Narrative review of the barriers and facilitators to chlamydia testing in general practice.

CSIRO PUBLISHING

Australian Journal of Primary Health, 2015, 21, 139–147 http://dx.doi.org/10.1071/PY13158

Review

Narrative review of the barriers and facilitators to chlamydia testing in general practice Anna Yeung A,E, Meredith Temple-Smith B, Christopher Fairley C,D and Jane Hocking A A

Melbourne School of Population and Global Health, L3, 207 Bouverie Street, The University of Melbourne, Vic. 3010, Australia. B General Practice and Primary Health Care Academic Centre, 200 Berkeley Street, The University of Melbourne, Vic. 3010, Australia. C Melbourne Sexual Health Centre, 580 Swanston Street, Carlton, Vic. 3053, Australia. D Central Clinical School, Monash University, Alfred Hospital, 55 Commercial Road, Melbourne, Vic. 3004, Australia. E Corresponding author. Email: [email protected]

Abstract. As the cornerstone of Australian primary health care, general practice is a setting well suited for regular chlamydia testing but testing rates remain low. This review examines the barriers and facilitators to chlamydia testing in general practice. Six databases – Medline, PubMed, Meditext, PsycInfo, Scopus and Web of Science – were used to identify peer-reviewed publications that addressed barriers and facilitators to chlamydia testing in general practice using the following terms: ‘chlamydia test*’, ‘STI test*’’general practice’, ‘primary care’, ‘family medicine’, ‘barriers’, ‘facilitators’ and ‘enablers’ from 1997 until November 2013. Data about the study design and key findings were extracted from the publications. A framework method was used to manage the data and organise publications into three categories –patient, general practitioner, and general practice. Key findings were then classified as a barrier or facilitator. Sixty-nine publications were included, with 41 quantitative studies, 17 qualitative studies, and 11 using mixed methods. Common barriers identified in all three groups included a lack of knowledge, awareness or training, demands on time and workload, and the social context of testing. Facilitators included the normalisation of testing, the use of nurses and other practice staff, education and incentives. Numerous barriers and facilitators to chlamydia testing in general practice have been identified. While the barriers are well studied, many of the facilitators are not as well researched, and highlight areas for further study. Additional keywords: general practitioner, primary health care. Received 23 November 2013, accepted 16 July 2014, published online 14 August 2014

Background Recent advances in sexual health have the potential to make a major impact on the rates of sexually transmissible infections (STIs) and reduce both the personal and economic cost of these infections (Walleser et al. 2006; Aghaizu et al. 2011). Implementing change in the general practice setting, where most STIs are diagnosed, is a slow process made complex by the competing demand of common complaints, and the varying levels of knowledge and expertise of health professionals (Overton et al. 2009). Chlamydia is the most common bacterial STI in Australia and notifications have risen four-fold over the last decade (NNDSS Annual Report Writing Group 2010; NNDSS Annual Report Writing Group 2012). Untreated chlamydia infection can cause pelvic inflammatory disease (PID), infertility (Cates and Wasserheit 1991) and epididymo-orchitis (Trojian et al. 2009). Approximately 80% of all infections are asymptomatic and as a Journal compilation Ó La Trobe University 2015

result, most infections are not detected (Peipert 2003). The Australian government made the increasing rate of chlamydia a priority in the National STI Strategy in 2005 (Commonwealth of Australia 2005). General practice is well suited for chlamydia testing as 75% of people under 30 years old attend at least once a year (Kong et al. 2011), and most diagnoses are made in this setting (Grulich et al. 2003). Patients do present in general practice to manage sexual health related problems – 67% of GPs recorded at least one encounter in a calendar year in one study (Freedman et al. 2006). However, testing rates are consistently low (Kong et al. 2011) and this minimal uptake suggests that there are many obstacles to testing that need to be addressed. The aim of this review is to identify the barriers and facilitators to chlamydia testing in the primary care setting. In identifying these key barriers and facilitators, we will highlight areas where improvements can be made to increase chlamydia testing. www.publish.csiro.au/journals/py

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Data extraction and analysis What is known about the topic? *

Despite high notification rates in young people, chlamydia testing in Australian general practice remains low. Barriers to testing are well studied while the facilitators are not as strongly researched.

What does this paper add? *

Barriers and facilitators were categorised at the patient, general practitioner and general practice levels in this comprehensive overview. Gaps in the literature identified areas for future research.

Methods Search strategy Six databases – Medline, PubMed, Informit Health Collection (Meditext), PsycInfo, Scopus and Web of Science – were utilised for this review. The following search terms were used ‘chlamydia test*’, ‘STI test*’ ‘general practice’, ‘primary care’, ‘family medicine’, ‘feasibility’, ‘barriers’, ‘facilitators’ and ‘enablers’. After the search was completed in November 2013, additional papers were included after handsearching references and discussion with other colleagues in the field; see Fig. 1 for the publication selection process. Authors of conference proceedings found in the search were emailed to identify full peer-reviewed publications. After removing duplicates, the records were sorted by inclusion and exclusion criteria (Table 1); records were only selected if they fit all of the inclusion criteria. The remaining abstracts were read by AY, JH and MTS to determine their relevance.

A barrier was defined as ‘a factor that restricts or prevents the process of chlamydia testing’ while a facilitator was defined as a ‘factor that assists or promotes the process of chlamydia testing’. These definitions were derived from the results and discussions of the included publications. Data about the study design, the study population, response rate (if described), and key findings were extracted, and collated into a Microsoft Excel (Microsoft Corporation, Redmond, WA, USA) spreadsheet. Using this matrix, the authors developed a framework to systematically manage the data for analysis. Following detailed examination, a consensus was reached that the publications were most usefully categorised into three groups – patient, GP and practice, based on the participants of the studies. Within these groups, the definitions of barrier and facilitator were applied to the findings. The quality of evidence presented in these publications was variable, but a broad range of study types were included, due to the narrative approach taken by this review. Details of study designs and summaries of evidence can be seen in Tables S1–S8, available as Supplementary Material for this paper. Results Of the initial 2590 records returned, 69 papers fulfilled the inclusion criteria and were included in the final analysis. The majority were quantitative analyses, with 41 papers. Another 17 were qualitative papers and 11 used mixed methods. The majority of papers came from STI/sexual and reproductive health journals (34), the rest from public health (16), general practice (13), medicine (2), and social science (4) journals. In regard to epidemiological study design, six were randomised controlled trials (RCTs), one was a cohort study, and 41 were cross-sectional

Papers identified through Medline, Informit Health Collection, PubMed, PsycInfo, Scopus and Web of Science

Number of papers Number of papers

excluded on basis

found = 2590

of title, including duplicates = 2084

Handsearching references and

Number of papers

discussion with

assessed for

other researchers

eligibility = 506

=6

Number of papers excluded = 437 (298 by abstract, 129 by full-text)

Number of papers included in final analysis Quantitative = 41 Qualitative = 17 Mixed methods = 11 Fig. 1. Publication selection process.

Barriers and facilitators to chlamydia testing


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Table 1. Inclusion and exclusion criteria Inclusion criteria – Study conducted after 1997 AND – Written in English AND – Addressed barriers and facilitators to chlamydia testing, applicable to the immediate consultation in the general practice setting AND – Study conducted in the UK, Ireland, New Zealand or Australia, as the general practice setting is comparable AND – Peer-reviewed publication

or observational studies. Of those using qualitative methods, 24 used individual interviews and five used focus groups; two papers used both. Barriers At the patient level Several barriers at the patient level were identified, with major themes emerging around perceptions of being judged, poor knowledge, and accessibility to services. Perceptions of being judged Many publications cited the social context of chlamydia to be a significant barrier to testing, using stigma (Balfe and Brugha 2009), embarrassment (Heritage and Jones 2008) and the creation of a ‘moral identity’ by the patient (Balfe and Brugha 2011) to describe these issues. Patients perceived that an invitation to test by the GP implied a value judgment about his or her sexuality (Hogan et al. 2010), and saw testing as a mark of a ‘dirty’ person, especially with women (Balfe et al. 2010a). Some young patients were not comfortable with discussing sexual health issues (Walker et al. 2013), particularly if the GP was older or male because of a perceived inability to relate to the patient (Balfe et al. 2010b). Additionally, testing sometimes brought up difficulties in discussing the issue with current or former partners (Pimenta et al. 2003a; Pavlin et al. 2008). Confidentiality and privacy issues were often mentioned as being a barrier (Balfe et al. 2010b), with 10% citing a fear of others finding out about testing (Zakher and Kang 2008). Poor knowledge Poor knowledge around STIs and services were identified as a significant barrier to chlamydia testing. Not all had heard of chlamydia before; 20% of men were unfamiliar (Mason 2005) and 63% of university students had little to no knowledge about the infection or risk factors (Zakher and Kang 2008), and thereby perceived their own level of risk to be low (Santer et al. 2003; Balfe et al. 2010a). Additionally, lack of correct information around services and testing procedures hindered accessibility to sexual health services (Burack 2000; Hogan et al. 2010). Without adequate awareness, a patient could not identify the need to test. Accessibility to services Accessing the practice and the cost of appointments or testing were cited as barriers (Balfe et al. 2010a; Walker et al. 2013).

Exclusion criteria – Exclusively set outside of general practice setting OR – High-risk populations – sex workers, men who have sex with men, incarcerated people or people living with HIV OR – Set in developing country OR – Exclusively focussed on partner notification

Many young people commented that they did not have a lot of disposable income, and expenses associated with chlamydia testing may not be a priority (Balfe and Brugha 2009). Alternatively, those who were able to access general practice also felt rushed during appointments (Burack 2000), and simply forgot to request a test (Hogan et al. 2010). At the GP level Barriers identified at the GP level included time and workload constraints, lack of knowledge and capacity, patient-related issues and a fear of appearing discriminatory. Time and workload constraints Lack of time and a heavy workload were the most cited barriers to chlamydia testing and addressing sexual health-related concerns. More than half of the GPs identified time as an issue (Griffiths and Cuddigan 2002; Rogstad and Henton 2004; Hocking et al. 2008; Khan et al. 2008a; Khan and Schofield 2009; Bilardi et al. 2010; Wallace et al. 2012). These were linked with administrative issues related to the testing of chlamydia and management of a diagnosis. A standard consultation did not allow sufficient time to introduce testing, particularly in a patient with limited knowledge, or in an unrelated consultation (Merritt et al. 2007). Lack of knowledge and capacity Another significant barrier was the lack of knowledge, skill, training and awareness around chlamydia testing (McNulty et al. 2004a; Rogstad and Henton 2004; Markham et al. 2005; Hocking et al. 2006). Many GPs were not aware of the key risk factors (Bennett et al. 2001), or the use of urine testing protocols (Hocking et al. 2006; Lusk et al. 2009), or the epidemiology of the infection (Temple-Smith et al. 2008). A lack of sexual health training in medical school was reported and manifested as discomfort in communicating sexual health-related issues with patients (Hocking et al. 2008). Patient-related issues Several logistical issues were also presented as barriers to chlamydia testing. Inadequate funding, resources and services for testing contributed to an inability to test, including difficulties in referring a patient for further counselling (Khan et al. 2008a; Khan and Schofield 2009) or not having sufficient or appropriate printed resources (Khan and Plummer 2008). The act of offering a

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test to the patient was easy to forget, particularly as time increased between the reminder and offer of a test (Bilardi et al. 2010), and was attributed in one study investigating opportunistic testing with low uptake (Santer et al. 2000). Additionally, GPs had difficulties introducing chlamydia testing when patients were presenting with non-sexual health-related issues or were accompanied by parents (Merritt et al. 2007; Wallace et al. 2012). The practicalities of offering a test were magnified in patients with comprehension issues or cultural barriers (Hocking et al. 2008; Wallace et al. 2012). Finally, legal concerns about confidentiality and privacy also hindered a GP’s ability to carry out testing, particularly around partner notification (Hocking et al. 2008; Khan et al. 2008a; Wallace et al. 2012). Fear of appearing discriminatory GPs feared offending their patients by offering testing. They worried that patients might perceive them as being discriminatory by judging them as likely to be infected (Temple-Smith et al. 1999, 2008). Sensitivity for both sides was increased when religious and cultural norms differed from one another (Hocking et al. 2008; Thompson et al. 2008), particularly if the patient was of non-heteronormative orientation (Hinchliff et al. 2005; Khan et al. 2008b). Moreover, when a patient is known to a GP socially, a GP may not ask to prevent an uncomfortable situation (Temple-Smith et al. 1999; Thompson et al. 2008). At the general practice level General practice level barriers were identified as lack of time and competing demands, lack of knowledge and evidence, attitudes of practice staff and inadequate promotional materials. Lack of time and competing demands Time was identified as a barrier to testing young people for chlamydia in general practice (Armstrong et al. 2003; McNulty et al. 2004a; Senok et al. 2005; Thompson et al. 2008; TempleSmith et al. 2012). In addition, there were competing demands and health campaigns in a practice, and not enough staff or funding to carry out these activities (Griffiths and Cuddigan 2002). A lack of formal practice protocol reduced the ability of nursing staff to carry out chlamydia testing and sexual healthrelated consults (Thompson et al. 2008). Lack of knowledge and evidence The lack of knowledge or evidence was identified as a barrier in some general practices; some staff wanted training in sexual health issues and testing procedures (McNulty et al. 2004a; Thompson et al. 2008), particularly with male patients (Robertson and Williams 2005a, 2005b). Additionally, those in rural practices believed chlamydia to be an urban problem, and that their patients were not at risk (McNulty et al. 2004b). Both nurses and doctors found raising chlamydia in a non-sexual health-related consult to be quite difficult (McNulty et al. 2004a). Attitudes of practice staff Insufficient support from practice staff was acknowledged as a barrier to testing overall, and to dedicated chlamydia testing campaigns (McNulty et al. 2008a). Negative attitudes towards chlamydia from GPs and senior personnel precipitated a lack of enthusiasm in the rest of the staff (Wallace et al. 2012). Some

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practices were identified as not being youth-friendly, resulting in low attendance by young people (Temple-Smith et al. 2012). Inadequate promotional materials Inadequate supplies of promotional materials were also recognised as barriers to testing. Few informational leaflets were provided in waiting rooms, or they were out-of-date or not replenished (Khan and Plummer 2008). Some were removed due to complaints that the material was offensive, or removed due to a lack of space (Freeman et al. 2009). Conversely, at times when they were available, patients did not bother to read them. Facilitators At the patient level Facilitators identified at the patient level included normalisation of testing, education, access to testing and services, patient comfort with general practice and incentives. Normalisation of testing As the context under which chlamydia testing was offered was highly influential in a patient’s decision to test, patients preferred their GP to have a non-judgmental manner for testing (Balfe et al. 2010b; Hogan et al. 2010). Patients liked being offered the test based on age, removing the need to take a personal sexual history (Pavlin et al. 2008), and most university students were comfortable being tested by the GP regardless of the reason for the consult (Zakher and Kang 2008). Additionally, patients were pleased when the test was GP-initiated and reinforced autonomy by giving them a choice to have the test (Santer et al. 2003). Patients were quite accepting of the idea of an annual chlamydia test (Walker et al. 2013). Framing the test as a preventive health procedure benefitting the patient and their partners allowed patients to maintain their moral identity of protecting their own health (Pimenta et al. 2003a; Balfe and Brugha 2011). Patients only accepted testing when they could trust that privacy and confidentiality were maintained by the GP (Heritage and Jones 2008). Education Education or increased awareness about chlamydia and testing was seen as a key facilitator for patients (Zakher and Kang 2008). The ability to educate, in both the practice and the community, was a necessary component for any STI program (Heritage and Jones 2008; Pavlin et al. 2008). In theory, patients could be more informed about their risk level, and seek health care and testing accordingly. Patients often learned directly about chlamydia when asked by the GP if they would like to be tested (Hogan et al. 2010). Education was also important to those who were offered testing, and those who were waiting for results (Santer et al. 2003), as knowledge about services, testing and treatment allowed patients to feel prepared and more at ease (Pimenta et al. 2003a). Access to testing and services Patients were more likely to accept an offer of chlamydia testing if given a choice of a urine test, over a vaginal or urethral swab because of convenience and efficiency (Oakeshott et al. 2002; Heritage and Jones 2008; Brugha et al. 2011; Sutcliffe et al.


2011). As the groups at risk for chlamydia do not have a lot of disposable income, it was demonstrated in general practice that free sexual health consults greatly increased the rate of testing (Morgan and Haar 2009). Patient comfort with general practice Patients preferred to be tested in a health-care setting like general practice, as they were primed to accept medical interventions, particularly in a sexual health-related consultation (Harris 2005; Hogan et al. 2010; Brugha et al. 2011; Saunders et al. 2012). However, many noted that having a health-care professional who was of the same sex and younger was preferred, as they were perceived to be less judgmental (Balfe et al. 2010b). Incentives Financial incentives for the patient were also mentioned as a possible facilitator. Vouchers were found to be more effective than prize draws, possibly because they are thought to be of higher value (Zenner et al. 2012). However, incentives are often not recommended due to concerns about sustainability and ethics. At the GP level Facilitators identified at the GP level included remembering to test/normalisation of testing, education/awareness/training and incentives. Remembering to test/normalisation of testing As remembering to test has been a significant barrier for GPs, reminders to offer a test to an eligible patient could have a major impact (Bilardi et al. 2010). Electronic alerts have been shown to increase testing rates (Walker et al. 2010), and with the use of non-heteronormative terminology (Hinchliff et al. 2005), these are theorised to also reduce the stigma around testing by reducing judgment towards the patient to normalise testing (Ma and Clark 2005; McNulty et al. 2008b, 2010; Wallace et al. 2012). Feedback on testing rates (Merritt et al. 2007; Lawton et al. 2010) or formal policy and guidelines (Hocking et al. 2008; Bangor-Jones 2011) may also help to normalise testing by increasing awareness. Linking it to sexual health-related consultations such as Pap smears was effective in increasing testing (Bowden et al. 2008). It should be noted that in papers that looked at the association between demographic characteristics of the GP and chlamydia testing, some found that younger or female GPs were more likely to test (Bennett et al. 2001; Sawleshwarkar et al. 2010) while others found that GPs with more experience were more likely to test (Giles et al. 2009). This association favours young, female GPs, but indicates that other GPs can be targeted to increase their chlamydia testing. Education/awareness/training Many GPs thought they lacked sufficient knowledge and skills around chlamydia testing. It was often postulated that the facilitator with the greatest impact would be better education, awareness and training (Wray et al. 1998; Doherty 2000; Hope et al. 2002; McNulty et al. 2004a; Rogstad and Henton 2004; Hinchliff et al. 2005; Bailey et al. 2008; Hocking et al. 2008; Khan et al. 2008a; McNulty et al. 2008b; Richards and Pattman 2008; Thompson et al. 2008; Khan and Schofield 2009; Lawton et al. 2010; Kalwij et al. 2012). Those with postgraduate training


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in STIs were twice as likely to test young men for chlamydia (Khan et al. 2006), and GPs with continuing medical education in STIs had reduced reluctance to taking a sexual history with a new or opposite sex patient (Temple-Smith et al. 1999). While many papers cited the need for education, few investigated the correlation between education and chlamydia testing behaviour. No publications identified the type or quantity of chlamydiaspecific education that was needed to have an impact on testing. Incentives Financial incentives were mentioned by GPs as a way to increase testing (Perkins et al. 2003; Ma and Clark 2005; Hocking et al. 2008) but questions remain about its effectiveness (Lawton et al. 2010). Payments in the UK of £10–25 (A$20–50) were cited as a reason for increasing testing but the impact of the individual incentive was not evaluated (Pimenta et al. 2003b). An Australian study suggested that a payment of A$5 per test was not enough to make a difference (Bilardi et al. 2010). Recent observations in the UK suggested that incentives in conjunction with a supported framework were effective in increasing testing (Sohal et al. 2008; Kalwij et al. 2012). At the general practice level Facilitators identified at the practice level included nurses and use of practice staff, increased education/awareness/training and supportive infrastructure. Nurses and use of practice staff Using nurses and other practice staff was suggested as a way to facilitate more testing by reducing the time pressures on the GPs (Griffiths and Cuddigan 2002; Perkins et al. 2003; Markham et al. 2005; Robertson and Williams 2005a; McNulty et al. 2010; Morgan et al. 2012). A nurse-led practice was more effective than a doctor-led practice, but this effect was not sustained (Lawton et al. 2010), and having a ‘champion’ was common in higher screening practices (McNulty et al. 2010). Several studies noted that testing was much easier when the entire practice supported the endeavour (McNulty et al. 2008a, 2010; Wallace et al. 2012). Increased education/awareness/training Increasing education, awareness and training was acknowledged as a facilitator for testing (Doherty 2000; Thompson et al. 2008). Nurses who received training and used an external adviser for information and support found it to be beneficial and requested the majority of tests (Armstrong et al. 2003; McNulty et al. 2004a; Senok et al. 2005). As with the GPs, decreasing the gaps in education and awareness for practice staff was strongly identified but not well studied in terms of effectiveness or delivery of training. Supportive infrastructure Having adequate resources and a recording system to manage patients was identified as a facilitator (Armstrong et al. 2003; Perkins et al. 2003). When promotional material was appropriate, discreet but attractive to young people and multilingual, it was more acceptable to practice staff (Freeman et al. 2009). Using technology was suggested as beneficial, such as recording systems to track testing history (Wallace et al. 2012), or computer prompts as a reminder to offer a test, although this may be

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vulnerable to fatigue (McNulty et al. 2010). Funding for youth or chlamydia-specific clinics could be provided to target testing in high-risk groups (McNulty et al. 2008a). Other practical facilitators include having sufficient supplies of urine testing kits (Ma and Clark 2005), and resources for partner notification (Griffiths and Cuddigan 2002). Updated policy and guidelines could also increase testing (McNulty et al. 2004a), although implementation of clinical guidelines in New Zealand (Morgan et al. 2012) and Scotland (Penney et al. 2005) did not lead to a sustained increase. An external screening team/adviser was useful for practices who found testing to be problematic, by helping to manage cases, and providing communication to the practice (Kalwij et al. 2012). Practices that had developed strong relationships with genitourinary medicine or sexual health clinics were better informed on STI epidemiology and presentation (McNulty et al. 2008a). Discussion Three major themes were repeated throughout the findings of this review. Chlamydia testing is hindered by a lack of knowledge, awareness and training, demands on time and workload, and the social context of sexual health, particularly around the GP–patient relationship. It has been thought that these barriers could be overcome with adequate education and training, appropriate allocation of time and resources, and normalising testing. The aim of the review was to identify the barriers and facilitators at each of the three levels: patient, GP and practice. Little evidence was provided on the effectiveness of the facilitators, and thus we could not evaluate their impact on chlamydia testing. It has been theorised that more testing would lead to a reduction in the overall prevalence (Regan et al. 2008) and then decrease the consequences of chlamydia and its costs, underscoring the need to reduce barriers to testing. Many of these barriers are related, such as the lack of education for patients, GPs and practice staff. However, it is not clear if a reduction in a barrier is equivalent to an increase in a facilitator. One overarching concept became evident in this review; because the primary interaction is between the GP and patient, communication is a key stone in the foundation of chlamydia testing. Without either participant in the GP–patient relationship communicating the need for testing, chlamydia testing will never be on the agenda. The normalisation of testing may prove to be the most important facilitator of chlamydia testing. It is the cumulative product of many minor changes, which may be assisted from external sources, such as national guidelines or government programs. Normalisation is an iterative process, and would need to be tailored to individual practices and GPs. Small modifications, such as the use of urine testing, has the ability to reduce multiple barriers such as time, workload, and stigma. Limitations Papers were limited to Australia, New Zealand, the UK, and Ireland to compare similar approaches to sexual health; other barriers or facilitators that were specific to a particular country were not addressed. Barriers or facilitators that were external to the general practice setting were not identified in this review but could have an impact on chlamydia testing; these include

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insurance schemes or testing in community settings like pharmacies. Few papers addressed ethnic or cultural differences in general practice, and those that did were more likely to have been based in the UK. None identified any barriers or facilitators around patients’ Aboriginal and/or Torres Strait Islander status. Papers were only assessed if they identified barriers and facilitators in the initial consultation in general practice. Partner notification has not been included in this review, although it plays a major role in the transmission of chlamydia. This omission is deliberate, as the focus of this paper was on the barriers and facilitators in an initial chlamydia testing consultation, although they may overlap with the barriers and facilitators in partner notification. Conclusion A large body of literature discussing barriers and facilitators to chlamydia testing was identified. Publications were categorised into three groups: patient, GP and practice. While the barriers to chlamydia testing are well documented, the facilitators remain poorly researched. This review helps to clarify some of the questions around chlamydia testing in general practice and highlights the aspects that require further investigation. Conflicts of interest None declared. References Aghaizu A, Adams EJ, Turner K, Kerry S, Hay P, Simms I, Oakeshott P (2011) What is the cost of pelvic inflammatory disease and how much could be prevented by screening for Chlamydia trachomatis? Cost analysis of the Prevention Of Pelvic Infection (POPI) trial. Sexually Transmitted Infections 87(4), 312–317. doi:10.1136/sti.2010.048694 Armstrong B, Kinn S, Scoular A, Wilson P (2003) Shared care in the management of genital Chlamydia trachomatis infection in primary care. Sexually Transmitted Infections 79, 369–370. doi:10.1136/sti.79.5.369 Bailey AC, Dean G, Hankins M, Fisher M (2008) Attending an STI Foundation course increases chlamydia testing in primary care, but not HIV testing. International Journal of STD & AIDS 19(9), 633–634. doi:10.1258/ijsa.2008.008110 Balfe M, Brugha R (2009) What prompts young adults in Ireland to attend health services for STI testing? BMC Public Health 9, 311. doi:10.1186/ 1471-2458-9-311 Balfe M, Brugha R (2011) What concerns do young adults in Ireland have about attending health services for STD testing? Deviant Behavior 32(4), 320–350. doi:10.1080/01639621003772795 Balfe M, Brugha R, O’Connell E, McGee H, O’Donovan D, Vaughan D (2010a) Why don’t young women go for chlamydia testing? A qualitative study employing Goffman’s stigma framework. Health Risk & Society 12(2), 131–148. doi:10.1080/13698571003632437 Balfe M, Brugha R, O’Donovan D, O’Connell E, Vaughan D (2010b) Young women’s decisions to accept chlamydia screening: influences of stigma and doctor-patient interactions. BMC Public Health 10, 425. doi:10.1186/ 1471-2458-10-425 Bangor-Jones RD (2011) Sexual health in general practice: do practitioners comply with the sexually transmitted infections guidelines for management of suspected chlamydial infections? International Journal of STD & AIDS 22(9), 523–524. doi:10.1258/ijsa.2009.009298 Bennett S, McNicholas A, Garrett N (2001) Screening and diagnostic practices for chlamydia infections in New Zealand. The New Zealand Medical Journal 114(1137), 349–352.


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www.publish.csiro.au/journals/py

Practice nurse chlamydia testing in Australian general practice: a qualitative study of benefits, barriers and facilitators.

Facilitators and barriers to chlamydia testing in general practice for young people using a theoretical model (COM-B): a systematic review protocol.

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Barriers and facilitators to the implementation of orthodontic mini implants in clinical practice: a systematic review.

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The views of general practitioners and practice nurses towards the barriers and facilitators of proactive, internet-based chlamydia screening for reaching young heterosexual men.

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Conducting research in clinical psychology practice: Barriers, facilitators, and recommendations.

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Systems and complexity thinking in the general practice literature: an integrative, historical narrative review.

The barriers and facilitators to evidence-based episiotomy practice in Jordan.

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A mixed-method investigation of patient monitoring and enhanced feedback in routine practice: Barriers and facilitators.