Retesting for Repeat Chlamydial Infection: Family Planning Provider Knowledge,Attitudes,and Practices

Abstract

Background:

Repeated genital infections with Chlamydia trachomatis are common and associated with serious adverse reproductive sequelae in women such as infertility, ectopic pregnancy, and chronic pelvic pain. Retesting for repeat chlamydial infection is recommended 3 months after treatment for an initial infection; however, retesting rates in various settings are low. In order to design interventions to increase retesting rates, understanding provider barriers and practices around retesting is crucial. Therefore, in this survey of family planning providers we sought to describe: (1) knowledge about retesting for chlamydia; (2) attitudes and barriers toward retesting; (3) practices currently utilized to ensure retesting, and predictors associated with their use.

Methods:

We conducted a cross-sectional, self-administered, Internet-based survey of a convenience sample of family planning providers in California inquiring about strategies utilized to ensure retesting in their practice setting. High-intensity strategies included chart flagging, tickler (reminder) systems, follow-up appointments, and phone/mail reminders.

Results:

Of 268 respondents, 82% of providers reported at least 1 barrier to retesting, and only 44% utilized high-intensity interventions to ensure that patients returned. Predictors associated with use of high-intensity interventions included existence of clinic-level retesting policies (OR 3.95, 95% CI 1.98-7.88), and perception of a high/moderate level of clinic priority toward retesting (OR 3.75, 95% CI 2.12-.6.63).

Conclusion:

Emphasizing the importance of retesting to providers through adoption of clinic policies will likely be an important component of a multimodal strategy to ensure that patients are retested and that provider/clinic staff take advantage of opportunities to retest patients. Innovative approaches such as home-based retesting with self-collected vaginal swabs and use of cost-effective technologies to generate patient reminders should also be considered.

Introduction

Genital infections with Chlamydia trachomatis are a leading cause of cervicitis and pelvic inflammatory disease (PID)^1,2 and can lead to severe reproductive sequelae such as ectopic pregnancy and tubal factor infertility.³ Furthermore, chlamydial infection can increase risk of HIV acquisition and transmission.^4
–6 Although infections with chlamydia can be easily treated, repeat infections occur commonly within a few months of treatment, with multiple studies demonstrating rates between 10% to 20% within 6 months.^7

–10 Repeat infections are often asymptomatic and are more likely than initial infections to ascend into the upper reproductive tract in women. One study of more than 11,000 women with chlamydia found double the odds of ectopic pregnancy and quadruple the odds of PID with repeated infection.¹¹

Prompt identification and treatment of repeat infections is crucial to help avoid adverse reproductive sequelae. The Centers for Disease Control and Prevention (CDC) has recommended retesting all women with chlamydia 3 months after treatment, regardless of whether the patient believes her partners were treated, with retesting encouraged anytime in the 3 to 12 months following initial infection.¹² It is important to note that retesting for repeat chlamydia infection is distinct from a “test-of-cure,” which is now routinely recommended only for pregnant women 4 to 6 weeks after treatment and is primarily aimed at detecting treatment failure, not repeat infection. Though national retesting guidelines have existed since 2002, retesting rates in various clinical settings remain low: 43% in Job Corps clinics,^13,14 15%–38% in STD clinics,^15
–17 and 21%–25% in California family planning clinics. (H. Howard, 2009, personal communication).

Young sexually active women in the United States often seek reproductive healthcare services in family planning clinics; therefore these clinics and providers can potentially play a key role in improving chlamydia retesting rates in women. Because providers typically dictate the provision of services at the patient level, identifying providers' knowledge gaps and barriers to retesting can provide valuable insight into reasons for low retesting rates as well as inform future interventions to increase retesting. However, there are no published data on provider knowledge or barriers regarding retesting for chlamydia, nor any description of strategies currently utilized in family planning clinics to ensure retesting among women.

Therefore, we undertook this study with the following objectives: (1) Describe the level of knowledge about retesting among family planning providers caring for chlamydia1-infected patients; (2) describe provider attitudes and barriers toward retesting; (3) describe practices currently utilized to ensure that patients return for retesting, and predictors associated with their use. The ultimate goal of this survey was to better inform agencies and clinics so that barriers to retesting can be addressed in future interventions.

Materials and Methods

This was a cross-sectional, self-administered, Internet-based survey of clinicians providing care at family planning clinics throughout the state of California. Eligibility criteria for participation in the survey included current provision of care to patients infected with genital chlamydia infection at the time the survey was administered. Eligible clinicians included physicians, nurse-practitioners, midwives, physician assistants, and other staff. Staff that dispensed medication to chlamydia-infected patients but did not make medical decisions were excluded from participation.

In July 2007, all California family planning agency directors (n = 65) representing 296 individual clinics (range 1–34 clinics per agency) were sent an introductory letter from staff of the California Family Health Council (CFHC), introducing the purpose of the survey. The CFHC distributes funding to family planning agencies in the state and has a well-established relationship with agency directors. The introductory letter emphasized that the purpose of the survey was simply to “gain understanding” of clinicians' retesting practices, and that responses were confidential, voluntary, and could not be traced back to individuals. Following this letter, an e-mail was sent to the agency directors with a hyperlink to the survey instrument and instructions to forward the e-mail to all clinicians who provide care for chlamydia-infected patients in their agency. Although we requested the exact number of clinicians recruited from each director, these data were incomplete. So as not to overestimate the response rate, only responses from agencies that provided complete data (40 of 65) were used to calculate the response rate, which was 42%. The respondents represent a convenience sample of all clinicians at California family planning clinics.

Agency directors received at least one reminder e-mail related to the survey, and responses to the survey questions were collected through September 2007. Incentives for clinics with high levels of participation included boxes of candy and eligibility for a raffle with a $200 prize. Respondents were not asked to provide identifying information. This survey was undertaken as part of clinical quality improvement activities and program evaluation conducted by our department in the scope of routine public health practice; therefore, ethics committee approval was not sought.

Survey instrument

The survey instrument was designed by investigators at the California Family Health Council, California Department of Public Health (CDPH) Sexually Transmitted Disease Control Branch, and CDPH Office of Family Planning. The instrument was pretested among members of the target population, with revisions made prior to its use. Demographic and practice characteristics collected included: provider type, years of practice, agency and clinic name, and number of chlamydia-infected patients seen per month.

To assess knowledge, providers were asked if they were “aware of national recommendations that patients who are treated for chlamydia or gonorrhea be retested 3 months after treatment” (yes/no). Providers were given 3 additional statements related to retesting knowledge for which agreement was assessed on a 5-point Likert-type scale: Strongly agree, Agree, Neutral, Disagree, Strongly disagree. Statements included: “Retesting is not necessary as long as annual screening programs are in place,” “Retesting is not important if partners are treated,” and “Test of cure at 3 weeks should be performed.”

Barriers and attitudes toward retesting were assessed using 4 statements for which agreement was assessed on the same 5-point Likert-type scale. Statements included: “Most strategies for improving retesting are too difficult to implement,” “Retesting visits are costly and time-consuming,” “Retesting is difficult because patients often will not return,” and “Retesting patients at 3 months improves reproductive health.”

Clinic-level policies and priorities related to retesting were assessed by asking: “Has the Medical Director at your clinic established clinical practice guidelines for retesting chlamydia and/or gonorrhea-infected clients 3 months after treatment?” (yes/no) and “What level of priority is it for your clinic to ensure that clients are retested 3 months after treatment?” (high, moderate, low).

Finally, providers were asked to report on clinic-level policies and strategies employed to ensure that patients return for retesting. A list of strategies was presented, and clinicians were asked to indicate all that the provider used routinely. The list included verbal counseling, written information sheets, posters, chart flagging systems to remind clinic staff that patients were due for retesting, a tickler system to remind staff to contact patients for retesting, making follow-up appointments for patients, and phone call, mail, e-mail, or text message reminders to ensure patients to return. An open-ended option for “other” was also included.

Statistical analysis

The primary objective of this survey was to describe the frequency of usage of various retesting interventions in family planning clinics and to examine predictors associated with their use. Clinic-level outcomes (retesting interventions) were compared with clinic-level predictors; similarly, individual level outcomes (e.g., level of knowledge) were examined for association with individual-level predictors.

For purposes of analysis, responses on a 5-point scale (Strongly agree to Strongly disagree) were collapsed into dichotomous categories, where “Strongly agree” and “Agree” were grouped into a single category, and the remaining responses were grouped into a second category. The χ-square test was utilized to compare proportions; a p value less than 0.05 was considered statistically significant. Univariate logistic regression was utilized to examine the association between demographic characteristics and level of knowledge or perceived barriers to retesting, and odds ratios (OR) with 95% confidence intervals (CI) were calculated as measures of relative risk.

Strategies to encourage retesting that required a structural-level action and commitment of additional staff time outside of the clinician-patient encounter were designated as “high-intensity/active” strategies: chart flagging systems to remind clinicians that patients were due for retesting, a tickler system to remind staff to contact patients for retesting, making follow-up to make appointments for patients, and/or phone or mail reminders asking patients to return. Strategies limited to patient education that did not require additional effort or staff time beyond what the clinician could do in the context of a single visit were designated as “low intensity” strategies: written handouts or posters, or verbal counseling about retesting. Level of intensity referred solely to level of provider or organizational effort outside of the initial office visit; it was not a reflection of cost or efficacy of the strategy.

To examine the association between the use of high-intensity interventions and clinic/agency-level predictors (retesting policy and level of priority toward retesting), univariate logistic regression was utilized, and odds ratios (OR) with 95% confidence intervals (CI) were calculated as measures of relative risk. Because providers from the same clinic are subject to the same clinic policies and priorities toward retesting, agencies/clinics with multiple respondents could potentially bias the outcome of this analysis. Therefore, we repeated the logistic regression analysis after weighting each participant's response according to the number of respondents from the same agency/clinic. Statistical analyses were performed using SAS version 9.1 software (SAS Institute, Cary, NC).

Results

Overall, 303 individuals registered online and completed at least one question of the survey. Of the 303 individuals who registered, 268 (88%) completed the questions pertaining to retesting. The characteristics of the clinician respondents are detailed in Table 1. In summary, the respondents were primarily nurse-practitioners or midwives with more than 5 years of experience in a family planning setting and who cared for an average of 5 to 20 chlamydia-infected female patients per month. Of the 65 agencies and 296 clinics in the Title X program, the respondents represented 52 agencies and 146 individual clinics. No more than 13% of clinicians came from an individual agency, and no more than 4% of clinicians came from any individual clinic.

Table 1.

Characteristics of Participating Providers (n = 268)

Demographics	n (%) ^a
Providers
Physician	56 (21)
Advanced practice clinician (NP, CNM)	168 (62)
Physician assistant	31 (12)
Other	8 (5)
Decline to state	5 (2)
Total years of practice
5 or less	60 (22)
6–10	66 (25)
11–20	72 (27)
More than 20	70 (26)
Years of experience with family planning
Less than 3	44 (16)
3–5	43 (16)
More than 5	175 (65)
Decline to answer	6 (2)
Agency type
Community health center/private clinic	90 (33)
Family planning organization	118 (44)
Public health clinic	49 (18)
Other	11 (4)
Female patients with chlamydia seen per month
Less than 5	101 (38)
5–20	142 (53)
More than 20	25 (9)

Percentages may not total 100 because of rounding.

NP, nurse-practitioner; CNM, certified nurse midwife.

Knowledge, attitudes, and barriers

Overall, knowledge around retesting for chlamydia was high; a large majority of providers were aware of national retesting guidelines, recognized the need for retesting despite partner treatment or annual screening, and knew that test-of-cure is generally not necessary. Of the 4 items pertaining to retesting knowledge, 74% of providers answered at least 3 items correctly. Though the vast majority of respondents felt that retesting improves health, barriers to retesting were common among providers. Eighty-two percent of providers reported at least 1 barrier or negative attitude toward retesting; the most common barrier was that retesting was “difficult because patients did not return” to be retested. Details regarding providers' knowledge, barriers, and association between knowledge and barriers are provided in Table 2. As knowledge level increased, the percent of providers reporting multiple barriers toward retesting significantly decreased (χ² = 38.6, p = <0.0001).

Table 2.

Knowledge, Attitudes and Barriers to Retesting Among Family Planning Providers

Knowledge item (correct answer)	(n = 268) n (%)
Aware of national retesting guidelines (Yes)	220 (82%)
Retesting is important even if partners are treated (Yes)	209 (78%)
Retesting is still necessary with annual screening (Yes)	196 (73%)
Test of cure at 3 weeks should be performed (No)	188 (70%)
Level of knowledge (out of 4)
Low (1–2 items correct)	70 (26%)
Moderate (3 items correct)	74 (28%)
High (4 items correct)	124 (46%)
Attitudes and barriers
Retesting improves health	243 (91%)
Retesting is difficult because patients will not return	196 (73%)
Strategies to improve retesting are too difficult to implement	134 (50%)
Retesting is costly and time consuming	80 (30%)
Level of barriers to retesting
Low (0–1 barrier)	123 (46%)
Moderate–high (2 or more barriers)	145 (54%)
% reporting moderate–high barriers by knowledge level
Low knowledge	60/70 (85%)
Moderate knowledge	34/74 (46%)
High knowledge	51/124 (41%)
χ² = 38.6, p = <0.0001

Association of demographic characteristics with knowledge and barriers

In the univariate logistic regression analysis, demographic characteristics such as provider type, total years of practice, years of family planning experience, agency type, and volume of chlamydia-infected patients seen were not significantly associated with level of knowledge or number of barriers regarding retesting. Because none of the predictors was significant in the univariate analysis, multivariate analysis was not performed.

Clinic level policies and strategies

Overall, 78% of providers reported that their medical director had established guidelines for retesting at 3 months. In terms of priorities, 21% reported that retesting was a high priority, 46% a moderate priority, and 33% a low priority for their clinics. Multiple strategies to ensure retesting could be reported by an individual provider. Of the high-intensity/active strategies, 17% used chart-based reminders or a tickler system for clinicians, 29% used patient contact via phone, 17% used mail reminders, and 33% made follow-up appointments or gave appointment cards to patients. Use of e-mail reminders was rare (1%), and no providers reported using text messaging. At least one high-intensity strategy was reported by 44% of participants, 50% utilized exclusively low-intensity strategies (written materials, wall posters, verbal counseling, or unknown strategy), and 6% of providers reported that no strategies were used in their clinic to ensure that patients returned.

Association of clinic-level predictors and retesting interventions

Clinic policy and priorities toward retesting had a significant influence on the intensity of intervention reported by providers. In clinics with a retesting policy set in place, providers had almost 4-fold greater odds of employing high-intensity/active interventions to ensure retesting compared to clinics with no retesting policies in place. Similarly, providers from clinics with a moderate or high level of priority toward retesting had almost 4-fold greater odds of employing high-intensity/active retesting interventions compared to clinics where retesting was of low priority. Results were similar in the weighted analysis (weighted according to number of responses from the same clinic/agency). Details of both analyses are shown in Table 3.

Table 3.

Odds of Using High-Intensity/Active Retesting Interventions According to Clinic-Level Predictors

	OR (95% CI) ^a
Presence of policy toward retesting
Retesting policy established by medical director	3.95 (1.98-7.88)
No retesting policy	1.00 (reference)
Retesting policy established by medical director^a	5.67 (2.47-12.90)
No retesting policy	1.00 (reference)
Level of clinic priorty toward retesting
Retesting is a high or moderate priority in clinic	3.75 (2.12-6.63)
Retesting is a low priority in clinic	1.00 (reference)
Retesting is a high or moderate priority for clinic^a	4.49 (2.10-9.60)
Retesting is a low priority in clinic	1.00 (reference)

Weighted for number of responses per clinic.

Discussion

Our survey illuminated key information about family planning providers' knowledge and barriers toward retesting for repeat chlamydia infection and identified the most common clinic practices employed to ensure that women return for retesting. Despite high levels of knowledge among providers and an overwhelming agreement that retesting for repeat infection improves the health of patients, our data demonstrated that significant barriers to retesting still exist.

We found that a greater number of provider-reported barriers was associated with lower levels of knowledge about retesting. This indicates that improving provider knowledge around the importance of retesting as well as retesting guidelines may help break down barriers. However, multiple studies of provider behavior demonstrate that knowledge of guidelines is not sufficient to ensure adherence.^18,19 Furthermore, despite awareness of guidelines, both internal and external barriers to provider implementation and practice change are common and must be addressed.²⁰

In addressing barriers to retesting, the most commonly reported barrier was “retesting is difficult because patients do not return.” However, data from the California Family Planning Access Care and Treatment insurance program demonstrated that of 4,527 women diagnosed with chlamydia in 2006, 58% returned for some type of visit within 1 to 6 months of their chlamydia diagnosis, but only 64% of those who returned received a repeat test for chlamydia (J. Chow, 2009, personal communication). The fact that providers' perception of patient return rates did not coincide with actual return rates is notable and suggests that providers and clinic staff were unaware that a patient was due for retesting and therefore missed testing opportunities even when patients did return.

To take advantage of opportunities for retesting, clinics should employ a strategy to alert providers and ancillary staff that a patient is due for retesting so that a patient returning for any reason will be retested even if she does not require face-to-face interaction with a provider (e.g., contraceptive injection, pregnancy-test-only, or emergency contraception visits). One method that has demonstrated marginal success when utilized for chlamydia screening is chart-based reminders for providers.²¹ Though there are no data on their efficacy in the context of retesting, it is a low-cost strategy that many clinics already have in place for other services (e.g., vaccinations, annual Pap testing, follow-up of abnormal lab tests) and thus could be easily adapted.

Another method that holds promise is self-collected vaginal swab specimens (SCVS). This method allows for home-based retesting; patients can mail specimens directly to a laboratory and forgo a clinic visit.²² This method is preferred over pelvic examinations by asymptomatic young women ²³ and has already been used in clinical and nonclinical settings to expand chlamydia screening, particularly for adolescent girls.^24,25

Patient reminders are another intervention that could potentially improve retesting rates. Though few studies that have evaluated this approach for improving retesting rates, Malotte and colleagues found that combinations of a $20 incentive, motivational counseling, and patient phone reminders resulted in increased rates of retesting among patients of STI clinics (24%–33%) compared with a brief recommendation to return (3%–11%).¹⁷ In contrast, a pilot study in New York of incentives and mail or telephone reminders found no substantial increase in return rates.²⁶ Though telephone reminders have been found to be the most effective intervention in increasing patient return rates and the least costly in terms of cost per infection treated,²⁷ our data demonstrate that only 29% of family planning providers report using phone reminders for retesting visits.

Because phone reminders may employ considerable staff time, other technologies to ensure patient follow-up should be considered. According to the Pew Internet and American Life Project, a large majority of adolescents (66%) and adults (60%) utilize the Internet to communicate via instant messaging or e-mail, with one-third of adolescents utilizing text messaging on a regular basis.²⁸ However, our data demonstrated that only 1% of family planning providers reported using e-mail to contact patients, and none reported using text messaging. These interventions, especially text messaging, may be a low-cost and efficient way to reach the current tech-savvy generation of patients since a single text message can be sent to many individuals simultaneously. Studies in the U.K. and New Zealand have demonstrated that text messaging is at least if not more effective than conventional methods (phone, mail) in reducing time needed to contact patients with chlamydia.^29,30

Finally, program-level changes within family planning organizations may also play a key role in improving retesting. Gudgel and colleagues evaluated the impact of widespread implementation of program guidelines in Washington State family planning clinics to improve chlamydia/gonorrhea retesting. A majority of clinics adopted the recommendations and implemented at least one procedure to ensure that patients were retested, and the rate of retesting increased from 9.3% in 2001 to 19.4% in 2004. ³¹ In our survey, having clinic policies for retesting and a high level of clinic priority toward retesting were both associated with use of high-intensity strategies to ensure that patients return. Though we do not know the exact effect that clinic policies and priorities would have on retesting rates, it seems likely that clinics with a high level of priority toward retesting that utilize high-intensity strategies would be more likely to have patients return.

There are several limitations to this survey. Though we attempted to reach all eligible providers by having the survey distributed by all California family planning agency directors, a third of the directors did not provide us with data regarding the number of providers to whom the survey was sent, despite multiple attempts at retrieving this information. Because only those agencies that provided complete data were included in the response rate calculation, our result may be an under- or overestimate of the true response rate. Though we did receive clinician responses from a large majority of the agencies, it is possible that directors of agencies with no respondents are not supportive of retesting and therefore did not forward the survey to their clinicians. We also did not have actual retesting rates for individual clinics and could not assess whether clinics with multiple high-level interventions or a high priority of retesting were successful in improving retesting rates.

In conclusion, barriers to retesting are common among family planning providers; however, instituting clinic policies, educational interventions, and reminder systems for clinicians/staff may help address these barriers and minimize missed opportunities for retesting. Though a majority of providers utilized at least one high-intensity strategy to ensure that patients return, no single strategy has proven to be clearly superior or have a dramatic effect on improving retesting rates. Therefore, a multimodal approach involving patient education, clinician/staff reminders, use of cost-effective technologies to generate patient reminders, and adoption of program-level retesting policies will be necessary to improve current retesting practices and ultimately reduce the sequelae of repeat chlamydia infection in women.

Footnotes

Acknowledgments

The authors would like to thank Joan Chow, Melanie Deal, Jessica Frasure, and Holly Howard for assistance with instrument development, and Ying-Ying Yu for assistance with statistical programming. Dr. Park's time was funded by the Centers for Disease Control and Prevention STD fellowship no.: 1H25PS001379-01.

Disclosure Statement

The authors do not acknowledge any commercial associations, and therefore no competing financial interests exist. The authors have no conflicts of interest to report.

A summary of these findings was presented at the Centers for Disease Control and Prevention Region IX Infertility Prevention Project Meeting, November 13–14, 2008, Redondo Beach, California.

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