Development and acceptability of a digital tool for promoting syphilis testing in Australian general practice: qualitative study using the Theoretical Framework of Acceptability
Barbara Hunter A , Jane S. Hocking
B , Jo-Anne Manski-Nankervis C , Jun Jung A D , Rebecca Wigan D , Marcus Y. Chen D , Douglas Boyle A , Christine Chidgey A , Heather O’Donnell E and Jane L. Goller B *
A
B
C
D
E
Abstract
In Australia, syphilis notifications increased 2.5-fold during 2013–2022 and 83 congenital syphilis cases were reported. Timely diagnosis and management are crucial. We developed a tool to promote syphilis testing into our existing ‘Future Health Today’ (FHT) software and explored its acceptability in general practice.
Our tool (FHT-syphilis) scans electronic medical record data to identify and prompt testing for pregnant women, and, people recently tested for sexually transmissible infection (STI) or HIV, but not syphilis. It links to relevant guidelines and patient resources. We implemented FHT-syphilis in 52 general practices using FHT for other conditions and interviewed practice clinicians (n = 9) to explore it’s acceptability. Data were analysed deductively guided by the Theoretical Framework of Acceptability.
Interviewees considered syphilis an important infection to focus on and broadly viewed FHT-syphilis as acceptable for identifying patients and giving clinicians authority to discuss syphilis testing. Time constraints and unrelated reasons for a patient’s visit were barriers to initiating syphilis testing discussions. Australian STI guidelines were considered appropriate to link to. Some interviewees considered prompts should be based on sexual behaviour, however this is not well captured in the electonic medical record. Two interviewees were alerted to updated Australian STI guidelines via their interaction with FHT-syphilis and expanded their syphilis testing practices. Expertise to initiate discussions about syphilis and risk was deemed important.
A digital tool for prompting syphilis testing was acceptable to clinicians already using FHT. Linkage to STI guidelines alerted some end-users to updated guidelines, informing STI testing practices.
Keywords: acceptability, Australia, clinical decision support, general practice, interventions, primary care, STIs, syphilis.
Introduction
In Australia, infectious syphilis notifications increased 2.5-fold during 2013–2022 (n = 6036 in 2022), 82% among males1 with increased notifications observed in major cities, regional and remote areas.1–3 Over this period, the infectious syphilis notification rate among females increased over 6-fold and 83 congenital syphilis cases were reported.1 Congenital syphilis is preventable if testing and treatment occur early enough. Its’ elimination is an Australian and global priority.4,5
Timely diagnosis and management are crucial to reducing syphilis transmission and complications. In response to rising syphilis rates and adverse outcomes in Australia, STI management guidelines have been updated to recommend a syphilis test with any STI or HIV test, and, for pregnant women in the first and third trimester.6 A range of health practitioner, consumer information and public awareness resources have been developed.6–8 Key messages aligning with Australian STI management guidelines6 are for doctors to take a sexual history from all patients and consider infectious syphilis possible in any sexually active patient.
In Australia, general practice is a crucial setting for diagnosis and management of sexually transmissible infections (STIs). Approximately 80% of Australians visited a general practitioner (GP) during 2018–2020,9,10 providing opportunity for STI testing and care. However, sexual health is not always front of mind in general practice where the consultation agenda is traditionally driven by the patient’s reason for visit.11,12 Clinical decision support tools that harness electronic medical record (EMR) data may provide a mechanism to prompt GPs to discuss syphilis testing and support effective case-management. We previously developed a digital intervention that uses EMR data to improve chronic disease identification and management in general practice.13–15 Also in our earlier research involving interviews with sexual health clinicians (n = 2) and GPs (n = 7) in Victoria, interviewees expressed favourable views toward the prospect of a digital tool for providing STI decision support, with syphilis deemed a priority.16 Drawing on these findings, we expanded our digital intervention’s functionality and developed a module that provides syphilis testing prompts, then implemented it in 52 general practices with the software already available. Here we describe our methods to develop our syphilis clinical decision support tool and present findings for our pilot study that explores its acceptability to Australian general practice.
Materials and methods
Clinical decision support software
This study involved development of new content for our existing general practice clinical decision support software ‘Future Health Today’ (FHT), developed by the University of Melbourne. FHT was co-designed with representatives from primary care, consumers, chronic disease specialists, technical experts and implementation scientists and provides clinical decision support for a range of conditions including chronic kidney disease, undiagnosed cancer risk, and medication management.13–15 FHT translates clinical guidelines into actionable and individualised recommendations for care, via sophisticated algorithms. It applies these algorithms to EMR data to improve detection and management of health conditions and provides two interactive components, both activated when algorithm criteria are met. The Cohort function operates outside consultations and generates patient lists to facilitate recalls or practice-wide audits. The Point-of-Care operates in the clinical consultation and provides pop-up recommendation/s in the corner of the GP’s computer screen and links to practitioner (e.g. clinical guidelines) and consumer resources. FHT incorporates links to clinician resources (including the. best practice guidelines from which the recommendations are translated) and patient resources to conveniently ensure GPs do not need to leave the EMR for guidance from other sources. FHT algorithms run over the EMR database during the night, rather than during daytime when the EMR is used by the practice. FHT algorithms are limited by available EMR data fields and their completeness.
Developing the syphilis module
To develop our syphilis module (FHT-syphilis), we established a Melbourne-based working group comprising sexual health clinicians, GPs, health informaticians, software developers and researchers. The working group identified priority patient groups to target, links to appropriate guidelines and resources, and developed algorithms and pop-up recommendations to identify patients for targeting for syphilis screening. The working group also drew on their knowledge of the Australian syphilis context including epidemiology,17 government priorities and guidelines.6 During 2022, the working group met on four occasions as well as several ad hoc meetings between members with specific expertise to progress the design.
Table 1 provides an overview of the features of FHT-syphilis. Our working group identified two patient groups to target; pregnant women, and people recently tested for an STI or HIV but not syphilis. Australian guidelines recommend syphilis testing6 with any STI or HIV test and, for pregnant women, at first antenatal visit and repeat testing in the third trimester according to local guidelines for women at high risk of syphilis infection. Of note, for guidance regarding repeat testing in pregnancy there is no single source in Australia. The Australian STI guidelines6 advise clinicians to refer to local guidelines for information regarding repeat testing due to varying syphilis epidemiology geographically and between population groups.
| Patient group | Pregnant women | Tested for STIs or HIV but not syphilis | |
|---|---|---|---|
| Algorithm | Female AND Currently pregnant AND No syphilis test in the past 4 months | Patient any age AND [a chlamydia test OR a gonorrhoea test OR a HIV test in the last 12 months] AND No syphilis test in the past 12 months | |
| Recommendation text | Syphilis serology recommended at first antenatal visit During pregnancy repeat testing recommended to reduce risk of foetal harm in people at high risk of infection | Recent STI testing performed; consider requesting syphilis serology | |
| Reason for recommendation (text displayed when the recommendation is hovered over) | Prototype: ‘Syphilis test not recorded during pregnancy’ Practice ready version: ‘Syphilis test not recorded during pregnancy OR syphilis test >4 months ago’ | Prototype and Practice ready version: ‘Syphilis test not conducted with other STI or HIV testing’ | |
| Basis for prompting testing | Australian STI management guidelines > Pregnant people | Australian STI management guidelines > Standard Asymptomatic Check-up | |
| Links for clinicians | Australian STI management guidelines > Standard Asymptomatic Check-up | ||
| Links for patient resources | Department of Health and Aged Care. Don’t fool around with syphilis |
Our FHT algorithms were pragmatically based on an exact match of data fields available in the EMR, including test name for laboratory syphilis test results. A timeframe was included for each patient group. For people recently tested for an STI or HIV this was absence of a syphilis test in the past 12 months. For pregnant women this was absence of a syphilis test in the past 4 months (to allow prompts in first trimester and later in pregnancy).
Drawing on the design specifications, a prototype FHT-syphilis was developed, and functionality (correct algorithm activation, links to resources) was assessed in a technical environment. Usability was tested in the University of Melbourne’s Validitron, a simulated general practice environment.18 This involved simulated consultations by four GPs with a mock patient attending for a reason unrelated to syphilis in which the algorithms and recommendations were activated and GPs interacted with the Point-of-Care feature as they considered relevant. The prototype prompted GPs in the simulation to review past visits and investigations and initiate a syphilis testing discussion. One GP was unclear about wording of the repeat testing in pregnancy prompt, leading to a minor modification (Table 1).
Next, our practice ready version was piloted in 52 general practices that had FHT available for use for other conditions for 2–3 years. Most practices were in the state of Victoria (with one each in Tasmania and New South Wales) and included large and small practices in metropolitan and regional areas with a mix of billing and ownership structures. These practices received an email advising that FHT-syphilis was available for use alongside other FHT modules with a short infographic to communicate FHT-syphilis’s intention (Supplementary material file S1). Practices were also advised that GPs and practice nurses (PNs) would be invited to participate in interviews about FHT-syphilis’s acceptability. While the overall objective of FHT-syphilis is to increase syphilis testing, assessment of acceptability is an important step in understanding our intervention’s implementation and uptake. Impact evaluation is beyond the scope of this study.
Acceptability assessment
We undertook a qualitative study to explore acceptability of FHT-syphilis for prompting syphilis testing in general practice. Our acceptability assessment was guided by the Theoretical Framework of Acceptability (TFA) comprising seven constructs (Box 1) that can help to assess acceptability of interventions and identify characteristics that may be improved.19 The TFA has been used in evaluation of a range of healthcare interventions.20,21
| Box 1.TFA constructs and definitions |
As defined by Sekhon et al.19
|
We conducted semi-structured interviews with GPs and PNs working in general practices that had FHT-syphilis available for at least 3 months. Interest in an interview was sought via email invitation to the practice manager or main contact person for FHT at each clinic and included a request for the invitation to be circulated to GPs and PNs at the clinic. Those interested contacted the researcher (JG) who provided a plain language statement, consent form, and organised a mutually suitable interview time. Participants provided written consent and confirmed this verbally immediately prior to interview.
Interviews were conducted online via Zoom (July–August 2023) and audio-recorded digitally. Questions focused on the interviewee’s experience of using FHT, their views and interactions with FHT-syphilis including its appropriateness, alignment with the clinic workflow, suitability of linked resources and any changes to practice resulting from FHT-syphilis. Where there was uncertainty about FHT, interviewees were given a description of FHT-syphilis and shown pictures of the FHT interface (by screenshare). Participants received a AUD100 Australian gift voucher in recognition of their contribution.
Analysis
Interviews were transcribed verbatim and uploaded for analysis in NVivo ver. 12 (QSR international). Analysis commenced with data familiarisation by one author (JG) involving reading transcripts, noting preliminary observations and discussion with co-authors. A deductive analysis (by JG) was then guided by the TFA to generate multiple sub-themes within the seven TFA constructs. Sub-themes were discussed between two researchers (JG, BH) to reach consensus on broader themes for each TFA construct.
Study approval was obtained from the University of Melbourne Human Research Ethics Committee (ID 25486).
Results
Interviews were conducted with nine clinicians (GPs = 6, PNs = 3) from nine general practices (eight in Victoria, one in New South Wales) with FHT-syphilis available. These general practices were located in metropolitan (n = 3) and regional areas (n = 6) with a median of 16,280 registered patients (range 5031–43,927). Interviewees had worked in general practice for a median of 14 years (range 4–45 years), two focused largely on sexual health in their clinical practice and seven had used FHT before FHT-syphilis. Overall, FHT-syphilis was viewed as acceptable for identifying patients to consider for syphilis testing and Australian STI guidelines as an appropriate basis for testing recommendations. Findings for each TFA construct are presented below with supporting quotations in Table 2.
| TFA construct | Theme | Supporting quotes | |
|---|---|---|---|
| Affective Attitude | Awareness of syphilis | Yeah, yeah, I am always happy to be prompted on preventative health. Because it’s very easy for a consult to just go with what the patient’s goals are for that day. But yeah, having a prompt come up and say ‘Oh, this person hasn’t had STI screening or syphilis screening’ then you can start that conversation. Yeah, it’s quite useful. (Part 5) | |
| Attitude to FHT | It was just very straightforward, and then very like It wasn’t confusing or anything.. It was just very like laid out very easily. This is what they’ve had, and this is what they haven’t had and this is what they need it was…it was good. It was easy to follow. (Part 3) So FHT has been a valuable tool because it works in the background. It looks for our file data, patient file data and it looks for particular disease possibilities, the existence of disease and whether the disease is managed optimally. And they’re absolutely magic tools because they work in the background. It saves an inordinate amount of time looking through files saying, ‘Oh, yes look at that EU’ [electrolytes and urea] even looking for trends, checking medications, making sure that they’re optimised. And then it’s very, very user friendly, in my view. (Part 1) So I’ve been aware that future health today, has been a pop up annoying me on my computer software for quite some time. And I found the little button that says to shrink it so that I don’t have to look at it. So I haven’t used it …. thinking It was just another layer of being prompted to do my job when I felt that I was doing my job already. (Part 2) | ||
| Burden | General practice workplace | The biggest barrier to that is time. And then once you’re kind of engrossed in the issue that the patients brought to you it becomes very hard to remember about the other things that were on the to do list. (Part 6) So I think…there might be times where it’s a bit challenging to kind of get to that in a consult if it isn’t the initial thing that people are coming for. But I think what it does do, is it really prompts and highlights to go ‘We need to follow that up’ and we.. ‘We need another appointment you know to talk about this.’ (Part 4) | |
| Engaging the patient | I see men less regularly, so they usually come in with one issue, and then I don’t see them again, for you know, a year or many more. Yes, and it is kind of harder to add in that preventative health stuff in the younger cohort, you know. And an older man coming in with a sore elbow, and you say, you know, you haven’t done any cholesterol testing in a while. That’s fine. But in a younger man you know, say, he’s hurt his toe at work or something, and if I pivoted then into sexual health screening. I don’t know. Maybe it’s my own personal discomfort, or it just seems a bit, I don’t know ……. abrupt …… probably it’s my personal discomfort. (Part 5) A bit of a barrier is that it’s a blood test, you know. Chlamydia and gonorrhoea screening is easy as a urine test and some people are uncomfortable with doing a blood test. Most people aren’t, but it is a little bit a little bit more of a step. I don’t know easier to do when you’re already sending them for bloods, perhaps or if you know they’ve come in for screening, absolutely, you know no problem. But yeah. a little bit of a barrier in that it’s a blood test, I guess. (Part 5) | ||
| FHT syphilis attributes | And so this is one of the fluffy things that … my doctors would time poor, ark up straight away, what the frig? I’ve got no time to fart around with this stuff [Referring to looking for relevant local guidelines to define if a patient is high risk]. (Part 8) It’d be really helpful to have prompts for people just prompts around, I don’t know, like just specific questions about asking people, do they have the same partner? Have they had new sexual partners? So that high risk gets kind of a little bit of a definition around it. (Part 4) And I was like…I’m still not sure who’s high risk. And I’m just assuming I have no higher risk patients, which is wrong, because, just like that, in the same way. Like, if you tell me. if someone says to me ‘this is what the guidelines are, this is what you’re meant to do’ I would try my utmost to do that like, you know that is the type of care I want to provide for people, but it has to be made easy for us, because, like, this is just one of the literally few hundred conditions I’m probably gonna have to think about tomorrow in 1 day. (Part 9) So I had a look at the cohorts …. and I just clicked into a few patients of my own. So I had someone who like who came in a male patient, female partner, …. new partner, wanted STI testing – did the full gamut bloods, HIV, hepatitis, syphilis. Well, because of how the syphilis pathology came in..so it came in serology report, and the hepatitis B was off the top, and the syphilis was like came in the same report. It obviously, for whatever reason, I mean, you know, like future health today hasn’t picked up that as being syphilis testing. So it’s [the prompt] appearing for that person, even though they’ve had syphilis testing. So that’s I think that’s a challenge always, because that’s the tuning out bit that people can do. They can just be like, oh, there’s that thing again. It was wrong the last time I looked at it I’m just gonna ignore that again. (Part 9) | ||
| Ethicality | Syphilis is important | I think it’s necessary and appropriate for pregnant women to be tested …because of the damage that congenital syphilis can do. (Part 7) The main kind of people I’ve seen it pop up on are people in their twenties or thirties who have come in recently for an STI screen, and I think they are probably the right population that I would be considering it, I mean, before looking at that module, I probably would have only really considered it for certain groups like men who have sex with men, aboriginal and Torres Strait Islander patients. They are probably the ones … or sex workers would be the ones that I’d be mostly thinking about. But now I guess it’s just prompted me to cast a bit of a wider net, and that to think about kind of I guess all people that are at risk of STIs. (Part 6) | |
| Engaging the patient | But I also think you know, for good clinicians they’re going …. I know that this person, we might lose them. So that makes that more urgent. We need to do it. So I think there’s two things in that. I think having the little pop-up tells you for those cohorts if you’re assessing that they may not come back, then it puts it up as a higher priority, and I think that’s a good thing. (Part 4) One of the things that we sometimes do with terminations is forget to end the pregnancy and then you’ve got in …that people then get sent letters that are, you know you’re pregnant, and you have not had a flu vaccine. So please come in and get your flu vaccine. And no one wants that kind of letter if they’ve had the termination 2 months earlier. Let alone, someone who’s maybe not disclosed to their partner that they’ve had a termination. So it’s yes, you have all sorts of vulnerabilities about chasing up patients in the STI and reproductive field. Yep, yep. So we just have to be, yeah, mindful. (Part 2) Well our core business is relationships between customers which are patients, and how do we provide them with what they want and sell them what they don’t know that they need? And that’s a really tricky one. (Part 1) | ||
| Guideline supported practice | Oh, why is that coming up for so many of my patient’s files? But I had never actually clicked to read why, I just kind of thought oh, that’s not relevant. This person’s low risk. But it was interesting doing a bit of reading and seeing that those recommendations seem to have changed in that now they are sort of saying, ‘Oh well, anyone getting an STI check should get a syphilis check’ and that was something that I wasn’t aware of. So I learned something out of this. (Part 6) I think with this syphilis guideline, I mean I suppose I’m the kind of person who, if that’s what the guidelines says, then I’m just going to do it now, like I know it now, and I’m going to do it. (Part 9) | ||
| Intervention Coherence | Design of FHT | I think people are accurately going to document the pregnancy so that should be in the notes, and be a reliable piece of data. (Part 2) I want FHT to bring up a flag for pregnant patients, aboriginal patients, men who have sex with men, patients automatically. I don’t want to have to go and select them. That defeats what I think is part of the purpose of FHT. To identify those patients that in this case, at this point in time really need a bit of extra attention. (Part 7) And so yes, seeing the guidelines where I was taken. Especially for like, we kind of get a quite a few GP registrars who are training. So even just having that for them to go ‘Okay, this links me here’. So they’ve kind of got access to that fairly quickly, I think, is a really great thing. (Part 4) I noticed the pop up. and you know take note of what it’s recommending, but I’ve never clicked on it before. And I didn’t realise that you could run audits through it. And I didn’t. Yeah. Didn’t realise what it does. (Part 5) | |
| Using FHT in practice | I mostly like access it before the patient walks into the room and use it as sort of a prompt for me in terms of what I’ll do during that consultation. I don’t tend to access it as much mid or during the consultation, primarily, because then the patients come with their own list of their own agenda for the consultation, so I’m usually kind of distracted by that. So yeah, I find it’s really something I kind of check beforehand. Admittedly I probably don’t use the link to guidelines and like the resources stuff quite as often. And that’s purely just a time constraint. So yeah, I don’t tend to kind of click on and then look at the online resources, I just kind of flick over the recommendation and close it. Yeah? And then thinking about whether it’s something to incorporate into that consultation or not. (Part 6) Okay, this is a syphilis recommendation. Why has that popped up? And I guess that’s still how I would always apply it. Like even with the others. I still say, why has that popped up for this person? Cause I know my patients very well. I mean all GPs will say that, of course, but you know I have very regular patients who come to see me. I don’t see a lot of new patients. So when I do see something like this, I think, oh, okay, why? Why has that come up? What is this about but I don’t think that because its syphilis because I don’t think that’s any different from how I approach it with the other diseases. If that makes sense. (part 9) To go we haven’t done these, so we haven’t got to this, but we need another appointment to do that. Yeah. And some people might go ‘Give me the form now, and I’ll go and do it.’ And so they might not need as much discussion because they’ve had discussion when they were tested. (Part 4) | ||
| Opportunity Costs | I think I always feel conscious of eyes not on the patient and it, it’s always a little impersonal when you know, when you’re looking at a screen and talking instead of actually engaging with the patient. (Part 2) | ||
| Perceived Effectiveness | Supporting changes in knowledge and practice | I get resources from the computer as a means of patient education and I think that any module that is already sitting there and quickly, and easily gives you access to the information you need, and maybe patient information that you want to print out then that actually promotes the amount of time that you’re actually engaging with the patient. (Part 2) And it’s probably something that I haven’t done it yet, but it’s probably something that I’ll say in passing to one of my colleagues. So did you know that there, …we’re actually meant to be doing syphilis testing like on everyone who comes in for STI? Did you know that? Am I the only person who missed that memo? ……. I definitely have had people who have come in for testing since, and I have tested them for syphilis as part of STI testing but they, of course, had no pop up because they were just people who came in and said ‘I wanna have an STI test’. So FHT wasn’t activated at that moment in time. But my brain was activated. If that makes sense, so that’s good. (Part 9) It was news to me that it’s recommended to consider repeating at 4 months later if they’re a higher risk patient. And I guess I kind of thought that’s probably less relevant for me because I don’t do shared care. So my patients by that point with the antenatal clinics. (Part 6) It’s highlighted the change in the guidelines. It’s maybe not so influential for that individual patient at that individual moment. But if it’s a long-term thing that’s been embedded into my learning, then I think that is actually a really good thing.’ (Part 9) | |
| Self-efficacy | Engage in syphilis testing | One of the hardest things is to have a tool that finds all these issues. But we’ve got to somehow sell it to the customer. I hate to put in that algorithm, but it is, we’re selling health. That’s what GPs do and to sell STI checks. You’ve got to have people that actually want to buy that. Its very hard to sell that. (Part 1) We need to ask people not make assumptions about, you know that someone whilst they’re pregnant, they still might have new partners, and they might have numerous multiple partners. (Part 4) And sexual health nursing, its not particularly easy and having people working in that particularly, its not everyone’s cup of tea. Its a bit difficult, they need special training, particularly with diversity and you’ve got to be very careful. Stepping on ice so to speak. And sometimes, the way you use language and maybe approach the situation. So there are barriers to meeting things that are a little bit difficult (Part 1) And the so things like STI screening, …you might not even have time, you know. By the time you got through whatever it is, a patient wants to get through their list. But at least, if you’ve got it there you can say, ‘Look, you need to come back and talk to me about your screening’. (Part 7) I feel I feel like it’s easier to do screening when there are clear recommendations and if I personally thought someone was high risk. Yep, I’d do screening more often, but I feel like you’d have to meet a fairly high threshold for me to say, Oh, yeah, we need to check you again for syphilis. And potentially, I’m under screening because I live in a fairly affluent community where most of my patients are in stable long term relationships. And I yeah, I’d potentially be under screening, because I’d rely on a bit of bias probably to detect those people that are a bit more high risk if it’s based on personal judgement rather than on a clear recommendation. (Part 5) |
Affective Attitude
All interviewees expressed a positive attitude about FHT-syphilis. They considered it useful that it could identify patients in consultations (Point-of-Care function) for whom a syphilis test might be indicated and generate lists of relevant patients outside a consultation (Cohort function) for follow up. The Point-of-Care and Cohort functions were viewed as giving clinicians authority to recall or start a conversation with a patient about syphilis and STI risk. Many interviewees commented positively that FHT was non-obstructive in how it interacted with the medical record software, was easy to use and provided direct access to relevant guidelines and resources. Many liked that FHT flagged areas aside from the patient’s reason for visit. One inexperienced FHT user with a strong clinical interest in sexual health considered FHT provided pop-ups they did not need.
Burden
Effort to engage with FHT-syphilis was discussed in terms of the general practice workplace, engaging the patient, and attributes of FHT-syphilis.
Time constraints were an important barrier to discussing syphilis testing if prompted. Most interviewees discussed that in Australian general practice, the patient sets the consultation agenda in terms of their reason for visit and it can be difficult to add other aspects of care, noting that extending a consultation had a monetary cost to the practice and/or patient. Time constraints were also discussed for the Cohort function, with some interviewees noting that the number of patients meeting syphilis testing recommendations at their clinic was too large to follow up, particularly for those tested for STIs/HIV but not syphilis. Some interviewees noted that much antenatal care occurs outside of general practice, and there could be gaps in syphilis testing data in the EMR if syphilis tests undertaken in obstetric settings were not communicated to general practice. PNs were viewed as having skills to contribute to syphilis testing discussions and recalls; however, lack of a funding stream (e.g. via Medicare) to help optimise the PN role in sexual health care was noted. Some interviewees noted there is limited Commonwealth funding to support the role of PNs for patients with chronic disease management plans, but this does not extend to sexual health.
Interviewees discussed the need to address the patient’s reason for visiting but this could limit time to discuss syphilis testing if prompted. Perceived ease of initiating a discussion about syphilis was considered in respect to reason for visit. For example, it was viewed as more logical to talk about STIs in a contraception appointment than one involving a work injury. Some found it simpler to engage women in preventive health care than men. Others mentioned that some patients may have less knowledge about syphilis than other STIs (e.g. chlamydia, gonorrhoea) or be uncomfortable about having a blood test. Opportunity to enhance patient awareness about syphilis was identified.
While interviewees liked that FHT linked directly to relevant guidelines and resources, many wanted a link to a definitive information source on how to identify high risk in pregnancy and its absence was a barrier to engaging with FHT-syphilis. Some interviewees suggested FHT-syphilis could include questions for patients (e.g. asking pregnant people if they have the same partner) to help determine if they were high risk. One interviewee noted a syphilis test had been conducted despite a syphilis testing prompt and this posed a risk of clinicians ignoring future prompts if they were uncertain about its reliability.
Ethicality
Three themes (syphilis is important; patient-centred care; and guideline-supported practice) emerged for ethicality.
All interviewees considered that syphilis is an important infection to test for and treat promptly if diagnosed. Pregnant women were viewed as an appropriate group for prompts due to the risks from congenital syphilis. Some interviewees noted that the prompt for a syphilis test with any STI test differed to their routine practice. Instead, they prioritised specific groups for syphilis testing, such as men who have sex with men (MSM), sex workers, people aged <30 years or Aboriginal and Torres Strait Islander people due to knowledge of higher STI rates, specific risk behaviours or previous guidelines. Interviewees whose clinical role largely focused on sexual health expressed that the testing prompts aligned with their current practices.
While the value of being reminded about syphilis was important, interviewees expressed that the individual patient situation should be central to any actions prompted by FHT. They were mindful that acting on FHT-syphilis prompts could be more urgent for some patients than others (e.g. high-risk pregnant women who may not return for care). Others noted it was important to manage actions prompted by FHT-syphilis, particularly the Cohort function (e.g. testing recalls) carefully to reduce risk of harms to the patient (e.g. a patient who had not disclosed their pregnancy).
Interviewees valued that FHT-syphilis aligned with current Australian syphilis testing guidelines. Some interviewees were not aware of all aspects of the Australian guidance, for example that repeat testing is recommended in pregnancy for high-risk women or that syphilis testing is recommended with all STI/HIV testing and were appreciative that FHT-syphilis had highlighted where their syphilis testing practices should be expanded. Others were comfortable with being prompted even if this was already part of their practice.
Intervention Coherence
Two themes (FHT design and using FHT in practice) emerged.
All interviewees expressed an understanding that FHT-syphilis identified patients for whom syphilis testing might be indicated. While most were aware that FHT identified these patients by scanning available EMR data they were not always aware of the data fields on which algorithms were based or that FHT algorithms did not function in real time. For example, some interviewees suggested syphilis testing prompts should pop-up when another STI test (e.g. chlamydia or gonorrhoea) was requested. Others questioned why prompts did not occur for priority groups such as MSM. However, this data is not well captured in the EMR. In contrast, pregnancy was viewed as being reliably entered.
Most interviewees considered the linked guidelines and resources as helpful by taking them directly to current relevant guidelines and printable patient resources. Some were unaware that FHT prompts could be interacted with to link to guidelines or that the Cohort function supported clinical audits.
Several interviewees commented about how they use FHT in clinical consultations for syphilis and/or other conditions. Some engaged with FHT prior to the consultation, noting that they routinely opened the patient record before the patient enters and if there is a recommendation from FHT they can decide whether to prioritise it for the current visit or address it later. For example, the syphilis testing in pregnancy recommendation was viewed as more urgent than other syphilis testing recommendations. Acting on FHT was influenced by the patient’s reason for visit and time available in the consultation. GPs generally focused more on the Point-of-Care than the Cohort function.
Opportunity Costs
There was minimal discussion about what was forfeited to engage with FHT-syphilis. A few interviewees considered the FHT icon was annoying, or they did not like to focus on the screen when engaging with a patient, with this distraction potentially diverting the clinicians’ attention from their interaction with the patient. This was balanced by comments that engagement with FHT may help them to quickly locate suitable patient resources. Other comments consistent with Burden (see above) conveyed that acting on FHT prompts could incur a cost to the clinic in terms of staff time.
Perceived Effectiveness
Discussion relating to Perceived Effectiveness largely focused on perceived and potential future benefits of FHT-syphilis to help: (1) support improvements in awareness of current guidelines; (2) identify patients for syphilis testing; (3) prompt discussions or follow-up regarding syphilis testing; and (4) support an increase in syphilis testing. This discussion often overlapped with views for Affective Attitude, Ethicality, and Intervention Coherence. Two interviewees reported that FHT-syphilis alerted them to updated Australian STI guidelines for syphilis testing and that they have changed their practice to include syphilis with all STI testing. Some interviewees were unsure about prompting repeat testing in pregnancy due to uncertainty about defining high risk and that this element of care is most likely to be provided in obstetric settings, particularly in the third trimester. Therefore, there were uncertainties about reliability of EMR data to inform repeat testing in pregnancy prompts or to generate a cohort list.
Self-efficacy
All interviewees discussed a combination of factors in respect to their ability to engage in or discuss syphilis testing for patients identified by FHT-syphilis. Many were consistent with other TFA constructs. For example, as for Affective Attitude, prompts were viewed as giving authority to discuss syphilis testing. Several interviewees discussed the expertise (e.g. language to use) in discussing syphilis and the importance of not making assumptions about STI risk. Several interviewees emphasised challenges to discussing syphilis testing in an unrelated consultation or had hesitations about recalling patients if they perceived them as low risk. The challenge in ‘selling’ (or prioritising) a ‘preventative health issue’ (or need for STI testing) to a patient was highlighted. Many discussed skills and experience for using FHT as in Intervention Coherence.
Discussion
In this study, we provide the first exploration of clinician views on acceptability of a digital clinical decision support tool to promote syphilis testing in Australian general practice. Our tool (FHT-syphilis) aligned strongly with clinician views that syphilis is an important infection to focus on and giving them authority to initiate a discussion about syphilis testing or recall patients. Importantly, FHT-syphilis alerted some GPs to updated STI testing guidelines, who expanded their STI testing practices to routinely include syphilis. All viewed antenatal testing as essential, but there was uncertainty about what constituted high risk for a repeat antenatal test and frustration that there was no indicative source of this information in Australia. Barriers to acting on testing prompts included time, financial constraints, and difficulty to incorporate a testing discussion in an unrelated visit. Inexperience with FHT was also a barrier, with some interviewees having little knowledge about its functions.
Our findings build on our earlier work showing high acceptability for the concept of digital tools to provide decision support for STI testing and care.16 In view of its potential harms, syphilis was deemed a priority, which was further supported in this study. The Point-of-Care function of FHT-syphilis operated as intended, alerting some GPs to current syphilis testing guidelines and prompting a change in syphilis testing practices. While measuring the impact of FHT-syphilis was not the objective of this study, changed syphilis testing practices could lead to increased case detection, more timely management and prevention of syphilis harms. Further work to evaluate the impact of FHT-syphilis will be informed by findings from this study.
Aligning with feedback about FHT’s chronic disease modules,13,22 we found that interviewees largely commented positively on FHT’s attributes; liking that pop-ups did not overwhelm the computer screen and direct links to relevant resources. However, there are possible differences in how effectively FHT might be used for STIs versus chronic disease. The Point-of-Care function relies on a repeat visit after relevant pathology tests for a pop-up to occur. Patients with chronic disease may attend their usual GP regularly as part of chronic disease management23 giving opportunity for pop-up prompts. Patients meeting criteria for syphilis testing prompts may have different attendance patterns. For example, some interviewees noted that men attend infrequently making preventive care difficult or to activate prompts. For pregnancy, there are many possible antenatal care arrangements in Australia (e.g. public hospital, private obstetrician, shared care between general practice and hospital). Within these pathways, some women may attend their GP in first trimester and less frequently later in pregnancy. It may be unclear who is organising or assessing risk for a repeat syphilis test. There are also instances of women receiving no antenatal care. Surveillance data for Victoria, Australia showed for congenital syphilis during 2017–2020, that mothers of six of nine cases had negative syphilis serology early in pregnancy and mothers of three cases did not receive any antenatal care.24 If capacity for real-time prompts is developed within FHT this might offer an option for flagging infrequently attending high-risk patients. Work for building real time capacity in FHT is underway and could offer an avenue for enhancing FHT-syphilis to instantly identify priority patients for offering syphilis testing during the consultation, such as when a chlamydia or gonorrhoea test is ordered.
The Australian general practice setting is currently facing significant challenges, including underfunding, increasing patient complexity and demand for services, workforce shortages and staff burnout.25 In this context, we found that although FHT-syphilis might give clinicians a rationale to start a syphilis testing conversation they may also experience difficulty in acting on prompts, particularly if it was unrelated to the patients reason for visit. Some interviewees emphasised that they routinely engage with FHT prior to consultations so that they could decide whether to address any recommended actions in the current or a later visit. This is consistent with findings for clinician interactions with FHT for other conditions (e.g. risk of undiagnosed cancer).26 Supportive materials for FHT could highlight that the Point-of-Care function is best interacted prior to the patient entering the consultation room. Time and financial constraints were also barriers to clinicians engaging with FHT-syphilis. While the potential for nurses to play a stronger role in sexual health care in general practice was noted, there is currently no specific subsidised funding item to support this via the Australian Government Medicare Benefits Schedule.
Some areas for enhancing FHT-syphilis were identified. First, as noted above, capacity for FHT algorithms to be activated in real time was viewed as suited to attendance patterns of priority groups for syphilis testing. Second, many interviewees wanted better support for identifying high-risk pregnant patients for repeat antenatal testing. Guidance for repeat syphilis testing in pregnancy for women at high risk differs between Australian jurisdictions and national STI guidelines direct clinicians to refer to local guidelines for further information.6 The Australasian Society for Infectious Diseases lists syphilis risk factors in antenatal syphilis screening algorithms that may help address this issue.27 Third, some interviewees suggested FHT-syphilis should provide prompts based on specific risk behaviours (e.g. MSM, patients reporting a new sexual partner). However, this data is not routinely collected in general practice EMR, aside from some clinics with high caseloads of gay and bisexual men, where EMR alerts along with audit and feedback resulted in increased comprehensive STI testing and recording of patient sexuality.28 Finally, there were instances of a syphilis test having been done despite a prompt. As FHT functions by looking for exact terminology matches, instances of ambiguous syphilis test name are not built into the algorithm. Increased consistency in pathology reporting of syphilis tests would help address this issue.
A strength of this study includes interviewing GPs and PNs to provide different clinical perspectives on FHT-syphilis use in general practice. Our analysis was guided by the TFA, providing a theory-based approach to understanding FHT-syphilis acceptability. An important limitation is the small sample size despite our efforts to engage participants and that some interviewees had limited experience of FHT-syphilis in practice, despite it being available for at least 3 months prior to interview. There was a reliance on patients meeting criteria for prompts attending in that period, and if the number of patients was small the opportunity for interviewees to engage with Point-of-Care prompts upon opening the patient’s record was limited. While many interviewees commented hypothetically about how they would interact with FHT-syphilis, our findings were very consistent across all interviewed. Another limitation is that there can be gaps in syphilis testing data in the EMR during pregnancy due to barriers in communication between general practice and external obstetric care. The state of Victoria has commenced developing a statewide syphilis enhanced case management database that can, over time, contain all syphilis testing data. Such a mechanism would help address this issue.
Conclusion
A digital tool for prompting syphilis testing was acceptable to end-users. Linkage to STI guidelines facilitated some end-users to be abreast of updated guidelines and alter routine STI testing practices. Enhancements will focus on incorporating updated Australian guidance for high risk in pregnancy as it becomes available.
Data availability
This manuscript reports on qualitative data. To protect participant confidentiality, this data is not publicly available.
Declaration of funding
JLG was funded by a University of Melbourne Early Researcher Grant for this research. Future Health Today was funded by the Paul Ramsey Foundation and is a collaborative initiative with Western Health.
Author contributions
JLG conceived and led the study, oversaw the development process, undertook the qualitative data collection and contributed to the analysis and manuscript writing. BH contributed to the development, qualitative data collection, analysis and wrote the manuscript. JH, JAMN, JJ, RW, MYC, CC, DB and HO’D contributed to the development, interpretation of findings and manuscript writing. All authors approved the final submitted version of the manuscript.
Acknowledgements
The authors acknowledge the contributions of the Future Health Today (FHT) project team and investigators and the team at the Centre for Digital Transformation of Health for their expertise in providing a simulated general practice environment. We also acknowledge the time and valuable contributions of our interviewees.
References
1 King J, McManus H, Kwon J, Gray R, McGregor S. HIV, viral hepatitis and sexually transmissible infections in Australia: annual surveillance report 2023. Australia: The Kirby Institute, UNSW Sydney; 2023. doi:10.26190/f5ph-f972
2 Australian Government Department of Health. Multijurisdictional syphilis outbreak surveillance report: February 2021. Department of Health; 2021. Available at https://www.health.gov.au/resources/publications/multijurisdictional-syphilis-outbreak-mjso-surveillance-report-february-2021?language=en [accessed 26 March 2024].
3 Zagon C. Outbreaks of syphilis rapidly spreading through Melbourne suburbs. 9 News; 2021. Available at https://www.9news.com.au/national/outbreaks-of-syphilis-rapidly-spreading-through-melbourne-suburbs/5ecf03a9-d3e1-4bc1-a913-d999f5edca83
4 World Health Organization. Global health sector strategy on sexually transmitted infections 2016–2021: towards ending STIs. Switzerland: WHO; 2016. Available at https://www.who.int/publications/i/item/WHO-RHR-16.09 [accessed 26 March 2024].
5 Australian Department of Health. Fourth national sexually transmissible infections strategy 2018-2022. Canberra: Department of Health; 2018. Available at https://www.health.gov.au/resources/publications/fourth-national-sexually-transmissible-infections-strategy-2018-2022?language=en [accessed 22 August 2024].
6 Australasian Society for HIV Viral Hepatitis and Sexual Health Medicine (ASHM). Australian STI Management Guidelines, for use in primary care. ASHM; 2021. Available at https://sti.guidelines.org.au/ [accessed 26 March 2024].
7 Department of Health. Syphilis: information for clinicians. Victorian Government; 2021. Available at https://www.health.vic.gov.au/infectious-diseases/syphilis [accessed 26 March 2024].
8 Department of Health and Aged Care. Don’t fool around with syphilis. Australia: Commonwealth of Australia; 2023. Available at https://www.health.gov.au/dont-fool-around-with-syphilis [accessed 26 March 2024].
9 Gordon J, Britt H, Miller GC, Henderson J, Scott A, Harrison C. General practice statistics in Australia: pushing a round peg into a square hole. Int J Environ Res Public Health 2022; 19: 1912.
| Crossref | Google Scholar | PubMed |
10 Australian Bureau of Statistics. Patient experience in Australia: summary of findings 2019-20 financial year. Available at www.abs.gov.au/statistics/health/health-services/patient-experiences/ [accessed 26 March 2024].
11 McNulty CAM, Freeman E, Howell-Jones R, Hogan A, Randall S, Ford-Young W, et al. Overcoming the barriers to chlamydia screening in general practice--a qualitative study. Fam Pract 2010; 27: 291-302.
| Crossref | Google Scholar | PubMed |
12 Hocking JS, Parker RM, Pavlin N, Fairley CK, Gunn JM. What needs to change to increase chlamydia screening in general practice in Australia? The views of general practitioners. BMC Public Health 2008; 8: 425.
| Crossref | Google Scholar | PubMed |
13 Hunter B, Biezen R, Alexander K, Lumsden N, Hallinan C, Wood A, et al. Future Health Today: codesign of an electronic chronic disease quality improvement tool for use in general practice using a service design approach. BMJ Open 2020; 10: e040228.
| Crossref | Google Scholar | PubMed |
14 Hunter B, Alexander K, Biezen R, Hallinan CM, Wood A, Nelson C, Manski-Nankervis J-A. The development of Future Health Today: piloting a new platform for identification and management of chronic disease in general practice. Aust J Prim Health 2023; 29: 8-15.
| Crossref | Google Scholar | PubMed |
15 Hunter B, Davidson S, Lumsden N, Chima S, Gutierrez JM, Emery J, et al. Optimising a clinical decision support tool to improve chronic kidney disease management in general practice. BMC Prim Care 2024; 25(1): 220.
| Crossref | Google Scholar |
16 Gezer M, Hunter B, Hocking JS, Manski-Nankervis J-A, Goller JL. Informing the design of a digital intervention to support sexually transmissible infection care in general practice: a qualitative study exploring the views of clinicians. Sex Health 2023; 20: 431-440.
| Crossref | Google Scholar |
17 King J, McManus H, Kwon A, Gray R, McGregor S. HIV, viral hepatitis and sexually transmissible infections in Australia: annual surveillance report 2021. Sydney: Kirby Institute, UNSW Sydney; 2022. Available at doi:10.26190/sx44-5366, https://kirby.unsw.edu.au/report/asr2021 [accessed 26 March 2024].
18 Centre for Digital Transformation of Health. The Digital Health Validitron. Melbourne: University of Melbourne; 2023. Available at https://mdhs.unimelb.edu.au/digitalhealth/our-work/validitron [accessed 26 March 2024].
19 Sekhon M, Cartwright M, Francis JJ. Acceptability of healthcare interventions: an overview of reviews and development of a theoretical framework. BMC Health Serv Res 2017; 17: 88.
| Crossref | Google Scholar | PubMed |
20 Wright MT, Smith D, Baird CS, Ibrahim JE. Using the theoretical framework of acceptability to understand the acceptability of e-training for nurse led prevention of unwanted sexual behaviour in Australia’s residential aged care services. Aust J Adv Nurs 2022; 39: 23-34.
| Crossref | Google Scholar |
21 Lafferty L, Rautenbach C, McNulty A, Ryder N, Slattery C, Houghton R, et al. Client and staff perceptions of acceptability of MyCheck: a direct-to-pathology telehealth and e-testing service for comprehensive bloodborne virus and sexually transmissible infection screening. Sex Health 2024; 21: SH23194.
| Crossref | Google Scholar |
22 McBride C, Hunter B, Lumsden N, Somasundaram K, McMorrow R, Boyle D, et al. Exploring clinical acceptability of a new quality improvement program aiming to reduce cardiovascular disease risk in people with chronic kidney disease in Australian general practice: qualitative study. JMIR Hum Factors 2023;
| Crossref | Google Scholar |
23 Australian Institute of Health and Welfare. Use of chronic disease management and allied health Medicare services. Australian Government; 2022. Available at https://www.aihw.gov.au/reports/chronic-disease/medicare-chronic-disease-allied-health-items/contents/chapter1 [accessed 26 March 2024].
24 Borg SA, Tenneti N, Lee A, Drewett GP, Ivan M, Giles ML. The reemergence of syphilis among females of reproductive age and congenital syphilis in Victoria, Australia, 2010 to 2020: a public health priority. Sex Trans Dis 2023; 50(8): 479-484.
| Crossref | Google Scholar | PubMed |
25 The Royal Australian College of General Practitioners. General practice: health of the nation 2023. East Melbourne: RACGP; 2023. Available at https://www.racgp.org.au/getmedia/122d4119-a779-41c0-bc67-a8914be52561/Health-of-the-Nation-2023.pdf.aspx [accessed 20–22 August 2024].
26 Chima S, Martinez-Gutierrez J, Hunter B, Manski-Nankervis J-A, Emery J. Optimization of a quality improvement tool for cancer diagnosis in primary care: qualitative study. JMIR Form Res 2022; 6(8): e39277.
| Crossref | Google Scholar |
28 Callander D, Bourne C, Wand H, Stoové M, Hocking JS, de Wit J, et al. Assessing the impacts of integrated decision support software on sexual orientation recording, comprehensive sexual health testing, and detection of infections among gay and bisexual men attending general practice: observational study. JMIR Med Inform 2018; 6(4): e10808.
| Crossref | Google Scholar |
