from the steering group identified that service providers would face a number of barriers to offering screening on behalf of COAST, particularly lack of time, heavy workloads and competing priorities. The COAST team therefore had to make the screening process as quick and simple as possible for frontline staff and provide a total patient care pathway, where COAST handled treatment and contact management for those who test positive. Incentives would also help to make participation in COAST attractive to providers.
In consultation with the steering group, the COAST team developed a screening programme that was directly informed by findings from the research with young people. The team continually fed back to the steering group as part of an iterative development process, making refinements where necessary.
Service design and delivery
Research suggested that concerns about cost and inconvenient locations were major barriers to young people being screened for chlamydia. Screening therefore needed to be offered free at a large number of venues in different settings across Northern Lincolnshire, so that young people could choose where and when to be screened, without needing to attend a special clinic.
GP surgeries that join COAST would be offered a range of benefits to incentivise participation in the programme. Staff would no longer need to generate prescriptions for patients aged 15 to 24, make referrals to sexual health units, or worry about tracing partners registered with other GP clinics. To make the screening process as quick and simple as possible, practice nurses would be provided all the necessary screening tools in a bag (‘clinic in a bag’). The COAST team would manage all client treatments and follow-up of sexual partners for those diagnosed as positive. Using the TPP SystmOne (the IT system used for electronic patient records by local GPs), COAST would be able to link all primary care users and ensure that records could be accessed cost-free by GPs across the local area. As an additional incentive, the most active screening site in each PCT would be offered free attendance to the annual NCSP conference, including free travel and overnight accommodation.
To make screening as accessible and convenient as possible for young people, DIY testing kits would also be available from collection points at venues that have a high footfall of young people. Without the need to make an appointment or have an embarrassing or awkward conversation with a ‘professional’, a young person could complete the test him/herself by simply peeing in the pot and completing the lab form contained in the kit. Instructions would be included as a pictorial step-by-step guide for those who have low literacy skills or who do not have English as a first language. The young person could then anonymously submit the completed test kit in the post using the freepost envelope provided.
Results would be sent to patients within seven working days via post, email, telephone or text message, whichever they prefer. If clients request a text message and their results prove negative, they would be sent the message ‘The COAST is clear’. For those who test positive, they would be asked to contact the COAST team at their earliest convenience and free treatment (a course of antibiotics) would be provided at a time and place that the user wants, such as a school or car park. The nurses at COAST would also help track down and inform any previous sexual partners and encourage them to be tested for chlamydia too.
Since many of the young people consulted during the research lacked knowledge about the chlamydia screening process, outreach activities and tutorials would be delivered at colleges to educate students on what a chlamydia test actually involves, where it is offered, and why they should get tested. Students would also be given the option of getting screened right there and then.
To raise awareness of chlamydia and the new programme, a localised brand was developed for COAST. A local graphic design company was commissioned to create sample logos and images for promotional material and the website, which were then voted on by young people. The team found this an extremely rewarding process as it revealed the gap between professional opinions of what would be effective and what users actually relate to and like, underscoring the importance of pre-testing before implementing.
Branded promotional material, such as posters and leaflets, would be distributed at locations where young people hang out. Since males were a key target group, promotional materials specifically aimed at young men were developed, using the football-related theme ‘Get your tackle tested’ and the image of a naked male torso with a football strategically placed over his ‘tackle’. Advertisements about COAST would also be broadcasted on radio channels popular with young people.
The COAST programme began screening in April 2007. The COAST team developed a thorough delivery plan and hold monthly meetings with the steering group to ensure that all the elements of the programme are prepared and delivered in a coordinated fashion.
“We had a delivery plan, and everything in the plan was red, amber, green, so we knew where there was progression. That was for the whole set up of the project, not just the user engagement and publicity, but getting the staff involved, making sure the IT was working before we started screening. Literally everything was there.” Paul Watson (COAST Coordinator)
To maintain engagement with key stakeholders, the COAST team provide regular feedback via monthly newsletters and visits to screening sites at least twice a year. Every month the team also send each site its screening figures, so that providers can see the impact they are having and keep track on how well they are performing.
With the programme set up to meet young people’s needs, there has been a big push to promote COAST and encourage the target audience to get tested. Eye-catching branded posters, leaflets and beer mats have been distributed at places popular with the target audience, such as hairdressers, nail salons and tanning salons for females, and football grounds and pubs for males.
Special efforts have been made to reach young males. COAST has worked with local football teams Grimsby Town FC and Scunthorpe United FC to publicise the screening programme. Full-page advertisements have been placed in match day programmes and A4 laminated posters in all toilets around the grounds. A ‘Get Your Tackle Tested’ match was held, during which players wore t-shirts with the slogan and COAST logo on the back, and young volunteers went out into the crowd to talk to young males. This resulted in over 70 requests for freepost testing kits. Urinal stickers have also been developed to create a talking point around chlamydia screening – these have been designed to change colour when urinated on to reveal a helpful reminder to ‘Get Your Tackle Tested’.
A number of innovative campaigns have been run to engage with young people and incentivise them to get tested. From September to December 2007, COAST ran a ‘Wee for a Wii’ competition, where any young person tested for chlamydia during those months were entered in a prize draw for a Wii games console. During summer 2009, COAST launched the ‘Pee 4 Pants’ campaign at the Freshers’ Fayre at Grimsby Institute and at a Grimsby Town FC home game. Free branded pants and boxer shorts were given to all young people who were screened. The underwear was branded ‘My tackle’s been tested’ for young men and ‘Squeaky Clean’ for young women, with logos woven into the waistband.
“This is a fun way to encourage young people to access chlamydia screening… We hope wearing the pants will be a reminder of the importance of using condoms and, of course, ensure that they undertake regular chlamydia screening.” Paul Watson (COAST Coordinator)
‘Pee for Pants’ has proved to be COAST’s most successful campaign to date and the programme has now produced its third version of the promotional underwear. Special themed underwear was even designed for the 2010 football World Cup. The success of this campaign has shown the value of incentives and suggests that smaller guaranteed gifts (such as the branded pants) can be more effective than a prize draw for a larger, more valuable reward (such as a Wii games console).
“The most successful has been things like ‘Pee for Pants’…We’re on our third lot now, and they do make a difference, because when we’ve gone into colleges without them the uptake hasn’t been great. Incentives for testing do work.” Paul Watson (COAST Coordinator)
Radio advertising was broadcasted five times on Viking FM in week-long slots between Valentine’s Day 2008 until February 2009. This was supported by the Viking Street Team, who attended community events (such as local football league matches and a bikers’ night) and completed freepost request cards. The radio advertising was discontinued after being assessed as having limited impact. The messages were either not reaching the target audience or not effective enough to spur them to act.
An audit carried out in 2008 with young people screening positive for chlamydia revealed a high degree of unprotected sex with multiple partners in North East Lincolnshire and North Lincolnshire (NEL 83%, NL 60% not using a condom for last sexual encounter; NEL 83%, NL 63% reporting unprotected sex with all partners - see ‘Results’). COAST has used this insight to work more closely with the C-Card scheme and contraceptive services to ensure tighter coordination of delivery. C-cards are now given to all those who have been tested positive for chlamydia.
The COAST website was launched in 2008. Following feedback from users that they would like to be able to request free testing kits online, the website was upgraded to allow this function. This has proved particularly popular for young people who are employed full-time and may not have access to traditional screening sites, as well as those in rural areas who may be geographically isolated. It also allows the user to request a kit at any time, day or night.
Following the success of the online ordering system for free testing kits, the ‘text to test’ scheme was launched in spring 2009, allowing young people to request a freepost kit by texting COAST, their name and address to 83010.
The COAST team have visited various local colleges to talk to individual tutor groups and offer chlamydia screening on site. Outreach activities have generally been successful, usually with at least 50 per cent of students in each tutorial taking a chlamydia test.
In an effort to involve young people in the programme, local college students were recruited to develop a DVD as part of their media studies about COAST and the screening and treatment process. Launched in summer 2009, the DVD is available on the COAST website and has been circulated to all partner organisations who deliver sex and relationship education in local secondary schools.
COAST is being monitored and evaluated in a number of ways:
- All screening data (including age and gender of young people screened and number of screens administered by individual screening sites) is collected on a quarterly basis for the NCSP, allowing screening figures to be compared against annual targets and previous performance.
In Year 1 (2007/08) North East Lincolnshire (NEL) screened 7.5 per cent of its 15- to 24-year-old population (higher than the England average of 4.9 per cent) and North Lincolnshire (NL) screened 3.8 per cent.
Year 2 (2008/09) NEL screened 17.6 per cent of its 15- to 24-year-old population (reaching the 2009 target of 17 per cent) and NL screened 13.2 per cent.
In Year 3 (2009/10) NEL screened 26.4 per cent of its 15- to 24-year-old population (exceeding the 2010 target of 25 per cent) and NL screened 20.4 per cent.
- An audit of all clients who test positive is carried out for the NCSP as part of its Patient and Partner Notification and Management dataset and is conducted four times a year. The programme advises that 0.6 contacts per case are treated. In 2009/10, COAST achieved 0.4 for NEL and 0.4 for NL, down from previous years when the rates had been higher than the national average. The COAST team are therefore reassessing its contact tracing capability and process. Nevertheless, this audit has highlighted a key success for COAST with both NEL and NL achieving 100 per cent of chlamydia positive index cases receiving treatment in 2008/09 and 2009/10.
- User surveys have been used on a number of occasions at local colleges and schools to gather information on topics such as STI awareness, treatment preferences and media channels used. Recognising that those who attend schools and colleges may be more educated and motivated to get screened, the COAST team are exploring ways of gathering wider user data.
- As part of the team’s efforts to incorporate the DH’s ‘You’re Welcome Quality Criteria’ (principles to support health services in becoming young people friendly), a 21-year-old male was recruited to assess COAST’s materials and website from a young person’s perspective, analyse results from patient satisfaction surveys (completed by 57 young people), and ‘mystery shop’ at a number of screening sites. Following this exercise, he produced a report in September 2010 and the findings are being fed into further developments for the screening programme.
In 2010/11 COAST will be refining its internal audit processes and working alongside the NCSP Regional Facilitator to develop an audit tool that it can be used across all 12 programmes in Yorkshire and Humber. This will enable COAST to benchmark its work against other local screening programmes in the region.
The findings from the young person’s assessment have been formally presented together with the latest screening rates to the steering group and key stakeholders, as well as at a recent regional meeting. The author of the assessment, Ben Kirton, was nominated in January 2011 for the Brook Young Person of the Year Award for the work he had conducted with COAST. Brook is the country's largest young people's sexual health charity.
A key focus of the programme, which has also been the biggest challenge, is keeping young people engaged and ensuring that professionals take on board their opinions. Consequently, the COAST team regularly feedback and consult with both the steering group and target audience on the programme. Plans are underway to recruit a young persons’ representative to sit on the steering group, which will help secure young peoples’ input in the programme.
“I had to be decisive and strong enough to say ‘no’ to the steering group, saying that ‘this is right and that I have to check back with the young people. Unless you bring me absolute solid evidence why this won’t work, we’re going with the young persons’ opinions’.” Paul Watson (COAST Coordinator)
COAST is working to ensure that the programme is sustainable and able to achieve the challenging 2010/11 target of screening 35 per cent of its 15- to 24-year-old population. Efforts have focused on core services (namely GP clinics, community pharmacies and community sexual health and contraceptive services) to integrate chlamydia screening into existing services and maximise opportunistic screening opportunities.
“To make sure it’s sustainable, we’re embedding a lot of this now into core screening sites - to get them to use an opt out, not an opt in approach - we want the majority of tests to come from screening sites and not the programme. It’s all well and good me going down to the local college and getting 500 screens, but I can’t do that week in and week out. It’s about pushing core services to up their screening volumes. It’s about taking the opportunity when young people come to them, so GP practices for example. It’s about saying, ‘well you’re here for a verruca, but actually I can see you haven’t done a chlamydia test recently, so let’s do it while you’re here’.” Paul Watson (COAST Coordinator)
In light of future reductions in public sector funding, COAST is assessing alternative delivery models, including the possibility of becoming part of a social enterprise.
The COAST team were fortunate to have been able to build the screening programme from scratch with the target audience in mind, thereby avoiding the challenges and resistance associated with adjusting an existing service.
“I think the advantage was I had a blank sheet of paper to work with. There was no history, no ‘oh my god this imaging looks bad, we’re going to have to change it, how much is that going to cost?’” Paul Watson (COAST Coordinator)
Working with young people is both imperative and part of the challenge of delivering a programme like COAST. Maintaining their engagement when there is plenty of competition is a constant challenge. One initiative that has not yet been used for COAST but has been trialled by SHOUT (Sexual Health Outreach Team), which runs in parallel with COAST, is a young persons’ panel that is used alongside a professional panel when employing new staff for the programme. This has been considered very successful and has allowed young people to feel ownership of a programme. Any future staff employed for the COAST team will be interviewed with a young persons’ panel.
Young people value consistency in brand image. COAST recently considered changing its branding and imagery, but decided against it when they consulted with young people and found that they recognised the COAST brand, knew what it stood for and did not want it to change. Although the imagery used is now tailored for particular segments of the target audience, the overarching COAST brand is maintained.
Some other lessons that the COAST team have found include:
- Freepost kits and incentives are very successful at engaging and motivating young people to get tested for chlamydia
- Clients prefer the ‘pee in a pot’ approach, which is quick, easy and painless
- Young people prefer to receive their results by text message, which is also financially the best option for the programme
- Sustained targeted advertising is essential to keep chlamydia screening relevant and top-of-mind
- Result to treatment time is critical
- Partner notification is more effective if undertaken by the nursing team rather than the young person.