The use of mailouts for chlamydia screening

1
The use of mailouts for chlamydia screening

• Version 1 - February 2009

2
Context for this guidance

• The NCSP is an opportunistic screening programme.
  Mailouts i.e. sending letters/ postal testing
  kits to young people using population registers
  may be used as an adjunct to opportunistic
  screening

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Types of mailout

• Letters inviting young people to complete an
  enclosed postal test kit
• Letters inviting young people to request a postal
  test kit e.g. via text or a website, by returning
  an enclosed test request card etc
• Letters inviting young people to attend a venue
  e.g. GP surgery for a chlamydia test
• Includes invitations to pick up a postal kit
  from a venue

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• THE EVIDENCE

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Mailout return rates within the NCSP(preliminary
data)

• Letters inviting young people to complete an
  enclosed postal test kit
• returning a sample approx. 13-15
• Letters inviting young people to request a postal
  test kit
• requesting a kit approx. 1-10
• returning a sample (of those initially sent
  letters) approx. 0.7-5
• returning a sample (of those who requested a
  kit) approx. 32-66
• 3. Letters inviting young people to attend a
  venue for a chlamydia test
• attending for a screen 0.9-9 (note in
  general this tended to be very low i.e. 1 and
  not all attendances were necessarily due to the
  letter)

Note these data are based on a small number of
evaluated NCSP mailout initiatives. Several other
mailout initiatives are currently underway and
the results of these are awaited. The findings
presented here are therefore preliminary and
likely to change. (Data as at February 2009)
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Positivity among NCSP mailouts (preliminary
data)

• Ensuring appropriate targeting of screening is
  important to avoid hitting the target but
  missing the point
• Positivity among young people tested via mailouts
  is around 7. This is lower than the average
  positivity among NCSP screens (8.7 in year 5)
  but within the range observed in the various NCSP
  screening settings

Note these data are based on a small number of
evaluated NCSP mailout initiatives. Several other
mailout initiatives are currently underway and
the results of these are awaited. The findings
presented here are therefore preliminary and
likely to change. (Data as at February 2009)
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The published evidence(UK-based literature)

• Postal chlamydia testing is feasible and
  acceptable to young people
• Mailouts have been shown to increase screening
  volumes compared to opportunistic screening alone
  (in the general practice setting)5
• Mailouts can achieve reasonably good return rates
  (30)1-6
• Ghost patients on GP registers can be a
  significant issue (20-45 of young adults on GP
  registers may be ghosts)1-3,6
• Return rates may vary in different population
  groups/areas of the country1-6
• There is some evidence that sending test kits
  directly to young people may result in higher
  return rates than inviting people to request a
  kit (Note no evidence from the UK since all
  studies sent test kits directly but some non-UK
  studies do suggest this7,8)
• Reminders (e.g. follow-up letters to
  non-responders) may result in small increases
  return rates1,2,6
• Note It is not currently clear why return rates
  reported in the published literature tend to be
  much higher than those achieved through NCSP
  mailout initiatives.

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What is the most effective mailout method?

• The current (limited) evidence-base suggests that
  the return rates from letters inviting young
  people to attend a venue for a chlamydia test or
  to request a postal test kit tend to be low.
  Sending test kits directly to young people is
  likely to achieve higher return rates
• However, one needs to consider the relative
  potential costs of each mailout method (bearing
  in mind the estimated return rates) e.g. wastage
  is likely to be higher when kits are sent out
  directly. Further costing data from NCSP mailout
  initiatives is awaited
• When deciding which method to use, take into
  consideration the most appropriate method for
  your population

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References

• Macleod J et al. Postal urine specimens are they
  a feasible method for genital chlamydial
  infection screening? Br.J.Gen.Pract.
  199949455-8
• Macleod J et al. Coverage and uptake of
  systematic postal screening for genital Chlamydia
  trachomatis and prevalence of infection in the
  United Kingdom general population cross
  sectional study. BMJ 2005330940.
• Pierpoint T et al. Prevalence of Chlamydia
  trachomatis in young men in north west London.
  Sex Transm.Infect. 200076273-6.
• Rogstad KE et al. The prevalence of Chlamydia
  trachomatis infection in male undergraduates a
  postal survey. Sex Transm.Infect. 200177111-3.
• Senok A et al. Can we evaluate population
  screening strategies in UK general practice? A
  pilot randomised controlled trial comparing
  postal and opportunistic screening for genital
  chlamydial infection. J.Epidemiol.Community
  Health 200559198-204.
• Stephenson J et al. Home screening for chlamydial
  genital infection is it acceptable to young men
  and women? Sex Transm.Infect. 2000 7625-7
• Andersen B et al. Population-based strategies for
  outreach screening of urogenital Chlamydia
  trachomatis infections a randomized, controlled
  trial. J.Infect.Dis. 2002185252-8
• Scholes D et al. Population-based outreach for
  Chlamydia screening in men results from a
  randomized trial. Sex Transm.Dis. 200734837-9

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• PRACTICAL GUIDANCE
• Should you decide to conduct a mailout within
  the context of the NCSP please consider the
  following practical guidance..
• This guidance is based largely on the knowledge
  and experience of the NCSP Regional Facilitators
  rather than documented evidence

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Duty of confidentiality and data protection
issues

• Consider all potential data protection issues
• Ensure you have discussed the mailout with your
  PCOs Caldicott Guardian so they are aware

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Have a good letter introducing the service

• Keep the letter short and simple one side of A4
  maximum
• You may wish to include your PCOs screening
  programmes logo on the letter or, alternatively,
  enclose some additional material on which the
  programmes imagery is clearly displayed this
  links to your marketing campaign and
  advertising/promotional material
• Ensure all contact details are clear and correct
• When sending letters inviting people to request a
  test kit consider including a website address
  and/or a text request number e.g. Text SCREEN and
  name and address to XXXX as well as the CSOs
  contact details (make sure all the contact
  details are correct on the letter and then check
  again avoid expensive and embarrassing
  mistakes!)

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Chlamydia testing as routine

• Ensure the letter reassures young people that
  being tested for chlamydia is routine i.e. all
  people in their age group are being written to
  highlight that thousands have already been tested
  and they are not being singled out. This helps
  normalise testing

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Key messages to convey

• Recent research carried out with young people on
  attitudes and messages about chlamydia that work
  for them shows that it is recommended that a
  letter covering all the following points makes
  the most impact
• 1. CHLAMYDIA IS INVISIBLE most people with
  chlamydia have NO symptoms
• 2. CHLAMYDIA IS SERIOUS can cause infertility
  if not detected and treated
• 3. CHLAMYDIA IS SPREADING ease of exposure
  having unprotected sex once is all it takes
• Research suggests that all three elements should
  be highlighted, as on their own the impact is
  noted to be less amongst the target group
• Define Research conducted by the NCSP and the
  Department of Health in 2008

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Preparation for mailing

• This is an essential part of your mailout
  insufficient capacity to cope with a large
  response to your mailout will, at the least, be
  embarrassing for your programme and at worst may
  lead to members of your target audience being put
  off screening in the future
• Therefore, ensure your programme has
• enough kits and Patient Information Leaflets in
  stock to send out on request based on assumed
  uptake
• re-examined your instruction leaflet for the use
  of the kit is it simple and idiot proof, could
  it be improved on? Provision of a sample needs to
  appear to be a simple process to encourage
  participation now and in the future
• ensured the packaging of kits is compliant with
  current Post Office regulations

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Preparation for mailing continued

• Ensure your programme has
• enough staff available to manage enquiries
  maybe signpost in the covering letter to a QA
  document to deal with FAQs on your website (if
  you have one) about the mailout e.g. Why have I
  been sent this kit?
• informed their lab of what is planned and check
  they have sufficient capacity
• enough treatment outlets to manage positives
  (extra resources to CCS, Pharmacists etc CSO
  staff alone will not cope if the uptake is high
  which is obviously what is hoped for)
• enough staff available to manage partner
  notification and follow-up calls
• If your area is conducting joint chlamydia and
  gonorrhoea screening, postal kits will need to
  contain additional information about gonorrhoea
  and gonorrhoea screening as agreed with the PCO
  clinical governance and/or ethical committees for
  your area

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Calculate monthly batches and possible returns

• Calculate, based on your preparation, how many
  letters or kits you need to send out each
  month/week. If the response is high will your
  service cope? Have a contingency plan in place
  to slow down the mailouts if the lab or the
  positive patient and partner management systems
  show signs that they are not coping
• Pre-empt and support the mail out with effective
  marketing so young people know the letter/kit is
  coming and, more importantly, what it is for
  again make the logo or imagery central to the
  campaign so it becomes a recognised brand in your
  area

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Use your outreach workers to promote the mailout

• Outreach workers can support the mailout by
  asking young people if theyve received a letter
  or test kit in the post and whether theyve
  responded to this (i.e. requested a kit, returned
  a sample)
• Outreach workers can very effectively
  reinforce/emphasise the message that screening is
  important and encourage them to request and/or
  return a test
• This outreach work builds on the advertising
  campaign and mailout parts of the programme

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Evaluation

• Only through effective evaluation of screening
  initiatives will we be able to identify what
  works and what does not work, in preparation for
  future screening initiatives
• Use the NCSP evaluation template to support your
  planning phase -try to ensure that you can
  measure the effectiveness of the mailout e.g
• include a drop down on the website so the young
  person can indicate where they heard about
  screening, or an auto text reply asking them
• obtain base-line data on the activity of postal
  kits prior to the mail-out
• ensure mailed out kits are identifiable in some
  way e.g. have a separate mailout project/clinic
  code to identify them when they are returned etc

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Optional extras

• You may wish to provide an envelope for unused
  kits or for a response slip to be returned
  allowing the young person to state why they have
  not used the kit/requested a kit this time
• Include a statement in the letter that they may
  be contacted next year for a screen if still
  under 25 build a recall database for use next
  year

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Amendments and additions
All ad hoc amendments or additions to this
document will be highlighted here, and will be
subsequently incorporated into the main body of
version 2 of this guidance (to be released later
this year) Date added  April 28th 2009 Change
Addition The NCSP aims to maximise access to
sexual health testing to young people. Some
strategies to increase access involve testing in
situations where there is no one to one
consultation with a health professional. Mailouts
are an example of this. This raises the
following issues 1. How do we ensure that
opportunities to protect all young people under
18 from abusive situations are not missed? 2.
How do we ensure that all those who access
testing in this way are competent to consent to
testing? The NCSP and Brook have convened an
expert group to meet in July 2009 to consider
these issues. In the interim all PCTs using
mailshots to under 18s should consider the
rationale of their approach and consult with
their local Child Protection Lead at the planning
stage of the campaign. Useful documents DH best
practice guidance on the provision of advice and
treatment to young people under 16 on
contraception, sexual and reproductive health
http//www.dh.gov.uk/en/Publicationsandstatistics/
Publications/PublicationsPolicyAndGuidance/DH_4086
960 NICE guidance http//www.nice.org.uk/PHI003
Every child matters safeguarding children
http//www.everychildmatters.gov.uk/_files/AE53C8F
9D7AEB1B23E403514A6C1B17D.pdf