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Abstract
Background In 2009, Sydney Sexual Health Centre implemented a short message service (SMS) reminder system to improve re-screening after chlamydia infection. SMS reminders were sent at 3 months recommending the patient make an appointment for a re-screen.
Methods Using a before-and-after study, the authors compared the proportion re-screened within 1–4 months of chlamydia infection in women and heterosexual men who were sent an SMS in January to December 2009 (intervention period) with a 18-month period before the SMS was introduced (before period). The authors used a χ2 test and multivariate regression. Visitors and sex workers were excluded.
Results In the intervention period, 141 of 343 (41%) patients were diagnosed with chlamydia and sent the SMS reminder. In the before period, 338 patients were diagnosed as having chlamydia and none received a reminder. The following baseline characteristics were significantly different between those sent the SMS in the intervention period and the before period: new patients (82% vs 72%, p=0.02), aged <25 years (51% vs 33% p<0.01), three or more sexual partners in the last 3 months (31% vs 27%, p<0.01) and anogenital symptoms (52% vs 38%, p<0.01). The proportion re-screened 1–4 months after chlamydia infection was significantly higher in people sent the SMS (30%) than the before period (21%), p=0.04, and after adjusting for baseline differences, the OR was 1.57 (95% CI 1.01 to 2.46).
Conclusions SMS reminders increased re-screening in patients diagnosed as having chlamydia at a sexual health clinic. The clinic now plans to introduce electronic prompts to maximise the uptake of the initiative and consider strategies to further increase re-screening.
- Chlamydia
- reminder systems
- intervention studies
- epidemiology (clinical)
- epidemiology (general)
- bacterial infection
- prevention
- primary care
- behavioural science
- biostatistics
- HIV
- users perspective
- testing
- surveillance
- sexual health
- service delivery
- gonorrhoea
- chlamydia trachomatis
- syphilis
- STD surveillance
- STD
- STD patients
- STD clinic
- STD services
- STDS
- STD control
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- Chlamydia
- reminder systems
- intervention studies
- epidemiology (clinical)
- epidemiology (general)
- bacterial infection
- prevention
- primary care
- behavioural science
- biostatistics
- HIV
- users perspective
- testing
- surveillance
- sexual health
- service delivery
- gonorrhoea
- chlamydia trachomatis
- syphilis
- STD surveillance
- STD
- STD patients
- STD clinic
- STD services
- STDS
- STD control
Introduction
Chlamydia trachomatis (here after referred to as chlamydia) is the most common notifiable infection in Australia, the USA and many European countries, with the largest proportion of diagnoses in young heterosexuals women aged <25 years and men 15–29 years.1–3 Chlamydia is largely asymptomatic, and if left untreated, chlamydia can lead to adverse health outcomes including pelvic inflammatory disease, ectopic pregnancy and tubal infertility.4
Repeat positive chlamydia tests are common and may be due to re-infection from the same partner, an infection from a new partner, inadequate treatment or treatment failure.5 In cohorts of women in the USA, 15.5% were found to have a repeat positive test at 6 months6 and 22% at 12 months in an Australian study of young women, with most repeat positive tests occurring in 4–5 months.7 In men, 10.9% had evidence of repeat positive chlamydia test at 4 months.8 Repeat positive chlamydia tests increase the risk of onward transmission and chlamydia-related sequelae such as pelvic inflammatory disease and infertility.9
Since 2002, clinical guidelines in many countries have recommended that any person diagnosed as having chlamydia should undergo re-screening within 3 months of treatment.10–12 Despite this recommendation, re-screening within 3 months of treatment remains low in many clinical settings.13–15 An analysis of heterosexuals attending 19 sexual health clinics in Australia in 2004–2008 found that the proportion of patients with a positive chlamydia test who were re-screened in 1–4 months was 11.9% in heterosexual men and 17.8% in heterosexual women.15
In 2009, Sydney Sexual Health Centre implemented a reminder system using short message service (SMS), otherwise known as text message, to improve the frequency of the re-screening within 3 months of a chlamydia infection. This paper describes the impact of the programme on chlamydia re-screening rates among women and heterosexual men attending the sexual health clinic.
Methods
Setting
Sydney Sexual Health Centre is a public sexual health clinic, offering free and confidential services including HIV testing, other sexually transmitted infections (STI) testing and treatment, hepatitis vaccinations, Pap tests, emergency contraception, patient counselling and referrals and partner management services. The clinic sees all patients with acute symptoms of STIs, STI contacts and asymptomatic clients from priority populations (men who have sex with men (MSM), Aboriginal people, sex workers, people who inject drugs, HIV-positive people, young people aged under 25 years).
Study design
We evaluated the impact of an SMS reminder system on chlamydia re-screening among women and heterosexual men attending the sexual health clinic, using a before-and-after study.
SMS programme
The programme was implemented by Sydney Sexual Health Centre in 2009. Clinicians were encouraged to offer an SMS reminder for re-screening in about 3 months after their initial infection. The SMS reminder was offered in person if the patient came back for treatment or over the telephone if they were treated presumptively for a chlamydia-associated condition or as a chlamydia contact. The SMS reminder programme was developed in-house as an additional template in the patient record system and enabled clinicians to check the mobile number and update if needed, and record the date the SMS would be sent. This allowed the clinician and patient to establish a convenient date for the reminder to be sent. On the pre-specified date set, SMS reminders were automatically sent to patients. The messages contained text reminding patients to make an appointment for another chlamydia test: “You are due for a repeat test. Please call SSHC on 93827440 to make an appointment”. Each text message cost $A0.05 to send. No other reminders (postal, email, phone) for chlamydia re-screening were sent to heterosexual patients during the study period.
Data extraction
For the evaluation, quantitative clinical data from 1 January 2007 to 31 May 2010 were extracted from the medical records system including an anonymous patient identifier, new/existing patient, age, sex, postcode, country of birth, arrival in Australia in last year (if overseas-born), self-reported traveller, sex of partner, number of male and female sexual partners in the last 3 and 12 months, current sex work, condom use, chlamydia test and result, other test results and the date the reminder was sent. In 2007–2008, information on the number of sexual partners in the past 3 and 12 months was only collected from new clients, thus for existing clients we used information from their first visit.
Definitions
Intervention period
All women and heterosexual men diagnosed as having chlamydia between January and December 2009 (12 months).
SMS group—intervention period
All women and heterosexual men diagnosed as having chlamydia in the intervention period who were sent an SMS reminder.
Non-SMS group—intervention period
All women and heterosexual men diagnosed as having chlamydia in the intervention period who were not sent an SMS reminder.
Before period
All women and heterosexual men diagnosed as having chlamydia between January 2007 and June 2008 (18 months) before the SMS reminder programme was implemented.
A heterosexual man was defined as a male reporting female sexual partners only in the last 12 months.
Exclusion criteria
Non-NSW residents and travellers were excluded from the analysis as they would not have had an opportunity to re-test or receive the SMS reminders. Sex workers were also excluded as they attend the clinic regularly for STI testing, and most were from culturally and linguistic diverse backgrounds and the SMS reminder text was in English.
Data analysis
Re-screening within 1–4 months after chlamydia infection was calculated as a second test occurring within 1–4 months of an initial positive test. The first chlamydia diagnosis was considered the baseline.
We compared the patient characteristics and proportion re-screened in 1–4 months of the initial chlamydia positive test: (1) the intervention period compared with the before period, (2) those sent an SMS reminder in the intervention period compared with those who did not and (3) those sent an SMS reminder in the intervention period compared with the before period. When comparing characteristics, missing data were include in the analysis. Chi-square tests or rank sum test with a significance level of 5% were used to assess difference in these groups. Multivariate logistic regression with a 95% CI was also used to determine if the SMS reminder was associated with increased re-screening at 1–4 months. Characteristics found to be significantly different between study groups were included in the regression analysis.
This study was conducted with the approval of the South Eastern Sydney Area Health Service research ethics committee.
Results
In the intervention period (January to December 2009), 486 women or heterosexual men were diagnosed as having chlamydia, of which 143 were excluded as they were non-NSW residents, travellers or sex workers. Of the remaining 343, 141 (41.1%) were sent the SMS reminder and 202 were not sent an SMS reminder. The majority of people had a mobile phone number; 100% of those sent the reminder and 97% of those not sent the reminder in the intervention period.
In the before period (January 2007 to June 2008), there were 458 women or heterosexual men diagnosed as having chlamydia, of which 120 were excluded as they were non-NSW residents, travellers or sex workers, leaving 338 in the analysis.
Intervention period versus before period
The following characteristics were significantly different between people diagnosed as having chlamydia in the intervention period and before period: new patients (79% vs 72%, p=0.03), aged <25 years (46% vs 33% p<0.01), three or more sexual partners in the last 3 months (31% vs 27%, p<0.01) and anogenital symptoms (47% vs 38%, p<0.01) (table 1). The proportion re-screened 1–4 months after their initial positive chlamydia test was 27% in the intervention period compared with 21% in the before period, p=0.08 (table 1), and the adjusted OR was 1.44 (95% CI 1.00 to 2.06) (table 2).
Baseline characteristics of the people in the intervention period compared with the before period (excludes non-NSW residents, travellers and sex workers)
ORs and 95% CIs of short message service (SMS) reminder on chlamydia re-screening rate in 1–4 months
SMS group versus non-SMS group intervention period
There were no significant differences in baseline characteristics among people sent an SMS reminder in the intervention period compared with those not sent an SMS reminder in the intervention period (table 3). The chlamydia re-screening rate 1–4 months after chlamydia infection was 30% in the those sent an SMS in the intervention period compared with 25% in the those not sent an SMS in the intervention period (p=0.30) (table 3) and the adjusted OR was 1.26 (95% CI 0.78 to 2.06) (table 2).
Baseline characteristics of people sent the short message service (SMS) reminder in the intervention period compared with those who were not (excludes non-NSW residents, travellers and sex workers)
SMS group intervention period versus before period
Of the people sent an SMS reminder in the intervention period, the following characteristics were significantly different compared with the before period: new patients (82% vs 72%, p=0.02), aged <25 years (51% vs 33% p<0.01), three or more sexual partners in the last 3 months (31% vs 27%, p<0.01) and anogenital symptoms (52% vs 38%, p<0.01) (table 4). The chlamydia re-screening rate 1–4 months after chlamydia infection was 30% in the SMS group in the intervention period compared with 21% in the before period, p=0.04 (table 4), and the adjusted OR was 1.57 (95% CI 1.01 to 2.46) (table 2).
Baseline characteristics of the people sent the short message service (SMS) reminder in the intervention period compared with the before period (excludes non-NSW residents, travellers and sex workers)
Discussion
Using a controlled observation study design, we found the SMS programme resulted in an increase in re-screening among women or heterosexual men with a positive chlamydia test who were reminded to attend the clinic using SMS. After adjusting for any significant differences in baseline characteristics among the two groups, we found re-screening 1–4 months after the initial positive chlamydia test was 1.6 times more likely in those sent an SMS reminder compared with those not sent an SMS in the before period.
The Sydney Sexual Health Centre SMS programme was designed to allow large numbers of messages to be sent simultaneously and automatically, thereby reducing labour costs compared with telephone or postal reminder systems.16 SMS reminders also have the advantage of directness, convenience, immediacy and confidentiality. The technology has been widely used for appointment reminders. A recent meta-analysis demonstrated their benefit in regards to increasing clinic attendance rates,17 and Chen and colleagues found that although SMS reminders and telephone reminders were equally effective at increasing attendance rates, SMS was more cost-effective.16 Despite this, a recent systematic review was unable to find any other published studies examining the effectiveness of SMS reminders for chlamydia re-screening.18 Also in family planning settings in the USA, an internet-based survey of clinicians at family planning clinics in California found of the 44% of clinicians who reported using active reminder strategies for re-screening, no provider used SMS reminders as a strategy.19
Increases in chlamydia re-screening have been demonstrated in interventions involving phone and postcards reminders. The recent systematic review and meta-analysis of interventions to increase chlamydia re-screening identified a number of studies involving phone, email, letter and postcard reminder systems. Three studies involved phone calls (+/− letters), and two of these three studies significantly increased re-screening. Although phone reminder calls have been found to be useful in other contexts,20 they have also been demonstrated to be the most expensive20 due to the staff time involved, there is a need for multiple attempts often outside typical business hours and many patients are never reached.21
Despite the SMS reminders in our evaluation being shown to significantly increase re-screening, only 41% of the target group had SMS reminders established in the intervention period. We believe that the main reason for the low coverage is clinicians simply forget to offer the SMS reminder, as the SMS template was located in a separate computer screen to their main clinical data entry portal and less likely to be due to patients refusing the offer of a reminder. Our analysis showed that those who received the SMS reminders has similar characteristic to those not sent an SMS reminder suggesting clinicians were not selecting a particularly subgroup to offer reminders to. In the next stage of the SMS programme, Sydney Sexual Health Centre plans to introduce electronic prompts to remind clinicians about setting SMS reminders and maximise the uptake of the initiative.
Although the SMS reminders were effective at increasing re-screening, the impact was moderate. We previously demonstrated that SMS reminders doubled re-screening rates 9 months after a HIV/STI test in MSM.22 The difference may be because MSM are more familiar with repeat testing for STIs, with over half of men having an STI test annually. Whereas young people may only attend a clinic once for an STI test, and thus, regularly testing is very low. A study of US women enrolled for two full years in 130 commercial health plans showed 11.5% were tested in either the first or the second enrolment year and only 2.1% had a test in both years, and in women enrolled for the entire 5-year study period, 25.9% had at least one test but only 0.1% had a chlamydia test every year. Heterosexuals who are diagnosed as having chlamydia at the beginning of a relationship may see little value in repeat testing in 3 months if the relationship is ongoing, is assumed monogamous and both partners have been treated.
In heterosexuals attending sexual health clinics, SMS reminders may need to be coupled with other effective strategies such as mailed screening kits. A systematic review of re-screening strategies found studies of mailed screening kits for self-collection of samples resulted in a significant increase in re-screening rates and the meta-analysis random effects model showing an average effect of 1.3 (95% CI 1.1 to 1.5).18 Xu et al 23 recently demonstrated the enhanced effect of coupling strategies. Among patients using mailed screening kits who also received a phone reminder, the re-screening rates were 59.2% at the family planning clinics and 43.5% at the STD clinic.23
Primary care clinics play an important role in the prevention and management of chlamydia. A large proportion of young people attend primary care clinics each year for one reason or another,23 ,24 and in Australia, most chlamydia infections are diagnosed in this setting.25 Use of SMS reminders in general practice could have broader population benefits; however, it would be important in the first instance to assess the feasibility, acceptability and effectiveness and also consider evaluation of other strategies. Medical alerts which prompt clinicians to consider an outstanding medical procedure/test or vaccination when a patients attends for their next consultation are used in primary care for various purposes such as immunisation catch ups and could also be particularly effective as re-screening reminders for clinicians in general practice where many patients attend for reasons unrelated to chlamydia.26
Our study has a few limitations. First, the study was not a randomised controlled trial and could have been biased by health promotion activities being undertaken to encourage chlamydia testing before or during the intervention; however, as the patients had already attended for initial testing, any health promotion activities are unlikely to have a major influence on re-screening. Second, as the intervention was not randomised, any patient imbalances in factors that may have influenced re-screening rates may have biased the study findings. We showed that the characteristics of people using the clinic and diagnosed as having chlamydia changed over the study period. To overcome this, we adjusted for all major potential biasing factors in the multivariate analysis. However, it is still possible that there could also have been participation bias, as the intervention group may have been a more motivated group of patients who were more likely to attend their appointments irrespective of receiving an SMS reminder. Third, qualitative interviews were not conducted with patients or clinicians to assess the acceptability of the intervention. However, the clinic received no formal complaints about the SMS messages, and acceptability has been demonstrated elsewhere.27 Finally, it is possible that patients may have attended another clinic such as general practice for re-screening, but we think this would be very uncommon as testing rates are very low in general practice,24 and even if re-testing did occur at another clinic, it would affect all study groups and not influence the OR calculated in the evaluation.
Our evaluation demonstrates that in a large sexual health clinic, SMS reminders were able to increase chlamydia re-screening rates and should be considered in other clinical services. To further enhance re-screening effectiveness, protocols incorporating two evidence-based approaches such as SMS reminders and mailed screening kits may be needed.
Key messages
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In a large sexual health clinic, SMS reminders were able to increase chlamydia re-screening rates in heterosexuals to 30% compared with 21% in the before period.
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The SMS programme was designed to allow large numbers of messages to be sent simultaneously and automatically, thereby reducing labour costs compared with telephone or postal reminder systems.
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To further enhance re-screening effectiveness, protocols incorporating two evidence-based approaches such as SMS reminders and mailed screening kits may be needed.
Acknowledgments
We would also like to gratefully acknowledge Heng Lu from Sydney Sexual Health Centre who designed the SMS programme in the clinic medical record system and extracted the data for the analysis.
References
Footnotes
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Competing interests None.
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Ethics approval This study was conducted with the approval of the South Eastern Sydney Area Health Service research ethics committee.
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Provenance and peer review Not commissioned; externally peer reviewed.