Allison R, Lecky D M, Town K, Rugman C, Ricketts E J, Ockendon-Powell N, Folkard K A, Dunbar J K, McNulty C A M
Primary Care Unit, National Infection Service, Public Health England, Microbiology Dept, Gloucestershire Royal Hospital, Great Western Road, Gloucester, GL1 3NN, UK.
HIV/STI Department, Centre for Infectious Disease Control and Surveillance, Public Health England, London, UK.
BMC Fam Pract. 2017 Mar 21;18(1):43. doi: 10.1186/s12875-017-0618-0.
Chlamydia trachomatis (chlamydia) is the most commonly diagnosed sexually transmitted infection (STI) in England; approximately 70% of diagnoses are in sexually active young adults aged under 25. To facilitate opportunistic chlamydia screening in general practice, a complex intervention, based on a previously successful Chlamydia Intervention Randomised Trial (CIRT), was piloted in England. The modified intervention (3Cs and HIV) aimed to encourage general practice staff to routinely offer chlamydia testing to all 15-24 year olds regardless of the type of consultation. However, when the 3Cs (chlamydia screening, signposting to contraceptive services, free condoms) and HIV was offered to a large number of general practitioner (GP) surgeries across England, chlamydia screening was not significantly increased. This qualitative evaluation addresses the following aims: a) Explore why the modified intervention did not increase screening across all general practices. b) Suggest recommendations for future intervention implementation.
Phone interviews were carried out with 26 practice staff, at least 5 months after their initial educational workshop, exploring their opinions on the workshop and intervention implementation in the real world setting. Interview transcripts were thematically analysed and further examined using the fidelity of implementation model.
Participants who attended had a positive attitude towards the workshops, but attendee numbers were low. Often, the intervention content, as detailed in the educational workshops, was not adhered to: practice staff were unaware of any on-going trainer support; computer prompts were only added to the female contraception template; patients were not encouraged to complete the test immediately; complete chlamydia kits were not always readily available to the clinicians; and videos and posters were not utilised. Staff reported that financial incentives, themselves, were not a motivator; competing priorities and time were identified as major barriers.
Not adhering to the exact intervention model may explain the lack of significant increases in chlamydia screening. To increase fidelity of implementation outside of Randomised Controlled Trial (RCT) conditions, and consequently, improve likelihood of increased screening, future public health interventions in general practices need to have: more specific action planning within the educational workshop; computer prompts added to systems and used; all staff attending the workshop; and on-going practice staff support with feedback of progress on screening and diagnosis rates fed back to all staff.
沙眼衣原体（衣原体）是英国最常被诊断出的性传播感染（STI）；大约70%的诊断病例是25岁以下性活跃的年轻人。为了促进全科医疗中的衣原体机会性筛查，基于一项此前成功的衣原体干预随机试验（CIRT）开展了一项复杂干预措施，并在英国进行了试点。改良后的干预措施（3C和HIV）旨在鼓励全科医疗工作人员常规性地为所有15至24岁的年轻人提供衣原体检测，无论咨询类型如何。然而，当在英格兰的大量全科医生（GP）诊所提供3C（衣原体筛查、避孕服务指引、免费避孕套）和HIV相关内容时，衣原体筛查并未显著增加。这项定性评估旨在实现以下目标：a）探究改良后的干预措施为何未能在所有全科医疗中增加筛查。b）为未来干预措施的实施提出建议。
在初始教育研讨会至少5个月后，对26名诊所工作人员进行了电话访谈，探讨他们对研讨会以及在现实环境中干预措施实施情况的看法。对访谈记录进行了主题分析，并使用实施保真度模型进行了进一步研究。
参加研讨会的参与者对其持积极态度，但参会人数较少。通常，教育研讨会上详细阐述的干预内容并未得到遵循：诊所工作人员未意识到有任何持续的培训师支持；计算机提示仅添加到了女性避孕模板中；未鼓励患者立即完成检测；临床医生并非总能随时获得完整的衣原体检测试剂盒；视频和海报也未得到利用。工作人员表示，经济激励本身并非动力因素；相互竞争的优先事项和时间被视为主要障碍。
未严格遵循确切的干预模式可能解释了衣原体筛查未显著增加的原因。为了在随机对照试验（RCT）条件之外提高实施保真度，进而提高筛查增加的可能性，未来全科医疗中的公共卫生干预措施需要具备：教育研讨会上更具体的行动计划；添加到系统并使用的计算机提示；所有工作人员参加研讨会；以及对诊所工作人员的持续支持，并将筛查和诊断率的进展反馈给所有工作人员。
