Innovative Resources Could Help Improve Partner Notification for Chlamydia in Primary Care

Abstract

Objective: 

To examine practices of general practitioners’ (GPs) in relation to partner notification for chlamydia and identify the supports they would find most useful to assist them.

Goal: 

To identify innovative resources that could improve partner notification for chlamydia in primary care.

Study Design: 

A postal survey was undertaken that involved GPs from several jurisdictions across Australia between August and December 2007. GPs were randomly selected from a national database.

Results: 

Of 521 eligible GPs, 234 (45%) returned a completed questionnaire. Ninety-five percent (n = 223) felt that it was their role to discuss partner notification with patients diagnosed with chlamydia; however, only 45% (105/232) were sure how best to assist their patients with this. Considerable variation was shown in the way partner notification was undertaken, including how far back in time GPs recommended contacting partners. GPs considered a wide range of possible resources useful, including a website supporting patients (90%), information sheets generated by practice software when chlamydia is diagnosed (90%), printed information packs for patients (85%), a website designed to assist GPs (80%), and referral to these websites via positive laboratory results (85%). Forty-three percent currently undertook patient delivered partner therapy for chlamydia.

Conclusion: 

GPs want and need greater guidance and resources to assist them with partner notification for chlamydia. Resources utilizing the internet and practice software and mechanisms where GPs are automatically directed to these when chlamydia is diagnosed have wide appeal and the potential to improve the effectiveness of partner notification for chlamydia.

In Brief

A study of general practitioners in Australia found that general practitioners supported a wide range of possible supports and resources that could help to improve partner notification for chlamydia.

Chlamydia is one of the most prevalent sexually transmitted infections (STI) worldwide and is responsible for substantial reproductive morbidity. In Australia, it is the most commonly reported bacterial STI, with annual notification rates increasing almost 4-fold in the last 10 years—from 74.4 per 100,000 people in 1999 to 273.9 per 100,000 people in 2008.¹

The treatment of sexual partners of individuals with chlamydia reduces the risk of reinfection and reduces transmission within the population^2,3; therefore, notification, testing, and treatment of partners should be an integral component of any chlamydia control strategy. In Australia, current recommendations suggest that when an individual is diagnosed with chlamydia, his or her sexual partners from the previous 6 months are contacted.⁴

A number of studies have also demonstrated the benefit of patient delivered partner therapy (PDPT) in reducing reinfection in the index patient,^5–7 although the extent to which this practice is supported by regulations or legislation varies across countries and states.⁸ While legalized in a number of US states, PDPT is not supported by specific legislation in any state or territory in Australia.^9,10

Partner notification outcomes have been found to improve when patients and public health agents are involved in the management of care for their sexual partners.¹¹ However, research indicates that partner notification for chlamydia is often poorly carried out: some studies have found that health care providers find it difficult^12,13 and rarely use tools such as partner letters and information brochures to assist them.¹⁴ Few data are available on the acceptability or need for supports that could enhance partner notification for chlamydia. The aim of this study was to examine current partner notification practices of general practitioners (GPs) in Australia and to identify the supports they would find most useful to assist them.

Methods

Population and Sample

This study was a cross sectional survey. A random sample of 550 GPs from 3 Australian jurisdictions (Victoria, Queensland, and the Australian Capital Territory) was obtained from a national database of medical practitioners (Australasian Medical Publishing Company).¹⁵ The sample was stratified by geographical location using the Rural, Remote and Metropolitan (RRMA) classification system.¹⁶ To ensure adequate representation of GPs in rural and remote areas, the database was weighted to provide a minimum 30% of GPs in rural and remote areas (RRMA: 3–7).

GPs were considered eligible to participate if they were currently working in general practice and were located at the address supplied in the database.

Procedure

The survey included questions on demographic and practice information, extent of computer and internet use during consultations, chlamydia testing and management practices, partner notification practices, views on partner notification, and opinions on possible supports and resources to assist GPs with partner notification. For the purposes of the study, partner notification was defined as “informing the partners of a person with a sexually transmitted infection that they may be at risk.” The questionnaire was initially piloted with a sample of 5 GPs. Nonresponders received up to 2 reminders, the final being sent by registered mail. GPs were offered a AU$50 gift voucher for their participation.

To ensure confidence intervals ranging from 43% to 57% around a survey response of 50%, a minimum sample size of 200 was required. Assuming a 40% response rate¹⁷ an overall sample of 550 was invited to participate.

Statistics

Data were analyzed using SPSS version 15.0. The χ square test was used to analyze categorical data. Answers to open ended questions were analyzed thematically and categorized where applicable by investigators J.E.B. and M.Y.C.

Ethics

Ethical approval for this study was granted by the Human Research Ethics Committee of The University of Melbourne.

Results

GP Characteristics

Of the 550 GPs invited to participate, 29 were ineligible either because they were no longer at the address provided, or because they were retired or no longer working in the area of general practice. Overall, 45% of GPs (234/524) returned the questionnaire. Table 1 outlines the characteristics of participating GPs and their practices. Most GPs reported using computers for maintaining medical records, prescribing, and pathology results. The majority used the internet at least sometimes to assist with patient management during consultations. Male GPs were significantly more likely than females to “always” or “usually” use the internet (19% vs. 8%, P = 0.02) to assist with patient management during consultations. Female GPs were more likely to test a patient for chlamydia once a week or more (72% vs. 48%; P ≤0.01).

TABLE 1: Characteristics and Practices of General Practitioners Surveyed (n = 234)

Partner Notification Practices

Almost all GPs (95%) reported that they felt it was their role to discuss partner notification with their patients and 97% felt comfortable to do so. Less than half however (45%), reported being sure of providing the best assistance to their patients with partner notification, with 23% reporting concern about breaching patient confidentiality or privacy.

Nearly 30% (63/234) of GPs also reported concern that the discussion of partner notification may have a negative impact on their patient or their patient’s relationship with their partner. GPs in rural areas were more often concerned about a negative impact on their patients than GPs in metropolitan areas (40% vs. 23%, P= 0.04).

The frequency of different methods adopted by GPs to assist with partner notification for chlamydia varied considerably between GPs (Table 2). Female GPs were more likely to provide their patients with a letter give to their partner (26% vs. 14%; P = 0.03) and younger GPs more likely to ask their patients to bring their partner in for a consultation (80% vs. 66%; P= 0.02). While few GPs phoned their patient’s partners directly to inform them of their risk (n = 6), GPs in rural areas were more likely to do so (7% vs. 1%; P = 0.02). Only 1 in 5 GPs (20%) felt that they did not have time to assist patients with partner notification.

TABLE 2: Methods Used by General Practitioners for Facilitating the Notification of Partners of Chlamydia Infected Patients (n = 234)

Supports and Resources for Partner Notification

Eighty-four percent of GPs indicated that they would find resources that support partner notification useful. GP views on various possible resources are shown in Table 3. A number of potential resources were considered useful, including a website that GPs could access themselves, a website patients could be referred to, and printed information for patients. Reminders directing GPs to these resources when chlamydia is diagnosed either on laboratory reports or on practice software were also considered useful by most GPs.

TABLE 3: General Practitioners’ Views on Possible Resources Supporting Partner Notification for Chlamydia (n = 234)

Patient Delivered Partner Therapy

Forty-three percent (100/234) of GPs indicated that they sometimes or always prescribed an additional dose of antibiotic for their patient to give to their partner. Practice location was found to be the only statistically significant predictor of PDPT, with a higher proportion of GPs in rural areas “always” or “usually” using PDPT (26% vs. 9%, P = 0.01).

GPs gave a range of reasons for why they did or did not use PDPT. The main situations in which GPs chose to use PDPT were if they knew the partner, or the partner was a patient of the practice, or where the GP felt the partner was unlikely to attend for testing or treatment. The most common concern raised by GPs about PDPT was the potential for an allergic reaction to the antibiotics prescribed. The main reasons GPs cited for not using PDPT where when partners were not their patients or when they felt that the partners needed an assessment and testing before treatment. GPs commonly instructed patients to tell their partners to see their own GP. Nearly half the GPs (107/234, 46%), including 13% of those who never use PDPT, reported that they would support laws and regulations permitting the use PDPT.

Discussion

In this survey, GPs overwhelmingly felt that it was their role to discuss partner notification for chlamydia with their patients; however, only half were sure how best to assist their patients with this. Considerable variation was apparent in the way GPs undertook partner notification. Most GPs indicated that they would find further information and resources useful in assisting them with partner notification. These included a website that GPs could access themselves, a website to which patients could be referred, and printed information for patients. Automatic reminders directing GPs to these resources when chlamydia is diagnosed were also highly rated.

Strengths and Limitations

Our study has a number of strengths and limitations. This is the largest study to date conducted in Australia examining GP opinions on possible resources supporting partner notification for chlamydia. This study provided a representative sample of Australian GPs in terms of age and practice location (metropolitan/rural breakdown), when compared to the general Australian GP population.¹⁸ As is common in surveys in general practice however,^17,19–22 females were overrepresented. As past studies have shown that females GPs are more likely to both offer chlamydia testing²¹ and undertake partner notification,²³ it is possible that our results may be biased. The information provided by GPs was also reliant on self-reporting which gives scope for inaccuracy due to social desirability responding.²⁴ Finally, despite the use of financial incentives and reminders, our response rate of 45% was somewhat low, although, it is on par with or higher than recent STI postal surveys with GPs.^14,17,21,25

Past research has shown that partner notification is poorly carried out in general practice in Australia, with GPs commonly reporting that partner notification is largely a patient’s responsibility.^1,5,13 Available resources are rarely used¹⁴ and most often assistance is provided through patient referral,^13,22,23 that is, the health professional asks the patient to contact their sexual partners. Barriers often reported by GPs include difficulty raising the issue of sexual health or STIs, lack of knowledge or skill in partner notification, lack of time, resources and written guidelines; and uncertainty around patients’ ability or willingness to contact their partners.^13,17,23 Barriers reported by GPs in this study or evident in their practices included uncertainty around how best to assist their patients with partner notification, wide variation in how far back in time to trace partners, concern around patient confidentiality or privacy, and the possible negative impact of partner notification on their patients or their patients’ relationships. Notably, in a recent Australian study of patients diagnosed with chlamydia, only 5% of individuals reported experiencing a negative reaction from a partner as a result of notifying their partners.²⁶ In qualitative interviews, most patients reported that they felt notifying partners was the “right thing to do.”²⁷ It is likely that partner notification does not have as negative an impact on patients or their relationships as GPs commonly fear. However, as a routine precaution, GPs concerned about potential negative impacts of partner notification may wish to get a sense of any real or perceived impacts when discussing partner notification with their patients.

Despite these barriers, GPs in this study reported strong levels of support for additional resources that would support partner notification for chlamydia, a finding also reflected in a recent study,¹⁴ in which GPs felt they could improve their partner notification practices if further support was provided. Our GPs supported a range of possible resources, including partner notification websites for GPs and patients, printed information packs, and patient information sheets built into practice software. In response to these findings, we developed 2 websites to assist GPs (available at: www.gpassist.org.au) and chlamydia infected individuals (available at: www.letthemknow.org.au) with partner notification. In a recent study in which GPs were directed to simple partner notification resources on a website, via a link on positive chlamydia laboratory reports, a significant increase in the use of resources was found, with up to 25% of study GPs utilising the site.²⁸

The effectiveness of these websites and resources in enhancing partner notification for chlamydia remains to be determined; however, on the basis of the strong support voiced by GPs in this survey, we believe there is potential for such resources to improve the effectiveness of partner notification for chlamydia. Two-thirds of Australian GPs use the internet at work²⁹ and so web-based resources can be accessed widely.

The use of PDPT for chlamydia appears to be common both in Australia as well as other countries.^13,22,30 In the current environment where there is no clear legal or regulatory support for PDPT in Australia, further examination of PDPT and its role in the control of chlamydia needs to be undertaken.