Quick wins and sustainable services20104617392

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					The use of mailouts for
 chlamydia screening

   Version 1 - February 2009
             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
                                      Types of mailout

1.       Letters inviting young people to complete an enclosed postal test
2.       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
3.       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
       Mailout return rates within the NCSP
                                     (preliminary data)

1.      Letters inviting young people to complete an enclosed postal test kit
        % returning a sample: approx. 13%-15%

2.      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)
             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)
                       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
•   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.
      What is the most effective mailout
• 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
1.   Macleod J et al. Postal urine specimens: are they a feasible method for genital chlamydial
     infection screening? Br.J.Gen.Pract. 1999;49:455-8
2.   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 2005;330:940.
3.   Pierpoint T et al. Prevalence of Chlamydia trachomatis in young men in north west London.
     Sex Transm.Infect. 2000;76:273-6.
4.   Rogstad KE et al. The prevalence of Chlamydia trachomatis infection in male undergraduates:
     a postal survey. Sex Transm.Infect. 2001;77:111-3.
5.   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 2005;59:198-204.
6.   Stephenson J et al. Home screening for chlamydial genital infection: is it acceptable to young
     men and women? Sex Transm.Infect. 2000; 76:25-7
7.   Andersen B et al. Population-based strategies for outreach screening of urogenital Chlamydia
     trachomatis infections: a randomized, controlled trial. J.Infect.Dis. 2002;185:252-8
8.   Scholes D et al. Population-based outreach for Chlamydia screening in men: results from a
     randomized trial. Sex Transm.Dis. 2007;34:837-9

     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
               Duty of confidentiality and
                data protection issues

• Consider all potential data protection issues
• Ensure you have discussed the mailout with your PCO’s Caldicott
  Guardian so they are aware
      Have a good letter introducing the
• Keep the letter short and simple – one side of A4 maximum
• You may wish to include your PCO’s screening programme’s logo on
  the letter or, alternatively, enclose some additional material on which
  the programme’s 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 CSO’s
  contact details (make sure all the contact details are correct on the
  letter and then check again – avoid expensive and embarrassing
          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
                     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
                  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
    – ensured the packaging of kits is compliant with current Post Office
    Preparation for mailing continued…
• Ensure your programme has:
   – enough staff available to manage enquiries – maybe signpost in the
     covering letter to a Q&A 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
   – 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
            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
         Use your outreach workers to
             promote the mailout
•   Outreach workers can support the mailout by asking young people if
    they’ve received a letter or test kit in the post and whether they’ve
    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
• 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
    – 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…
                      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
                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:
NICE guidance: http://www.nice.org.uk/PHI003
Every child matters: safeguarding children: