Facilitators and barriers to adopting a multifaceted chlamydia management intervention in general practice: qualitative findings from Management of Chlamydia Cases in Australia (MoCCA)

Setting and intervention

This qualitative study is part of The Management of Chlamydia Cases in Australia (MoCCA) study, which focuses on partner notification, timely retesting to detect reinfection and early detection of PID to strengthen chlamydia management in general practice (Goller et al. 2022). General practices were recruited via advertising through general practice communication networks, including study project partners, such as state governments, primary health networks, family planning organisations, sexual health clinics and laboratories. Eligibility criteria are detailed in the published MoCCA protocol (Goller et al. 2022). Fifteen general practices from three states in Australia (Queensland, New South Wales and Victoria) were recruited by identifying a key contact person in each clinic, and asking them to facilitate the implementation and use resources to support management of patients with a chlamydia infection during a 12-month intervention period. The key contact person for each clinic was typically the practice manager or practice principal, and written consent to participate in the study was obtained from general practice management. The co-designed chlamydia management interventions available to clinics are shown in Box 1. Support was provided to clinic staff through formal induction meetings, regular email and phone contact, and 3-monthly newsletters.

Outcomes of MoCCA include examining the acceptability, adoption, appropriateness, costs, feasibility, fidelity, penetration and sustainability of this multifaceted chlamydia management intervention, and its impact on chlamydia retesting, reinfection and PID diagnosis. Here, we report on the perceived facilitators and barriers to the uptake and early use of the MoCCA chlamydia management interventions.

Participant sampling

Invitations to participate in a semi-structured interview were provided via email and phone calls to the key contact person from each of the 15 participating clinics in MoCCA. All clinic staff, including GPs, practice managers and practice nurses, were invited to participate. The key contact person was also asked to identify GPs and practice nurses or managers who might be interested in participating in an interview. A maximum of three phone calls and emails, respectively, were attempted. Purposive sampling ensured that participants included clinicians and non-clinicians from a range of clinics.

Data collection

Interviews were conducted by SM and JG, qualitative researchers with experience in clinical medicine, nursing and public health, using a semi-structured interview guide developed by MoCCA researchers (Supplementary material 1). A plain language statement was sent via email on initial invitation, and again to all participants prior to their interview. Verbal consent was obtained at the beginning of the interview. Interviews were conducted, audio-recorded, and transcribed verbatim using Zoom videoconferencing and transcription software from the privacy of their own homes or clinic rooms with only the interviewer and participant present. Each transcript was verified, cleaned and deidentified by SM and JG. Transcripts were stored in a password-protected secure server at the University of Melbourne. Participant demographic data was obtained at the start of the interview, and clinic demographic data was obtained during clinic recruitment. The MoCCA study, including this qualitative component, was approved by the University of Melbourne Human Research Ethics Committee (ID: 22665).

Data analysis

Inductive content analysis (Vears and Gillam 2022) was used by author SM to analyse the data using NVivo 14 software to facilitate analysis. This method was chosen as the aim of inductive content analysis is to stay close to the phenomenon being investigated and produce a rich interpretation of the data that is practically relevant to the research context (Vears and Gillam 2022). To begin the inductive content analysis process and become familiar with the data, all interview transcripts were read through thoroughly. On repeat review, each transcript was then coded into broad categories of content or ‘big picture meaning units’ (Vears and Gillam 2022). The text within these broad categories was coded again into sub-categories according to the varied ideas within each. Following this, sub-categories were refined by either collapsing or consolidating within other more relevant sub-categories to minimise repetition while maintaining data richness. Finally, the codes were interpreted and synthesised to create meaning. Throughout the analysis process, preliminary codes were discussed with authors JC, JG and HB, without any discrepancies, followed by a repeat discussion to finalise the coding framework.

Ethics approval

Ethics approval for the MoCCA study was provided by the University of Melbourne Human Research Ethics Committee (ID: 22665).

Staff motivation and engagement

Supporting best practice was a key motivator to be involved in MoCCA. Interviewees spoke about their own and their colleagues’ motivations for joining the study, including one GP who stated that their clinic performs more STI screening than a standard GP clinic and, thus, felt motivated to participate to ensure that they were adhering to the latest evidence-based standards. Another PM saw joining the MoCCA study as a learning opportunity to assist their staff in knowing what to do when a patient presents with chlamydia.

…there’s not really a, like a structure … with these (chlamydia) patients, what to do with them, always ‘Yes, okay, yes, you go and have a test’, and they come back if they’re positive, but then what? (Participant 13, female, PM)

Improving patient outcomes also motivated MoCCA involvement, with practice staff describing their participation as a way of helping audit their work and improve practice and patient outcomes, including promoting testing and retesting among patients.

And there was also talk about the goals … we’re trying to keep an eye on how things are going and treatment failures and testing and all that sort of stuff. (Participant 7, male, GP)

…and for the retesting, we’re definitely getting more effort into having them back, no matter which method they choose… (Participant 1, female, PM/PN)

Others described that engaging in MoCCA was an opportunity to facilitate sharing their specialised sexual health knowledge with other practice staff. A sexual health nurse also felt motivated by the broader public health benefit likely to result from study participation.

…we just want (to) make services better. We want (to) make it, improve services. (Participant 8, female, PN)

Involvement in the MoCCA study also prompted one GP to refresh her knowledge on the management of STIs and complications, facilitating ongoing professional development and self-learning.

going through the MoCCA stuff then, kind of motivated me to read up on things. So I went in and read up on our, our local sexual health clinic … kind of just jogged my mind about their services, and how people access them. (Participant 12, female, GP)

Interviews highlighted that practice champions and clinic leaders played a significant role in driving their clinic’s initial study involvement in MoCCA. Practice champions included nurses, practice managers and GPs who appeared to go above and beyond their usual roles to ensure others were aware of study resources and supported in using them. Participants also noted that it was often nurses who have the capacity to drive practice involvement with research studies. One nurse described how she had adapted flexibly to find opportunities throughout the day to remind GPs of study processes and updates, even if it meant adding extra time into her own day.

…we (practice nurses) have driven it and set it up and spoon-, not spoon fed them (the GPs), but kind of gone ‘Okay we’re gonna talk you through it, we’re gonna show you the templates, we’re gonna do all of that, and we really step people through. So they’re invested and interested. But if it had of been left up to them to do it, I don’t know if we would have got it up and running… (Participant 8, female, PN)

Interview participants also reported that they had observed varying levels of engagement among other practice staff. Younger and female GPs were perceived to be more likely to see patients with chlamydia and, therefore, more likely to be engaged with MoCCA. Conversely, older GPs were reported to see fewer chlamydia cases, either because their patient population was older or due to a perceived lack of interest in chlamydia management, and thus were perceived to be less engaged in the study.

Definitely some that are more engaged than others. Um, the wom-, the ones who do more women’s health, I think are the ones. It’s just on your radar more … one of the practice doctors, he’s 60 something year old male, he’d have no idea. He’d be like ‘MoCCA?’ but he probably hasn’t ordered a chlamydia test in a long time. (Participant 6, female, GP)

Availability of clinic resources

Several logistical issues were identified as barriers to entry into the study and initial use of MoCCA resources. For example, many participating clinics had competing priorities above the clinic’s usual day-to-day operations, making time and staff availability to effectively engage in the study difficult. For one clinic, an upcoming clinic accreditation process was consuming staff time, and for another, changes to clinic processes due to the COVID-19 pandemic were still having downstream impacts. These events created challenges to becoming involved in the MoCCA study and led to delayed study start dates.

COVID was consuming all of us, and we were having to move to telehealth … I think our reason for not picking it (the MoCCA study) up then was because we’re all just too overwhelmed with managing COVID. (Participant 8, female, PN)

For another clinic, time constraints faced by GPs highlighted the need for study resources to be readily accessible. Additionally, at some clinics, difficulty retaining GPs and the transient nature of locum staff were barriers to study engagement.

…the biggest challenge is clinical staffing. So we’ve relied mainly on locum doctors … They don’t have time to be committed to anything. They just wanna do their 2 weeks and be out, 3 weeks and be out, so that does make it hard… (Participant 2, male, PM)

In another clinic, unreliable and intermittent internet access limited access to the MoCCA website and resources. As a workaround, one GP opted to save useful study resources onto their desktop, so they could be provided to patients even without internet access.

Usefulness of interventions

The perceived usefulness of specific MoCCA interventions appeared to facilitate or reduce their uptake. Interviewees reported that study resources that were easily accessible and could be integrated within existing workflow processes, such as the documentation shortcut and patient factsheets, improved workflow efficiency within their clinic.

Anything integrated with the practice management software is more likely to be useful for the doctors, if they don’t have to go to an external source. Doctors are just always short on time, so anything that’s a short cut, or quicker. (Participant 5, female, PM)

Practice staff also reported the MoCCA study website was convenient, easy to navigate and contained many resources in the one place.

Things are at your fingertips … that’s great. That’s what you need in general practice … so many things that are in the air, struggling, lots of demands. It’s nice to know ‘Oh, that’s where I find it’. (Participant 6, female, GP)

In addition to the website, many spoke highly of the patient factsheets, stating that the succinct format and clear information assisted in explaining the clinical situation to their patients and informing them of next steps.

A lot of them (patients) like, sometimes are young, they don’t understand what it (chlamydia) is, and they like having something to look at and or something to show ‘this is what I have’, and you need to go and get tested. So just having that information helps.(Participant 9, female, GP)

For three practice staff, the MoCCA chlamydia patient factsheets superseded the factsheets they were previously using.

I like the factsheets, I like the chlamydia one better than the one I’ve been using previously. (Participant 12, female, GP)

MoCCA chlamydia and PID documentation shortcuts also helped to save time in a demanding environment and improve consistency by providing a comprehensive checklist, reassuring one nurse that she was not forgetting anything in her consultations with patients.

Some days you’re just so under the pump … and then you’re like ‘Hang on! I’ve got this (documentation shortcut) template that just steps me through’, and you can go, ‘Yep, yep, yep, done … And so, therefore, there’s this consistency across staff following the same thing. And so stuff, then, isn’t getting missed. (Participant 8, female, PN)

MoCCA interventions also complemented existing practices by supporting staff communication, teaching and learning. Practice staff reported that the MoCCA resources facilitated handover and communication between staff, ensuring continued use and study engagement by remaining staff members, even when implementation leaders were away from the clinic.

…now I’ve got like a MoCCA file that I’ve created here so they know where that is if they need any information it’s all in the one spot so they can just go to it and, makes it a bit easy for them too if I’m not here, you know, like where to go to get anything. (Participant 13, female, PM)

Other GPs reported that the MoCCA resources were helpful when used to facilitate teaching interactions with doctors in training, and in orientating doctors new to sexual health.

We’ve had a new couple of new GP registrars start as well, so it’s good to them, to kind of, start them off with MoCCA. (Participant 8, female, PN)

MoCCA interventions were also seen to enhance existing practices at one clinic where the GPs and PM realised that it was difficult to provide patients with information electronically in their chlamydia follow-up consultations via telehealth. As a solution, the PM activated the text messaging function within Best Practice (EMR software) to send resources electronically, a function not previously used by the clinic. This practice was expanded to other clinic processes, such as recalling patients for non-urgent matters.

So now it’s become this big clinic thing where we’re using the text message function within Best Practice, so we’re doing it for all the patients now… (Participant 11, female, PM)

However, not all MoCCA interventions were able to be integrated easily within existing clinic workflow processes. This became apparent when one GP realised that the MoCCA patient factsheets could not be sent electronically to her patients from their medical software, requiring additional steps to provide these to their telehealth patients.

We are doing a lot of our results on the phone for this, because it’s not something we would normally bring the patient back for unless we had a different reason to, it’s much more helpful to have stuff that you can send electronically (Participant 10, female, GP)

Staff also reported they were less likely to use an intervention if there was uncertainty or concern about its use. For example, variation in state-based government guidance on patient-delivered partner therapy (PDPT) created uncertainty for some doctors about whether they would be covered medicolegally if they prescribed PDPT, resulting in a reluctance to use the prescription template.

The insurance, the indemnity company, they’re not covering (PDPT) prescription, so we didn’t give any (of) this prescription yet, ‘cause (the) doctors don’t feel comfortable. (Participant 1, female, PM/PN)

In contrast, a GP at another clinic stated that it was through participating in MoCCA that they realised they were able to prescribe PDPT in their state, and subsequently started incorporating PDPT into their routine care.

I actually didn’t know before the MoCCA trial things that we legally allowed to do it (prescribe PDPT) in (participant’s state) … so I’ve been using that actually a reasonable amount now that I know it’s legal to do so… (Participant 10, female, GP)

Although many practice staff felt that MoCCA interventions benefited their practice, some staff reported feeling disheartened if their patients did not engage with the interventions, as was the case for one GP whose patients declined the offer of postal retesting. Additionally, the extra steps required when ordering a postal retesting kit were perceived as inconvenient by one GP, and the chlamydia documentation shortcut was perceived as ‘clunky’ with too much information by another GP, resulting in a reluctance to use these interventions.

Despite finding some MoCCA interventions useful, such as the website, chlamydia patient factsheet and PDPT prescription template, four participants felt that MoCCA had not changed their practice, with one GP stating that they felt adequately proficient in their sexual health management due to prior experience.

Um, to be honest, I think not so much (changed my practice). Just because I felt quite confident of managing STI because of my previous experience of working (in) the Sexual Health Clinic. (Participant 4, female, GP)

Strengths and limitations

The main strength of our study is that by collecting data during the implementation phase of the MoCCA study, we could incorporate feedback in real-time into our work with participating clinics and apply learnings to scale-up plans. However, when interpreting our findings, it is important to note that interviews reflect the early perceived benefits and limitations of the MoCCA study by clinic staff and do not provide an indication of study effectiveness, for which outcome data are yet to be analysed. During the next MoCCA study stages, electronic patient and laboratory testing data, patient and staff surveys and workshops, and study documentation will be collected and analysed to provide further data on the outcomes and sustainability of study interventions. Additionally, clinics that participated in these interviews are likely to be more engaged in the study, and although the six of the 15 clinics that did not respond to invitations to participate in an interview varied in their state, rurality, billing method and staff size, they may present a different point of view to those outlined in this study. Finally, although the early detection and management of PID was one of the aims of the MoCCA study, participating clinics had not seen much PID at this point in the study, thus we were unable to investigate this more thoroughly.