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Abstract
Background and methodology The National Chlamydia Screening Programme offers opportunistic screening for genital Chlamydia trachomatis infection to young people aged 15–24 years in England. Screening packs are available in many different settings, including community sexual health clinics, colleges and community pharmacies. This article focuses on screening through community pharmacies. Currently, pharmacies provide only a small proportion of screening nationally despite the assumption that community pharmacies are an ideal location to undertake chlamydia screening. This article reports on semistructured interviews undertaken with a sample of 10 pharmacists offering chlamydia screening in Greenwich, London, UK in order to understand the issues facing pharmacists in offering chlamydia screening.
Results Participants had good awareness of the importance of chlamydia infection and the need for screening. The majority were supportive of it, although some were concerned about approaching some younger individuals. Many pharmacists only raised opportunistically the provision of free chlamydia screening when customers were attending for emergency hormonal contraception. The pharmacists felt it was more difficult to discuss the subject of chlamydia screening with customers attending for non-sexual health-related services. The local chlamydia screening programme had undertaken other initiatives including mail outs. Some pharmacists had broached the subject of chlamydia screening but had discovered customers already had a screening pack at home.
Discussion and conclusions These findings have highlighted challenges in opportunistically offering chlamydia screening to young people in community pharmacies. These challenges can be overcome through a combination of training and service innovation, in order to capitalise on the potential of community pharmacies to contribute to this important sexual health service.
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Introduction
Community pharmacies are being used to deliver a growing number of health services. The Department of Health's 2008 White Paper on pharmacy services in England recommended a greater role for pharmacies in services such as emergency hormonal contraception (EHC).1
Key message points
▶ Pharmacists have a good understanding of the importance of chlamydia infection and the need for screening.
▶ Pharmacists have expressed difficulties in opportunistically offering chlamydia screening.
▶ Many pharmacists only approached customers accessing emergency hormonal contraception about chlamydia screening.
A pilot study of testing and treatment of genital Chlamydia trachomatis infection in community pharmacies found the service to be acceptable to patients, although the services were limited by availability of trained pharmacists and difficulties in preserving confidentiality.2 This study also found that it was mostly young women who made use of this service rather than young men.
England's National Chlamydia Screening Programme (NCSP) offers chlamydia screening opportunistically to young persons aged 15–24 years. There is a target of 25% coverage of this age group for the 2009–2010 financial year, therefore it is a priority for every primary care trust (PCT) to maximise the potential of all settings to undertake chlamydia screening.
Between 2007 and 2008, 2.7% of all chlamydia screens in England3 were performed in a pharmacy setting, with a positive rate of 8.5% (95% CI 7.9–9.1). There is great scope for the number of screens performed in pharmacies to increase, due to sexually active young people attending for other services such as regular contraception and EHC, purchasing pregnancy testing kits and condoms and attending pharmacies for unrelated services. There is also wide recognition that pharmacies are a means of widening access to health services in areas of deprivation.1
However, a study of pharmacies providing EHC in Manchester, UK4 found that in those pharmacies with large volumes of NHS-funded EHC provision (40 doses or more per year) only 24.8% of eligible women who received EHC were offered C. trachomatis screening. Of these women, 46.4% accepted a screening kit. Again, only a proportion (17.6%) of those who accepted a free postal screening kit returned it.
In Greenwich, 30 different pharmacy contractors are registered to provide chlamydia screening as part of the NCSP in England. However, they only form a relatively small share of all screens performed in Greenwich: less than 5% during a 12-month period from 2008 to 2009.
The aim of the present study was to understand the issues facing pharmacists in offering chlamydia screening.
Methods
A sampling frame was produced including all pharmacists registered with the chlamydia screening programme in Greenwich. Quota sampling was used so that the pharmacies interviewed reflected the mix of multiple-site (where the owner operates more than one premises) and single-site pharmacies that are registered to provide chlamydia screening kits in Greenwich. Of 30 such contractors, nine were multiples and 21 were single sites. Pharmacists approached were supplied with an information sheet about the research project and were given an opportunity to question the principal investigator, and were then asked to give written consent if they agreed to participate in the study.
The interviewer was a member of the local PCT public health department. Pharmacists were interviewed using a topic guide to examine the following areas: suitability of offering chlamydia screening in the pharmacy environment, practical administration of the screens, personal skills and attitudes towards offering screening, and impressions of successes and challenges related to screening.
Written notes were made during the interviews, which were subsequently word processed. Thematic analysis of these interview notes was undertaken, whereby emerging themes were identified from participants’ responses. No further pharmacists were recruited following theoretical saturation.
Results
Response rate
Of the 17 pharmacists who were approached, 10 agreed to participate. All the pharmacists were based within the local urban setting.
A comparison of those pharmacists who participated and did not participate in the study is shown in Table 1. This indicates that there is little difference between participants and non-participants in terms of type of contractor (independent or not) or average volume of screens returned during the first quarter of the 2009–2010 financial year. We would argue, therefore, that this sample is unlikely to be biased towards pharmacists who perform higher numbers of screens than other pharmacists.
Comparison of pharmacists who participated and did not participate in the study
Thematic analysis
Written notes, taken during the interviews, of participants’ responses during the interviews were used to identify important emerging themes.
Thematic analysis yielded the following key themes: (1) decisions to begin screening, (2) knowledge about chlamydia infection and the need for screening, (3) concerns about offering screening, (4) capacity to offer screening, (5) introducing the issue of screening to customers, (6) response to screening and (7) working with the screening service. These themes are expanded upon below, with verbatim quotes from the interviews shown in italic type. The text in square brackets has been inserted by the investigator to explain the context of the quote.
Decisions to begin screening
All pharmacists had accepted specific requests from the PCT to participate in the chlamydia screening programme, as they were already providing other services such as EHC.
One said: “We started as were approached by the PCT [primary care trust], as we already do EHC [emergency hormonal contraception – also known as the ‘morning after pill’].”
Knowledge about chlamydia infection and the need for screening
Pharmacists were asked to describe what they knew about chlamydia infection and why screening was offered. All the pharmacists were able to describe how chlamydia is transmitted, its complications and how it can be prevented.
“It is important to prevent infertility, target the maximum number of the population and improve awareness of the risk of chlamydia and other STDs.”
Pharmacists used different sources of information for chlamydia screening. Some community pharmacists used their existing continuing professional development structures, and others attended specific PCT-based training events.
Across pharmacies there were variations in the staff members who were trained to offer screening kits to customers. For instance, one pharmacist said:
“both pharmacists and dispensers are trained in it” [giving out chlamydia screening kits]
while another was more reserved:
“I suppose counter staff could explain screening if trained enough and if both pharmacists [sic] busy.”
Concerns about offering screening
All the pharmacists were agreeable to the concept of offering chlamydia screening in the pharmacy. However, some expressed reservations about the level of privacy available in which to explain it. One pharmacist said:
“The consultation room has privacy but if in the shop and other people there, it is ten times worse.”
There were also some concerns expressed by two pharmacists about screening those aged under 16 years for chlamydia infection. In some instances, this was based on concerns over young people's pre-existing knowledge of sexual health:
“I avoid under-16s as I wonder do they know about that?”
Additionally, there was a concern about the sensitivity of asking about sexual activity around this age:
“I am careful about 16-, 17-year-olds and I get staff to witness.”
Capacity to offer screening
A number of pharmacists suggested that the extra services they offered did not specifically prevent them from offering screening. One pharmacist said:
“We offer NRT [nicotine replacement therapy], and supervised methadone and care homes work needs to be done by the end of the month but you can make time if you keep it [chlamydia screening] in the forefront of your mind.”
This view was shared by some providers and suggests that for some, time pressures may not be the limiting factor for offering screening. Instead, other factors, such as ease of approaching screening with young people, could be important.
The majority of community pharmacies gave patients the screening kit to collect urine and post themselves. One pharmacy with customer toilet facilities collected the samples and posted these themselves in an effort to ensure that the screening kit was sent in. One respondent said:
“We collect the sample from the patient and send it ourselves. Otherwise it is 50-50 she or he will send it.”
Introducing the issue of chlamydia screening to customers
In some community pharmacies there was a perception that screening was only appropriately discussed in relation to other sexual health services such as EHC.
“I offer the screening to everyone who attends for EHC or if clients ask for it. So far, I don't think it's appropriate for other customers, only if it's better advertised.”
There was recognition that it was more challenging to raise the issue of screening when clients attended for other non-sexual health complaints. Pharmacists noted:
“If they bring it up it's easy, if they did not bring it up it's hard, you get this look as if you have preconceived ideas.”
“…they might be offended if we offer this service…”.
One solution to this was suggested:
“A leaflet to put in the bag would be good so you don't have to speak about it and they don't either.”
The idea of using promotions such as prize draws to encourage screening participation was generally well accepted among participants.
“Promotions are okay if they’re for something young people like.”
Response to screening
Providers reported good responses from users, in terms of the screening process being user-friendly.
“The test was so easy.”
Other interviewees felt that unsolicited mass mailing of kits to local young people coincided with a decline in the number of people asking for screening kits:
“Numbers are dropping off, they’re getting kits through the post.”
Sometimes it was felt that kits sent home were an excuse for not participating:
“When they come for EHC, most already know about it and have got one at home.”
“They have the kit at home, so it's an excuse, they're doing it in schools as well.”
Discussion
This study focused on pharmacists working in both multiple- and single-site community pharmacies in south east London, and provides important initial insights into the attitudes and experiences of this group in relation to chlamydia screening.
While the majority of pharmacists were supportive of offering chlamydia screening, the concerns about approaching younger age groups may prove a barrier towards successfully offering screening to young people aged 15 and 16 years. This is important as these age groups are an important part of the target population for screening. Knowledge of issues relating to consent and child protection should not act as a barrier, as these topics are included in training sessions for pharmacists beginning chlamydia screening.
Participants commented on the difficulty of broaching the topic of screening with young people; such approaches were often limited only to those individuals attending for EHC. This suggests that discussion of screening opportunistically in a non-sexual health encounter can prove difficult for pharmacists, since there is a concern about causing offence in a consumer-driven environment. This is an obstacle to increasing the number of screens collected through community pharmacies, as the success of screening relies on being able to successfully offer it opportunistically. Therefore, alternative methods for extending screening to other customers are needed, such as distributing screening leaflets in carrier bags.
An evaluation of a pilot of chlamydia screening in a large multiple pharmacy contractor also found that staff offered screening more proactively with EHC but waited for other customers to request it.5 This evaluation also commented on the embarrassment of young people when approached about screening and the need to act appropriately.
A separate study4 has highlighted that where pharmacists actively targeted chlamydia screening only towards EHC users, the result was that a minority of service users were offered chlamydia screening and less than half accepted a screening kit. Relying on this strategy alone is therefore likely to fail to achieve the full potential of pharmacies to improve screening coverage. This approach also neglects young men, who already form a minority of screening users nationally.3 It has been suggested that linking screening to condom provision could help address this inequality, and is feasible within community pharmacies.6
Previous research has identified a number of different types of relationships between pharmacists and the clients who use their services: analytic–authoritative, emotive–interactive, opportunistic–expedient, reliant–paternalistic and autonomous–informative.7 This diversity of pharmacist–client relations may also affect the depth of health promotion pharmacists can achieve with different clients, such as offering chlamydia screening.
The pharmacists reported that there was competition for screening from other sources such as schools, and through mail outs (unsolicited kits sent to all eligible young people locally). In particular, they highlighted how mail outs were possible reasons for young people not undertaking screening in pharmacies. In one case, it was suggested that the presence of kits at home was an excuse used by young people not to take part. These comments indicate that pharmacists may find it difficult to convince young people to take part in the presence of competing screening initiatives. However, the authors’ local experience of screening data indicates pharmacy-based screening locally has been low before and after the introduction of chlamydia screening mail outs.
In this study, the investigator made written notes during the interviews. This was an efficient and effective approach at the time that provided useful data for rapid analysis. However, audio recordings of interviews (having gained the appropriate consents) could have been an alternative study method.
This study is a useful examination of pharmacists’ views on the chlamydia screening programme. Despite the sample being representative of the diversity of pharmacies within the authors’ local screening programme, a larger sample size could yield a wider range of views than reported on in this article. The sample size was small as recruitment ended once theoretical saturation was reached. Despite the small numbers of interviewees, this sample represents one-third of the pharmacy contractors participating in chlamydia screening within the authors’ local scheme.
The views reported here may be subject to volunteer bias, as some pharmacists did not respond or refused to participate in the study. Those pharmacists who refused to participate may differ in some systematic way to those who did participate in the study in their approach to screening. However, as shown in the Results section, there was little difference in the average number of screens returned from pharmacists who did and did not participate in this study.
It is possible that pharmacists’ knowledge of the interviewer's role within the local public health team may have influenced their responses during the interviews. Additionally, this small study was developed for the purpose of improving the coverage of chlamydia screening locally and so subsequent analysis was specifically undertaken from a health service perspective. This may have influenced the investigators’ perception and analysis of the emerging themes, perhaps focusing specifically on the processes of delivering screening. Nevertheless, the authors believe that this study still represents a useful practical approach to tackling a real-world problem affecting sexual health services. Although the study is small in scale, it will help develop this local service; further training and approaches have since been developed. Despite the limitations of the present study, its findings are unlikely to be unique to the authors’ geographical area and could be observed in other urban settings, where pharmacy-based chlamydia screening activity is low.
Additionally, it would be useful in the future to explore the reasons why some pharmacists have decided not to offer chlamydia screening in their pharmacy.
This study has highlighted the strengths of pharmacy-based chlamydia screening in terms of an established knowledge base and skilled professionals. However, it has also highlighted difficulties in the opportunistic promotion of screening and competition with other screening modes.
Acknowledgments
The authors would like to thank all the pharmacists who kindly agreed to participate in this study, Professor Nick Black for guidance in developing the project and Hilary Guite for helpful comments relating to the final manuscript. The authors are also grateful to the invited peer reviewers for their insightful comments on the manuscript.
Footnotes
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Competing interests All the authors work for NHS Greenwich, which commissions chlamydia screening for young people including pharmacist-delivered screening.
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Provenance and peer review Not commissioned; externally peer reviewed.