The use of mailouts for chlamydia screening

1. The use of mailouts for chlamydia screening Version 1 - February 2009

3. 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

4. THE EVIDENCE

5. 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)

6. 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

7. 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.

8. 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

9. References 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 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. Pierpoint T et al. Prevalence of Chlamydia trachomatis in young men in north west London. Sex Transm.Infect. 2000;76:273-6. Rogstad KE et al. The prevalence of Chlamydia trachomatis infection in male undergraduates: a postal survey. Sex Transm.Infect. 2001;77:111-3. 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 2005;59:198-204. 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 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 Scholes D et al. Population-based outreach for Chlamydia screening in men: results from a randomized trial. Sex Transm.Dis. 2007;34:837-9

10. 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

11. 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

12. Have a good letter introducing the service 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 mistakes!)

13. 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

14. 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

15. 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

16. 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 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

17. 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

18. 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

19. 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�

20. 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

21. Amendments and additions