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Responding to the editorial by Miller et al regarding the methodology of
our study , we would challenge the assessment of the Zelen design as
representing a form of 'deception'. Zelen design is employed to generate
real life responses to help understand the translation challenges of
introducing any similar or modified intervention across a whole area.
When general practices involved in...
When general practices involved in our study were later informed of their
participation none expressed concern. Qualitative work undertaken with
these practices since the study has further confirmed they were supportive
of the study design selected, and stated it reduced bias. Chlamydia data
from general practice are routinely collected and published in England.
The editorial correctly identifies that levels of chlamydia screening
within general practices in England is currently low. Viewed in this
context, the 60% uptake generated by this intervention is significant. In
terms of the increases in testing observed during and after the
intervention period, our results were reported without inflation. Further,
while the results from the intervention may be modest, repeated on a
national scale a substantial increase in overall testing rates would be
The National Chlamydia Screening Programme identifies general practice as
an important venue through which opportunistic screening can be offered to
young adults. We also know the most common form of contact young people
have with medical services is with their GP. The results generated through
our intervention represent a positive development in our understanding of
how to increase screening in this setting. By engaging GPs in chlamydia
screening, opportunities are created to discuss wider sexual health issues
with young people, in a familiar and trusted surrounding.
We concur with Miller et al that changing practitioner behaviour is
challenging. General practice is a complex environment where practitioner
behaviour is subject to the influence of previous education and training,
practice managers and partners, competing targets, and other priorities
determined by the NHS. Other further research has shown that sustained
support is important to maintain the impact of any multifaceted
intervention, , and therefore Public Health England is continuing to
provide such support. However, further research into how to sustain and
maximise the impact of interventions to improve the sexual health service
delivered in primary care would also be beneficial.
AUTHOR NAMES; Cliodna A M McNulty 1, Angela H Hogan 2, Ellie J Ricketts 3, Louise Wallace 5, Isabel Oliver 6, Rona Campbell 7, Sebastian Kalwij 8, Elaine O'Connell 4, Andre Charlett 9
1 Public Health England Primary Care Unit, Microbiology Department, Gloucestershire Royal Hospital, and Cardiff University, Cardiff, UK
2 (Previously) Public Health England Primary Care Unit, (Currently) Integrated Biobank of Luxembourg, Luxembourg, Luxembourg
3 Public Health England Primary Care Unit, Microbiology Department, Gloucestershire Royal Hospital
4 (Previously) Public Health England Primary Care Unit, (Currently) University of Bristol, Bristol, UK
5 Applied Research Centre Health & Lifestyle Interventions, Coventry University, Coventry, UK
6 Field Epidemiology Service, Public Health England, and University of Bristol, Bristol, UK
7 School of Social and Community Medicine, University of Bristol, Bristol, UK
8 Amersham Vale Training Practice, London, UK
9 Statistics, Modelling and Economics Department, Public Health England, 61 Colindale Avenue, London, UK
Miller W, Nguyen N. Relative or Absolute? A significant intervention
for chlamydia screening with small absolute benefit. Sex Transm Infec
[Editorial -in print] 2014
McNulty C a M, Hogan AH, Ricketts EJ, Wallace L, Oliver I, Campbell
R, et al. Increasing chlamydia screening tests in general practice: a
modified Zelen prospective Cluster Randomised Controlled Trial evaluating
a complex intervention based on the Theory of Planned Behaviour. Sex
Transm Infec [Internet]. 2013 Sep 4 [cited 2013 Oct 23];1-7. Available
Shafer M-AB, Tebb KP, Pantell RH, Wibbelsman CJ, Neuhaus JM, Tipton
AC, et al. Effect of a clinical practice improvement intervention on
Chlamydial screening among adolescent girls. JAMA?: J. Amer Med Assoc.
2002 p. 2846-52.
Kalwij S, French S, Mugezi R, Baraitser P. Using educational outreach
and a financial incentive to increase general practices' contribution to
chlamydia screening in South-East London 2003-2011. BMC public health
[Internet]; 2012 Jan [cited 2013 Oct 23];12(1):802. Available from:
PHE National Chlamydia Screening Programme (NCSP) website;
http://www.chlamydiascreening.nhs.uk/ps/index.asp accessed on 8th April
All authors have completed the Unified Competing Interest form at http://www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare that '(1) CM, ER, AH, LW, RC, IS, EO, SK, AC have support from the Public Health England for the submitted work. Dr Cliodna McNulty leads the Public Health England Primary Care Unit that has an ongoing programme of work aimed at improving the management of infectious disease in primary care. Public Health England leads the National Chlamydia Screening Programme in England.