Abstract
In order to investigate the overall impact of the British Association for Sexual Health and HIV (BASHH) Sexually Transmitted Infections Foundation (STIF) course taught in Ireland since 2007, attendees were sent two questionnaires to investigate the overall impact of the course, its effect on clinical practice and the need for further education. Response rate was 19.4%. The majority found the course beneficial and that it did cover their practice needs (96.4%), with 83.6% saying that their confidence and technique in sexual history taking had improved. There was a 3.7% increase in the provision of HIV testing from precourse levels, although only 80% did so routinely; a 12.7% increase in syphilis testing; a 5.4% increase in testing for Chlamydia and a 12.7% increase for gonorrhoea. Some confusion seems to persist in relation to sexually transmitted infection (STI) risk factors. The second questionnaire tested STI knowledge. Most respondents scored well (average 81 % correct answers); however, respondents who attended four years previously scored, on average, 7% worse than the others, suggesting the need for a periodic update in the area of STI education.
Introduction
The provision of targeted sexually transmitted infection (STI) training for general practitioners (GPs) has been available in parts of the UK for quite some time, and it has been shown to be very beneficial and useful, in terms of both immediate and sustained gains in knowledge 1 and improved self-reported practice. 2 However, surveys raised a concern that availability and quality of undergraduate and postgraduate training in STI medicine varied significantly across the UK, with some primary care professionals having to travel significant distances to access teaching in this area. 3
It is with these considerations in mind, and in light of the recommendations included within the Department of Health National Sexual Health and HIV strategy documents,4,5 that the Sexually Transmitted Infections Foundation (STIF) Course was developed by the Medical Society for the Study of Venereal Diseases (now the British Association for Sexual Health and HIV – BASHH), with the first courses held in January 2002. 6 It is a two-day course designed to equip participants with the basic knowledge, skills and attitudes for the effective management of STIs, 7 mainly aimed at doctors, nurses and any clinician working in primary care, genitourinary medicine/STI clinics or who may encounter patients with (or at risk of) STI on a regular basis. 8
The course has been analysed in a number of surveys and studies since its introduction, generally aimed at assessing its effectiveness in terms of awareness, knowledge and change in practice. A 2003 Scottish prospective study attempted to evaluate the impact that attending a STIF course has on family planning nurses and doctors in terms of their knowledge. 3 Although the numbers were limited, this work did suggest that knowledge increased following the attendance of the STIF course. A more recent study 8 identified a self-reported improvement in practice and increase in testing following the course, although a worrying number of course participants were still not testing for HIV, syphilis and gonorrhoea to the levels advocated by the 2001 National Strategy for Sexual Health and HIV for the UK. 4 These studies focused either on self-reported (i.e. subjective) changes in practice or on objective changes in participants’ knowledge, while a 2008 study 9 attempted to measure the objective effect on practice by measuring the number of Chlamydia tests performed by GPs prior and following attendance. Although the study had a few limitations, it highlighted how increases in Chlamydia testing seen just after attending the course were actually not sustained. Also HIV testing did not increase in spite of the significant amount of time that is dedicated to this area in the course.
Since the year after the publication of the Irish study of Sexual Health and Relationships in 2006, 10 the STIF course has been offered in Ireland too, between two to three times per year. So far it has proved a very popular course, suggesting the existence of a gap in this aspect of education and training for health-care professionals in Ireland as well. Although anecdotal feedback has so far been very positive, we felt the need for more specific and quantifiable feedback, in addition to some indication of the impact that attending the course had on attendees/delegates practice in the various aspects of STI screening and management.
Materials and Methods
A total of 284 people attended the course between 2007 (the year the course began in Ireland) and 2010. In March of this year, all 284 past delegates/attendees were sent two questionnaires:
Our research/investigational questionnaire (Table 1);
A knowledge-based questionnaire: the same one that attendees are asked to fill in just before attending the STIF course in order to assess baseline knowledge (not included as it is still in use by BASHH);
For the first questionnaire's results, statistical significance was set at P < 0.05 using a Chi square distribution for non-independent data, while for the second questionnaire we used an analysis of variance test (with significance set at P < 0.05 as well).
Investigational questionnaire structure
Open question, however, a list of examples was provided
Results
Out of the 284 delegates who were sent the two questionnaires, 55 (19.4%) responded. Of these, all of them returned the new/investigational questionnaire completed, while only 44 (15.5% of total) returned also the old (knowledge) one.
Demographic comparison between whole cohort and respondents
Of the 55 respondents, 42 (76.4%) were women and 13 (23.6% – 3.24:1 ratio) were men. In comparison, the whole cohort of attendees/delegates was made up of 82.7% women and 17.3% men (4.78:1 ratio);
Of the respondents, 48 were doctors (87.3%), 5 (9.1%) were nurses and 2 did not indicate their profession. Among the doctors, GPs were 81.8% of the total, and Public Health doctors were 5.5%. Nurses were therefore slightly under-represented as in the whole group only 73.2% were doctors and 26.8% were nurses.
Overall course
The majority of respondents (72.7% – N = 40) worked in primary care, 5.5% (N = 3) in a hospital environment, 9.1% (N = 5) in a student health clinic, 3.6% (N = 2) in the Sexual Assault Treatment Unit (SATU), 7.3% (N = 4) in a sexual health/Well Woman clinic/centre (although two of them also worked in a ‘traditional’ GP practice). One delegate (a GP) did not declare their usual working environment.
In terms of year of attendance, the distribution was quite even, with 12.7% of delegates having attended in 2007, 20.0% in 2008, 29.1% in 2009 and 29.1% in 2010. In total, 9.1% did not declare the year.
When asked what were the reasons for attending the STIF course (this was an open-ended question, and attendees were allowed to list as many reasons at they wanted), the main reasons listed were:
A perceived knowledge gap (25 mentions);
A perceived need to update on STI management (16 mentions);
Perceived service needs (11 mentions);
A perceived need to up-skill (7 mentions);
Lack of confidence with respect to STI medicine (4 mentions);
General interest (3 mentions);
Part of a study/college/post-grad programme – e.g. Higher Diploma in Nursing (2 mentions).
In total, 96.4% (N = 53) of delegates said that the course did cover their practice needs, 3.6% (N = 2) that it did not. These two respondents both worked in a general practice environment.
A total of 90.9% (N = 50) had actually referred to the course manual since attendance, while 9.1% (N = 5) had not. Among these five respondents are the two that felt that the STIF course did not cover their practice needs.
Most respondents felt that, since attending the STIF course:
Their confidence and ability in sexual history-taking had actually improved (83.6% – N = 46), while 16.4% (N = 9) felt it did not really change;
Their technique in eliciting a sexual history had actually changed (72.7% – N = 40), and 27.3% (N = 15) that it had remained the same.
In terms of risk factors for acquiring an STI, the Delegates Manual 7 identifies as the main ones:
Young age (less than 25 but especially less than 20 years of age);
Single;
Two or more sexual partners in the last six months;
Non use of barrier contraception;
Ethnicity for some specific STIs (e.g. hepatitis B in Asians, gonorrhoea and trichomoniasis in Black Caribbeans, HIV in Black Africans);
Sexual orientation;
Residence in metropolitan areas.
Interestingly, among the respondents’ answers there was a very wide range of risk factors identified. The three most commonly mentioned were:
Young age (38.2%);
Having multiple sexual partners (29.1%);
Being sexually active (20.0%).
In general this question was not answered well:
14.6% did not answer;
Most only mentioned three or four of the seven risk factors taught in the course;
Nobody answered more than five correct factors;
Nobody identified ‘residence in a metropolitan area’ as a risk factor.
Some of the risk factors identified by attendees are actually neither in STIF course material nor in the Oxford handbook of genitourinary medicine, HIV and AIDS:
Maturity;
Any sexual activity;
Any socioeconomic group;
Intimate touching;
Social background;
Opportunistic screening done on cervical smear taking.
When asked about their confidence in diagnosing and managing a list of specific presentations, of respondents:
76.4% were comfortable regarding genital lumps (N = 42);
78.2% were comfortable regarding genital sores (N = 43);
72.7% were comfortable regarding male dysuria (N = 40);
89.1% were comfortable regarding vaginal discharge (N = 49).
Disease-Specific Results
Results in relation to changes in testing for each STI are shown in Table 2.
Changes in testing levels after attending the STIF course
STIF = Sexually Transmitted Infections Foundation
The most encouraging results were (as expected) in HIV, with 98.2% of delegates providing HIV testing. Of note, however, only 80.0% (N = 44) offered it routinely. The most common answer to ‘why not’ was that they offered it only to patients considered to be high risk. One respondent also mentioned the cost associated with the test.
With regard to syphilis, there was a significant increase in testing following the course. Some of the reasons mentioned by those who did not offer syphilis serology after attending the course (18.2%) were:
Only to homosexuals;
Refer to STI clinic;
Does not always think about it.
Chlamydia testing increased as well, although not in a significant manner. Among the 7.3% who did not offer it, the only reason mentioned for not doing so was that they ‘did not see too many high-risk patients’.
Gonorrhoea testing showed a significant increase in testing as well. Among those who did not offer it (9.1%), reasons mentioned for not doing so were:
Local lab does not test for it;
Takes too long to get the swabs to a lab that tests for it;
Refer all STI patients to STI clinic.
STI knowledge questionnaire
Attendees also received a copy of the questionnaire they filled in at the beginning and at the end of the course together with the research questionnaire. Out of the 55 respondents, only 44 (15.5% of all STIF attendees, 80.0% of responses) filled this in and included it in the return letter.
Most respondents answered the old questionnaire well, with only a few disappointing results (3 were below 60%).
Excluding the responders who did not return the ‘old’ questionnaire, the average result was 81% (median 83%), with the lowest score 45% and highest 98%. Although this result is encouraging, unfortunately we were not able to compare it to the results delegates achieved at the end of the course (to evaluate for long-term retention of knowledge) as these were not available.
The areas where scores were the poorest were pelvic inflammatory disease (PID) (average 70%, median 75%) and epididymo-orchitis (average 74%, median 80%), while the best scores were in the areas of urethritis (average 90%, median 100%) and Trichomonas vaginalis (average 86%, median 90%). When analysed by year of attendance, all years scored very similar results, with only the 2007 respondents (i.e. the first year the course was offered in Ireland) scoring, on average, between 3% and 7% below more recent attendees. This reduction in score was however not statistically significant (P = 0.506).
The area of work does not seem to have a significant impact in how well the course material is retained by attendees. However, as may be expected, practitioners working in the SATU or in STI clinics and in third level Student Health Centres did score better than the average (Table 3).
Scores in the knowledge questionnaire by area of work
GP = general practitioner; STI = sexually transmitted infection; SATU = Sexual Assault Treatment Unit
Discussion/Conclusion
This study aimed at evaluating both self-reported changes in STI knowledge and related practice post BASHH STIF course attendance and the need for further education in the area of STIs, particularly in Primary care.
We are satisfied with a return rate of 19.4%, as we feel that is what can be expected given attendees’ work commitments. We do however recognize that this is probably the study's biggest limitation.
Overall feedback for the course was good, especially in terms of changes and improvements in practice. As in previous similar studies,8,9 our results suggest the need for a periodic update in the area of STI management for primary care and other sexual health practitioners. The recent introduction of a one-day refresher course may address this need.
Overall, answers regarding HIV were encouraging, although this does not seem to relate to the course, as they were already high prior to attendance.
Our survey however highlighted a few areas that are probably worth addressing in future revisions of the course. In particular, the syphilis results highlight that syphilis awareness is quite low. Although testing increased by 12.7%, a significant minority (18.2%) still do not provide syphilis testing post-course. The reasons for this merit further investigation, especially given recent syphilis outbreaks in this country.
Results for Chlamydia are more encouraging than those for syphilis, with a baseline level of testing of 87.3% and a (non-significant) increase in testing of 5.5%. However, similarly to what was found in previous studies, 11 uptake is still not at the level recommended for jurisdictions like the UK (which shares many similarities with the Irish reality), and it is not clear why it is still not as high as for HIV. Again this may be worth addressing in future course revisions.
The course improved the number of practitioners testing for gonorrhoea by 12.7%. The ‘difficulty of access to testing facilities’ and the ‘delay in getting the sample to the lab’ quoted by some of those not testing for it is however concerning, as it may reflect lack of knowledge about modern testing techniques and of facilities which may be available to primary care structures.
The area that raised the highest concerns among the authors was the poor congruence between what delegates perceive as being risk factors for acquiring an STI and the actual risk factors as taught in the course. Early diagnosis of STIs may be delayed or missed when practitioners fail to test those most at risk, and, in our opinion, ensuring that this does not happen should be one of the course priorities.