title: Tools to overcome potential barriers to chlamydia screening in general practice: Qualitative evaluation of the implementation of a complex intervention.
abstract: BACKGROUND
  Chlamydia trachomatis remains a significant public health problem. We used a complex intervention, with general practice staff, consisting of practice based workshops, posters, computer prompts and testing feedback and feedback to increase routine chlamydia screening tests in under 25 year olds in South West England. We aimed to evaluate how intervention components were received by staff and to understand what determined their implementation into ongoing practice.
  
  
  METHODS
  We used face-to-face and telephone individual interviews with 29 general practice staff analysed thematically within a Normalisation Process Theory Framework which explores: 1. Coherence (if participants understand the purpose of the intervention); 2. Cognitive participation (engagement with and implementation of the intervention); 3. Collective action (work actually undertaken that drives the intervention forwards); 4. Reflexive monitoring (assessment of the impact of the intervention).
  
  
  RESULTS
  Our results showed coherence as all staff including receptionists understood the purpose of the training was to make them aware of the value of chlamydia screening tests and how to increase this in their general practice. The training was described by nearly all staff as being of high quality and responsible for creating a shared understanding between staff of how to undertake routine chlamydia screening. Cognitive participation in many general practice staff teams was demonstrated through their engagement by meeting after the training to discuss implementation, which confirmed the role of each staff member and the use of materials. However several participants still felt unable to discuss chlamydia in many consultations or described sexual health as low priority among colleagues. National targets were considered so high for some general practice staff that they didn't engage with the screening intervention. Collective action work undertaken to drive the intervention included use of computer prompts which helped staff remember to make the offer, testing rate feedback and having a designated lead. Ensuring patients collected samples when still in the general practice was not attained in most general practices. Reflexive monitoring showed positive feedback from patients and other staff about the value of screening, and feedback about the general practices testing rates helped sustain activity.
  
  
  CONCLUSIONS
  A complex intervention including interactive workshops, materials to help implementation and feedback can help chlamydia screening testing increase in general practices.
authors.affiliation: Public Health England Primary Care Unit, Microbiology Department, Gloucestershire Royal Hospital, Great Western Road, Gloucester, GL1 3NN, UK.
authors.forename: Ellie J
authors.initials: EJ
authors.lastname: Ricketts
authors.affiliation: NIHR CLAHRC West Midlands Chronic Disease Theme, Institute of Applied Health Research, University of Birmingham, Edgbaston B15 2TT, Birmingham, UK.
authors.forename: Elaine O'Connell
authors.initials: EO
authors.lastname: Francischetto
authors.affiliation: Faculty of Health and Social Care, National Institutes of Health Research Health Services and Delivery Research Programme, The Open University, Walton Hall, Milton Keynes, MK7 6AA, UK.
authors.forename: Louise M
authors.initials: LM
authors.lastname: Wallace
authors.affiliation: Health Protection Agency Primary Care Unit, Personalised Medicine Consortium Integrated Biobank of Luxembourg 6, Rue Nicolas Ernest Barblé, L-1210, Luxembourg.
authors.forename: Angela
authors.initials: A
authors.lastname: Hogan
authors.affiliation: Public Health England Primary Care Unit, Microbiology Department, Gloucestershire Royal Hospital, Great Western Road, Gloucester, GL1 3NN, UK. cliodna.mcnulty@phe.gov.uk.
authors.forename: Cliodna A M
authors.initials: CA
authors.lastname: McNulty
mesh_terms: D000293:Adolescent; D000328:Adult; D001291:Attitude of Health Personnel; D002690:Chlamydia Infections / Q000175:diagnosis*; D004502:Education, Medical, Continuing / Q000379:methods*; D004739:England; D005260:Female; D000068156:Formative Feedback; D058006:General Practice / Q000193:education* / Q000379:methods / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000706:statistics & numerical data*; D010348:Patient Care Team; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D017064:Process Assessment, Health Care; D036301:Qualitative Research; D055815:Young Adult
keywords: Chlamydia screening; Education; General practice; Normalisation process theory; Primary care; Sexual health