Chlamydia testing and treatment in community pharmacies: findings and lessons learned from setting out to evaluate an unexpectedly short lived service in Lothian, Scotland
Kapadia, Mufiza Zia
Genital chlamydia is the most commonly diagnosed sexually transmitted infection. In August 2008, the Scottish government directed its health boards to involve community pharmacies in providing chlamydia testing and treatment for young people. Lothian Health Board envisaged a pharmacy-based chlamydia testing and treatment (CT&T) service to be able to reach deprived population. This research project set out to evaluate the implementation of the CT&T in Lothian, Scotland. However, the Lothian CT&T service suffered from setbacks such as; implementation delays, minimal advertising of the service, low uptake, withdrawal by central government of specific funding to support the service costs, and subsequent termination of the service in Lothian by March 2011. As it turned out, the CT&T service ran in Lothian for only 10 months. As events unfolded, the aims of the PhD research were successively revised so as to undertake an integrated set of studies that provide important insights and generalizable knowledge about the rationale for such a service, the process of implementation, including barriers and facilitators, and the potential to utilise routine data to assess the impact of a new service. An additional component was added, in that I undertook an analysis of an anonymous routine data on chlamydia testing obtained from the microbiology reference laboratory of Lothian to describe the epidemiology of chlamydia in Lothian (2006-2010) and to report an impact of recent policy changes (2008-2009) on chlamydia surveillance activity. Methods The Centre for Disease Control (CDC) framework for programme evaluation was used to guide design the evaluation of the CT&T service, and a subset of ‘strategic’ stakeholders for the service was involved throughout. Four studies were undertaken towards the evaluation, and these employed diverse methods, as follows: (i) A training need survey of pharmacists and their support staff was undertaken in 166 community pharmacies in Lothian, to inform the training session held prior to the CT&T service launch. (ii) A survey of 33 strategic stakeholders in Lothian was undertaken to provide input to the evaluation objectives and to identify their perceptions and concerns in relation to the CT&T initiative and its evaluation. (iii) A survey of potential service users, young people aged 15-24 years, was carried out at the Genito-Urinary Medicine (GUM) clinic and two other sexual health drop-in clinics in Lothian. The survey ascertain their preferences regarding specific aspects of the CT&T service, and their views on issues identified in previous literature as facilitators or barriers with regard to utilising of such a service. (iv) In order to understand the service provider’s perspective on setting up and delivering of the CT&T service, in-depth interviews were undertaken with participating and nonparticipating pharmacists. Eleven pharmacists were purposively sampled from 66 pharmacies invited by NHS Lothian to pilot the service roll-out. Finally, after the Lothian CT&T service had been terminated, 3 strategic stakeholders for Lothian, and a Scottish Government representative were contacted by email, to elicit their views on factors contributing to policy decisions regarding pharmacybased CT&T services. Results The analysis of disaggregated (individual) routine laboratory data showed that age, gender, year of testing and deprivation were associated with the chlamydia testing outcome measures. The before-and-after analysis, with respect to recent major policy/guidance changes (that is, publication of the sexual health service standards for Scotland in 2008, and of SIGN guidelines for chlamydia in 2009), showed that surveillance activity for chlamydia increased only transiently (i.e. in 2009 only). The annual surveillance target for women aged 15-24 years, of 300 tests / 1000 population, was achieved in 2009 only, but targets for males aged 15-24 years (of 100 tests / 1000 population) were not achieved. With respect to the evaluation studies, the training needs survey (i) had a 53% pharmacy response rate from the pharmacies comprised 41% pharmacists, 32% technicians and 26% counter assistants. The survey showed differences in selfassessed training needs between pharmacy staff groups (pharmacists/ technicians/ counter staff). With regard to pharmacist-only competencies, the highest rates of substantial training needs were for clarity regarding the medico-legal aspects (Fraser guidelines), taking a sexual history, criteria for referral and reviewing own and staff competencies for the CT&T service (83% to 77%). With respect to all staff competencies, the greatest self-reported training need was for inter-communicative aspects of providing the service – for respondents overall, 56% to 83% across competencies within this domain. For the stakeholder survey (ii), the response rate was 52% (n=17). Sixteen stakeholders indicated their strong or moderate concern regarding young peoples’ knowledge about the service. The stakeholders also acknowledged the difficulty inherent in promoting the service to those who might benefit from using it. A view commonly expressed by respondents was that sexual health counselling concomitant with testing would be difficult to deliver through the CT&T service, due to: the difficulty in achieving privacy; a busy retail environment; and pharmacists tending not to have the necessary skills. However, they also acknowledged that chlamydia service delivery is problematic everywhere and not just in pharmacies. The key benefits of the service suggested for young people included increase accessibility, normalization of chlamydia testing and its ability of provision of sexual health service to hard-to-reach population. Such a service was perceived to enhance the role of pharmacist in public health provision. The survey also sought input of strategic stakeholders to ensure that the evaluation questions of most importance to them were included. All the proposed evaluation questions were marked as important. Some suggested questions such as client’s satisfaction with the service or related to the service logistical planning could not be incorporated in the later components of the intended evaluation as the service uptake was too low to answer those questions. The survey of potential service users (iii) had an overall response rate of 20% (n=78). Young people who responded indicated that they felt confident that a pharmacy would offer complete confidentiality for testing, provide reliable test results and have knowledgeable staff to provide the service (90% to 93%). That said, these respondents indicated a preference to be tested in GUM clinic (32%) or drop-in clinics (34%), with only 11% indicating a preference for being tested in a pharmacy. Those who had not previously been tested for chlamydia placed more importance on a toilet facility in a pharmacy they would chose for chlamydia testing, whereas younger respondents (≤ 19 years) placed more importance on a less busy pharmacy. Analysis of in-depth interviews with pharmacists (iv) comprising interviews with 11 lead pharmacists (4 respondents from pilot pharmacies and 7 from non-pilot pharmacies) found that pharmacists were enthusiastic about their newly developed public health role. The respondents foresee a shift to pharmacies for being a first port of call for clients. They were also generally positive about the anticipated attitude of general practitioners and pharmacy support staff towards their provision of chlamydia service. From a pharmacist’s perspective, barriers to delivering the CT&T service were identified as workload and lack of adequate physical infrastructure within a pharmacy such as a consultation room and a toilet facility. On the other hand, the assurance of financial incentives for providing the service was a facilitator. Given the poor uptake of service, the pilot service interviewees did not have enough experience of service delivery to reflect on different aspects of the service. The key explanation proposed by pharmacists for the low uptake of the service was inadequate advertising, and it was felt that the service had been withdrawn too soon to judge its effect. This study also revealed that miscommunication between Lothian Health Board and pharmacies had been a common reason why many invited pharmacies did not take part in the pilot service. Conclusion The Lothian CT&T service had been designed to improve access to chlamydia services for young people living in deprived areas in Lothian, which generally are more geographically distant from existing (non-GP) chlamydia services that are available in Lothian. The enthusiasm found among pharmacists to deliver the CT&T service, and the acceptability to potential service users of the various characteristics of the service, suggests that as part of a multi-faceted approach to chlamydia service, a pharmacy-based testing and treatment would be a useful additional choice for young people to such a service. Despite this, the uptake of the service was very low. It is possible that this is due to the virtual absence of advertising for the service. Furthermore, the service was short lived, being cancelled after 10 months. Both these circumstances might reflect the fact that the initial impetus for the service was at Government level, not within Lothian Health Board, and the service being supported by special central government funding that ceased after 10 months. This highlights the importance of robust commitment to any new service initiative that is being considered, in particular among key policy-makers / budget-holders. Nevertheless the research findings of this thesis are useful to inform planning of future initiatives in provision of chlamydia testing to young people in community pharmacies, and as such will enhance the chances of successful outcomes. Furthermore, many of the findings will be of considerable utility in developing chlamydia services in other health care settings, and even for other public health programmes in pharmacies.