Table 1

Behavioural diagnosis of chlamydia testing with the COM-B Model: barriers to testing in general practice with illustrative quotations

COM-B componentsThemes and subthemesIllustrative quotations
Physical capability
Skills, abilities or proficiencies
Self-sampling—collecting and sealing the sample (in)correctlyQ1.1: ‘Even doing this swab… I don’t know how wrong you can do it, but sometimes you still worry like!’ (P01, female, 24 years)
Q1.2: ‘People might worry they’ve not done the test right, especially if they’re younger and not done them before. I actually did do one wrong once! I told the nurse about it and she said, ‘What did you do? Did you stick it up your arse?’ But it is possible to do it wrong, I think medical professionals maybe don’t really realise.' (P11, female, 21 years)
Q1.3: ‘If I was doing it, I would be quite nervous about messing it up and getting it wrong. I’d prefer to be able to talk to the nurse or doctor and ask them questions about it first, and even after you do the test, you could still have questions, you know. ' (P09, female, 17 years)
Psychological capability
Knowledge, memory, attention, decision processes, behavioural regulation
Lack of information and awarenessAsymptomaticQ1.4: ‘If they don’t have symptoms and they don’t think it’s anything bad, but they don’t know that it can lead to bad thing.' (P07, female, 20 years)
Risk of transmissionQ1.5: ‘I don’t think a lot of people know enough about chlamydia, like the dangers and stuff… not knowing how they could get it, I guess, if they don’t really know much about it.' (P27, female, 16 years)
Testing processQ1.6: ‘Before I ever got one done, you think it is a bit kind of intrusive because you don’t know what it is.' (P03, female, 22 years)
Q1.7: ‘Isn’t it just like where they prick your finger and test the blood?' (P18, male, 19 years)
Ease of treatmentQ1.8: ‘But I know when I was younger when I used to think of sexually transmitted diseases and infections, I used to think that’s it, that’s the end of it; if you get one, you’re stuck with it for life.' (P03, female, 22 years)
Availability in general practiceQ1.9: ‘I didn’t even know myself you could do that at the GP…' (P28, female, 16 years)
Q1.10: ‘Maybe I’m naïve, but I didn’t even know that was something you would get at the GP really. I suppose I don’t know where you would go for it, obviously there’s clinics, but I suppose it’s not something you, well I would relate to the GP, going for a sexual health test.' (P12, male, 23 years)
Reflective motivation
Beliefs about capabilities and consequences, roles, identity, intentions, goals, optimism
Testing not a priorityQ1.11: ‘I probably did do something I shouldn’t have done, and then realising that I should probably go, but not quite having the time. And then you might forget about it for a few weeks.' (P01, female, 24 years)
Perceived low riskSexual invincibilityQ1.12: ‘It’s one of these things where people think that it’ll never happen to them, where, you know, obviously it can happen to anyone. I think people are a bit oblivious about it.' (P08, female, 23 years)
Relationship status (monogamy)Q1.13: ‘Because I had a boyfriend I was like it’s very unlikely that I have chlamydia, or so I thought…' (P11, female, 21 years)
Q1.14: ‘I’m not very much at risk of having chlamydia because I have a long term girlfriend, I’m faithful and all that stuff, so… well, I was going to say I haven’t had any reported symptoms in the past, but as it’s symptomless, it would be difficult to find out… But I think my girlfriend got tested and she’s clean, so I just assumed that, you know, so am I.' (P16, male, 23 years)
Belief chlamydia is not seriousQ1.15: ‘That’s (chlamydia) not the one I’m worried about, like I’ve had it once, and I suppose I’d be more worried about the other STIs.' (P11, female, 21 years)
Q1.16: ‘For me it would seem a little bit pointless to go and get it done just for chlamydia, because I don’t worry about chlamydia specifically.' (P17, male, 21 years)
Automatic motivation
Emotions, reinforcement such as rewards, incentives, punishment
EmbarrassmentKnowing their GPQ1.17: ‘People are quite embarrassed about going to their GP because it’s somebody they know quite well… you know your GP, so to have that embarrassment of going through that stuff with them, it can be a bit uncomfortable sometimes.' (P15, female, 24 years)
Being seenQ1.18: ‘It might be like an uncomfortable situation, just in case you see someone you know or like, along those lines.' (P25, female, 18 years)
Procedure as invasiveQ1.19: ‘But I think maybe if it was a swab test - if it’s just chlamydia, like I might be put off because that’s a bit intrusive as a test.' (P06, female, 24 years)
Having to take clothes offQ1.20: ‘Well, I mean I’m not entirely sure how you get tested for some stuff, you know. No one really wants to walk in to the doctor’s and have to drop your pants in front of them, it wouldn’t be the most memorable day of your life. So I think embarrassment definitely is probably the number one problem.' (P26, male, 20 years)
FearLong term consequenceQ1.21: ‘Because there’s fear about this silent killer that is chlamydia, which shows no symptoms until you try to make babies and they don’t happen' (P16, male, 23 years)
Expectations of stigmaQ1.22: ‘Some people probably would be quite afraid, maybe some people see the stigma around it, so would feel quite scared going for that reason.' (P17, male, 21 years)
UnknownQ1.23: ‘I was scared because I didn’t know. I was scared because I was like, oh, I don’t know what I have to do.' (P03, female, 22 years)
Positive resultQ1.24: ‘Yeah, because I suppose giving out figures of how dangerous STIs can be and stuff, because what I was going to say earlier was, I guess, like one of the reasons some people don’t get tested is because they’re maybe scared of the results.' (P12, male, 23 years)
GuiltQ1.25: ‘The hesitating element is that you know you’ve done something wrong, either you’ve cheated on your girlfriend and you think you might have it, or maybe you were with a girl that you maybe had a one night stand.' (P16, male, 23 years)
Physical opportunity
Environmental context and resources
UK primary care contextStrained systemQ1.26: ‘It’s just a problem with the whole way that the NHS is being treated at the moment, with just cutting and cutting and cutting, which means that actually GPs don’t have the time and they don’t have the energy, like, extra resources to do extra, like, promote these kind of things, when they need to be.' (P02, female, 24 years)
RegistrationQ1.27: ‘I think the problem with the GP would be that I have to be registered with one and I’m not.' (P16, male, 23 years)
Getting appointmentsQ1.28: ‘It’s really hard to get an appointment at my GP.' (P11, female, 21 years)
Q1.29: ‘Appointments are really hard to get at GPs anyway… So to go at all requires getting up one morning and ringing at eight, and also managing to get time off work… So actually to go to the GP at all is an ordeal.' (P01, female, 24 years)
Lacks urgencyQ1.30: ‘At my GP, you either get an appointment about a month in advance or, if you call up on the day, then you can be on the phone for like an hour waiting for it to clear. Then you feel like if I’m going to wait that long, it needs to be for an emergency not just for a chlamydia test. Or you can go down at 8.45 am and literally queue up outside, which again, for a chlamydia test feels like a bit much. Because it’s not like necessarily, oh, my hand won’t stop bleeding(!) (slight laugh) and something immediately is going to happen. I guess with chlamydia, it feels like something you can put off.' (P02, female, 24 years)
Q1.31: ‘It just might be a general GP problem, when you go to a GP especially when it’s not urgent, you can have a 2 week wait to get an appointment… so sure it doesn’t have symptoms so you mightn’t bother and forget it.' (P25, female, 18 years)
Time constraintsQ1.32: ‘I suppose if you’re sick and you go to the GP, the main focus is getting rid of your cold or your chest infection, so there’s not time to think about chlamydia.' (P11, female, 21 years)
Q1.33: ‘And also sometimes I’ve been to the GP where it seems like they’re pressed for time and they’re trying to rush through everything. So if they asked me for a chlamydia test and it became clear that they kind of were pushed for time, then I’d be like, ‘Oh, no, it’s OK’.' (P11, female, 21 years)
Location of toilet (links to embarrassment)Q1.34: ‘For me, I guess, like the only thing that ever really makes me feel slightly uncomfortable is when the toilets are in the patient waiting room… I’ve experienced that once or twice, and when you have to go and do something yourself, like a swab or pee somewhere, and they just give it to you, it’s like you have to walk in there in front of everyone and walk out.' (P04, female, 24 years)
Social opportunity
Social influence, pressure, norms, conformity, comparisons
StigmaSex tabooQ1.35: ‘It’s funny because it is your doctor and they are supposed to do your health issues like that, but I think with sex and sexual health, people often need, eh it’s like you feel it’s that taboo thing.' (P02, female, 24 years)
Presumed promiscuityQ1.36: ‘Think some people associate a stigma with going to get a test.' (P05, male, 23 years)
Q1.37: ‘I think it’s just the whole stigmatisation around chlamydia and having chlamydia. I feel like if someone had it, they’d rather not know that they had it, because it’s so stigmatised.' (P20, female, 19 years)
Q1.38: ‘Just the stigmatisation around having chlamydia, because if you have it, people assume that you sort of like sleep around loads and stuff, but it’s not always because of that… but that’s what’s stopped me in the past.' (P20, female, 19 years)
Judgement from HCPQ1.39: ‘I think a lot of young people think that health practitioners, they feel like they’re getting judged by them because of their lifestyle and the way they kind of go about things.' (P15, female, 24 years).
Judgement from receptionistsQ1.40: ‘It can be quite difficult if they say, ‘What’s the reason for your appointment?’ and trying to explain it to a receptionist, they maybe think oh, she’s a receptionist, I can imagine some people thinking, that receptionist isn’t going to like it, she’s going to know what I’m saying, and she’ll think I’m really gross.' (P13, female, 22 years)
Younger ageQ1.41: ‘I guess because if it’s ranging from ages 16 to 24, I guess that depends on your age, because if you’ve got a 24 year old, I think there’s less stigma attached; it’s only for a 16 year old I think, yeah, I think there is still a social stigma… people worry about getting tested.' (P14, male, 24 years)
Q1.42: ‘It’s (chlamydia) got a lot of stigma, I’d definitely say it’s 100% stigma, definitely.' (P23, male, 17 years)
Never testedQ1.43: ‘Like, when you’ve not tested before, you just feel even more stigma and embarrassment about it, then once you’ve done it once, I think it eases then, a bit.' (P25, female, 18 years)
Sexual orientationQ1.44: ‘The issue is if they’re not out to family, or friends, they might not be comfortable coming out to some member of staff.' (P25, female, 18 years)
Q1.45: ‘I would be slightly more worried about the doctor or the nurse practitioners turning their noses up slightly.' (P09, female, 17 years)
Q1.46: The last time I was in for a non-sexual related reason, and they asked me something sexually related, about my sexuality, and I felt hostility in the question. And that was quite insulting really. So I think, yes, people being hostile to sort of LGBT definitely is slightly off-putting… So I went in for a non-sexual related issue and she thought it could have been caused by gay sex. And had a rant about the damage it gave you, that people can do to themselves, through gay sex and stuff. And it was quite an aggressive thing. There was no support and no nice comment. It was just how badly we could hurt ourselves and stuff like that.' (P26, male, 20 years)
Q1.47: ‘People maybe don’t want to share that they’re LGBT with their GP or whatever. I suppose that’s why I like (GUM clinic), a lot of people go there instead of going to the GP… they probably feel more comfortable there. Everyone that’s going there is LGBT and the people that are testing them are maybe more familiar with LGBT specific sexual health issues.' (P12, male, 23 years)
  • COM-B Model, Capability, Opportunity and Motivation Model of Behaviour; GP(s), general practitioner(s); LGBT, lesbian, gay, bisexual, transgender; NHS, National Health Service; P, participant number; Q, Quote number; STI, sexually transmitted infection.