‘It Opened My Eyes’—examining the impact of a multifaceted chlamydia testing intervention on general practitioners using Normalization Process Theory

‘It Opened My Eyes’—examining the impact of a multifaceted chlamydia testing intervention... Abstract Background Chlamydia is the most common notifiable sexually transmissible infection in Australia. Left untreated, it can develop into pelvic inflammatory disease and infertility. The majority of notifications come from general practice and it is ideally situated to test young Australians. Objectives The Australian Chlamydia Control Effectiveness Pilot (ACCEPt) was a multifaceted intervention that aimed to reduce chlamydia prevalence by increasing testing in 16- to 29-year-olds attending general practice. GPs were interviewed to describe the effectiveness of the ACCEPt intervention in integrating chlamydia testing into routine practice using Normalization Process Theory (NPT). Methods GPs were purposively selected based on age, gender, geographic location and size of practice at baseline and midpoint. Interview data were analysed regarding the intervention components and results were interpreted using NPT. Results A total of 44 GPs at baseline and 24 at midpoint were interviewed. Most GPs reported offering a test based on age at midpoint versus offering a test based on symptoms or patient request at baseline. Quarterly feedback was the most significant ACCEPt component for facilitating a chlamydia test. Conclusions The ACCEPt intervention has been able to moderately normalize chlamydia testing among GPs, although the components had varying levels of effectiveness. NPT can demonstrate the effective implementation of an intervention in general practice and has been valuable in understanding which components are essential and which components can be improved upon. Chlamydia infections, general practice, normalization process theory Introduction Chlamydia is the most common notifiable sexually transmissible infection (STI) in Australia, with notification rates quadrupling in the last decade and a half (1). The majority of notifications come from general practice (2) but ≤10% of 15- to 29-year-olds are tested in this setting (3). The asymptomatic nature of chlamydia leads to inadvertent transmission to sexual partners. Untreated infections have serious sequelae, including pelvic inflammatory disease and infertility in women (4), and epididymo-orchitis in men (5), and can act as a cofactor in human immunodeficiency virus transmission (6). GPs report many barriers to testing (7), including the lack of consultation time, heavy workload and lack of resources, resulting in low testing coverage. Education initiatives or GP incentives to overcome these barriers have had limited success (7). Additionally, Australian general practices operate as small businesses and charge higher fees to cover costs (8). Further limitations for young people include these associated costs (9) and discomfort with asking for a test (10). Prior research found the most effective facilitator was an age-based offer of a chlamydia test and was associated with a systems change across the entire clinic (11). Methods Overview of the Australian Chlamydia Control Effectiveness Pilot The Australian Chlamydia Control Effectiveness Pilot (ACCEPt) is a cluster randomized control trial in general practices in rural towns across four states—Victoria, New South Wales, Queensland and South Australia (12). The aim of ACCEPt is to determine if a multifaceted intervention can increase testing to sufficiently high levels to decrease the prevalence of chlamydia in men and women aged 16–29 years. Each town constitutes a cluster and was randomized into the control or intervention after the first prevalence survey, and prevalence was measured again after the intervention period. Briefly, ACCEPt is primarily targeted to GPs and uses computer alerts, education resources, financial incentives, recall system support, visual media (posters and reminder cards), and quarterly feedback to increase testing rates in the intervention arm. Another component of ACCEPt focusses on practice nurses; nurse perspectives and GP perspectives on nurses in ACCEPt and chlamydia testing have been previously published (13,14). These materials were tailored to the needs of the practice and the GP. We conducted interviews with a sample of participating GPs prior to randomization (‘baseline’) and halfway through the intervention period (‘midpoint’) to explore factors influencing the offer of a chlamydia test, assess the feasibility of the intervention and modify trial components to facilitate testing. Selection of participants After enrolment to ACCEPt and prior to randomization to the control or intervention arms, GPs in all towns were purposively selected by accounting for location, age and gender of the GP and the size of the practice to maximize the breadth of views. One GP from half of the towns enrolled in ACCEPt in each state was interviewed at baseline. Midpoint interviews were conducted with GPs from half of the intervention towns in each state after 1 year in the intervention; GPs from control towns were not interviewed at midpoint. Interview schedule A semi-structured interview schedule was developed, reviewed by the investigators for face and content validity, and pilot-tested on two GPs (see supplementary material). Baseline interviews covered the GP’s general experience with preventive health screening programmes, chlamydia testing and research. The midpoint interviews were informed by baseline data and focused on the GP’s experiences with ACCEPt. Interviews were conducted with analysis occurring concurrently until thematic saturation was reached. Normalization Process Theory To increase the effectiveness of the ACCEPt intervention, Normalization Process Theory (NPT) was used as a framework to guide the implementation of the project and assisted with the interview analysis (Table 1). NPT was developed to explain how new or modified practices are successfully integrated into routine practice in a clinical setting (15). The theory has four elements: coherence (understanding of the intervention by clinic staff), cognitive participation (commitment and engagement to the intervention), collective action (work carried out to make the intervention function) and reflexive monitoring (evaluation of the intervention). While NPT addresses a whole-of-clinic approach, the focus of this paper is on the GPs (Table 1) (16). Table 1. Overview of Normalization Process Theory (NPT) and as modelled by the Australian Chlamydia Control Effectiveness Pilot (ACCEPt). (Adapted from the NPT website: www.normalizationprocess.org.) Element Coherence Cognitive participation Collective action Reflexive monitoring NPT Have participants ascribed meaning to the intervention by? 1) Differentiating it from current practices 2) Understand its objectives, values and benefits 3) Comprehend what the individual tasks and responsibilities are Are the participants willing to invest time and energy into the problem by? 1) Driving the new practice forward 2) Contributing to the work 3) Defining the actions and procedures necessary to sustain the practice Are the participants producing and reproducing the actions required to make the intervention function by? 1) Dividing up the labour as needed 2) Integrating protocols into the workplace Have they examined why the intervention is/is not working by? 1) Evaluating the effectiveness and usefulness of the intervention 2) Modifying actions to increase effectiveness NPT as addressed in ACCEPt Do the GPs understand the benefits of an annual chlamydia test? How does it differ from the usual practice of testing based on symptoms or patient request? What will they need to do in order to test more young people? Is it feasible to include sexual health in a consult? What tasks need to be done to increase testing? By whom? Is the practice sustainable? Do the GPs have the support of other staff and management to increase chlamydia testing? Are there enough resources and training? Are the tasks appropriately allocated to the clinic staff? Are the GPs increasing testing rates? Are the GPs receiving feedback on their performance? Are they able to modify their practices in response to the feedback? Element Coherence Cognitive participation Collective action Reflexive monitoring NPT Have participants ascribed meaning to the intervention by? 1) Differentiating it from current practices 2) Understand its objectives, values and benefits 3) Comprehend what the individual tasks and responsibilities are Are the participants willing to invest time and energy into the problem by? 1) Driving the new practice forward 2) Contributing to the work 3) Defining the actions and procedures necessary to sustain the practice Are the participants producing and reproducing the actions required to make the intervention function by? 1) Dividing up the labour as needed 2) Integrating protocols into the workplace Have they examined why the intervention is/is not working by? 1) Evaluating the effectiveness and usefulness of the intervention 2) Modifying actions to increase effectiveness NPT as addressed in ACCEPt Do the GPs understand the benefits of an annual chlamydia test? How does it differ from the usual practice of testing based on symptoms or patient request? What will they need to do in order to test more young people? Is it feasible to include sexual health in a consult? What tasks need to be done to increase testing? By whom? Is the practice sustainable? Do the GPs have the support of other staff and management to increase chlamydia testing? Are there enough resources and training? Are the tasks appropriately allocated to the clinic staff? Are the GPs increasing testing rates? Are the GPs receiving feedback on their performance? Are they able to modify their practices in response to the feedback? View Large Table 1. Overview of Normalization Process Theory (NPT) and as modelled by the Australian Chlamydia Control Effectiveness Pilot (ACCEPt). (Adapted from the NPT website: www.normalizationprocess.org.) Element Coherence Cognitive participation Collective action Reflexive monitoring NPT Have participants ascribed meaning to the intervention by? 1) Differentiating it from current practices 2) Understand its objectives, values and benefits 3) Comprehend what the individual tasks and responsibilities are Are the participants willing to invest time and energy into the problem by? 1) Driving the new practice forward 2) Contributing to the work 3) Defining the actions and procedures necessary to sustain the practice Are the participants producing and reproducing the actions required to make the intervention function by? 1) Dividing up the labour as needed 2) Integrating protocols into the workplace Have they examined why the intervention is/is not working by? 1) Evaluating the effectiveness and usefulness of the intervention 2) Modifying actions to increase effectiveness NPT as addressed in ACCEPt Do the GPs understand the benefits of an annual chlamydia test? How does it differ from the usual practice of testing based on symptoms or patient request? What will they need to do in order to test more young people? Is it feasible to include sexual health in a consult? What tasks need to be done to increase testing? By whom? Is the practice sustainable? Do the GPs have the support of other staff and management to increase chlamydia testing? Are there enough resources and training? Are the tasks appropriately allocated to the clinic staff? Are the GPs increasing testing rates? Are the GPs receiving feedback on their performance? Are they able to modify their practices in response to the feedback? Element Coherence Cognitive participation Collective action Reflexive monitoring NPT Have participants ascribed meaning to the intervention by? 1) Differentiating it from current practices 2) Understand its objectives, values and benefits 3) Comprehend what the individual tasks and responsibilities are Are the participants willing to invest time and energy into the problem by? 1) Driving the new practice forward 2) Contributing to the work 3) Defining the actions and procedures necessary to sustain the practice Are the participants producing and reproducing the actions required to make the intervention function by? 1) Dividing up the labour as needed 2) Integrating protocols into the workplace Have they examined why the intervention is/is not working by? 1) Evaluating the effectiveness and usefulness of the intervention 2) Modifying actions to increase effectiveness NPT as addressed in ACCEPt Do the GPs understand the benefits of an annual chlamydia test? How does it differ from the usual practice of testing based on symptoms or patient request? What will they need to do in order to test more young people? Is it feasible to include sexual health in a consult? What tasks need to be done to increase testing? By whom? Is the practice sustainable? Do the GPs have the support of other staff and management to increase chlamydia testing? Are there enough resources and training? Are the tasks appropriately allocated to the clinic staff? Are the GPs increasing testing rates? Are the GPs receiving feedback on their performance? Are they able to modify their practices in response to the feedback? View Large Data collection and analysis GPs were initially contacted by telephone at the clinic, with a minimum of two attempts per GP between 2011 and 2014. Telephone interviews were conducted by an ACCEPt research officer (AV) and a PhD student (AY), with consent obtained verbally, and recorded and transcribed; GPs were reimbursed with a $100 voucher for their time. Participants did not have any interactions with the interviewer prior to the interview but were aware that the female interviewers were part of the research team and provided participants with additional strategies to increase testing, or advised other research team members to follow up if requested by the participant. Transcripts were compared with audio recordings for clarification (AY). Coding was completed using NVivo (QSR International, Melbourne, Australia) and analysed using a two-step process (AY). Firstly, data were examined regarding the specific intervention components to better understand the contributions of ACCEPt to the normalization of the testing process—financial incentives, quarterly feedback, recall system, education resources, visual media and computer alert. Primary analysis involved highlighting content, grouping and labelling these components and secondary analysis was conducted for emerging themes. A selection of the interviews was then given to an experienced qualitative researcher (MTS) to verify codes and themes found during primary and secondary analyses. Discussion of codes and themes was undertaken until a consensus was reached (AY and MTS). Additionally, data were interpreted using the four elements of NPT—coherence, cognitive participation, collective action and reflexive monitoring—to examine changes in the acceptability of ACCEPt between baseline and midpoint. Results A total of 44 out of 63 GPs contacted at baseline and 24 out of 38 GPs contacted at midpoint participated in an interview (Table 2). Table 2. General practitioner characteristics at baseline and midpoint Baseline n = 44 (%) Midpoint n = 24 (%) Gender of GP Male 29 (65.9) 11 (45.8) Female 15 (34.1) 13 (54.2) Location of GP Victoria – Metro 5 (11.4) 3 (12.5) Victoria – Rural new 15 (34.1) 6 (25.0) South Wales – Rural 11 (25.0) 10 (41.7) Queensland – Rural 10 (22.7) 3 (12.5) South Australia – Rural 3 (6.8) 2 (8.3) Size of practice ≤4 25 (56.8) 10 (41.7) Number of GPs >4 19 (43.2) 14 (58.3) Age of GP (years) <30 3 (6.8) 4 (16.7) 30–44 19 (43.2) 10 (41.7) 45–59 19 (43.2) 10 (41.7) 60+ 3 (6.8) – Years in general practice <5 10 (22.7) 12 (50.0) 5–19 19 (43.2) 7 (29.2) 20+ 15 (34.1) 5 (20.8) Employment statusa Full-time 37 (86.0) 17 (70.8) Part-time 6 (14.0) 7 (29.2) Postgraduate qualifications Yes 35 (79.5) 16 (66.7) No 9 (20.5) 8 (33.3) Baseline n = 44 (%) Midpoint n = 24 (%) Gender of GP Male 29 (65.9) 11 (45.8) Female 15 (34.1) 13 (54.2) Location of GP Victoria – Metro 5 (11.4) 3 (12.5) Victoria – Rural new 15 (34.1) 6 (25.0) South Wales – Rural 11 (25.0) 10 (41.7) Queensland – Rural 10 (22.7) 3 (12.5) South Australia – Rural 3 (6.8) 2 (8.3) Size of practice ≤4 25 (56.8) 10 (41.7) Number of GPs >4 19 (43.2) 14 (58.3) Age of GP (years) <30 3 (6.8) 4 (16.7) 30–44 19 (43.2) 10 (41.7) 45–59 19 (43.2) 10 (41.7) 60+ 3 (6.8) – Years in general practice <5 10 (22.7) 12 (50.0) 5–19 19 (43.2) 7 (29.2) 20+ 15 (34.1) 5 (20.8) Employment statusa Full-time 37 (86.0) 17 (70.8) Part-time 6 (14.0) 7 (29.2) Postgraduate qualifications Yes 35 (79.5) 16 (66.7) No 9 (20.5) 8 (33.3) aUnknown at baseline. View Large Table 2. General practitioner characteristics at baseline and midpoint Baseline n = 44 (%) Midpoint n = 24 (%) Gender of GP Male 29 (65.9) 11 (45.8) Female 15 (34.1) 13 (54.2) Location of GP Victoria – Metro 5 (11.4) 3 (12.5) Victoria – Rural new 15 (34.1) 6 (25.0) South Wales – Rural 11 (25.0) 10 (41.7) Queensland – Rural 10 (22.7) 3 (12.5) South Australia – Rural 3 (6.8) 2 (8.3) Size of practice ≤4 25 (56.8) 10 (41.7) Number of GPs >4 19 (43.2) 14 (58.3) Age of GP (years) <30 3 (6.8) 4 (16.7) 30–44 19 (43.2) 10 (41.7) 45–59 19 (43.2) 10 (41.7) 60+ 3 (6.8) – Years in general practice <5 10 (22.7) 12 (50.0) 5–19 19 (43.2) 7 (29.2) 20+ 15 (34.1) 5 (20.8) Employment statusa Full-time 37 (86.0) 17 (70.8) Part-time 6 (14.0) 7 (29.2) Postgraduate qualifications Yes 35 (79.5) 16 (66.7) No 9 (20.5) 8 (33.3) Baseline n = 44 (%) Midpoint n = 24 (%) Gender of GP Male 29 (65.9) 11 (45.8) Female 15 (34.1) 13 (54.2) Location of GP Victoria – Metro 5 (11.4) 3 (12.5) Victoria – Rural new 15 (34.1) 6 (25.0) South Wales – Rural 11 (25.0) 10 (41.7) Queensland – Rural 10 (22.7) 3 (12.5) South Australia – Rural 3 (6.8) 2 (8.3) Size of practice ≤4 25 (56.8) 10 (41.7) Number of GPs >4 19 (43.2) 14 (58.3) Age of GP (years) <30 3 (6.8) 4 (16.7) 30–44 19 (43.2) 10 (41.7) 45–59 19 (43.2) 10 (41.7) 60+ 3 (6.8) – Years in general practice <5 10 (22.7) 12 (50.0) 5–19 19 (43.2) 7 (29.2) 20+ 15 (34.1) 5 (20.8) Employment statusa Full-time 37 (86.0) 17 (70.8) Part-time 6 (14.0) 7 (29.2) Postgraduate qualifications Yes 35 (79.5) 16 (66.7) No 9 (20.5) 8 (33.3) aUnknown at baseline. View Large Normalization of chlamydia testing: impact of the Australian Chlamydia Control Effectiveness Pilot components The midpoint interviews investigated the contribution of ACCEPt towards integrating chlamydia testing into routine practice. Financial incentives The financial incentives recognized the value of the GP’s work, thereby reinforcing the responsibility to test the age group but GPs also identified that the amount per test was too small to be noticeable, and many could not recall receiving incentives directly from ACCEPt. Some felt that the incentives were unnecessary as testing was part of everyday care but were appreciated, and reported higher incentives would be more memorable. When asked which component had the most impact, financial incentives were rarely mentioned. Midpoint GP 12: I think it makes you, probably when you are suddenly overloaded with all this stuff, there is a lot of non-paid work that you know, maybe it would make you think, ‘Look I am getting paid for that, I have got a bit of responsibility for that.’ Midpoint GP 37: Is it necessary? I don’t think so, I mean you really are just telling us to do our job, and do our job better. I feel I am benefitting the community by actually doing what you guys are trying to do...I think it should be a bit more, because it’s 10 bucks for everyone you get, and you might have it more in the forefront of your mind. Recall systems and support Chlamydia recall systems were often informal and relied on the GP to manually add the reminder, resulting in inconsistent systems; one GP noted that her practice was shifting to more part-time GPs and needed a more cohesive system. Recall systems were considered prohibitively expensive or not useful for chlamydia because it relied on the patient returning. In practices with a formal system, recalls were easier to implement because of prior infrastructure. Midpoint GP 32: We would just do that manually. As results come through, if we do need to follow people up then we check them. I usually make patient follow up arrangements at the time of requesting the test, if they are of an age where I am testing for chlamydia but for instance they still live at home with their parents, I make sure that I have a current number, so a mobile phone number rather than the family landline. Education resources Resources included an education folder containing peer-reviewed publications and testing tools, information about partner notification, STI management guideline handbook and patient information sheets. Initially, the education resources were useful as they raised the overall level of knowledge and awareness, but then required too much physical space or were not readily accessed. Midpoint GP 12: I think it [education and resources] certainly raised my awareness…I attempt to routinely and I don’t always do it, to routinely screen everyone who comes in for a pap smear or a contraceptive advice. Or for other things in that age group I try to target, I think it has increased my awareness, it has been very helpful. I think our education from the ACCEPt team has been very good. Midpoint GP 4: I don’t actually use them. I get things off, generally I print things off the computer if I want to get anyone any information about things. I just find tear-offs pads get lost in the bottom drawer and never can find the right one at the right time. Visual media and computer alert The visual media—colourful posters and business card-sized reminders—were acceptable to GPs. The posters were placed in waiting rooms, where patients became aware of an ongoing chlamydia campaign. This was useful in non-sexual health-related consultations but eventually blended into the scenery. Reaction to the computer alert was mixed; some found the alert irritating and turned it off while others found that it jogged their memory. Both components reminded the GP that the patient was in the eligible age group and introduced the offer of a test using nondiscriminatory language. Midpoint GP 3: I can’t remember looking at it in the last few months. We have got posters on the wall and they are there and after the first time I no longer see them. Walk past them five to ten times per day. Midpoint GP 13: Honestly the best is this side-bar [computer alert] because it comes up, it pops in front of your head every time you open a file in that age group. Even if they come in for a cold you are prompted into saying something. Role of nurses Many GPs were unaware if the nurses in their practice were involved in ACCEPt. Alternatively, their practice was not structured in a way where nurses could see patients, or frequent nurse turnover left them without someone to fulfil that role. Conversely, some GPs admitted to using the nurses as a ‘cheat’, catching patients that they had missed. Nurses with a pre-existing role in chlamydia testing such as providing Pap smears were more likely to have added testing to their repertoire. Midpoint GP 8: We have got one of our nurses does the pap smears, so she is part of [ACCEPt] and then our Head Nurse is helping to set up a recall system with me, we are going to be working on it together. Midpoint GP 31: They can always play a role but I think at this stage I don’t think they are involved very heavily at all [because] it’s about practice strategy. Feedback At midpoint, the most significant component of the ACCEPt intervention was the quarterly feedback reports. GPs were given a report on the number of tests and young people seen in the preceding 3 months based on clinic records. Few had any idea of what their testing rates were like before ACCEPt began. Feedback was effective in two ways—firstly, GPs gauged how well they were doing (or not doing), and secondly, reports were delivered during visits by the research officer (RO) and reminded GPs that the project was ongoing. During clinic visits, an RO could discuss the feedback with the GP, reinforcing the importance of testing and offering strategies and resources to increase their numbers. Most GPs had difficulty identifying which had the greater impact, but reported that the visits were more memorable. Midpoint GP 41: Yes, I think a big part of the visit for me is not necessarily information about chlamydia but just being accountable to someone outside the practice for what you are doing the screening and getting those report cards on how you are going... I think the feedback is important because it shows you’re on track but I think having an actual person there makes it more powerful. I think you get a lot of information on new stuff you are supposed to be doing as a doctor and actually having someone who is willing to sit down with you and go, ‘I understand it is tricky, what can I do to help?’. Components and strategies that were within the GP’s control were more likely to facilitate increases in testing, such as language for normalizing testing. Despite GPs expressing a preference for shifting the responsibility of chlamydia testing away from them like school-based sex education at baseline, components that were external to the GP–patient relationship, such as recall systems, were less likely to have an impact. Attrition was also evident with these components, as education resources, visual media and computer alerts were highlighted as being necessary but use of these declined over time. When asked to recall the component with the greatest impact, about half of the GPs indicated that the regular feedback reports were the most effective facilitator because of its two-pronged approach. The remaining components—education resources, financial incentives, recall support, nurses and computer alerts and visual media—were also cited as facilitators of increased chlamydia testing but varied in their effectiveness. This suggests that many small steps were needed to promote changes in testing practices because the needs of each GP were different. Normalization of chlamydia testing: using the NPT framework To assess the overall effectiveness of the ACCEPt intervention, the responses of the GPs were examined in relation to the four elements of NPT. Coherence—understanding of the issue To make sense of the ACCEPt intervention, GPs had to identify chlamydia as a problem in young people, and most GPs could do so at baseline. However, many were unclear which age groups were affected, or it was identified as primarily a problem in women because of the sequelae (Table 3). Many GPs agreed that chlamydia testing was a necessary preventive health action for young people. However, some voiced concerns about increased workload and risks around confidentiality like dealing with partner notification, although this issue is already present in symptomatic testing. Table 3. A comparison of coherence in the baseline and midpoint interviews Baseline Midpoint Baseline GP 26: But from a male point of view, chlamydia is not a great issue other than the fact they give it to females. From a female point of view, they play Russian roulette with their fertility and also with ectopic pregnancies. Midpoint GP 32: So from my point of view the aim would be to assess the rates of chlamydia prevalence within our target age group, but also to increase the rates of screening and I guess improve that rate wherever possible. Baseline Midpoint Baseline GP 26: But from a male point of view, chlamydia is not a great issue other than the fact they give it to females. From a female point of view, they play Russian roulette with their fertility and also with ectopic pregnancies. Midpoint GP 32: So from my point of view the aim would be to assess the rates of chlamydia prevalence within our target age group, but also to increase the rates of screening and I guess improve that rate wherever possible. View Large Table 3. A comparison of coherence in the baseline and midpoint interviews Baseline Midpoint Baseline GP 26: But from a male point of view, chlamydia is not a great issue other than the fact they give it to females. From a female point of view, they play Russian roulette with their fertility and also with ectopic pregnancies. Midpoint GP 32: So from my point of view the aim would be to assess the rates of chlamydia prevalence within our target age group, but also to increase the rates of screening and I guess improve that rate wherever possible. Baseline Midpoint Baseline GP 26: But from a male point of view, chlamydia is not a great issue other than the fact they give it to females. From a female point of view, they play Russian roulette with their fertility and also with ectopic pregnancies. Midpoint GP 32: So from my point of view the aim would be to assess the rates of chlamydia prevalence within our target age group, but also to increase the rates of screening and I guess improve that rate wherever possible. View Large By midpoint, most GPs recognized that their role with ACCEPt was to facilitate chlamydia testing of 16- to 29-year-olds with the aim of reducing prevalence and understood what was being asked of them as testing was already within their responsibilities. Many agreed that ACCEPt was feasible but some were hesitant if it would be successful in all general practices. Cognitive participation—commitment and engagement with the intervention At baseline, GPs cited barriers that prevented testing patients opportunistically, such as time and workload, as well as potential facilitators like school-based sex education. At midpoint, many GPs noted that they became more comfortable offering a test and that most patients accepted the offer of a test. As a result, some had normalized testing, demonstrating that they could engage and commit to the intervention (Table 4). Table 4. A comparison of cognitive participation in the baseline and midpoint interviews Baseline Midpoint Baseline GP 61: I think certainly at the moment, chlamydia is a significant problem and therefore I think we should be trying to catch as many people as we can. But whether it can become routine screening like Pap smear screening, I am not too sure about at this stage. I would need to know a little bit more about the actual percentage of patients in our area before I could commit myself to absolutely supporting that. Midpoint GP 37: Even at the beginning of the ACCEPt program, I was probably a bit hesitant. Now, I don’t know whether that is me growing as a doctor or just having you guys around and people being used to it. The whole town now is kind of a little bit more aware of chlamydia or at least in the age group that you are shooting at. And I certainly admit that I may use social word of mouth a little to say, ‘Hey you should get tested’. And they tell their mates and so forth. Baseline Midpoint Baseline GP 61: I think certainly at the moment, chlamydia is a significant problem and therefore I think we should be trying to catch as many people as we can. But whether it can become routine screening like Pap smear screening, I am not too sure about at this stage. I would need to know a little bit more about the actual percentage of patients in our area before I could commit myself to absolutely supporting that. Midpoint GP 37: Even at the beginning of the ACCEPt program, I was probably a bit hesitant. Now, I don’t know whether that is me growing as a doctor or just having you guys around and people being used to it. The whole town now is kind of a little bit more aware of chlamydia or at least in the age group that you are shooting at. And I certainly admit that I may use social word of mouth a little to say, ‘Hey you should get tested’. And they tell their mates and so forth. ACCEPt, The Australian Chlamydia Control Effectiveness Pilot. View Large Table 4. A comparison of cognitive participation in the baseline and midpoint interviews Baseline Midpoint Baseline GP 61: I think certainly at the moment, chlamydia is a significant problem and therefore I think we should be trying to catch as many people as we can. But whether it can become routine screening like Pap smear screening, I am not too sure about at this stage. I would need to know a little bit more about the actual percentage of patients in our area before I could commit myself to absolutely supporting that. Midpoint GP 37: Even at the beginning of the ACCEPt program, I was probably a bit hesitant. Now, I don’t know whether that is me growing as a doctor or just having you guys around and people being used to it. The whole town now is kind of a little bit more aware of chlamydia or at least in the age group that you are shooting at. And I certainly admit that I may use social word of mouth a little to say, ‘Hey you should get tested’. And they tell their mates and so forth. Baseline Midpoint Baseline GP 61: I think certainly at the moment, chlamydia is a significant problem and therefore I think we should be trying to catch as many people as we can. But whether it can become routine screening like Pap smear screening, I am not too sure about at this stage. I would need to know a little bit more about the actual percentage of patients in our area before I could commit myself to absolutely supporting that. Midpoint GP 37: Even at the beginning of the ACCEPt program, I was probably a bit hesitant. Now, I don’t know whether that is me growing as a doctor or just having you guys around and people being used to it. The whole town now is kind of a little bit more aware of chlamydia or at least in the age group that you are shooting at. And I certainly admit that I may use social word of mouth a little to say, ‘Hey you should get tested’. And they tell their mates and so forth. ACCEPt, The Australian Chlamydia Control Effectiveness Pilot. View Large Collective action—organizing and enacting the intervention While the GPs were keen to involve nurses at baseline, most were not aware of nurse involvement unless the nurse had a pre-existing role in sexual health such as Pap smears. Arrangements for quarterly visits by the ROs were made through the practice manager, indicating that there was support from management. Their support was essential to the implementation of ACCEPt as they oversee the logistics in running a clinic. Individually, GPs reported increasing their personal testing practices, thereby performing the tasks required for the intervention. Circumstances in offering a test At baseline, the most common reason for offering a chlamydia test to young people was that the patient was symptomatic, requested a general STI check or had engaged in high-risk practices. Tests were much easier to offer in a sexual health-related consultation like contraceptive appointments. Few GPs reported testing based on age or guideline recommendations. Some GPs said they did not offer a test because it was inappropriate and would stigmatize a patient. The circumstances in offering a test underwent a major shift from baseline to midpoint (Table 5). At midpoint, the most frequently cited reason for offering a test was age, and the GPs were offering it opportunistically. Testing had become easier through repetition, even in non-sexual health-related examinations. Increased chlamydia awareness and education had helped, particularly with the knowledge that it was relevant to their town as shown in prevalence surveys conducted prior to the intervention. Utilizing the nondiscriminatory language provided by ACCEPt for age-based testing reduced stigma; thus, patients were more willing to accept testing and the interaction could occur quickly. This shift is vital to effective chlamydia control because few GPs take sexual histories regularly (17) and miss many asymptomatic infections. [Table 5] Table 5. A comparison of collective action and the circumstances of offering a test at baseline and midpoint Baseline Midpoint Baseline GP 15: Anyone who has got a symptom, like discharge, break- through bleeding on the pill, pain obviously, coming in for a Pap smear, anyone who wants an STD check. That is pretty much it. Baseline GP 29: I don’t know if some of them would feel that their behaviour warranted a chlamydia test and might be upset that that they were asked to have one. Midpoint GP 14: Knowing some of the figures for the local town helped. In that I can say, ‘You know we have this ridiculously high rate of chlamydia and we are trying to get it down so I am trying to test everybody’. So they can kind of feel that they are not being singled out as someone that I feel is at high risk as well, want to get everybody. Midpoint GP 30: I think what it changed is the age group that opened my eyes. Without the ACCEPt, I would still do anyone coming in again with an infection or whatever but it did open my eyes, just look at the age group. Baseline Midpoint Baseline GP 15: Anyone who has got a symptom, like discharge, break- through bleeding on the pill, pain obviously, coming in for a Pap smear, anyone who wants an STD check. That is pretty much it. Baseline GP 29: I don’t know if some of them would feel that their behaviour warranted a chlamydia test and might be upset that that they were asked to have one. Midpoint GP 14: Knowing some of the figures for the local town helped. In that I can say, ‘You know we have this ridiculously high rate of chlamydia and we are trying to get it down so I am trying to test everybody’. So they can kind of feel that they are not being singled out as someone that I feel is at high risk as well, want to get everybody. Midpoint GP 30: I think what it changed is the age group that opened my eyes. Without the ACCEPt, I would still do anyone coming in again with an infection or whatever but it did open my eyes, just look at the age group. ACCEPt, The Australian Chlamydia Control Effectiveness Pilot; STD, sexually transmitted disease. View Large Table 5. A comparison of collective action and the circumstances of offering a test at baseline and midpoint Baseline Midpoint Baseline GP 15: Anyone who has got a symptom, like discharge, break- through bleeding on the pill, pain obviously, coming in for a Pap smear, anyone who wants an STD check. That is pretty much it. Baseline GP 29: I don’t know if some of them would feel that their behaviour warranted a chlamydia test and might be upset that that they were asked to have one. Midpoint GP 14: Knowing some of the figures for the local town helped. In that I can say, ‘You know we have this ridiculously high rate of chlamydia and we are trying to get it down so I am trying to test everybody’. So they can kind of feel that they are not being singled out as someone that I feel is at high risk as well, want to get everybody. Midpoint GP 30: I think what it changed is the age group that opened my eyes. Without the ACCEPt, I would still do anyone coming in again with an infection or whatever but it did open my eyes, just look at the age group. Baseline Midpoint Baseline GP 15: Anyone who has got a symptom, like discharge, break- through bleeding on the pill, pain obviously, coming in for a Pap smear, anyone who wants an STD check. That is pretty much it. Baseline GP 29: I don’t know if some of them would feel that their behaviour warranted a chlamydia test and might be upset that that they were asked to have one. Midpoint GP 14: Knowing some of the figures for the local town helped. In that I can say, ‘You know we have this ridiculously high rate of chlamydia and we are trying to get it down so I am trying to test everybody’. So they can kind of feel that they are not being singled out as someone that I feel is at high risk as well, want to get everybody. Midpoint GP 30: I think what it changed is the age group that opened my eyes. Without the ACCEPt, I would still do anyone coming in again with an infection or whatever but it did open my eyes, just look at the age group. ACCEPt, The Australian Chlamydia Control Effectiveness Pilot; STD, sexually transmitted disease. View Large Reflexive monitoring A key component of ACCEPt is the provision of feedback to the GPs, which allows GPs to reflect and evaluate the progress of the intervention (Table 6). At baseline, GPs welcomed the idea of receiving feedback to monitor their progress. By midpoint, many GPs cited feedback as a primary driver of their testing as it identified areas for improvement and provided opportunities to discuss testing strategies with the RO. Some concerns about the accuracy of the data arose and may have prevented some GPs from fully engaging with the intervention. These concerns stem from a 3-month time lag in between the period of testing and receiving a feedback report, as clinic data were validated against laboratory data. Most agreed that the project was feasible but would ideally have more staff and resource support. Table 6. A comparison of reflexive monitoring in the baseline and midpoint interviews Baseline Midpoint Baseline GP 34: A lot of times you are there and you are doing all this work but you don’t really hear back so you don’t really know what is happening until the end. I think whilst the process is going so you have a bit of an idea and you can also see that your work is counting towards something, it is quite good. Midpoint GP 12: I think it has been an extremely useful learning exercise for me but I was very disappointed in my first set of results. So I am hoping I have improved, that sort of feedback is fantastic because we all strive to be better. Baseline Midpoint Baseline GP 34: A lot of times you are there and you are doing all this work but you don’t really hear back so you don’t really know what is happening until the end. I think whilst the process is going so you have a bit of an idea and you can also see that your work is counting towards something, it is quite good. Midpoint GP 12: I think it has been an extremely useful learning exercise for me but I was very disappointed in my first set of results. So I am hoping I have improved, that sort of feedback is fantastic because we all strive to be better. View Large Table 6. A comparison of reflexive monitoring in the baseline and midpoint interviews Baseline Midpoint Baseline GP 34: A lot of times you are there and you are doing all this work but you don’t really hear back so you don’t really know what is happening until the end. I think whilst the process is going so you have a bit of an idea and you can also see that your work is counting towards something, it is quite good. Midpoint GP 12: I think it has been an extremely useful learning exercise for me but I was very disappointed in my first set of results. So I am hoping I have improved, that sort of feedback is fantastic because we all strive to be better. Baseline Midpoint Baseline GP 34: A lot of times you are there and you are doing all this work but you don’t really hear back so you don’t really know what is happening until the end. I think whilst the process is going so you have a bit of an idea and you can also see that your work is counting towards something, it is quite good. Midpoint GP 12: I think it has been an extremely useful learning exercise for me but I was very disappointed in my first set of results. So I am hoping I have improved, that sort of feedback is fantastic because we all strive to be better. View Large Discussion and conclusions Discussion Most of the GPs understood the purpose of the intervention over time, a crucial part of coherence in NPT. However, some had difficulty in assigning value to the work and prioritizing it in an already cumbersome workload. In terms of cognitive participation, the GPs engaged with the intervention, although the level of commitment varied. Many found that their confidence increased in offering a test due to the education and strategies provided. Individually, GPs modified their behaviour, recognizing that age-based testing was less stigmatizing than testing based on symptoms and sexual history, thus partially fulfilling collective action. Feedback was the most frequently cited reason for increasing testing, and thus, the most successful element of NPT in ACCEPt was reflexive monitoring, as the quarterly feedback reports gave the GPs an opportunity to reflect and appraise their work. In turn, GPs were able to identify changes within their control that could be made to their practices and facilitate chlamydia testing. The strength of this analysis is that it uses the NPT as a framework to explore the effectiveness of the ACCEPt intervention. A recent systematic review found that NPT was beneficial in analysing and informing implementation processes (18) and highlighted the dynamic relationship between the four elements. For example, a UK intervention used NPT to examine shared decision making with health professionals (19) and found that coherence was often limited with divergent viewpoints expressed by participants and hindered intervention implementation. A study set in primary care utilized NPT in evaluating the introduction of chronic kidney disease management checks and found it was successful in embedding the checks into review appointments with nurses who had roles that overlapped with their existing roles (20). This is similar to ACCEPt; nurses who were Pap smear providers or sexual health educators were able to add chlamydia testing to their repertoire. The use of NPT in ACCEPt has also led to research in understanding sustainability in general practice and may be helpful for stakeholders in increasing effectiveness of implementing future interventions. A further strength of this analysis was that GPs were represented from different geographical areas to capture problems unique to their region. Perspectives from both male and female GPs were presented in this analysis; however, the female GPs were more likely to be younger and work part-time and none of the GPs interviewed at midpoint were older than 60 years of age. A limitation of this analysis is that it only examines the perspectives of the GPs but both the ACCEPt intervention and NPT encompass a whole-of-clinic approach. The roles of the nurses and practice managers in ACCEPt are being investigated by other researchers (13,14). These findings may not be generalizable as the analysis is specifically about the ACCEPt intervention. Despite our best efforts to get a broad cross-section of GPs, some declined to participate and those who participated may have been more interested in chlamydia testing. Some GPs noted that ACCEPt did not provide many strategies around communicating with culturally and linguistically diverse populations about chlamydia testing. However, these GPs also noted that their towns were not very multicultural, and few made specific reference to the indigenous population. ACCEPt is based in rural areas to capture sexual networks, and these have a more homogeneous patient population with 97% being born in Australia (21). Conclusion The facilitators provided by ACCEPt shifted the GPs from symptom- based testing to age-based testing and have moderately normalized chlamydia testing into routine practice. The use of computer alerts, financial incentives, visual media and nurses varied in their contribution to this shift but the most impactful component was the quarterly feedback report combined with a visit from the RO. All components were necessary to incrementally push chlamydia testing onto the GP’s agenda. Utilizing NPT as a framework to demonstrate the effective implementation of a chlamydia testing intervention in general practice was valuable in understanding which components are essential and which components can be improved upon. Supplementary material Supplementary data are available at Family Practice online. Declaration Funding: ACCEPt was commissioned and funded by the Australian Government Department of Health. Additional funding has been received from the National Health and Medical Research Council, the Victorian Department of Health and NSW Health. Ethical approval: This project was conducted in accordance with the National Statement on Ethical Conduct in Human Research produced by the National Health and Medical Research Council of Australia. Ethical approval was granted by the Royal Australian College of General Practitioners (RACGP) National Research and Evaluation Ethics Committee and the Aboriginal Health and Medical Research Council Ethics Committee. Conflict of interest: None declared. Acknowledgements This evaluation was conducted as part of the Department of Health-funded Australian Chlamydia Control Effectiveness Pilot. Additional funding and support have been provided by National Health and Medical Research Council, Department of Health—Victoria, NSW (New South Wales) Health, Royal Australian College of General Practitioners and the Australian Primary Health Care Nurses Association. Ethical approval was obtained from the Royal Australian College of General Practitioners National Research and Evaluation Ethics Committee, the Aboriginal Health and Medical Research Council Ethics Committee and the University of Melbourne Human Research Ethics Committee. We thank Jane Tomnay from the Centre for Excellence in Rural Sexual Health, University of Melbourne for providing resources, support and advice on conducting this study in rural Victoria and Douglas Boyle and the GHRANITE team from the Health Informatics Unit, University of Melbourne; Carolyn Murray and Chris Bourne from the NSW Sexually Transmissible Infections Program Unit for providing advice and resources. We acknowledge the support from pathology providers in providing chlamydia testing data for the analysis and thank Capital Pathology, Dorevitch Pathology, Douglass Hanly Moir Pathology, Healthscope Pathology, Institute of Clinical Pathology & Medical Research, Melbourne Pathology, Pathology North, Pathology Queensland, South Australia Pathology, St John of God Pathology, St. Vincent’s Health Pathology, Sullivan and Nicolaides Pathology, and Victorian Cytology Service. A big thank you to the ACCEPt research officer team of Rebecca Lorch, Anna Wood, Belinda Ford, Michelle King, Eris Smyth, Jennifer Walker, Dyani Lewis, Lisa Edward, Chantal Maloney, Danielle Newton, Paula Nathan and Anne Shaw for their help with recruiting clinics and providing them ongoing support. We acknowledge input from the ACCEPt Consortium of investigators: Marcus Chen and Lena Sanci from the University of Melbourne; David Wilson and David Regan from the University of New South Wales; Sepehr Tabrizi from the Royal Women’s Hospital; James Ward from the South Australian Health and Medical Research Institute; Marian Pitts and Anne Mitchell from La Trobe University; Rob Carter from Deakin University; Marion Saville and Dorota Gertig from the Victorian Cytology Service; Margaret Hellard from the Burnet Institute; and Nicola Low from the University of Bern. References 1. National Notifiable Diseases Surveillance System . Notification Rate of Chlamydial Infection, Received from State and Territory Health Authorities 2018 . http://www9.health.gov.au/cda/source/rpt_3.cfm (accessed on 7 January 2018 ). 2. Grulich AE , de Visser RO , Smith AM , Rissel CE , Richters J . Sex in Australia: sexually transmissible infection and blood-borne virus history in a representative sample of adults . Aust N Z J Public Health 2003 ; 27 : 234 – 41 . Google Scholar CrossRef Search ADS PubMed 3. Kong FY , Guy RJ , Hocking JS et al. Australian general practitioner chlamydia testing rates among young people . Med J Aust 2011 ; 194 : 249 – 52 . Google Scholar PubMed 4. Peipert JF . Clinical practice. Genital chlamydial infections . N Engl J Med 2003 ; 349 : 2424 – 30 . Google Scholar CrossRef Search ADS PubMed 5. Trojian TH , Lishnak TS , Heiman D . Epididymitis and orchitis: an overview . Am Fam Physician 2009 ; 79 : 583 – 7 . Google Scholar PubMed 6. Fleming DT , Wasserheit JN . From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection . Sex Transm Infect 1999 ; 75 : 3 – 17 . Google Scholar CrossRef Search ADS PubMed 7. Yeung A , Temple-Smith M , Fairley C , Hocking J . Narrative review of the barriers and facilitators to chlamydia testing in general practice . Aust J Prim Health 2015 ; 21 : 139 – 47 . Google Scholar CrossRef Search ADS PubMed 8. General Practice NSW [New South Wales] . A Guide to Understanding and Working with General Practice in NSW . Sydney : NSW Department of Health , 2011 . 9. Walker J , Walker S , Fairley CK et al. What do young women think about having a chlamydia test? Views of women who tested positive compared with women who tested negative . Sex Health 2013 ; 10 : 39 – 42 . Google Scholar PubMed 10. Pavlin NL , Parker R , Fairley CK , Gunn JM , Hocking J . Take the sex out of STI screening! Views of young women on implementing chlamydia screening in general practice . BMC Infect Dis 2008 ; 8 : 62 . Google Scholar CrossRef Search ADS PubMed 11. Guy RJ , Ali H , Liu B et al. Efficacy of interventions to increase the uptake of chlamydia screening in primary care: a systematic review . BMC Infect Dis 2011 ; 11 : 211 . Google Scholar CrossRef Search ADS PubMed 12. Hocking J , Low N , Guy R et al. Protocol 12 PRT 09010: Australian chlamydia control effectiveness pilot (ACCEPt): a cluster randomised controlled trial of chlamydia testing in general practice . Lancet 2013 . http://www.thelancet.com/protocol-reviews/12PRT-9010 13. Lorch R , Hocking J , Guy R et al. ; ACCEPt consortium . Do Australian general practitioners believe practice nurses can take a role in chlamydia testing? A qualitative study of attitudes and opinions . BMC Infect Dis 2015 ; 15 : 31 . Google Scholar CrossRef Search ADS PubMed 14. Lorch R , Hocking J , Guy R et al. ; ACCEPt Consortium . Practice nurse chlamydia testing in Australian general practice: a qualitative study of benefits, barriers and facilitators . BMC Fam Pract 2015 ; 16 : 36 . Google Scholar CrossRef Search ADS PubMed 15. May C , Finch T . Implementing, embedding, and integrating practices: an outline of normalization process theory . Sociology 2009 ; 43 : 535 – 54 . Google Scholar CrossRef Search ADS 16. May C , Rapley T , Mair FS et al. Normalization Process Theory On-line Users’ Manual, Toolkit and NoMAD instrument . 2015 ; http://www.normalizationprocess.org (accessed on 16 March 2016). 17. Temple-Smith M , Hammond J , Pyett P , Presswell N . Barriers to sexual history taking in general practice . Aust Fam Physician 1996 ; 25 ( 9 suppl 2 ): S71 – 4 . Google Scholar PubMed 18. McEvoy R , Ballini L , Maltoni S et al. A qualitative systematic review of studies using the normalization process theory to research implementation processes . Implement Sci 2014 ; 9 : 2 . Google Scholar CrossRef Search ADS PubMed 19. Lloyd A , Joseph-Williams N , Edwards A , Rix A , Elwyn G . Patchy ‘coherence’: using normalization process theory to evaluate a multi-faceted shared decision making implementation program (MAGIC) . Implement Sci 2013 ; 8 : 102 . Google Scholar CrossRef Search ADS PubMed 20. Blakeman T , Protheroe J , Chew-Graham C , Rogers A , Kennedy A . Understanding the management of early-stage chronic kidney disease in primary care: a qualitative study . Br J Gen Pract 2012 ; 62 : e233 – 42 . Google Scholar CrossRef Search ADS PubMed 21. Yeung AH , Temple-Smith M , Fairley CK et al. Chlamydia prevalence in young attenders of rural and regional primary care services in Australia: a cross-sectional survey . Med J Aust 2014 ; 200 : 170 – 5 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Family Practice Oxford University Press

‘It Opened My Eyes’—examining the impact of a multifaceted chlamydia testing intervention on general practitioners using Normalization Process Theory

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Abstract

Abstract Background Chlamydia is the most common notifiable sexually transmissible infection in Australia. Left untreated, it can develop into pelvic inflammatory disease and infertility. The majority of notifications come from general practice and it is ideally situated to test young Australians. Objectives The Australian Chlamydia Control Effectiveness Pilot (ACCEPt) was a multifaceted intervention that aimed to reduce chlamydia prevalence by increasing testing in 16- to 29-year-olds attending general practice. GPs were interviewed to describe the effectiveness of the ACCEPt intervention in integrating chlamydia testing into routine practice using Normalization Process Theory (NPT). Methods GPs were purposively selected based on age, gender, geographic location and size of practice at baseline and midpoint. Interview data were analysed regarding the intervention components and results were interpreted using NPT. Results A total of 44 GPs at baseline and 24 at midpoint were interviewed. Most GPs reported offering a test based on age at midpoint versus offering a test based on symptoms or patient request at baseline. Quarterly feedback was the most significant ACCEPt component for facilitating a chlamydia test. Conclusions The ACCEPt intervention has been able to moderately normalize chlamydia testing among GPs, although the components had varying levels of effectiveness. NPT can demonstrate the effective implementation of an intervention in general practice and has been valuable in understanding which components are essential and which components can be improved upon. Chlamydia infections, general practice, normalization process theory Introduction Chlamydia is the most common notifiable sexually transmissible infection (STI) in Australia, with notification rates quadrupling in the last decade and a half (1). The majority of notifications come from general practice (2) but ≤10% of 15- to 29-year-olds are tested in this setting (3). The asymptomatic nature of chlamydia leads to inadvertent transmission to sexual partners. Untreated infections have serious sequelae, including pelvic inflammatory disease and infertility in women (4), and epididymo-orchitis in men (5), and can act as a cofactor in human immunodeficiency virus transmission (6). GPs report many barriers to testing (7), including the lack of consultation time, heavy workload and lack of resources, resulting in low testing coverage. Education initiatives or GP incentives to overcome these barriers have had limited success (7). Additionally, Australian general practices operate as small businesses and charge higher fees to cover costs (8). Further limitations for young people include these associated costs (9) and discomfort with asking for a test (10). Prior research found the most effective facilitator was an age-based offer of a chlamydia test and was associated with a systems change across the entire clinic (11). Methods Overview of the Australian Chlamydia Control Effectiveness Pilot The Australian Chlamydia Control Effectiveness Pilot (ACCEPt) is a cluster randomized control trial in general practices in rural towns across four states—Victoria, New South Wales, Queensland and South Australia (12). The aim of ACCEPt is to determine if a multifaceted intervention can increase testing to sufficiently high levels to decrease the prevalence of chlamydia in men and women aged 16–29 years. Each town constitutes a cluster and was randomized into the control or intervention after the first prevalence survey, and prevalence was measured again after the intervention period. Briefly, ACCEPt is primarily targeted to GPs and uses computer alerts, education resources, financial incentives, recall system support, visual media (posters and reminder cards), and quarterly feedback to increase testing rates in the intervention arm. Another component of ACCEPt focusses on practice nurses; nurse perspectives and GP perspectives on nurses in ACCEPt and chlamydia testing have been previously published (13,14). These materials were tailored to the needs of the practice and the GP. We conducted interviews with a sample of participating GPs prior to randomization (‘baseline’) and halfway through the intervention period (‘midpoint’) to explore factors influencing the offer of a chlamydia test, assess the feasibility of the intervention and modify trial components to facilitate testing. Selection of participants After enrolment to ACCEPt and prior to randomization to the control or intervention arms, GPs in all towns were purposively selected by accounting for location, age and gender of the GP and the size of the practice to maximize the breadth of views. One GP from half of the towns enrolled in ACCEPt in each state was interviewed at baseline. Midpoint interviews were conducted with GPs from half of the intervention towns in each state after 1 year in the intervention; GPs from control towns were not interviewed at midpoint. Interview schedule A semi-structured interview schedule was developed, reviewed by the investigators for face and content validity, and pilot-tested on two GPs (see supplementary material). Baseline interviews covered the GP’s general experience with preventive health screening programmes, chlamydia testing and research. The midpoint interviews were informed by baseline data and focused on the GP’s experiences with ACCEPt. Interviews were conducted with analysis occurring concurrently until thematic saturation was reached. Normalization Process Theory To increase the effectiveness of the ACCEPt intervention, Normalization Process Theory (NPT) was used as a framework to guide the implementation of the project and assisted with the interview analysis (Table 1). NPT was developed to explain how new or modified practices are successfully integrated into routine practice in a clinical setting (15). The theory has four elements: coherence (understanding of the intervention by clinic staff), cognitive participation (commitment and engagement to the intervention), collective action (work carried out to make the intervention function) and reflexive monitoring (evaluation of the intervention). While NPT addresses a whole-of-clinic approach, the focus of this paper is on the GPs (Table 1) (16). Table 1. Overview of Normalization Process Theory (NPT) and as modelled by the Australian Chlamydia Control Effectiveness Pilot (ACCEPt). (Adapted from the NPT website: www.normalizationprocess.org.) Element Coherence Cognitive participation Collective action Reflexive monitoring NPT Have participants ascribed meaning to the intervention by? 1) Differentiating it from current practices 2) Understand its objectives, values and benefits 3) Comprehend what the individual tasks and responsibilities are Are the participants willing to invest time and energy into the problem by? 1) Driving the new practice forward 2) Contributing to the work 3) Defining the actions and procedures necessary to sustain the practice Are the participants producing and reproducing the actions required to make the intervention function by? 1) Dividing up the labour as needed 2) Integrating protocols into the workplace Have they examined why the intervention is/is not working by? 1) Evaluating the effectiveness and usefulness of the intervention 2) Modifying actions to increase effectiveness NPT as addressed in ACCEPt Do the GPs understand the benefits of an annual chlamydia test? How does it differ from the usual practice of testing based on symptoms or patient request? What will they need to do in order to test more young people? Is it feasible to include sexual health in a consult? What tasks need to be done to increase testing? By whom? Is the practice sustainable? Do the GPs have the support of other staff and management to increase chlamydia testing? Are there enough resources and training? Are the tasks appropriately allocated to the clinic staff? Are the GPs increasing testing rates? Are the GPs receiving feedback on their performance? Are they able to modify their practices in response to the feedback? Element Coherence Cognitive participation Collective action Reflexive monitoring NPT Have participants ascribed meaning to the intervention by? 1) Differentiating it from current practices 2) Understand its objectives, values and benefits 3) Comprehend what the individual tasks and responsibilities are Are the participants willing to invest time and energy into the problem by? 1) Driving the new practice forward 2) Contributing to the work 3) Defining the actions and procedures necessary to sustain the practice Are the participants producing and reproducing the actions required to make the intervention function by? 1) Dividing up the labour as needed 2) Integrating protocols into the workplace Have they examined why the intervention is/is not working by? 1) Evaluating the effectiveness and usefulness of the intervention 2) Modifying actions to increase effectiveness NPT as addressed in ACCEPt Do the GPs understand the benefits of an annual chlamydia test? How does it differ from the usual practice of testing based on symptoms or patient request? What will they need to do in order to test more young people? Is it feasible to include sexual health in a consult? What tasks need to be done to increase testing? By whom? Is the practice sustainable? Do the GPs have the support of other staff and management to increase chlamydia testing? Are there enough resources and training? Are the tasks appropriately allocated to the clinic staff? Are the GPs increasing testing rates? Are the GPs receiving feedback on their performance? Are they able to modify their practices in response to the feedback? View Large Table 1. Overview of Normalization Process Theory (NPT) and as modelled by the Australian Chlamydia Control Effectiveness Pilot (ACCEPt). (Adapted from the NPT website: www.normalizationprocess.org.) Element Coherence Cognitive participation Collective action Reflexive monitoring NPT Have participants ascribed meaning to the intervention by? 1) Differentiating it from current practices 2) Understand its objectives, values and benefits 3) Comprehend what the individual tasks and responsibilities are Are the participants willing to invest time and energy into the problem by? 1) Driving the new practice forward 2) Contributing to the work 3) Defining the actions and procedures necessary to sustain the practice Are the participants producing and reproducing the actions required to make the intervention function by? 1) Dividing up the labour as needed 2) Integrating protocols into the workplace Have they examined why the intervention is/is not working by? 1) Evaluating the effectiveness and usefulness of the intervention 2) Modifying actions to increase effectiveness NPT as addressed in ACCEPt Do the GPs understand the benefits of an annual chlamydia test? How does it differ from the usual practice of testing based on symptoms or patient request? What will they need to do in order to test more young people? Is it feasible to include sexual health in a consult? What tasks need to be done to increase testing? By whom? Is the practice sustainable? Do the GPs have the support of other staff and management to increase chlamydia testing? Are there enough resources and training? Are the tasks appropriately allocated to the clinic staff? Are the GPs increasing testing rates? Are the GPs receiving feedback on their performance? Are they able to modify their practices in response to the feedback? Element Coherence Cognitive participation Collective action Reflexive monitoring NPT Have participants ascribed meaning to the intervention by? 1) Differentiating it from current practices 2) Understand its objectives, values and benefits 3) Comprehend what the individual tasks and responsibilities are Are the participants willing to invest time and energy into the problem by? 1) Driving the new practice forward 2) Contributing to the work 3) Defining the actions and procedures necessary to sustain the practice Are the participants producing and reproducing the actions required to make the intervention function by? 1) Dividing up the labour as needed 2) Integrating protocols into the workplace Have they examined why the intervention is/is not working by? 1) Evaluating the effectiveness and usefulness of the intervention 2) Modifying actions to increase effectiveness NPT as addressed in ACCEPt Do the GPs understand the benefits of an annual chlamydia test? How does it differ from the usual practice of testing based on symptoms or patient request? What will they need to do in order to test more young people? Is it feasible to include sexual health in a consult? What tasks need to be done to increase testing? By whom? Is the practice sustainable? Do the GPs have the support of other staff and management to increase chlamydia testing? Are there enough resources and training? Are the tasks appropriately allocated to the clinic staff? Are the GPs increasing testing rates? Are the GPs receiving feedback on their performance? Are they able to modify their practices in response to the feedback? View Large Data collection and analysis GPs were initially contacted by telephone at the clinic, with a minimum of two attempts per GP between 2011 and 2014. Telephone interviews were conducted by an ACCEPt research officer (AV) and a PhD student (AY), with consent obtained verbally, and recorded and transcribed; GPs were reimbursed with a $100 voucher for their time. Participants did not have any interactions with the interviewer prior to the interview but were aware that the female interviewers were part of the research team and provided participants with additional strategies to increase testing, or advised other research team members to follow up if requested by the participant. Transcripts were compared with audio recordings for clarification (AY). Coding was completed using NVivo (QSR International, Melbourne, Australia) and analysed using a two-step process (AY). Firstly, data were examined regarding the specific intervention components to better understand the contributions of ACCEPt to the normalization of the testing process—financial incentives, quarterly feedback, recall system, education resources, visual media and computer alert. Primary analysis involved highlighting content, grouping and labelling these components and secondary analysis was conducted for emerging themes. A selection of the interviews was then given to an experienced qualitative researcher (MTS) to verify codes and themes found during primary and secondary analyses. Discussion of codes and themes was undertaken until a consensus was reached (AY and MTS). Additionally, data were interpreted using the four elements of NPT—coherence, cognitive participation, collective action and reflexive monitoring—to examine changes in the acceptability of ACCEPt between baseline and midpoint. Results A total of 44 out of 63 GPs contacted at baseline and 24 out of 38 GPs contacted at midpoint participated in an interview (Table 2). Table 2. General practitioner characteristics at baseline and midpoint Baseline n = 44 (%) Midpoint n = 24 (%) Gender of GP Male 29 (65.9) 11 (45.8) Female 15 (34.1) 13 (54.2) Location of GP Victoria – Metro 5 (11.4) 3 (12.5) Victoria – Rural new 15 (34.1) 6 (25.0) South Wales – Rural 11 (25.0) 10 (41.7) Queensland – Rural 10 (22.7) 3 (12.5) South Australia – Rural 3 (6.8) 2 (8.3) Size of practice ≤4 25 (56.8) 10 (41.7) Number of GPs >4 19 (43.2) 14 (58.3) Age of GP (years) <30 3 (6.8) 4 (16.7) 30–44 19 (43.2) 10 (41.7) 45–59 19 (43.2) 10 (41.7) 60+ 3 (6.8) – Years in general practice <5 10 (22.7) 12 (50.0) 5–19 19 (43.2) 7 (29.2) 20+ 15 (34.1) 5 (20.8) Employment statusa Full-time 37 (86.0) 17 (70.8) Part-time 6 (14.0) 7 (29.2) Postgraduate qualifications Yes 35 (79.5) 16 (66.7) No 9 (20.5) 8 (33.3) Baseline n = 44 (%) Midpoint n = 24 (%) Gender of GP Male 29 (65.9) 11 (45.8) Female 15 (34.1) 13 (54.2) Location of GP Victoria – Metro 5 (11.4) 3 (12.5) Victoria – Rural new 15 (34.1) 6 (25.0) South Wales – Rural 11 (25.0) 10 (41.7) Queensland – Rural 10 (22.7) 3 (12.5) South Australia – Rural 3 (6.8) 2 (8.3) Size of practice ≤4 25 (56.8) 10 (41.7) Number of GPs >4 19 (43.2) 14 (58.3) Age of GP (years) <30 3 (6.8) 4 (16.7) 30–44 19 (43.2) 10 (41.7) 45–59 19 (43.2) 10 (41.7) 60+ 3 (6.8) – Years in general practice <5 10 (22.7) 12 (50.0) 5–19 19 (43.2) 7 (29.2) 20+ 15 (34.1) 5 (20.8) Employment statusa Full-time 37 (86.0) 17 (70.8) Part-time 6 (14.0) 7 (29.2) Postgraduate qualifications Yes 35 (79.5) 16 (66.7) No 9 (20.5) 8 (33.3) aUnknown at baseline. View Large Table 2. General practitioner characteristics at baseline and midpoint Baseline n = 44 (%) Midpoint n = 24 (%) Gender of GP Male 29 (65.9) 11 (45.8) Female 15 (34.1) 13 (54.2) Location of GP Victoria – Metro 5 (11.4) 3 (12.5) Victoria – Rural new 15 (34.1) 6 (25.0) South Wales – Rural 11 (25.0) 10 (41.7) Queensland – Rural 10 (22.7) 3 (12.5) South Australia – Rural 3 (6.8) 2 (8.3) Size of practice ≤4 25 (56.8) 10 (41.7) Number of GPs >4 19 (43.2) 14 (58.3) Age of GP (years) <30 3 (6.8) 4 (16.7) 30–44 19 (43.2) 10 (41.7) 45–59 19 (43.2) 10 (41.7) 60+ 3 (6.8) – Years in general practice <5 10 (22.7) 12 (50.0) 5–19 19 (43.2) 7 (29.2) 20+ 15 (34.1) 5 (20.8) Employment statusa Full-time 37 (86.0) 17 (70.8) Part-time 6 (14.0) 7 (29.2) Postgraduate qualifications Yes 35 (79.5) 16 (66.7) No 9 (20.5) 8 (33.3) Baseline n = 44 (%) Midpoint n = 24 (%) Gender of GP Male 29 (65.9) 11 (45.8) Female 15 (34.1) 13 (54.2) Location of GP Victoria – Metro 5 (11.4) 3 (12.5) Victoria – Rural new 15 (34.1) 6 (25.0) South Wales – Rural 11 (25.0) 10 (41.7) Queensland – Rural 10 (22.7) 3 (12.5) South Australia – Rural 3 (6.8) 2 (8.3) Size of practice ≤4 25 (56.8) 10 (41.7) Number of GPs >4 19 (43.2) 14 (58.3) Age of GP (years) <30 3 (6.8) 4 (16.7) 30–44 19 (43.2) 10 (41.7) 45–59 19 (43.2) 10 (41.7) 60+ 3 (6.8) – Years in general practice <5 10 (22.7) 12 (50.0) 5–19 19 (43.2) 7 (29.2) 20+ 15 (34.1) 5 (20.8) Employment statusa Full-time 37 (86.0) 17 (70.8) Part-time 6 (14.0) 7 (29.2) Postgraduate qualifications Yes 35 (79.5) 16 (66.7) No 9 (20.5) 8 (33.3) aUnknown at baseline. View Large Normalization of chlamydia testing: impact of the Australian Chlamydia Control Effectiveness Pilot components The midpoint interviews investigated the contribution of ACCEPt towards integrating chlamydia testing into routine practice. Financial incentives The financial incentives recognized the value of the GP’s work, thereby reinforcing the responsibility to test the age group but GPs also identified that the amount per test was too small to be noticeable, and many could not recall receiving incentives directly from ACCEPt. Some felt that the incentives were unnecessary as testing was part of everyday care but were appreciated, and reported higher incentives would be more memorable. When asked which component had the most impact, financial incentives were rarely mentioned. Midpoint GP 12: I think it makes you, probably when you are suddenly overloaded with all this stuff, there is a lot of non-paid work that you know, maybe it would make you think, ‘Look I am getting paid for that, I have got a bit of responsibility for that.’ Midpoint GP 37: Is it necessary? I don’t think so, I mean you really are just telling us to do our job, and do our job better. I feel I am benefitting the community by actually doing what you guys are trying to do...I think it should be a bit more, because it’s 10 bucks for everyone you get, and you might have it more in the forefront of your mind. Recall systems and support Chlamydia recall systems were often informal and relied on the GP to manually add the reminder, resulting in inconsistent systems; one GP noted that her practice was shifting to more part-time GPs and needed a more cohesive system. Recall systems were considered prohibitively expensive or not useful for chlamydia because it relied on the patient returning. In practices with a formal system, recalls were easier to implement because of prior infrastructure. Midpoint GP 32: We would just do that manually. As results come through, if we do need to follow people up then we check them. I usually make patient follow up arrangements at the time of requesting the test, if they are of an age where I am testing for chlamydia but for instance they still live at home with their parents, I make sure that I have a current number, so a mobile phone number rather than the family landline. Education resources Resources included an education folder containing peer-reviewed publications and testing tools, information about partner notification, STI management guideline handbook and patient information sheets. Initially, the education resources were useful as they raised the overall level of knowledge and awareness, but then required too much physical space or were not readily accessed. Midpoint GP 12: I think it [education and resources] certainly raised my awareness…I attempt to routinely and I don’t always do it, to routinely screen everyone who comes in for a pap smear or a contraceptive advice. Or for other things in that age group I try to target, I think it has increased my awareness, it has been very helpful. I think our education from the ACCEPt team has been very good. Midpoint GP 4: I don’t actually use them. I get things off, generally I print things off the computer if I want to get anyone any information about things. I just find tear-offs pads get lost in the bottom drawer and never can find the right one at the right time. Visual media and computer alert The visual media—colourful posters and business card-sized reminders—were acceptable to GPs. The posters were placed in waiting rooms, where patients became aware of an ongoing chlamydia campaign. This was useful in non-sexual health-related consultations but eventually blended into the scenery. Reaction to the computer alert was mixed; some found the alert irritating and turned it off while others found that it jogged their memory. Both components reminded the GP that the patient was in the eligible age group and introduced the offer of a test using nondiscriminatory language. Midpoint GP 3: I can’t remember looking at it in the last few months. We have got posters on the wall and they are there and after the first time I no longer see them. Walk past them five to ten times per day. Midpoint GP 13: Honestly the best is this side-bar [computer alert] because it comes up, it pops in front of your head every time you open a file in that age group. Even if they come in for a cold you are prompted into saying something. Role of nurses Many GPs were unaware if the nurses in their practice were involved in ACCEPt. Alternatively, their practice was not structured in a way where nurses could see patients, or frequent nurse turnover left them without someone to fulfil that role. Conversely, some GPs admitted to using the nurses as a ‘cheat’, catching patients that they had missed. Nurses with a pre-existing role in chlamydia testing such as providing Pap smears were more likely to have added testing to their repertoire. Midpoint GP 8: We have got one of our nurses does the pap smears, so she is part of [ACCEPt] and then our Head Nurse is helping to set up a recall system with me, we are going to be working on it together. Midpoint GP 31: They can always play a role but I think at this stage I don’t think they are involved very heavily at all [because] it’s about practice strategy. Feedback At midpoint, the most significant component of the ACCEPt intervention was the quarterly feedback reports. GPs were given a report on the number of tests and young people seen in the preceding 3 months based on clinic records. Few had any idea of what their testing rates were like before ACCEPt began. Feedback was effective in two ways—firstly, GPs gauged how well they were doing (or not doing), and secondly, reports were delivered during visits by the research officer (RO) and reminded GPs that the project was ongoing. During clinic visits, an RO could discuss the feedback with the GP, reinforcing the importance of testing and offering strategies and resources to increase their numbers. Most GPs had difficulty identifying which had the greater impact, but reported that the visits were more memorable. Midpoint GP 41: Yes, I think a big part of the visit for me is not necessarily information about chlamydia but just being accountable to someone outside the practice for what you are doing the screening and getting those report cards on how you are going... I think the feedback is important because it shows you’re on track but I think having an actual person there makes it more powerful. I think you get a lot of information on new stuff you are supposed to be doing as a doctor and actually having someone who is willing to sit down with you and go, ‘I understand it is tricky, what can I do to help?’. Components and strategies that were within the GP’s control were more likely to facilitate increases in testing, such as language for normalizing testing. Despite GPs expressing a preference for shifting the responsibility of chlamydia testing away from them like school-based sex education at baseline, components that were external to the GP–patient relationship, such as recall systems, were less likely to have an impact. Attrition was also evident with these components, as education resources, visual media and computer alerts were highlighted as being necessary but use of these declined over time. When asked to recall the component with the greatest impact, about half of the GPs indicated that the regular feedback reports were the most effective facilitator because of its two-pronged approach. The remaining components—education resources, financial incentives, recall support, nurses and computer alerts and visual media—were also cited as facilitators of increased chlamydia testing but varied in their effectiveness. This suggests that many small steps were needed to promote changes in testing practices because the needs of each GP were different. Normalization of chlamydia testing: using the NPT framework To assess the overall effectiveness of the ACCEPt intervention, the responses of the GPs were examined in relation to the four elements of NPT. Coherence—understanding of the issue To make sense of the ACCEPt intervention, GPs had to identify chlamydia as a problem in young people, and most GPs could do so at baseline. However, many were unclear which age groups were affected, or it was identified as primarily a problem in women because of the sequelae (Table 3). Many GPs agreed that chlamydia testing was a necessary preventive health action for young people. However, some voiced concerns about increased workload and risks around confidentiality like dealing with partner notification, although this issue is already present in symptomatic testing. Table 3. A comparison of coherence in the baseline and midpoint interviews Baseline Midpoint Baseline GP 26: But from a male point of view, chlamydia is not a great issue other than the fact they give it to females. From a female point of view, they play Russian roulette with their fertility and also with ectopic pregnancies. Midpoint GP 32: So from my point of view the aim would be to assess the rates of chlamydia prevalence within our target age group, but also to increase the rates of screening and I guess improve that rate wherever possible. Baseline Midpoint Baseline GP 26: But from a male point of view, chlamydia is not a great issue other than the fact they give it to females. From a female point of view, they play Russian roulette with their fertility and also with ectopic pregnancies. Midpoint GP 32: So from my point of view the aim would be to assess the rates of chlamydia prevalence within our target age group, but also to increase the rates of screening and I guess improve that rate wherever possible. View Large Table 3. A comparison of coherence in the baseline and midpoint interviews Baseline Midpoint Baseline GP 26: But from a male point of view, chlamydia is not a great issue other than the fact they give it to females. From a female point of view, they play Russian roulette with their fertility and also with ectopic pregnancies. Midpoint GP 32: So from my point of view the aim would be to assess the rates of chlamydia prevalence within our target age group, but also to increase the rates of screening and I guess improve that rate wherever possible. Baseline Midpoint Baseline GP 26: But from a male point of view, chlamydia is not a great issue other than the fact they give it to females. From a female point of view, they play Russian roulette with their fertility and also with ectopic pregnancies. Midpoint GP 32: So from my point of view the aim would be to assess the rates of chlamydia prevalence within our target age group, but also to increase the rates of screening and I guess improve that rate wherever possible. View Large By midpoint, most GPs recognized that their role with ACCEPt was to facilitate chlamydia testing of 16- to 29-year-olds with the aim of reducing prevalence and understood what was being asked of them as testing was already within their responsibilities. Many agreed that ACCEPt was feasible but some were hesitant if it would be successful in all general practices. Cognitive participation—commitment and engagement with the intervention At baseline, GPs cited barriers that prevented testing patients opportunistically, such as time and workload, as well as potential facilitators like school-based sex education. At midpoint, many GPs noted that they became more comfortable offering a test and that most patients accepted the offer of a test. As a result, some had normalized testing, demonstrating that they could engage and commit to the intervention (Table 4). Table 4. A comparison of cognitive participation in the baseline and midpoint interviews Baseline Midpoint Baseline GP 61: I think certainly at the moment, chlamydia is a significant problem and therefore I think we should be trying to catch as many people as we can. But whether it can become routine screening like Pap smear screening, I am not too sure about at this stage. I would need to know a little bit more about the actual percentage of patients in our area before I could commit myself to absolutely supporting that. Midpoint GP 37: Even at the beginning of the ACCEPt program, I was probably a bit hesitant. Now, I don’t know whether that is me growing as a doctor or just having you guys around and people being used to it. The whole town now is kind of a little bit more aware of chlamydia or at least in the age group that you are shooting at. And I certainly admit that I may use social word of mouth a little to say, ‘Hey you should get tested’. And they tell their mates and so forth. Baseline Midpoint Baseline GP 61: I think certainly at the moment, chlamydia is a significant problem and therefore I think we should be trying to catch as many people as we can. But whether it can become routine screening like Pap smear screening, I am not too sure about at this stage. I would need to know a little bit more about the actual percentage of patients in our area before I could commit myself to absolutely supporting that. Midpoint GP 37: Even at the beginning of the ACCEPt program, I was probably a bit hesitant. Now, I don’t know whether that is me growing as a doctor or just having you guys around and people being used to it. The whole town now is kind of a little bit more aware of chlamydia or at least in the age group that you are shooting at. And I certainly admit that I may use social word of mouth a little to say, ‘Hey you should get tested’. And they tell their mates and so forth. ACCEPt, The Australian Chlamydia Control Effectiveness Pilot. View Large Table 4. A comparison of cognitive participation in the baseline and midpoint interviews Baseline Midpoint Baseline GP 61: I think certainly at the moment, chlamydia is a significant problem and therefore I think we should be trying to catch as many people as we can. But whether it can become routine screening like Pap smear screening, I am not too sure about at this stage. I would need to know a little bit more about the actual percentage of patients in our area before I could commit myself to absolutely supporting that. Midpoint GP 37: Even at the beginning of the ACCEPt program, I was probably a bit hesitant. Now, I don’t know whether that is me growing as a doctor or just having you guys around and people being used to it. The whole town now is kind of a little bit more aware of chlamydia or at least in the age group that you are shooting at. And I certainly admit that I may use social word of mouth a little to say, ‘Hey you should get tested’. And they tell their mates and so forth. Baseline Midpoint Baseline GP 61: I think certainly at the moment, chlamydia is a significant problem and therefore I think we should be trying to catch as many people as we can. But whether it can become routine screening like Pap smear screening, I am not too sure about at this stage. I would need to know a little bit more about the actual percentage of patients in our area before I could commit myself to absolutely supporting that. Midpoint GP 37: Even at the beginning of the ACCEPt program, I was probably a bit hesitant. Now, I don’t know whether that is me growing as a doctor or just having you guys around and people being used to it. The whole town now is kind of a little bit more aware of chlamydia or at least in the age group that you are shooting at. And I certainly admit that I may use social word of mouth a little to say, ‘Hey you should get tested’. And they tell their mates and so forth. ACCEPt, The Australian Chlamydia Control Effectiveness Pilot. View Large Collective action—organizing and enacting the intervention While the GPs were keen to involve nurses at baseline, most were not aware of nurse involvement unless the nurse had a pre-existing role in sexual health such as Pap smears. Arrangements for quarterly visits by the ROs were made through the practice manager, indicating that there was support from management. Their support was essential to the implementation of ACCEPt as they oversee the logistics in running a clinic. Individually, GPs reported increasing their personal testing practices, thereby performing the tasks required for the intervention. Circumstances in offering a test At baseline, the most common reason for offering a chlamydia test to young people was that the patient was symptomatic, requested a general STI check or had engaged in high-risk practices. Tests were much easier to offer in a sexual health-related consultation like contraceptive appointments. Few GPs reported testing based on age or guideline recommendations. Some GPs said they did not offer a test because it was inappropriate and would stigmatize a patient. The circumstances in offering a test underwent a major shift from baseline to midpoint (Table 5). At midpoint, the most frequently cited reason for offering a test was age, and the GPs were offering it opportunistically. Testing had become easier through repetition, even in non-sexual health-related examinations. Increased chlamydia awareness and education had helped, particularly with the knowledge that it was relevant to their town as shown in prevalence surveys conducted prior to the intervention. Utilizing the nondiscriminatory language provided by ACCEPt for age-based testing reduced stigma; thus, patients were more willing to accept testing and the interaction could occur quickly. This shift is vital to effective chlamydia control because few GPs take sexual histories regularly (17) and miss many asymptomatic infections. [Table 5] Table 5. A comparison of collective action and the circumstances of offering a test at baseline and midpoint Baseline Midpoint Baseline GP 15: Anyone who has got a symptom, like discharge, break- through bleeding on the pill, pain obviously, coming in for a Pap smear, anyone who wants an STD check. That is pretty much it. Baseline GP 29: I don’t know if some of them would feel that their behaviour warranted a chlamydia test and might be upset that that they were asked to have one. Midpoint GP 14: Knowing some of the figures for the local town helped. In that I can say, ‘You know we have this ridiculously high rate of chlamydia and we are trying to get it down so I am trying to test everybody’. So they can kind of feel that they are not being singled out as someone that I feel is at high risk as well, want to get everybody. Midpoint GP 30: I think what it changed is the age group that opened my eyes. Without the ACCEPt, I would still do anyone coming in again with an infection or whatever but it did open my eyes, just look at the age group. Baseline Midpoint Baseline GP 15: Anyone who has got a symptom, like discharge, break- through bleeding on the pill, pain obviously, coming in for a Pap smear, anyone who wants an STD check. That is pretty much it. Baseline GP 29: I don’t know if some of them would feel that their behaviour warranted a chlamydia test and might be upset that that they were asked to have one. Midpoint GP 14: Knowing some of the figures for the local town helped. In that I can say, ‘You know we have this ridiculously high rate of chlamydia and we are trying to get it down so I am trying to test everybody’. So they can kind of feel that they are not being singled out as someone that I feel is at high risk as well, want to get everybody. Midpoint GP 30: I think what it changed is the age group that opened my eyes. Without the ACCEPt, I would still do anyone coming in again with an infection or whatever but it did open my eyes, just look at the age group. ACCEPt, The Australian Chlamydia Control Effectiveness Pilot; STD, sexually transmitted disease. View Large Table 5. A comparison of collective action and the circumstances of offering a test at baseline and midpoint Baseline Midpoint Baseline GP 15: Anyone who has got a symptom, like discharge, break- through bleeding on the pill, pain obviously, coming in for a Pap smear, anyone who wants an STD check. That is pretty much it. Baseline GP 29: I don’t know if some of them would feel that their behaviour warranted a chlamydia test and might be upset that that they were asked to have one. Midpoint GP 14: Knowing some of the figures for the local town helped. In that I can say, ‘You know we have this ridiculously high rate of chlamydia and we are trying to get it down so I am trying to test everybody’. So they can kind of feel that they are not being singled out as someone that I feel is at high risk as well, want to get everybody. Midpoint GP 30: I think what it changed is the age group that opened my eyes. Without the ACCEPt, I would still do anyone coming in again with an infection or whatever but it did open my eyes, just look at the age group. Baseline Midpoint Baseline GP 15: Anyone who has got a symptom, like discharge, break- through bleeding on the pill, pain obviously, coming in for a Pap smear, anyone who wants an STD check. That is pretty much it. Baseline GP 29: I don’t know if some of them would feel that their behaviour warranted a chlamydia test and might be upset that that they were asked to have one. Midpoint GP 14: Knowing some of the figures for the local town helped. In that I can say, ‘You know we have this ridiculously high rate of chlamydia and we are trying to get it down so I am trying to test everybody’. So they can kind of feel that they are not being singled out as someone that I feel is at high risk as well, want to get everybody. Midpoint GP 30: I think what it changed is the age group that opened my eyes. Without the ACCEPt, I would still do anyone coming in again with an infection or whatever but it did open my eyes, just look at the age group. ACCEPt, The Australian Chlamydia Control Effectiveness Pilot; STD, sexually transmitted disease. View Large Reflexive monitoring A key component of ACCEPt is the provision of feedback to the GPs, which allows GPs to reflect and evaluate the progress of the intervention (Table 6). At baseline, GPs welcomed the idea of receiving feedback to monitor their progress. By midpoint, many GPs cited feedback as a primary driver of their testing as it identified areas for improvement and provided opportunities to discuss testing strategies with the RO. Some concerns about the accuracy of the data arose and may have prevented some GPs from fully engaging with the intervention. These concerns stem from a 3-month time lag in between the period of testing and receiving a feedback report, as clinic data were validated against laboratory data. Most agreed that the project was feasible but would ideally have more staff and resource support. Table 6. A comparison of reflexive monitoring in the baseline and midpoint interviews Baseline Midpoint Baseline GP 34: A lot of times you are there and you are doing all this work but you don’t really hear back so you don’t really know what is happening until the end. I think whilst the process is going so you have a bit of an idea and you can also see that your work is counting towards something, it is quite good. Midpoint GP 12: I think it has been an extremely useful learning exercise for me but I was very disappointed in my first set of results. So I am hoping I have improved, that sort of feedback is fantastic because we all strive to be better. Baseline Midpoint Baseline GP 34: A lot of times you are there and you are doing all this work but you don’t really hear back so you don’t really know what is happening until the end. I think whilst the process is going so you have a bit of an idea and you can also see that your work is counting towards something, it is quite good. Midpoint GP 12: I think it has been an extremely useful learning exercise for me but I was very disappointed in my first set of results. So I am hoping I have improved, that sort of feedback is fantastic because we all strive to be better. View Large Table 6. A comparison of reflexive monitoring in the baseline and midpoint interviews Baseline Midpoint Baseline GP 34: A lot of times you are there and you are doing all this work but you don’t really hear back so you don’t really know what is happening until the end. I think whilst the process is going so you have a bit of an idea and you can also see that your work is counting towards something, it is quite good. Midpoint GP 12: I think it has been an extremely useful learning exercise for me but I was very disappointed in my first set of results. So I am hoping I have improved, that sort of feedback is fantastic because we all strive to be better. Baseline Midpoint Baseline GP 34: A lot of times you are there and you are doing all this work but you don’t really hear back so you don’t really know what is happening until the end. I think whilst the process is going so you have a bit of an idea and you can also see that your work is counting towards something, it is quite good. Midpoint GP 12: I think it has been an extremely useful learning exercise for me but I was very disappointed in my first set of results. So I am hoping I have improved, that sort of feedback is fantastic because we all strive to be better. View Large Discussion and conclusions Discussion Most of the GPs understood the purpose of the intervention over time, a crucial part of coherence in NPT. However, some had difficulty in assigning value to the work and prioritizing it in an already cumbersome workload. In terms of cognitive participation, the GPs engaged with the intervention, although the level of commitment varied. Many found that their confidence increased in offering a test due to the education and strategies provided. Individually, GPs modified their behaviour, recognizing that age-based testing was less stigmatizing than testing based on symptoms and sexual history, thus partially fulfilling collective action. Feedback was the most frequently cited reason for increasing testing, and thus, the most successful element of NPT in ACCEPt was reflexive monitoring, as the quarterly feedback reports gave the GPs an opportunity to reflect and appraise their work. In turn, GPs were able to identify changes within their control that could be made to their practices and facilitate chlamydia testing. The strength of this analysis is that it uses the NPT as a framework to explore the effectiveness of the ACCEPt intervention. A recent systematic review found that NPT was beneficial in analysing and informing implementation processes (18) and highlighted the dynamic relationship between the four elements. For example, a UK intervention used NPT to examine shared decision making with health professionals (19) and found that coherence was often limited with divergent viewpoints expressed by participants and hindered intervention implementation. A study set in primary care utilized NPT in evaluating the introduction of chronic kidney disease management checks and found it was successful in embedding the checks into review appointments with nurses who had roles that overlapped with their existing roles (20). This is similar to ACCEPt; nurses who were Pap smear providers or sexual health educators were able to add chlamydia testing to their repertoire. The use of NPT in ACCEPt has also led to research in understanding sustainability in general practice and may be helpful for stakeholders in increasing effectiveness of implementing future interventions. A further strength of this analysis was that GPs were represented from different geographical areas to capture problems unique to their region. Perspectives from both male and female GPs were presented in this analysis; however, the female GPs were more likely to be younger and work part-time and none of the GPs interviewed at midpoint were older than 60 years of age. A limitation of this analysis is that it only examines the perspectives of the GPs but both the ACCEPt intervention and NPT encompass a whole-of-clinic approach. The roles of the nurses and practice managers in ACCEPt are being investigated by other researchers (13,14). These findings may not be generalizable as the analysis is specifically about the ACCEPt intervention. Despite our best efforts to get a broad cross-section of GPs, some declined to participate and those who participated may have been more interested in chlamydia testing. Some GPs noted that ACCEPt did not provide many strategies around communicating with culturally and linguistically diverse populations about chlamydia testing. However, these GPs also noted that their towns were not very multicultural, and few made specific reference to the indigenous population. ACCEPt is based in rural areas to capture sexual networks, and these have a more homogeneous patient population with 97% being born in Australia (21). Conclusion The facilitators provided by ACCEPt shifted the GPs from symptom- based testing to age-based testing and have moderately normalized chlamydia testing into routine practice. The use of computer alerts, financial incentives, visual media and nurses varied in their contribution to this shift but the most impactful component was the quarterly feedback report combined with a visit from the RO. All components were necessary to incrementally push chlamydia testing onto the GP’s agenda. Utilizing NPT as a framework to demonstrate the effective implementation of a chlamydia testing intervention in general practice was valuable in understanding which components are essential and which components can be improved upon. Supplementary material Supplementary data are available at Family Practice online. Declaration Funding: ACCEPt was commissioned and funded by the Australian Government Department of Health. Additional funding has been received from the National Health and Medical Research Council, the Victorian Department of Health and NSW Health. Ethical approval: This project was conducted in accordance with the National Statement on Ethical Conduct in Human Research produced by the National Health and Medical Research Council of Australia. Ethical approval was granted by the Royal Australian College of General Practitioners (RACGP) National Research and Evaluation Ethics Committee and the Aboriginal Health and Medical Research Council Ethics Committee. Conflict of interest: None declared. Acknowledgements This evaluation was conducted as part of the Department of Health-funded Australian Chlamydia Control Effectiveness Pilot. Additional funding and support have been provided by National Health and Medical Research Council, Department of Health—Victoria, NSW (New South Wales) Health, Royal Australian College of General Practitioners and the Australian Primary Health Care Nurses Association. Ethical approval was obtained from the Royal Australian College of General Practitioners National Research and Evaluation Ethics Committee, the Aboriginal Health and Medical Research Council Ethics Committee and the University of Melbourne Human Research Ethics Committee. We thank Jane Tomnay from the Centre for Excellence in Rural Sexual Health, University of Melbourne for providing resources, support and advice on conducting this study in rural Victoria and Douglas Boyle and the GHRANITE team from the Health Informatics Unit, University of Melbourne; Carolyn Murray and Chris Bourne from the NSW Sexually Transmissible Infections Program Unit for providing advice and resources. We acknowledge the support from pathology providers in providing chlamydia testing data for the analysis and thank Capital Pathology, Dorevitch Pathology, Douglass Hanly Moir Pathology, Healthscope Pathology, Institute of Clinical Pathology & Medical Research, Melbourne Pathology, Pathology North, Pathology Queensland, South Australia Pathology, St John of God Pathology, St. Vincent’s Health Pathology, Sullivan and Nicolaides Pathology, and Victorian Cytology Service. A big thank you to the ACCEPt research officer team of Rebecca Lorch, Anna Wood, Belinda Ford, Michelle King, Eris Smyth, Jennifer Walker, Dyani Lewis, Lisa Edward, Chantal Maloney, Danielle Newton, Paula Nathan and Anne Shaw for their help with recruiting clinics and providing them ongoing support. We acknowledge input from the ACCEPt Consortium of investigators: Marcus Chen and Lena Sanci from the University of Melbourne; David Wilson and David Regan from the University of New South Wales; Sepehr Tabrizi from the Royal Women’s Hospital; James Ward from the South Australian Health and Medical Research Institute; Marian Pitts and Anne Mitchell from La Trobe University; Rob Carter from Deakin University; Marion Saville and Dorota Gertig from the Victorian Cytology Service; Margaret Hellard from the Burnet Institute; and Nicola Low from the University of Bern. References 1. National Notifiable Diseases Surveillance System . Notification Rate of Chlamydial Infection, Received from State and Territory Health Authorities 2018 . http://www9.health.gov.au/cda/source/rpt_3.cfm (accessed on 7 January 2018 ). 2. Grulich AE , de Visser RO , Smith AM , Rissel CE , Richters J . Sex in Australia: sexually transmissible infection and blood-borne virus history in a representative sample of adults . Aust N Z J Public Health 2003 ; 27 : 234 – 41 . Google Scholar CrossRef Search ADS PubMed 3. Kong FY , Guy RJ , Hocking JS et al. Australian general practitioner chlamydia testing rates among young people . Med J Aust 2011 ; 194 : 249 – 52 . Google Scholar PubMed 4. Peipert JF . Clinical practice. Genital chlamydial infections . N Engl J Med 2003 ; 349 : 2424 – 30 . Google Scholar CrossRef Search ADS PubMed 5. Trojian TH , Lishnak TS , Heiman D . Epididymitis and orchitis: an overview . Am Fam Physician 2009 ; 79 : 583 – 7 . Google Scholar PubMed 6. Fleming DT , Wasserheit JN . From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection . Sex Transm Infect 1999 ; 75 : 3 – 17 . Google Scholar CrossRef Search ADS PubMed 7. Yeung A , Temple-Smith M , Fairley C , Hocking J . Narrative review of the barriers and facilitators to chlamydia testing in general practice . Aust J Prim Health 2015 ; 21 : 139 – 47 . Google Scholar CrossRef Search ADS PubMed 8. General Practice NSW [New South Wales] . A Guide to Understanding and Working with General Practice in NSW . Sydney : NSW Department of Health , 2011 . 9. Walker J , Walker S , Fairley CK et al. What do young women think about having a chlamydia test? Views of women who tested positive compared with women who tested negative . Sex Health 2013 ; 10 : 39 – 42 . Google Scholar PubMed 10. Pavlin NL , Parker R , Fairley CK , Gunn JM , Hocking J . Take the sex out of STI screening! Views of young women on implementing chlamydia screening in general practice . BMC Infect Dis 2008 ; 8 : 62 . Google Scholar CrossRef Search ADS PubMed 11. Guy RJ , Ali H , Liu B et al. Efficacy of interventions to increase the uptake of chlamydia screening in primary care: a systematic review . BMC Infect Dis 2011 ; 11 : 211 . Google Scholar CrossRef Search ADS PubMed 12. Hocking J , Low N , Guy R et al. Protocol 12 PRT 09010: Australian chlamydia control effectiveness pilot (ACCEPt): a cluster randomised controlled trial of chlamydia testing in general practice . Lancet 2013 . http://www.thelancet.com/protocol-reviews/12PRT-9010 13. Lorch R , Hocking J , Guy R et al. ; ACCEPt consortium . Do Australian general practitioners believe practice nurses can take a role in chlamydia testing? A qualitative study of attitudes and opinions . BMC Infect Dis 2015 ; 15 : 31 . Google Scholar CrossRef Search ADS PubMed 14. Lorch R , Hocking J , Guy R et al. ; ACCEPt Consortium . Practice nurse chlamydia testing in Australian general practice: a qualitative study of benefits, barriers and facilitators . BMC Fam Pract 2015 ; 16 : 36 . Google Scholar CrossRef Search ADS PubMed 15. May C , Finch T . Implementing, embedding, and integrating practices: an outline of normalization process theory . Sociology 2009 ; 43 : 535 – 54 . Google Scholar CrossRef Search ADS 16. May C , Rapley T , Mair FS et al. Normalization Process Theory On-line Users’ Manual, Toolkit and NoMAD instrument . 2015 ; http://www.normalizationprocess.org (accessed on 16 March 2016). 17. Temple-Smith M , Hammond J , Pyett P , Presswell N . Barriers to sexual history taking in general practice . Aust Fam Physician 1996 ; 25 ( 9 suppl 2 ): S71 – 4 . Google Scholar PubMed 18. McEvoy R , Ballini L , Maltoni S et al. A qualitative systematic review of studies using the normalization process theory to research implementation processes . Implement Sci 2014 ; 9 : 2 . Google Scholar CrossRef Search ADS PubMed 19. Lloyd A , Joseph-Williams N , Edwards A , Rix A , Elwyn G . Patchy ‘coherence’: using normalization process theory to evaluate a multi-faceted shared decision making implementation program (MAGIC) . Implement Sci 2013 ; 8 : 102 . Google Scholar CrossRef Search ADS PubMed 20. Blakeman T , Protheroe J , Chew-Graham C , Rogers A , Kennedy A . Understanding the management of early-stage chronic kidney disease in primary care: a qualitative study . Br J Gen Pract 2012 ; 62 : e233 – 42 . Google Scholar CrossRef Search ADS PubMed 21. Yeung AH , Temple-Smith M , Fairley CK et al. Chlamydia prevalence in young attenders of rural and regional primary care services in Australia: a cross-sectional survey . Med J Aust 2014 ; 200 : 170 – 5 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Family PracticeOxford University Press

Published: Mar 28, 2018

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