Service evaluation of an educational intervention to improve sexual health services in primary care implemented using a step-wedge design: analysis of chlamydia testing and diagnosis rate changes

Abstract

BackgroundProviding sexual health services in primary care is an essential step towards universal provision. However they are not offered consistently. We conducted a national pilot of an educational intervention to improve staff’s skills and confidence to increase chlamydia testing rates and provide condoms with contraceptive information plus HIV testing according to national guidelines, known as 3Cs&HIV. The effectiveness of the pilot on chlamydia testing and diagnosis rates in general practice was evaluated.MethodsThe pilot was implemented using a step-wedge design over three phases during 2013 and 2014 in England. The intervention combined educational workshops with posters, testing performance feedback and continuous support. Chlamydia testing and diagnosis rates in participating general practices during the control and intervention periods were compared adjusting for seasonal trends in chlamydia testing and differences in practice size. Intervention effect modification was assessed for the following general practice characteristics: chlamydia testing rate compared to national median, number of general practice staff employed, payment for chlamydia screening, practice urban/rurality classification, and proximity to sexual health clinics.ResultsThe 460 participating practices conducted 26,021 tests in the control period and 18,797 tests during the intervention period. Intention-to-treat analysis showed no change in the unadjusted median tests and diagnoses per month per practice after receiving training: 2.7 vs 2.7; 0.1 vs 0.1. Multivariable negative binomial regression analysis found no significant change in overall testing or diagnoses post-intervention (incidence rate ratio (IRR) 1.01, 95 % confidence interval (CI) 0.96–1.07, P = 0.72; 0.98 CI 0.84–1.15, P = 0.84, respectively). Stratified analysis showed testing increased significantly in practices where payments were in place prior to the intervention (IRR 2.12 CI 1.41–3.18, P < 0.001) and in practices with 6–15 staff (6–10 GPs IRR 1.35 (1.07–1.71), P = 0.012; 11–15 GPs IRR 1.37 (1.09–1.73), P = 0.007).ConclusionThis national pilot of short educational training sessions found no overall effect on chlamydia testing in primary care. However, in certain sub-groups chlamydia testing rates increased due to the intervention. This demonstrates the importance of piloting and evaluating any service improvement intervention to assess the impact before widespread implementation, and the need for detailed understanding of local services in order to select effective interventions.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-016-3343-z) contains supplementary material, which is available to authorized users.

Exploring why a complex intervention piloted in general practices did not result in an increase in chlamydia screening and diagnosis: a qualitative evaluation using the fidelity of implementation model

“…Data from the quantitative analysis showed that 58% (268/460) of practices that agreed to participate in the intervention received at least one educational workshop [19]. When discussing reasons for their colleagues non-attendance at the educational workshops, participants reported reasons, such as: lack of time (especially GPs); staff feeling that it is not their field, role, or area of expertise (especially male, older GPs); and the perception that chlamydia tests are offered in contraception consultations, which are generally for female patients, who prefer to see female staff.

“We didn’t complete it… only did the chlamydia and it’s not because she didn’t try, she kept trying to get in, but we had a massive, massive staff change round and then we’ve had a lot of sickness so I couldn’t, I just cannot get the meetings together for the rest of them.” (YNYER121- nurse)

“you’re going to find that female staff will go… it’s also in your area of speciality and it’s going to be interesting whereas, yeah, someone who’s just not got that in their kind of bag is not, unless it’s a learning need for them, they’re probably not going to rush to be there… are going to miss training” (DCR120- GP)

“[male GP talking about patient’s preference]…see the female doctors for, for consultations… I think it’s less of an issue less of something I’ve had to deal with than some of my colleagues but that of course puts me at risk of being less good at it” (NSKT124- GP)

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“…Practices that had participated in the 3Cs and HIV intervention were stratified by chlamydia screening rate per 100 registered 15–24 year old patients, from January 2013 until September 2014 [19]. Practices were then contacted in a random order from this list via the practice managers.…”

“…Data saturation was achieved after 18 interviews [24]. However, as the quantitative analysis showed locally enhanced service (LES) payments to be a relevant factor [19], purposive sampling [25] was used recruit a further 8 participants from areas with an existing LES, at the time of the intervention. At this stage, male practice staff were prioritised, where there was an option, to reduce the gender imbalance.…”

“…The one sheet of paper (OSOP) method [31] was used to clarify findings within, and between, themes. As the quantitative evaluation found that the intervention was not successful in increasing chlamydia screening and diagnosis rates in all general practices [19], deductive analysis [32] was used, whereby the principles of the fidelity of implementation model (Fig. 2) were applied to further analyse the themes.…”

“…Although immediately after the workshop, practice staff who attended the educational workshops fed back that they intended to increase their chlamydia screening as a result of the training, the quantitative evaluation shows that there was no overall significant increase in chlamydia testing or diagnosis across all of the practices offered the workshops [19]. However, chlamydia testing and diagnosis significantly increased in practices that received specific payments for testing before the intervention began.…”