National Social Marketing Centre

1. Improved and standardised induction session for new sites
Before this project, the initial induction given to new sites when they joined the NWCSP varied in content and length from 10 minutes to 1 hour, depending on the site and the CSO member delivering the induction. The project team recognised the need to standardise the induction session so that all new sites received at least the minimum information required to successfully carry out screening, thereby ensuring quality control and consistent messaging.

The CSO team improved and standardised the induction materials to fit into a 1.5 hour session, which all new sites are now required to receive when they joined the NWCSP. Depending on the setting, different information (e.g. how to complete DIY vs. postal kits, or ideas on when/how to offer screening to specific young audiences) can be ‘bolted on' to the generic basic material. Starting in June 2009, all new screening sites have received this improved and standardised induction session.

Desired outcomes included:

• More confident, engaged and active screening providers
• Better quality of screens returned (e.g. fewer tests incorrectly done)
• Greater cascading of knowledge to other colleagues

2. Sexual health communication training
One of the main barriers identified in the research was that some providers, particularly those whose main remit was not sexual health, were apprehensive about raising the issue of chlamydia screening, particularly in unrelated situations. To overcome this barrier, the Central Office of Information (COI) was commissioned, with funding from the Department of Health (DH), to develop a bespoke training resource to help providers build their confidence and skills in discussing sexual health issues with young people.

The resulting ‘Talking Chlamydia' workshop was designed to complement, rather than replace, the induction session delivered to new providers, which focuses more on the practical information necessary to carry out screening. This three-hour workshop, which can be delivered as three one-hour modules, focuses on skills, confidence and behaviour around discussing chlamydia screening with young people.

The workshop was piloted in October 2009 with a group of screening providers in Norfolk and Waveney. The SHPU has continued to offer this workshop to those providers interested in or who may benefit most from this additional training. Following the success of this pilot, the training resource has been made available via the NCSP to other CSOs.

Desired outcomes included:

• Greater willingness from providers to offer chlamydia screening to young people
• Increased confidence and sensitivity with which providers handle discussions around chlamydia screening and sexual health

3. Systematic, personal catch-ups from CSO
Proactive contact with screening sites, particularly those that are medium/low screeners, on a regular basis from a designated CSO Health Advisor would demonstrate interest in and support for providers, as well as allow the CSO to gather issues arising in practice and offer tailored advice to sites. Although Health Advisors had been contacting screening sites, this had not been done in a systematic or consistent way.

To help the CSO focus their efforts on those sites that had greatest potential to screen more actively, all screening sites were analysed and segmented based on footfall of 15 to 24-year-olds (or a proxy measure) and current engagement in or ‘warmth' towards the NWCSP. A contact strategy was then developed to set out when and how each segment of screening sites should be contacted by the CSO. For example, those sites that needed greater handholding or encouragement and had potential to return large numbers of screens would receive more frequent and direct (i.e. face-to-face or phone) contact. Those sites that were relatively prolific screeners or who were unlikely to ever return many screens would receive less frequent and direct (i.e. email) contact.

To help the CSO implement the contact plan and manage their growing network of sites, the CSO database was enhanced with automatic prompts to remind Health Advisers to contact each site at least once a month, and extra prompts were set for GP sites when their screening volumes fell below 5% of registered 15 to 24-year-olds. A new field was added to the database to record any comments, feedback or follow-on actions required. An additional function was also added to the database to automatically send each site their monthly screening volumes and positivity rates.

During the project, the team focused on laying the groundwork for this new systematic contact process. Due to staff shortages, the CSO will begin implementing the contact plan in April 2010, after the end of this project.

Desired outcomes included:

• More awareness, engagement and confidence in the NWCSP from providers
• Stronger management and coordination of sites by the CSO
• Continual adjustments and improvements to the NWCSP based on feedback from providers

4. Quarterly newsletter
To keep the profile of the NWCSP high and to create a sense that chlamydia screening is an ongoing priority, a quarterly newsletter was distributed to all sites from July 2009. The newsletter provided updates on the programme's progress (e.g. chlamydia rates in the local area, screening levels, quarterly/annual targets, new initiatives/sites), dates of events/training coming up, and tips on good practice. An anonymised league table was included to show how each site was performing in relation to others and to introduce an element of competition between the sites. Recognition was also given to high or enthusiastic screeners to encourage local screening ‘champions' who may serve as role models for other sites.

Desired outcomes included:

• More awareness and engagement in the NWCSP from providers
• Greater cohesion and sense of joint working from NWCSP providers
• Increased screening activity

5. Promotional materials to display in screening sites
Providers requested more hard-hitting, appealing promotional materials to display alongside or instead of the NCSP materials, to catch the attention of young people and clearly signpost the chlamydia screening service within sites. Pharmacists in particularly were keen to receive fresh promotional materials to advertise that they were now offering free chlamydia screening to young people.

A range of locally branded materials, including posters, flyers, shelf wobblers and dump bins, were produced and offered to all screening sites from December 2009.

Desired outcomes included:

• Greater awareness and engagement in the NWCSP from screening providers and young people
• Increased confidence and willingness with which providers offer chlamydia screening to young people

6. Register-based pop-up reminders
For many providers whose main remit is not sexual health, chlamydia screening often slipped their minds in the face of competing priorities. To remind providers about chlamydia screening and to help normalise the practice of offering every 15 to 24-year-old a screen, register-based pop-up reminders were piloted in three GP clinics between June and August 2009. Given that GPs were now being paid per screen, the pop-up reminders were promoted as a way to increase their financial return.

Desired outcomes included:

• Higher profile of chlamydia screening amongst GPs
• More proactive and routine screening of young people for chlamydia within GPs

Secondary research
Desk-based research was conducted by the NSMC in autumn 2007 to define the issue, provide initial audience insights and analyse the behaviour. Existing data and literature were reviewed, along with evidence and learning from previous studies and initiatives. Relevant behavioural theories were considered to understand factors that influence human behaviour. Young people's lifestyles and media usage were also explored to develop a rounded view of the target audience.

Stakeholder consultations
As part of the initial scoping work, the project team carried out informal stakeholder consultations. DH and NCSP members were approached to understand what the national guidance, strategies and priorities were. Other CSO leads from across the country were contacted to learn what approaches had or hadn't worked in increasing chlamydia screening rates, and why. Seven screening providers in Norfolk and Waveney were also interviewed over the phone to explore their experiences with chlamydia screening, the barriers they faced, and any suggestions they had for improving their experiences of offering screening.

Primary research
With funding from the Department of Health, the project team commissioned research agency Define to carry out 40 in-depth telephone or face-to-face interviews with a range of NWCSP screening providers. The purpose of this research, which took place in summer 2008, was to understand what the primary barriers were with regard to screening and what could be done to increase the number of young people sites screened. Findings were presented to the DH Sexual Health Board in late 2008 and helped inform national strategy.

Concept testing
Based on findings from the primary research, the project team came up with a number of interventions to address screening providers' barriers. A stakeholder event was held in November 2008 to engage internal PCT stakeholders and frontline screening staff, feed back on the research, and to test and brainstorm the intervention ideas. Following the event, five screening providers volunteered to form the Solutions Group, which would help develop, pre-test and promote the interventions.

Primary research with healthcare providers
The NSMC commissioned independent researcher Kate Melvin to undertake further qualitative research with screening providers to help inform the development of the Talking Chlamydia training intervention. The research aimed to explore areas of knowledge or skills providers felt they needed to develop to proactively offer chlamydia screening to young people, and the nature of training they wanted or needed in terms of format, length, location and provider. In-depth face-to-face interviews were conducted with four pharmacists, four GPs and four nurses across Norfolk in May 2009.

Pre-testing
In June 2009, members of the Solutions Group pre-tested the improved and standardised induction materials, newsletter, and promotional materials (which were also pre-tested with young people). The Talking Chlamydia workshop was formally pre-tested in September 2009 with a group of seven screening providers.

The qualitative research with screening providers and stakeholder event identified various insights that were were used to inform the selection and development of interventions:

• Low awareness of annual targets and NWCSP performance to date meant that providers neither felt urgency to offer screening, nor that they were part of a larger initiative. The quarterly newsletters and ongoing contact from the CSO aimed to keep the profile of the NWCSP high and motivate sites to screen more proactively by providing ongoing updates on screening levels achieved and required.
• Some providers perceived a lack of interest and support from the CSO once they signed up to the programme, which sometimes led to cynicism and the assumption that there was no real need for screening. Offering sites ongoing proactive support from the CSO would help maintain any initial enthusiasm for the programme and the sense that screening is an ongoing priority.
• For providers whose main remit was not sexual health, chlamydia screening often fell to the back of their minds. Screening was also often only offered when a young person presented for a sexual health related reason. By piloting pop-up reminders, offering fresh promotional materials, ongoing support and enhanced training through the Talking Chlamydia workshop, the interventions aimed to keep chlamydia screening top of mind and help providers develop the confidence and strategies to introduce screening in unrelated situations.

The behavioural goal of this project was for existing screening providers (particularly in core services) to actively offer chlamydia screening to 15 to 24-year-olds.

Monthly screening data by site, which is routinely collected from the CSO, was used as the baseline and plotted against when interventions were delivered to identify any changes to screening activity during implementation.

Although the anticipated target audience was young people, initial research highlighted the importance of screening providers as a potential target audience. With over 200 sites signed up to screen as part of the NWCSP, but the majority returning few if any screens, there were many opportunities being missed for routine screening. Given the NCSP was set up to be an opportunistic programme and were encouraging CSOs to focus on engaging and supporting core services, existing screening providers were selected as the main target audience for the project. With limited resources available to meet increasingly challenging targets, the project team decided to capitalise on the large network of providers already established by the CSO, and to maximise their screening potential over the longer-term.

Using findings from the primary research, screening providers were segmented into four main groups according to provider type (e.g. GP clinic, pharmacy, youth organisation, etc.), as well as current screening activity and ability and motivation to screen.

1. Engaged and motivated - These sites were those where sexual health was a key focus of service provision to young people, e.g. sexual health services, family planning clinics, and GP surgeries that had an enthusiastic sexual health lead. These providers tended to have the highest numbers of young people in the target age group presenting for treatment in a number of closely related areas. The individuals responsible for screening were not only experienced and confident in raising the issue of chlamydia, but also highly motivated in relation to screening, and therefore had potential to act as spokespeople for the NWCSP. Signing up as many of this type of provider to the screening programme would help to raise screening levels across the area. In addition, since these types of provider were already highly motivated and proactive, they were likely to need less support and resources, which could be diverted to providers who needed more of both.

Providers with potential to increase screening levels (those conducting medium to low screens) ranged from those who had a high level of interest in the programme, but were restricted in terms of screening delivery (‘Interested but restricted') to those who currently had low interest levels (‘Low interest'). Both these types of provider tended to consult and offer support on sexual health and other medical matters, and included GP surgeries, educational establishments, and other clinical settings e.g. in military bases.

2. Interested but restricted - This category of provider may have capacity to increase screens, but time available to screen was minimal given other issues and priorities. In addition, whilst staff were positively inclined towards screening, they typically experienced limitations around their knowledge and expertise in matters of sexual health, and specifically chlamydia screening (i.e. lacked the strategies or skill sets to discuss chlamydia testing with young people). For this type of provider, greater levels of support would be instrumental in enabling them to engage more proactively with the programme and increase screening levels.

3. Low interest - These sites were generally those where screening was seen as beneficial but ancillary to their primary service provision. They were currently more resistant as they felt they didn't have the time or the resources to dedicate to this service and typically had low interest or experience in this area. However, it was at least on their radar and these providers generally conceded that they could be more proactive, given greater support. Information in relation to the ‘bigger picture' in terms of infection levels and how their personal contribution was important might persuade them into striving for higher screening levels.

4. Low priority - These tended to be providers where other life issues experienced by young people they were in contact with dominated service provision - e.g. drug and substance abuse, mental health problems and homelessness (often in combination) and tended to be hostels and some outreach services (e.g. drug and alcohol, teen pregnancy). These providers either felt that they should be participating in the programme, or that they shouldn't refuse to participate even though in reality they would be unlikely to do a high number of screens. Often, limited and non-specialist resources were another barrier. This type of provider is unlikely to want or be able to engage with the programme beyond the minimum effort, but if the message is right, may increase their efforts. Additional coaching and support may help, and as long as performance expectations are not too high, these providers can be valuable in helping to raise the profile of the screening programme.

The interventions were targeted at groups 2 and 3, as they had greatest potential to increase screening, but needed greater handholding and encouragement.

Through the scoping research the team identified several real and perceived barriers faced by screening providers when offering chlamydia screening.

These included:

• Limited time and/or staffing
• Anxieties about raising the issue of screening (particularly in an unrelated consultation)
• Limited specific understanding of the NWCSP, including its targets.

To help providers overcome these barriers, the induction session promoted screening as a quick and easy offer to make, which didn't necessarily require special training in sexual health. The Talking Chlamydia workshop and newsletters offered tips on how to link the offer of chlamydia screening to other (sometimes unrelated) situations. These interventions, along with ongoing follow-up from the CSO, aimed to clarify and provide sites with continual updates on the NWCSP, including its aims, targets and performance.

Perceived benefits the team aimed to promote to screening providers through the various interventions included:

• Providing a better service to young people
• Being part of an important national initiative
• Professional development and networking opportunities
• Earlier diagnosis and treatment of chlamydia
• Free screening kits and other collateral
• Payment per screen.

Factors that competed for screening providers' time and attention included:

• Other responsibilities and targets at work
• Third party pressure not to offer chlamydia screening
• Competing and/or stronger health messages and priorities

Response strategies included:

• Making screening as quick and easy as possible
• Using influential individuals to communicate the relevance and importance of screening - GP champions have just been recruited by the NWCSP to promote chlamydia screening to their peers
• Providing regular communication about the NWCSP
• Incentivising screening
• Promotion to raise the profile of chlamydia screening.

The Theory of Planned Behaviour (TPB) suggests that attitude, subjective norms and perceived behavioural control can influence providers' screening behaviour.

This project therefore tried to:

• Promote attitudes that favour screening - e.g. by stressing that chlamydia is prevalent in young people and that screening is effective and important
• Encourage providers to see screening as a socially approved behaviour - e.g. by highlighting and rewarding high screeners and best practice, regularly publishing screening data for all NWCSP sites, and providing networking opportunities
• Help providers develop the confidence and skills to effectively offer screening to young people - e.g. through enhanced training and tailored advice and resources