Research ArticleWeb exclusive

Partner notification by family physicians for sexually transmitted infections

Facilitators and barriers

Alexandra Choi, Audrey Campbell, Theodora Consolacion, Jasmine Pawa, Brian Ng and Jason Wong
Canadian Family Physician June 2022; 68 (6) e182-e189; DOI: https://doi.org/10.46747/cfp.6806e182

Abstract

Objective To explore Canadian FPs’ experiences with, perceived barriers to, and perceived facilitators of FP-initiated partner notification (PN) for HIV and other sexually transmitted infections (STIs), as well as to inform the development of tools that might enhance this work.

Design Online survey.

Setting British Columbia.

Participants A total of 146 FPs recruited through the Divisions of Family Practice community-based networks of FPs throughout the province.

Main outcome measures Family physicians’ current STI and PN practices, opinions regarding FP-initiated PN, perceived barriers to and facilitators of FP-initiated PN, and preferred PN resources.

Results More than 90% of FPs had diagnosed an STI within the past year, and most (60.3% to 96.6%, depending on the STI) told patients to inform their partners. Two-thirds (66.4%) felt that PN should not be done by FPs, and fewer than 10% reported contacting partners. Reported barriers included inaccurate or incomplete lists of partners (67.1%), poor compensation (54.1%), and insufficient time (54.1%). Facilitators chosen by respondents included another health professional assigned to follow up with PN (77.4%) and improved remuneration (74.7%). Electronic PN tools directed at patients (eg, PN slips) were favoured over resources directed at providers.

Conclusion Family physicians regularly manage STIs and currently take part in PN primarily through educating index cases. However, most do not feel that PN should be conducted by FPs, and most believe that FP-initiated PN would require additional personnel, remuneration, and legal guidance.

Effective management of sexually transmitted infections (STIs) requires the timely diagnosis and treatment of both index patients and their partners. Partner notification (PN) is the process of identifying, screening, treating, and counseling partners potentially exposed to an STI.1 Partner notification reduces overall STI incidence and prevalence by preventing reinfection and onward transmission.2,3 However, PN is highly resource intensive. This effect is compounded by the growing burden of bacterial STIs in Canada.4,5 Between 2007 and 2016, rates of chlamydia, gonorrhea, and infectious syphilis increased by 24% (10,060 cases to 15,057 cases), 135% (1224 to 3259), and 123% (301 to 759), respectively, in British Columbia (BC).6

Partner notification can be initiated by patients or providers. In patient-initiated PN, index cases notify their partners. In provider-initiated PN, health care providers (eg, nurses, physicians, or public health practitioners) collect information about partners from index cases and notify those partners. In contract or conditional referral, index cases initially notify partners, but health care providers become involved if patient referral is not completed within an agreed-upon time frame.7,8 While patient-initiated PN is common, provider-initiated PN is associated with higher rates of partners receiving medical evaluation.9,10

In many jurisdictions public health providers perform provider-initiated PN. However, resources have not kept pace with the increasing burden of disease,11,12 resulting in a minority of patients receiving formal partner referral services.13,14 One proposed solution has been extending the involvement of primary care providers and FPs (FP-initiated PN) who already assess, diagnose, and treat STIs. In some jurisdictions clinicians have responded favourably to this proposal15; however, in others attitudes have been mixed.16,17

Partner notification programs for HIV in BC generally use provider referral and are the responsibility of the Medical Health Officer or designated nurses.18 Following diagnosis of gonorrhea or chlamydia, the diagnosing provider completes a surveillance form on which clinician-, patient-, or public health-initiated PN can be selected.19 However, there is no provincial standard for PN for bacterial STIs, there is no routine physician training, there are no fee codes, and it is not clear how FPs practise PN. The primary objective of this study was to explore Canadian FPs’ current PN practices, their attitudes toward FP-initiated PN, their perceptions of barriers to and facilitators of FP-initiated PN, and their preferences for FP-initiated PN tools. Secondarily, we sought to determine how these findings differed by regions of practice, years in practice, and populations served, potentially to guide the tailoring of resources. Ultimately, this work was intended to inform the development of tools and resources to support FPs in PN.

METHODS

Participants

The Divisions of Family Practice (DoFP) are community-based networks of FPs in BC that include more than 90% of the 6372 FPs in BC.20,21 We distributed an online, selfadministered survey through several DoFP mailing lists using a survey link. While we could not track how many FPs received the link, we followed up with each DoFP to confirm that the survey invitation was communicated to its members.

Eligibility criteria were competence in English and membership in a DoFP, which requires current licensure as an FP in BC. The survey was conducted from December 8, 2016, to February 14, 2017.

The survey included information on consent, and ethics approval was received from the University of British Columbia Behavioural Research Ethics Board. Survey participants were compensated based on a standard sessional rate.

Survey

The content of our questionnaire was informed by previously published surveys detailing physicians’ opinions regarding PN practices.15,16,22 Our 17-item questionnaire (available from CFPlus*) included 3 sections. The first pertained to personal, educational, and practice characteristics and experience diagnosing STIs. The second focused on PN attitudes and practices. The third focused on expedited partner therapy and is not within the scope of this article.

Before rollout, the online survey was pilot-tested by 5 FPs to improve content and clarity. Questions were structured in multiple-choice, dichotomous, or rankorder formats. Survey participants were also able to create a free-text response for most questions.

Analysis

We used descriptive statistics to understand current PN practices, attitudes toward PN, and facilitators of and barriers to PN via FP referral. We used χ2 tests to explore differences in practices, attitudes, and perceptions of facilitators and barriers by regions,23 populations served (urban vs rural), and years in practice (above vs below the median).

We described physician preferences for different tools and resources to support FPs and patients in performing PN by calculating the proportions who ranked the tool useful, neutral, and not useful. We assessed preferences for the different tools by calculating the median ranking of each tool, finding the tool ranked most highly by FPs based on their regions, populations served, and years in practice.

We considered P<.05 to be statistically significant. Univariate logistic regressions were used to calculate odds ratios [ORs] for associations found to be statistically significant. All analyses were performed using SAS, version 9.4.

RESULTS

A total of 181 clinicians started the survey; 146 answered at least 10 questions and were retained in the sample for analysis (81% completion rate). Table 1 describes the demographic characteristics of respondents. Two-thirds were female (67.8%) and most (80.8%) were between the ages of 30 and 59. About three-quarters served urban or suburban populations (73.3%). Most were FPs with a general practice (74.0%). Participants had been in practice for a median (interquartile range) of 9 (4 to 21) years.

View this table:
Table 1.

Demographic characteristics of survey respondents: N=146.

A total of 93.2% (n=136) of respondents had diagnosed at least 1 patient with an STI within the past year. Respondents were most likely to have diagnosed chlamydia (n=133, 91.1%), followed by genital herpes (n=110, 75.3%), genital warts (n=107, 73.3%), and gonorrhea (n=67, 45.9%). A minority of physicians had diagnosed syphilis (n=22, 15.1%) or HIV (n=11, 7.5%) within the past year.

Current PN practices

Table 2 presents the PN actions respondents stated they took for specific STIs. For chlamydia or gonorrhea, most FPs told patients to inform their partners and instruct those partners to seek care. Approximately half of FPs instructed patients to provide public health providers with partner information. Fewer than 10% of FPs personally collected partners’ information and contacted partners.

View this table:
Table 2.

Current partner notification practices: N=146.

There were no statistically significant associations between region of practice and stated PN practices for any of the reportable STIs.

Physicians serving rural populations were more likely than those serving urban populations to collect partner information for those diagnosed with chlamydia and to contact partners (OR=3.85, 95% CI 1.15 to 12.91). There were no statistically significant associations between population served and current PN practices for gonorrhea, syphilis, or HIV.

Physicians in practice 9 or more years were more likely than physicians in practice fewer than 9 years to instruct patients diagnosed with HIV to provide public health providers with partner information (OR=3.57, 95% CI 1.25 to 10.18). There were no statistically significant associations between median years in practice and current PN practices for chlamydia, gonorrhea, or syphilis.

Attitudes toward PN and perceived barriers and facilitators

Two-thirds of physician respondents (n=97, 66.4%) thought that PN should not be done by FPs. There were no statistically significant associations between attitudes toward FP-initiated PN and region, population served, or years in practice.

In the free text responses, participants expressed concern that FP-delivered partner services could be less consistent than those offered by public health, while others thought that given the sensitive nature of STI testing and treatment, patients would prefer PN be conducted through an external third party. Several FPs indicated that it might be inappropriate to treat a partner who could have their own FP, and they thought it might lead to poorer continuity of care.

The most frequently cited barriers to PN included challenges in having patients provide accurate lists of partners and their contact information (67.1%), poor compensation (54.1%), and insufficient time (54.1%) (Table 3). There were no statistically significant associations between the barriers cited and regions, populations served, or years in practice.

View this table:
Table 3.

Barriers to and facilitators of FP-led partner notification: N=146.

The factors that respondents thought would most effectively facilitate FP-initiated PN were the availability of another health professional (eg, a nurse) assigned to follow up with PN (77.4%), followed closely by improved remuneration (74.7%). There were no statistically significant associations between the facilitators cited and regions, populations served, or years in practice.

Tools and resources to support PN

Survey respondents favoured tools directed at patients over those designed for providers, and they preferred electronic resources to printed materials (Figure 1).

Figure 1.
Figure 1.

Provider assessment of potential resources for partner notification

The highest ranked resource was referral to a public health employee for PN (median rank of 1), followed by information and notification slips for partners (median rank of 4). Practice guidelines were ranked last (median rank of 5). This was consistent across both rural and urban settings.

DISCUSSION

Most FPs surveyed had diagnosed an STI within the past year. A high proportion of practitioners always or usually told patients to inform their partners, but few physicians performed PN.

Partner notification practices

As in previous studies, we found that PN practices differed by STI.13 In contrast to previous surveys,22 a greater proportion of FPs instructed patients to contact public health for PN following chlamydia and gonorrhea diagnoses, compared with syphilis and HIV diagnoses. This likely relates to the intensive centralized public health support (including for PN) for those newly diagnosed with syphilis or HIV in BC.24,25

Relative to international comparators, there were higher levels of reporting to the provincial public health agency.16,22 Of interest, rural physicians were more likely to initiate PN for patients diagnosed with chlamydia compared with their urban counterparts. Contributory factors could include variations in scope of practice and practice expectations in rural versus urban communities, and proximity and connection to public health.

Attitudes toward PN and perceived barriers and facilitators

Rising STI rates have created an increased need for partner services; however, two-thirds of survey respondents thought that PN was not the role of FPs. In keeping with the findings of previous studies, time and compensation were among the most consistent themes cited, suggesting that PNs’ operational resource intensity could be the key limiting factor.16,26 Current public health resources are insufficient to meet the need for PN; however, our study suggests that FP operational resources (both human and financial) are also insufficient to support taking on this work. It is therefore essential that we identify better ways to support the PN system, whether it is initiated by FPs or by other providers. This will likely require additional human and financial investments.

Tools and resources to support PN

More than half of respondents thought that clearer clinical guidelines could facilitate FP-initiated PN, yet guidelines achieved the lowest median rank among potential resources. At present, there are no FP-oriented provincial PN guidelines. This seemingly contradictory result suggests that while guidelines could support this work, a lack of familiarity with procedures was not the chief impediment to implementation. Instead, FPs favoured tools that could help support patients in performing PN, consistent with our findings that missing partner information and inadequate time for PN were identified as barriers. Acknowledging preferences for both electronic and patient-initiated PN, tools such as websites, e-mails, text messages, and social media or chatroom-based outreach have increased PN in other jurisdictions.27-30 Work on patient-oriented resources, including Internet-based notification tools, is currently under way in BC.

Our survey also found concerns regarding patient privacy and legality to be consistent themes. More extensive ethical and legal guidance may be necessary to enable FPs to become increasingly involved in PN initiation.31

Study strengths and limitations

Strengths of our study include the diversity of responding physicians’ practice settings, populations, geographic locations, and experiences. However, while we sampled a large number of practitioners, our overall response rate was low, as is typical for studies of physicians.32-34 A precise response rate could not be calculated, as DoFPs confirmed distribution of the link but could not track how many FPs received it. Moreover, in contrast to other surveys addressed to specific physicians, ours was intentionally anonymous and widely shared through general distribution methods (eg, newsletters). Volunteer bias could also have affected results. Respondents were more likely to be 30 to 59 years of age and practising in an urban or suburban setting, potentially reflecting the higher burden of STIs in urban areas.35 More female than male FPs responded, as is frequently seen in survey-based studies of physicians.36 Since the survey was primarily quantitative, there was a limited set of response options.

Conclusion

As STI rates increase, there is a need to increase the overall capacity for PN. Our study adds specific information regarding BC FPs’ practices, attitudes, and opinions regarding FP-initiated PN.

Although most FPs’ practices included some form of PN, most commonly through the education of index cases, most believed that PN should not be conducted by FPs. Insufficient time, poor compensation, and challenges in gathering partner information were commonly reported barriers. Better support for PN through a separate health care provider to follow up with partners, improved remuneration, and clearer clinical and legal guidance could increase uptake of FP-initiated PN. Development of PN resources for patients and reminders or resources linked to FPs’ electronic medical records or laboratory reports might also support engagement. These findings can be used to develop tools most useful to FPs in the effort to reduce the burden of STIs in our communities.

Acknowledgment

Funding for this project was provided by the Provincial Health Services Authority Shared Care and Specialist Services Committee’s Health Authority.

Notes

Editor’s key points

  • ▸ Effective management of sexually transmitted infections (STIs) requires timely diagnosis and treatment of both index patients and their partners. Partner notification (PN) reduces overall STI incidence and prevalence by preventing reinfection and onward transmission; however, PN is highly resource intensive. This study aimed to explore British Columbian FPs’ experiences with, perceived barriers to, and perceived facilitators of FP-initiated PN.

  • ▸ Most FPs surveyed always or usually told patients diagnosed with STIs to inform their partners, but few physicians performed PN. Two-thirds thought that PN should not be done by FPs. Time and compensation were among the most commonly cited barriers. Respondents expressed concern that FP partner services could be less consistent than those offered by public health. Others thought that given the sensitive nature of STIs patients would prefer PN be conducted through an external third party. Several FPs indicated that it might be inappropriate to treat a partner who could have their own FP, and thought it might lead to poorer continuity.

  • ▸ Physicians serving rural populations were more likely than those serving urban populations to collect partner information for those diagnosed with chlamydia and to contact partners (odds ratio of 3.85, 95% CI 1.15 to 12.91). There were no statistically significant associations between population served and current PN practices for gonorrhea, syphilis, and HIV.

Points de repère du rédacteur

  • ▸ Une gestion efficace des infections transmises sexuellement (ITS) exige un diagnostic et un traitement en temps opportun autant des patients de référence que de leurs partenaires. La notification des partenaires (NP) réduit l’incidence et la prévalence globales des ITS en prévenant une réinfection et une transmission en aval; toutefois, la NP nécessite beaucoup de ressources. Cette étude visait à explorer les expériences des médecins de famille (MF) de la Colombie-Britannique entourant leur perception des obstacles et des facteurs facilitants de la NP initiée par les MF.

  • ▸ La plupart des MF qui ont répondu au sondage disaient toujours ou habituellement aux patients ayant reçu un diagnostic d’ITS d’en informer leurs partenaires, mais rares étaient ceux qui procédaient à la NP. Les deux tiers d’entre eux étaient d’avis que la NP ne devrait pas être faite par les MF. Le temps requis et la rémunération insuffisante comptaient parmi les obstacles les plus souvent mentionnés. Les répondants se sont dit préoccupés par le fait que les services des MF aux partenaires puissent être moins uniformes que ceux offerts par la santé publique. D’autres croyaient que, compte tenu de la nature délicate des ITS, les patients ayant une ITS préféreraient que la NP se fasse par l’intermédiaire d’un tiers. Plusieurs MF ont indiqué qu’il pourrait être inapproprié de traiter des partenaires qui ont déjà leur propre MF, ce qui pourrait nuire à la continuité des soins.

  • ▸ Les médecins qui desservaient des populations rurales étaient plus enclins que ceux des populations urbaines à recueillir des renseignements sur les partenaires pour les personnes ayant reçu un diagnostic de chlamydia et à communiquer avec les partenaires (rapport de cotes de 3,85, IC à 95 % de 1,15 à 12,91). Il n’y avait pas d’associations statistiquement significatives entre la population desservie et les pratiques actuelles de NP pour la gonorrhée, la syphilis et le VIH.

Footnotes

  • ↵* The survey instrument is available from https://www.cfp.ca. Go to the full text of the article online and click on the CFPlus tab.

  • Contributors

    Drs Choi, Campbell, Pawa, Ng, and Wong contributed to the concept and design of the study, data collection, analysis, and interpretation. Dr Consolacion completed the statistical analyses. All authors contributed to writing or editing the manuscript and approving the final version for submission.

  • Competing interests

    None declared

  • This article has been peer reviewed.

  • Cet article a fait l’objet d’une révision par des pairs.

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Partner notification by family physicians for sexually transmitted infections
Alexandra Choi, Audrey Campbell, Theodora Consolacion, Jasmine Pawa, Brian Ng, Jason Wong
Canadian Family Physician Jun 2022, 68 (6) e182-e189; DOI: 10.46747/cfp.6806e182
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