Patient delivered partner therapy for chlamydia infection is used by some general practitioners, but more support is needed to increase uptake: findings from a mixed-methods study.

OBJECTIVES: Patient-delivered partner therapy (PDPT) describes the giving of a prescription or antibiotics by an index case with chlamydia to their sexual partners. PDPT has been associated with higher numbers of partners receiving treatment. In Australia, general practitioners (GPs) previously expressed negative views about PDPT. Health authority guidance for PDPT has since been provided in some areas. We investigated recent use and perceptions of PDPT for chlamydia among GPs in Australia. METHODS: In 2019, we conducted an online survey comprising multiple-choice and open-ended questions to investigate GPs' chlamydia management practices, including PDPT. Logistic regression identified factors associated with ever offering PDPT. A directed content analysis of free-text data explored GPs' perceptions towards PDPT. RESULTS: The survey received responses from 323 GPs; 85.8% (n=277) answered PDPT-focused questions, providing 628 free-text comments. Over half (53.4%) reported never offering PDPT, while 36.5% sometimes and 10.1% often offered PDPT. GPs more likely to offer PDPT were aged ≥55 years (adjusted OR (AOR) 2.9, 95% CI 1.4 to 5.8), worked in non-metropolitan areas (AOR 2.5, 95% CI 1.5 to 4.4) and jurisdictions with health authority PDPT guidance (AOR 2.3, 95% CI 1.4 to 3.9). Qualitative data demonstrated that many GPs recognised PDPT's potential to treat harder to engage partners but expressed hesitancy to offer PDPT because they considered partners attending for care as best practice. GPs emphasised a case-by-case approach that considered patient and partner circumstances to determine PDPT suitability. To alleviate medicolegal concerns, many GPs indicated a need for professional and health authority guidance that PDPT is permissible. They also desired practical resources to support its use. CONCLUSION: GPs appear to accept the place of PDPT as targeted to those who may otherwise not access testing or treatment. Availability of health authority guidance appears to have supported some GPs to incorporate PDPT into their practice.

'Most women really actually do just appreciate being asked': clinicians' views on integrating sexual wellbeing into contraceptive care.

A growing body of literature suggests that contraceptives' impact on sexual experiences influences willingness to initiate and continue with a method. Little is known, however, about how clinicians engage with clients on this topic during contraceptive consultations. Fifteen clinicians in South Eastern Australia participated in semi-structured interviews between April and June 2019. Interviews were analysed using inductive, semantic thematic analysis. Participants varied in their evaluation and management of contraceptives' sexual side effects and the legitimacy given to women's bodily experience versus their own understanding of the evidence in the medical literature. We identified two distinct groups of clinicians: those who prioritised sexual wellbeing as a primary issue in contraceptive consultations and those who perceived sexual wellbeing as a secondary concern. The difference in practices was influenced by whether participants considered sexual wellbeing to be part of holistic care provision and their views on the clinician's role in raising the topic. Strategies to equip clinicians to integrate sexual wellbeing into contraceptive consultations include interactive clinical training and incorporating information about sexual side effects into contraceptive guidelines and client resources. Benefits gained from normalising sexual wellbeing could extend beyond contraceptive care to help clinicians address clients' sexual wellbeing in other contexts.

Alcohol availability and prevalent Chlamydia trachomatis in young Australians: a multi-level analysis.

Background Prevalence of sexually transmissible infections (STIs) has been associated with availability of alcohol. This paper investigates potential associations between prevalent cases of chlamydia in young people in Australia and the availability of alcohol within their local area, defined as postcode of residence. Methods Alcohol availability was determined at the postcode level using liquor licensing data, classified as total number of licences, number of 'take-away' licences and number of licenses by population. Participant data were drawn from a survey targeting Australians aged 16-29years in rural and regional Australia, capturing demographic details including postcode of residence, indicators of sexual behaviour including condom use and chlamydia test results. Mixed-effects logistic regression was used to examine potential associations between first, alcohol availability and chlamydia, and second, between condom use and chlamydia. Results We found little evidence of associations between alcohol availability and chlamydia in either unadjusted or adjusted models. After adjusting for alcohol availability, we observed significant associations between inconsistent condom use and chlamydia prevalence, whether alcohol availability was measured as total number (adjusted odds ratio (AOR) 2.20; 95% confidence interval (CI) 1.20, 3.70), number of take-away licenses (AOR 2.19; 95% CI1.30, 3.69) or licenses per 1000 population (AOR 2.19; 95% CI 1.30, 3.68). Conclusion Little evidence of association between alcohol availability and chlamydia at the postcode level was found. Further research is required to determine appropriate measures of 'local area' and how characteristics thereof may impact on sexual health.

Sexual behaviour during COVID-19: a repeated cross-sectional survey in Victoria, Australia.

BACKGROUND: During 2020, the State of Victoria (Australia) experienced two COVID-19 waves. Both resulted in community lockdowns followed by eased restrictions. We examined variation of sexual behaviour in Victorians over time during COVID-19. METHODS: We conducted a repeated online survey at four timepoints corresponding with two lockdown (LD1, LD2) and two reduced restriction (RR1, RR2) periods in Victoria. A convenience sample of participants aged ≥18years was recruited via social media and asked about their recent (past 4weeks) sexual behaviour. Using multivariable logistic regression, we investigated variation in sexual behaviour between surveys. RESULTS: A total of 1828 surveys were completed; 72% identified as female, 69% were aged 18-29years, 90% were metropolitan residents. The proportion reporting recent partnered sex ranged from 54.9% (LD2) to 70.2% (RR1). Across all timepoints, the most common sexual partners were regular (81.5%, n =842) and 10.8% (n =111) reported casual partners (e.g. hook-ups). Compared with LD1, respondents were >2-fold more likely to report casual partner(s) during reduced restrictions (RR1: aOR 2.0; 95% CI 1.1-3.7; RR2: aOR 2.8; 95% CI 1.3-5.9). Across all timepoints, 26.6% (n =486) reported using dating apps. Compared with LD1, dating app use for face-to-face activities (e.g. dates, hook-ups) was >4-fold higher during reduced restrictions (RR1: aOR 4.3; 95% CI 2.3-8.0; RR2: aOR 4.1; 95% CI 1.9-8.8). App use for distanced activities (e.g. sexting, virtual dates) was highest during LD1 (48.8%) than other periods. CONCLUSIONS: In this convenience sample, self-reported sexual behaviours fluctuated between lockdowns and reduced restrictions. While dating apps may provide a mechanism for virtual connections, this may be temporary until physical connections are possible.

'It's literally giving them a solution in their hands': the views of young Australians towards patient-delivered partner therapy for treating chlamydia.

OBJECTIVES: Patient-delivered partner therapy (PDPT) is a method for providing antibiotic treatment for the sexual partners of an index patient with an STI by means of a prescription or medication that the index patient gives to their sexual partner(s). Qualitative research regarding barriers and enablers to PDPT has largely focused on the views of healthcare providers. In this study, we sought to investigate the views of young people (as potential health consumers) regarding PDPT for chlamydia. METHODS: Semi-structured telephone interviews were conducted with young Australian men and women. Participants were asked to provide their views regarding PDPT from the perspective of both an index patient and partner. Purposive and snowball sampling was used. Data were analysed thematically. RESULTS: We interviewed 22 people (13 women, 9 men) aged 18-30 years, 15 of whom had previously been tested for chlamydia. Despite none having previous knowledge of or experience using PDPT, all viewed it positively and thought it should be widely available. Participants reported that they would be willing to give PDPT to their sexual partners in situations where trust and comfort had been established, regardless of the relationship type. Protecting their partners' privacy was essential, with participants expressing reluctance to provide their partners' contact details to a doctor without consent. Beyond logistical benefits, PDPT was viewed as a facilitator to partner notification conversations by offering partners a potential solution. However, most interviewees indicated a preference to consult with a healthcare provider (GP or pharmacist) before taking PDPT medication. Participants indicated that legitimacy of information when navigating a chlamydia diagnosis was crucial and was preferably offered by healthcare providers. CONCLUSIONS: Though PDPT is unlikely to fully replace partners' interactions with healthcare providers, it may facilitate partner notification conversations and provide partners greater choice on how, when and where they are treated.

Love during lockdown: findings from an online survey examining the impact of COVID-19 on the sexual health of people living in Australia.

INTRODUCTION: Australia recorded its first case of COVID-19 in late January 2020. On 22P March 2020, amid increasing daily case numbers, the Australian Government implemented lockdown restrictions to help 'flatten the curve'. Our study aimed to understand the impact of lockdown restrictions on sexual and reproductive health. Here we focus on sexual practices. METHODS: An online survey was open from the 23PP April 2020 to 11P May 2020. Participants were recruited online via social media and other networks and were asked to report on their sexual practices in 2019 and during lockdown. Logistic regression was used to calculate the difference (diff) (including 95% CIs) in the proportion of sex practices between time periods. RESULTS: Of the 1187 who commenced the survey, 965 (81.3%) completed it. Overall, 70% were female and 66.3% were aged 18-29 years. Most (53.5%) reported less sex during lockdown than in 2019. Compared with 2019, participants were more likely to report sex with a spouse (35.3% vs 41.7%; diff=6.4%; 95% CI 3.6 to 9.2) and less likely to report sex with a girl/boyfriend (45.1% vs 41.8%; diff=-3.3%; 95% CI -7.0 to -0.4) or with casual hook-up (31.4% vs 7.8%; 95% CI -26.9 to -19.8). Solo sex activities increased; 14.6% (123/840) reported using sex toys more often and 26.0% (218/838) reported masturbating more often. Dating app use decreased during lockdown compared with 2019 (42.1% vs 27.3%; diff= -14.8%; 95% CI -17.6 to -11.9). Using dating apps for chatting/texting (89.8% vs 94.5%; diff=4.7%; 95% CI 1.0 to 8.5) and for setting up virtual dates (2.6% vs 17.2%; diff=14.6%; 95% CI 10.1 to 19.2) increased during lockdown. CONCLUSION: Although significant declines in sexual activity during lockdown were reported, people did not completely stop engaging in sexual activities, highlighting the importance of ensuring availability of normal sexual and reproductive health services during global emergencies.

Condom use in young women using long-acting reversible contraception (LARC): a qualitative study.

Young women in Australia disproportionately experience unintended pregnancy and sexually transmissible infections (STIs). As the promotion of highly effective pregnancy prevention methods such as long-acting reversible contraception (LARC) increases, concurrent use of condoms with LARC remains optimal for pregnancy and STI prevention. There is little data exploring condom use behaviour in young Australian women using LARC. In this qualitative study we interviewed twenty women using LARC about their experiences of making decisions regarding condom use. We used inductive thematic analysis to identify factors influencing participant decision-making. We found that while LARC had an impact on condom use and sexual practices, decisions regarding condom use were influenced by multiple factors including mood, menstrual changes related to LARC, and relationship dynamics. Participants' views of 'safe sex' extended beyond pregnancy and STI protection, to include desired outcomes such as pleasure, consent and communication. Access to STI testing and treatment was key to how participants managed STI risk. Findings highlight the need for a more comprehensive approach to safer sex health promotion, and the importance of ensuring STI testing and treatment services continue to be available and accessible to all young people.

Contraceptive use and pregnancy plans among women of reproductive age during the first Australian COVID-19 lockdown: findings from an online survey.

PURPOSE: Australia introduced 'lockdown' measures to control COVID-19 on 22 March 2020 which continued for a period of two months. We aimed to investigate the impact this had on sexual and reproductive health (SRH). MATERIALS AND METHODS: Australians aged 18+ were eligible to participate in an online survey from 23 April to 11 May 2020. We report on the experiences of 518 female participants aged <50 years. Pregnancy intentions and contraceptive use were analysed using descriptive statistics. Odds ratios and 95% confidence intervals were calculated to investigate difficulty accessing SRH products and services. Qualitative data were analysed using conventional content analysis. RESULTS: Most participants were aged 18-24 years, and indicated they were trying to avoid pregnancy. The oral contraceptive pill was the most common single method used however nearly 20% reported they were not using contraception. Women who were employed had less trouble accessing contraception during lockdown. Participants reported delaying childbearing or deciding to remain childfree due to COVID-19. CONCLUSION: COVID-19 lockdown impacted the SRH of Australian women. Findings highlight the importance of continued access to SRH services and products during global emergencies.

The Views of Patients and Partners Toward Patient-Delivered Partner Therapy for Chlamydia: A Systematic Review.

BACKGROUND: The majority of research on patient-delivered partner therapy (PDPT) has focused on its impact on reinfections. This study aimed to systematically review the evidence regarding the acceptability of PDPT by patients and partners for chlamydia infection. METHODS: Three electronic databases were searched in March 2019 using terms related to PDPT. Studies were included if they reported on patient or partner acceptance of PDPT for chlamydia and were conducted in high-income countries. Actual and perceived acceptabilities of PDPT were assessed. RESULTS: Thirty-three studies were included: 24 quantitative, 3 qualitative, and 6 mixed methods. Most were clinic based. Quantitative data showed that participants' perceived willingness to give PDPT to their partner(s) ranged from 44.7% to 96.3% (median, 84%), and 24% to 71% (median, 65%) of people who offered PDPT for their partner(s) accepted it. Partners' perceived willingness to accept ranged from 42.7% to 67% (median, 62%), and actual acceptance ranged from 44.7% to 80% (median, 77%). Those in longer-term relationships were generally more likely to accept PDPT; however, beyond this, we identified few clear trends. Qualitative studies found that convenience of PDPT and assurance of partner treatment were benefits, whereas partners not seeing a health care professional was viewed as a downside. Packaging that appeared legitimate and coaching on delivering PDPT were facilitators. CONCLUSIONS: Because patients bear responsibility for the success of PDPT, this information is crucial in clinical settings. Acceptance, perceived and real, of PDPT was generally high. Patients are best placed to determine whether PDPT is appropriate for them, and it should be offered as an option.

Corrigendum to: Condom use among young women in Australia using long-acting reversible contraceptives or other hormonal contraceptives.

Background:Dual condom and long-acting reversible contraceptive (LARC) or non-LARC hormonal contraceptive use is the most effective way to protect against unwanted pregnancy and sexually transmissible infections (STIs). This study aimed to determine whether condom use varied between users of LARC and non-LARC hormonal contraceptives and explore their motivations for condom use. Methods: Women aged 16-24 years attending a sexual and reproductive health centre in Melbourne, Australia, completed a survey about contraceptives and sexual practices. The proportion of LARC and non-LARC hormonal contraceptive users using condoms was calculated and logistic regression compared condom use between the two groups. Condom use was based on frequency of use and coded as a binary variable 'never, not usually or sometimes' versus 'usually or always'. Results: In all, 294 (97%) women participated in the study; 23.8% (95% confidence interval (CI) 19.0-29.1%) used LARC and 41.7% (95% CI 36.0-47.6%) used non-LARC hormonal contraceptives. Condom use was reported by 26.1% (95% CI 16.3-38.1%) of LARC users and by 27.8% (95% CI 19.9-37.0%) of non-LARC hormonal contraceptive users. There was no difference in condom use between groups (odds ratio (OR) 0.9; 95% CI 0.4-1.9). Condom use reduced with increasing relationship length (≥6 months vs no relationship: OR 0.2; 95% CI 0.1-0.6). Non-LARC hormonal contraceptive users were more motivated to use condoms if worried about pregnancy than LARC users (62.8% vs 47.8%; P = 0.04). Conclusion: Condom use was low and similar between users of LARC and non-LARC hormonal contraceptives, and was associated with the length of the relationship. These results highlight the need to promote condom use when prescribing LARCs and non-LARC hormonal contraceptives to reduce the risk of STIs.

Sexually transmissible infections, partner notification and intimate relationships: a qualitative study exploring the perspectives of general practitioners and people with a recent chlamydia infection.

Background Individuals diagnosed with a chlamydia infection are advised to notify their sexual partners from the previous 6 months so that they too can get tested and treated as appropriate. Partner notification is an essential component of chlamydia management, helping to prevent ongoing transmission and repeat infection in the index case. However, partner notification can be challenging, particularly in circumstances where a relationship has ended or transmission has occurred beyond the primary relationship. METHODS: In this study we use data from 43 semistructured interviews with general practitioners (GPs) and people with a recent diagnosis of chlamydia. The interviews examined experiences of chlamydia case management in the general practice context. Here, we focus specifically on the effect of a chlamydia infection on intimate relationships in the context of the consultation and beyond.? RESULTS: A chlamydia infection can have significant consequences for intimate relationships. Although GPs reported speaking to their patients about the importance of partner notification and participants with a recent chlamydia infection reported notifying their sexual partners, both would appreciate further support to engage in these conversations. CONCLUSIONS: Conversations with patients should go beyond simply informing them of the need to notify their sexual partners from the previous 6 months, and should provide information about why partner notification is important and discuss strategies for informing partners, particularly for those in ongoing relationships. Ensuring GPs have the training and support to engage in these conversations with confidence is vital.

Patient-delivered partner therapy for chlamydia in Australia: can it become part of routine care?

Background Patient-delivered partner therapy (PDPT) is a method for an index patient to give treatment for genital chlamydia to their sexual partner(s) directly. In Australia, PDPT is considered suitable for heterosexual partners of men and women, but is not uniformly endorsed. We explored the policy environment for PDPT in Australia and considered how PDPT might become a routine option. METHODS: Structured interviews were conducted with 10 key informants (KIs) representing six of eight Australian jurisdictions and documents relevant to PDPT were appraised. Interview transcripts and documents were analysed together, drawing on KIs' understanding of their jurisdiction to explore our research topics, namely the current context for PDPT, challenges, and actions needed for PDPT to become routine. RESULTS: PDPT was allowable in three jurisdictions (Victoria, New South Wales, Northern Territory) where State governments have formally supported PDPT. In three jurisdictions (Western Australia, Australian Capital Territory, Tasmania), KIs viewed PDPT as potentially allowable under relevant prescribing regulations; however, no guidance was available. Concern about antimicrobial stewardship precluded PDPT inclusion in the South Australian strategy. For Queensland, KIs viewed PDPT as not allowable under current prescribing regulations and, although a Medicine and Poisons Act was passed in 2019, it is unclear if PDPT will be possible under new regulations. Clarifying the doctor-partner treating relationship and clinical guidance within a care standard were viewed as crucial for PDPT uptake, irrespective of regulatory contexts. CONCLUSION: Endorsement and guidance are essential so doctors can confidently and routinely offer PDPT in respect to professional standards and regulatory requirements.

Population effectiveness of opportunistic chlamydia testing in primary care in Australia: a cluster-randomised controlled trial.

BACKGROUND: Screening young adults who are sexually active for genital Chlamydia trachomatis infection is promoted in several high-income countries, but its effectiveness at the population level is highly debated. We aimed to investigate the effects of opportunistic chlamydia testing in primary care on the estimated chlamydia prevalence in the population aged 16-29 years in Australia. METHODS: We did a cluster-randomised controlled trial. Clusters were rural towns with a minimum of 500 women and men aged 16-29 years and no more than six primary care clinics. We randomly allocated each cluster using a computer-generated minimisation algorithm to receive a multifaceted, clinic-based chlamydia testing intervention or to continue usual care. The intervention included computerised reminders to test patients, an education package, payments for chlamydia testing, and feedback on testing rates. The primary outcome was chlamydia prevalence, estimated before randomisation (survey 1) and at the end of the trial (survey 2) in patients aged 16-29 years who attended the clinics. Analyses were done by intention to treat. General practitioners and clinic staff were aware of group allocation, whereas patients and laboratory staff who performed the chlamydia tests were not. This trial was completed on Dec 31, 2015, and is registered (ACTRN12610000297022). FINDINGS: Between Dec 14, 2010, and Sept 14, 2015, 26 clusters (63 clinics) received the chlamydia testing intervention and 26 (67 clinics) continued usual care. Over a mean duration of 3·1 years (SD 0·3), 93 828 young adults attended intervention clinics and 86 527 attended control clinics. The estimated chlamydia prevalence decreased from 5·0% (95% CI 3·8 to 6·2) at survey 1 to 3·4% (2·7 to 4·1) at survey 2 in the intervention clusters (difference -1·6%, 95% CI -2·9 to -0·3) and from 4·6% (95% CI 3·5 to 5·7) at survey 1 to 3·4% (2·4 to 4·5) at survey 2 in the control clusters (difference -1·1%, -2·7 to 0·5). The unadjusted odds ratio for the difference between intervention and control clusters was 0·9 (95% CI 0·5 to 1·5). INTERPRETATION: These findings, in conjunction with evidence about the feasibility of sustained uptake of opportunistic testing in primary care, indicate that sizeable reductions in chlamydia prevalence might not be achievable. FUNDING: Australian Government Department of Health, National Health and Medical Research Council, Victorian Department of Health and Human Services, and New South Wales Ministry of Health.

Condom use among young women in Australia using long-acting reversible contraceptives or other hormonal contraceptives.

Background Dual condom and long-acting reversible contraceptive (LARC) or non-LARC hormonal contraceptive use is the most effective way to protect against unwanted pregnancy and sexually transmissible infections (STIs). This study aimed to determine whether condom use varied between users of LARC and non-LARC hormonal contraceptives and explore their motivations for condom use. METHODS: Women aged 16-24 years attending a sexual and reproductive health centre in Melbourne, Australia, completed a survey about contraceptives and sexual practices. The proportion of LARC and non-LARC hormonal contraceptive users using condoms was calculated and logistic regression compared condom use between the two groups. Condom use was based on frequency of use and coded as a binary variable 'never, not usually or sometimes' versus 'usually or always'. RESULTS: In all, 294 (97%) women participated in the study; 23.8% (95% confidence interval (CI) 19.0-29.1%) used LARC and 41.7% (95% CI 36.0-47.6%) used non-LARC hormonal contraceptives. Condom use was reported by 26.1% (95% CI 16.3-38.1%) of LARC users and by 27.8% (95% CI 19.9-37.0%) of non-LARC hormonal contraceptive users. There was no difference in condom use between groups (odds ratio (OR) 0.9; 95% CI 0.4-1.9). Condom use reduced with increasing relationship length (≥6 months vs no relationship: OR 0.2; 95% CI 0.1-0.6). Non-LARC hormonal contraceptive users were more motivated to use condoms if worried about pregnancy than LARC users (62.8% vs 47.8%; P = 0.04). CONCLUSION: Condom use was low and similar between users of LARC and non-LARC hormonal contraceptives, and was associated with the length of the relationship. These results highlight the need to promote condom use when prescribing LARCs and non-LARC hormonal contraceptives to reduce the risk of STIs.

'It Opened My Eyes'-examining the impact of a multifaceted chlamydia testing intervention on general practitioners using Normalization Process Theory.

Background: Chlamydia is the most common notifiable sexually transmissible infection in Australia. Left untreated, it can develop into pelvic inflammatory disease and infertility. The majority of notifications come from general practice and it is ideally situated to test young Australians. Objectives: The Australian Chlamydia Control Effectiveness Pilot (ACCEPt) was a multifaceted intervention that aimed to reduce chlamydia prevalence by increasing testing in 16- to 29-year-olds attending general practice. GPs were interviewed to describe the effectiveness of the ACCEPt intervention in integrating chlamydia testing into routine practice using Normalization Process Theory (NPT). Methods: GPs were purposively selected based on age, gender, geographic location and size of practice at baseline and midpoint. Interview data were analysed regarding the intervention components and results were interpreted using NPT. Results: A total of 44 GPs at baseline and 24 at midpoint were interviewed. Most GPs reported offering a test based on age at midpoint versus offering a test based on symptoms or patient request at baseline. Quarterly feedback was the most significant ACCEPt component for facilitating a chlamydia test. Conclusions: The ACCEPt intervention has been able to moderately normalize chlamydia testing among GPs, although the components had varying levels of effectiveness. NPT can demonstrate the effective implementation of an intervention in general practice and has been valuable in understanding which components are essential and which components can be improved upon.

Do Australian general practitioners believe practice nurses can take a role in chlamydia testing? A qualitative study of attitudes and opinions.

BACKGROUND: Chlamydia notifications continue to rise in young people in many countries and regular chlamydia testing is an important prevention strategy. Although there have been initiatives to increase testing in primary care, none have specifically investigated the role of practice nurses (PNs) in maximising testing rates. PNs have previously expressed a willingness to be involved, but noted lack of support from general practitioners (GPs) as a barrier. We sought GPs' attitudes and opinions on PNs taking an expanded role in chlamydia testing and partner notification. METHODS: In the context of a cluster randomised trial in mostly rural towns in 4 Australian states, semi structured interviews were conducted with 44 GPs between March 2011 and July 2012. Data relating to PN involvement in chlamydia testing were thematically analysed using a conventional content analysis approach. RESULTS: The majority of GPs interviewed felt that a role for PNs in chlamydia testing was appropriate. GPs felt that PNs had more time for patient education and advice, that patients would find PNs easier to talk to and less intimidating than GPs, and that GPs themselves could benefit through a reduction in their workload. Although GPs felt that PNs could be utilised more effectively for preventative health activities such as chlamydia testing, many raised concerns about how these activities would be renumerated whilst some felt that existing workload pressures for PNs could make it difficult for them to expand their role. Whilst some rural GPs recognised that PNs might be well placed to conduct partner notification, they also recognised that issues of patient privacy and confidentiality related to living in a "small town" was also a concern. CONCLUSION: This is the first qualitative study to explore GPs' views around an increased role for PNs in chlamydia testing. Despite the concerns raised by PNs, these findings suggest that GPs support the concept and recognise that PNs are suited to the role. However issues raised, such as funding and remuneration may act as barriers that will need to be addressed before PNs are supported to make a contribution to increasing chlamydia testing rates in general practice.

Practice nurse chlamydia testing in Australian general practice: a qualitative study of benefits, barriers and facilitators.

BACKGROUND: Chlamydia infection is a significant public health issue for young people; however, testing rates in Australian general practice are low. Practice nurses (PNs) could have an important role in contributing to increasing chlamydia testing rates. The Australian Chlamydia Control Effectiveness Pilot (ACCEPt), a large cluster randomised control trial of annual testing for 16 to 29 year olds in general practice, is the first to investigate the role of PNs in maximising testing rates. In order to assess the scope for PN involvement, we aimed to explore PN's views in relation to involvement in chlamydia testing in general practice. METHODS: Semi structured interviews were conducted between June 2011 and April 2012 with a purposive sample of 23 PNs participating in ACCEPt. Interview data was thematically analysed using a conventional content analysis approach. RESULTS: The participants in our study supported an increased role for PNs in chlamydia testing and identified a number of patient benefits from this involvement, such as an improved service with greater access to testing and patients feeling more comfortable engaging with a nurse rather than a doctor. An alleviation of doctors' workloads and expansion of the nurse's role were also identified as benefits at a clinic level. Time and workload constraints were commonly considered barriers to chlamydia testing, along with concerns around privacy in the "small town" rural settings of the general practices. Some felt negative GP attitudes as well as issues with funding for PNs' work could also be barriers. The provision of training and education, streamlining chlamydia testing pathways in clinics and changes to pathology ordering processes would facilitate nurse involvement in chlamydia testing. CONCLUSION: This study suggests that PNs could take a role in increasing chlamydia testing in general practice and that their involvement may result in possible benefits for patients, doctors, PNs and the community. Strategies to overcome identified barriers and facilitate their involvement must be further explored.

Chlamydia prevalence in young attenders of rural and regional primary care services in Australia: a cross-sectional survey.

OBJECTIVE: To estimate chlamydia prevalence among 16-29-year-olds attending general practice clinics in Australia. DESIGN, PARTICIPANTS AND SETTING: A cross-sectional survey was conducted from May 2010 to December 2012. Sexually experienced 16-29-year-olds were recruited from 134 general practice clinics in 54 rural and regional towns in four states and in nine metropolitan clinics (consecutive patients were invited to participate). Participants completed a questionnaire and were tested for chlamydia. MAIN OUTCOME MEASURE: Chlamydia prevalence. RESULTS: Of 4284 participants, 197 tested positive for chlamydia (4.6%; 95% CI, 3.9%-5.3%). Prevalence was similar in men (5.2% [65/1257]; 95% CI, 3.9%-6.4%) and women (4.4% [132/3027]; 95% CI, 3.5%-5.2%) (P = 0.25) and high in those reporting genital symptoms or a partner with a sexually transmissible infection (STI) - 17.0% in men (8/47; 95% CI, 2.8%-31.2%); 9.5% in women (16/169; 95% CI, 5.1%-13.8%). Nearly three-quarters of cases (73.4% [130/177]) were diagnosed in asymptomatic patients attending for non-sexual health reasons, and 83.8% of all participants (3258/3890) had attended for non-sexual health reasons. Prevalence was slightly higher in participants from rural and regional areas (4.8% [179/3724]; 95% CI, 4.0%-5.6%) than those from metropolitan areas (3.1% [17/548]; 95% CI, 1.5%-4.7%) (P = 0.08). In multivariable analysis, increasing partner numbers in previous 12 months (adjusted odds ratio [AOR] for three or more partners, 5.11 [95% CI, 2.35-11.08]), chlamydia diagnosis in previous 12 months (AOR, 4.35 [95% CI, 1.52-12.41]) and inconsistent condom use with most recent partner (AOR, 2.90 [95% CI, 1.31-6.40]) were significantly associated with chlamydia in men. In women, increasing partner numbers in previous 12 months (AOR for two partners, 2.59 [95% CI, 1.59-4.23]; AOR for three or more partners, 3.58 [95% CI, 2.26-5.68]), chlamydia diagnosis in previous 12 months (AOR, 3.13 [95% CI, 1.62-6.06]) and age (AOR for 25-29-year-olds, 0.23 [95% CI, 0.12-0.44]) were associated with chlamydia. CONCLUSIONS: Chlamydia prevalence is similar in young men and women attending general practice. Testing only those with genital symptoms or a partner with an STI would have missed three-quarters of cases. Most men and women are amenable to being tested in general practice, even in rural and regional areas.

The chlamydia knowledge, awareness and testing practices of Australian general practitioners and practice nurses: survey findings from the Australian chlamydia control effectiveness pilot (ACCEPt).

BACKGROUND: ACCEPt, a large cluster randomized control trial, aims to determine if annual testing for 16 to 29 year olds in general practice can reduce chlamydia prevalence. ACCEPt is the first trial investigating the potential role of practice nurses (PN) in chlamydia testing. To inform the design of the ACCEPt intervention, we aimed to determine the chlamydia knowledge, attitudes, and testing practices of participating general practitioners (GPs) and PNs. METHODS: GPs and PNs from 143 clinics recruited from 52 areas in 4 Australian states were asked to complete a survey at time of recruitment. Responses of PNs and GPs were compared using conditional logistic regression to account for possible intra cluster correlation within clinics. RESULTS: Of the PNs and GPs enrolled in ACCEPt, 81% and 72% completed the questionnaire respectively. Less than a third of PNs (23%) and GPs (32%) correctly identified the two age groups with highest infection rates in women and only 16% vs 17% the correct age groups in men. More PNs than GPs would offer testing opportunistically to asymptomatic patients aged ≤25 years; women having a pap smear (84% vs 55%, P<0.01); antenatal checkup (83% vs 44%, P<0.01) and Aboriginal men with a sore throat (79% vs 33%, P<0.01), but also to patients outside of the guideline age group at the time of the survey; 26 year old males presenting for a medical check (78% vs 30%, P = <0.01) and 33 year old females presenting for a pill prescription (83% vs 55%, P<0.01). More PNs than GPs knew that retesting was recommended after chlamydia treatment (93% vs 87%, P=0.027); and the recommended timeframe was 3 months (66% vs 26%, P<0.01). A high proportion of PNs (90%) agreed that they could conduct chlamydia testing in general practice, with 79% wanting greater involvement and 89% further training. CONCLUSIONS: Our survey reveals gaps in chlamydia knowledge and management among GPs and PNs that may be contributing to low testing rates in general practice. The ACCEPt intervention is well targeted to address these and support clinicians in increasing testing rates. PNs could have a role in increasing chlamydia testing.

An evaluation of existing text de-identification tools for use with patient progress notes from Australian general practice.

INTRODUCTION: Digitized patient progress notes from general practice represent a significant resource for clinical and public health research but cannot feasibly and ethically be used for these purposes without automated de-identification. Internationally, several open-source natural language processing tools have been developed, however, given wide variations in clinical documentation practices, these cannot be utilized without appropriate review. We evaluated the performance of four de-identification tools and assessed their suitability for customization to Australian general practice progress notes. METHODS: Four tools were selected: three rule-based (HMS Scrubber, MIT De-id, Philter) and one machine learning (MIST). 300 patient progress notes from three general practice clinics were manually annotated with personally identifying information. We conducted a pairwise comparison between the manual annotations and patient identifiers automatically detected by each tool, measuring recall (sensitivity), precision (positive predictive value), f1-score (harmonic mean of precision and recall), and f2-score (weighs recall 2x higher than precision). Error analysis was also conducted to better understand each tool's structure and performance. RESULTS: Manual annotation detected 701 identifiers in seven categories. The rule-based tools detected identifiers in six categories and MIST in three. Philter achieved the highest aggregate recall (67%) and the highest recall for NAME (87%). HMS Scrubber achieved the highest recall for DATE (94%) and all tools performed poorly on LOCATION. MIST achieved the highest precision for NAME and DATE while also achieving similar recall to the rule-based tools for DATE and highest recall for LOCATION. Philter had the lowest aggregate precision (37%), however preliminary adjustments of its rules and dictionaries showed a substantial reduction in false positives. CONCLUSION: Existing off-the-shelf solutions for automated de-identification of clinical text are not immediately suitable for our context without modification. Philter is the most promising candidate due to its high recall and flexibility however will require extensive revising of its pattern matching rules and dictionaries.