Background of partner notification practitioners
Ten out of twelve invited practitioners attended the workshop: HAs (n = 8) and senior nurses (n = 2), working in GUM clinics (n = 6), young people’s services (n = 2) or community outreach clinics (n = 2). The locations ranged from large urban areas to smaller towns across England, in London, the South East, the South West, and Yorkshire and the Humber. Practitioners’ experience ranged from 2 to > 20 years, with equal male–female representation.
Data collected
Over 7 hours of data were collected and transcribed, including 15 role plays (five for each of the three PN strategies). The following themes were identified.
Theme 1: partner notification in practice
Partner notification
All practitioners experienced PN practice as highly individualised, negotiating and adapting their strategy to individual patient needs. Patient-related factors such as age, sexual orientation, nature and length of relationship, and willingness to contact partners were considered. Practitioners described using their instinct to guide their PN offer, although they found this difficult to articulate.
Instinct
You get a feel, and I think that’s always the trouble that my profession has had is to try and quantify what the ‘getting a bit of a feel’ is when you’re in an interaction with a patient and actually then trying to actually explain to someone else.
HA5, male, London, GUM clinic
I suppose on the first offering, [it’s about] reading how they feel about letting someone know, really, and getting a feel.
HA8, female, large southern town, GUM clinic
Highly individualised
It really depends on the patients and the story or understanding of their partners that you get.
HA2, female, London, GUM clinic
But it’s very much their decision because I think the outcomes will be much better.
HA1, female, northern city, community clinics
You usually know quite soon if they are happy to let an individual know. Or they might be happy to let one know and not quite sure about another one. So for me, it’s one to one with that individual. And also you kind of know if they are telling the truth.
HA8, female, large southern town, GUM clinic
Sexual orientation
[I have] done the gay men’s clinic for quite some time in various long spells, and that’s where the vast majority of provider referrals come from. You’re talking 20 to 30 people per patient. And it’s me. I also get a kick out of that. So I’m really giving them that. Yeah, it becomes a mission, actually. I start making charts of them all.
HA2, female, London, GUM clinic
Age
Young people have a specific pro forma which goes into all the issues around young people; not just the sexual health content. So it’s social, education, job protection; all that sort of stuff.
SN2, male, London, young people’s clinic
Nature and length of relationship
If they are in a primary relationship with somebody then I talk about the cycles of reinfection, it’s important for the partner. But if it’s an ex-partner or multiple or casual, then we just say, ‘You do not have any symptoms. It’s really important that we get these people in for at least a test.’
HA7, male, south coast city, GUM and community clinic
In discussions about how clinic staff manage PN, the amount of HA effort available because of patient case load was mentioned. There was a perception that not all clinics pursue PN with equal thoroughness:
I do not think we are quite as rabid as some of the clinics about getting every single name. I think we are much more inclined to be patient focused, but we then do check later on what the outcome is. So we do not just do it and then leave it, but we check with the index [patient].
SN1, female, southern town, GUM clinic
Partner notification aims
Health advisers reported the following aims when undertaking PN and used a variety of techniques to achieve them:
review the current status of the patient and recent past with respect to the STI
facilitate the health and STI status of the patient, preventing reinfection
emphasise the ‘here to help you’ role: advise and encourage rather than order action; remain impartial at all times
‘read the patient’ by building up a view on whether or not they believe the patient will do what they are saying they will do
identify all appropriate partners and priority partner(s) with the patient (e.g. current partner)
minimise the onward transmission of the STI through unwitting partners.
Motivational interviewing
Some aspects of the negotiation process adopted by HAs fit well within a motivational interviewing framework, particularly the following methods:
Be collaborative, not authoritarian. For example, reinforce support available, maintain and reinforce the patient’s control in the PN process, formulate plans, ensure they are committed to agreed outcomes.
Engage the patient’s own motivation. For example, ask what their main priorities and concerns are, discover intentions to notify a partner, work through examples and consequences.
Reinforce the patient’s autonomy. For example, give extra time to absorb and think about courses of action, explain how provider referral works in an anonymous setting.
Techniques used by health advisers to achieve patient notification aims
Patient choice: maintain and reinforce the patient’s control in the situation, ‘what would you like to achieve?’
Education: give the patient facts about their STI, its transmission and symptoms, treatment and complications if left untreated; explain how the HA will proceed on the patient’s behalf with reassurance of anonymity if contacting partners; correct any myths about the infection (e.g. only women can become infertile if chlamydia is left untreated, or men do not get symptoms).
Build scenarios: point towards consequences that could be faced later in response to a decision made now; question potentially flawed thinking, for example noting how suspicions and concern will be aroused (possibly magnified) if the partner realises a delay has occurred unnecessarily.
Check for and identify risks: was protection used in the relationship? Was sex consensual? Is the patient at risk of violence? Did the relationship end badly? Will the patient be reinfected?
Support: give ideas for ways to broach the subject with a partner; offer to ring back after a short period to allow the patient time to consider their options; offer ways to help the patient.
Build rapport through reassurance, for example ‘Due to lack of symptoms it’s impossible to say where it came from’; empathy, for example ‘Puts you in a difficult situation, we realise that, we can help you’; normalising the STI, for example ‘All girls know about chlamydia, it’s in all the mags now’; jokes, for example ‘You have got better things to do than come here . . .’
Use of hooks: use information given by the patient to help the patient navigate their choices, for example, if the patient reveals they had chlamydia 6 months ago, ‘We can call that a failed treatment [and then there’s no blame here within the couple]’.
Overcome challenges: respond rapidly to a patient’s block or fear, and try to free up the dialogue to continue the conversation in a positive direction.
Use the patient’s moral conscience to encourage disclosure: ‘I think the right thing to do would be’, ‘He needs to have a choice about what to do’, ‘They both need to know’.
Review, check back and ‘park’: throughout the conversation review and check which PN process has been agreed for each partner. If the conversation moves away from a partner, ‘park’ and return to discuss at a later point in the conversation.
Support tools
Pro formas and contact slips were commonly used as support tools to facilitate PN.
Pro formas
Eight out of 10 HAs reported that they use a pro forma or guidelines to capture details from a patient and recorded the following details:
diagnosis
name of HA who saw them
date of treatment
number of partners
details about partners: whether regular or casual sex/type of sex/where the sex took place/nature of the relationship/time length of relationship
outcome of PN conversation: untraceable/patient to inform/method used to inform contact
additional details (e.g. the last sexual encounter, whether protection was used and risk factors such as smoking or alcohol) were recorded when working with student populations.
Contact slips
Most HAs have access to contact slips which are used by patients to inform partners about the need for screening and the location of their nearest clinics. When the partner attends for testing/treatment, the slip is used to close the PN loop. If the partner attends a different clinic, the slips are returned to the originating clinic. One HA reported that recently revamped and colourful contact slips were having a positive effect on return rates.
New initiatives
One HA reported a new initiative where HAs are now responsible for dispensing medication, which brings forward contact with the HA before the patient has a chance to disengage with the service:
One link we use into engaging the patient is to dispense medication . . . And that was used as a sort of way of actually trying to just really have an opening link with the patient, rather than health advisers being seen as an add-on and policing their sexual behaviour.
HA5, male, London, GUM clinic
Another HA reported strong enthusiasm by young patients and MSM for an anonymous web-based PN tool during a recent straw poll of patients. Other online strategies are being considered by HAs (i.e. dating sites such as Gaydar or Plenty of Fish), although issues with patient confidentiality need to be worked through before HAs can use websites to facilitate their work.
Complex cases
A number of difficult situations were mentioned where HAs were uncertain about progressing with PN. These included sex workers and their clients; sauna users; patients with a history of repeated reinfection; and patients who say that they have no way of contacting a partner they met online.
Patient notification timings
The general timeline for PN involved five stages over a 2-week period:
Day 0: test result is positive.
Day 0–1: initial contact with patient to discuss the STI and next steps in managing the infection. PN is discussed and a plan of action on who will perform PN is agreed. Contact slips may be used for patients to pass information to their partners.
Day 1–14: PN undertaken by patient or HA.
Day 2–14: follow-up call by HA to check on PN progress and medicine compliance. The time delay varies depending on whether a patient referral had been agreed or if the patient wanted more time to consider their options.
Day 2 onwards: when partners have presented, the HAs attempt loop closure on PN, contributing to service auditing ().
Telephone call content from HA to patient during PN
Patient referral
Patient referral was the preferred first approach for most practitioners, who were concerned about the long-term impact if patients did not disclose themselves. Where clients were in a relationship, practitioners used motivational interviewing techniques to encourage patients to notify partners themselves.
But you’re responsible, it’s your body, it’s your relationship, it’s your partner, we are just trying to facilitate . . . you’re treated, we do not want you to get reinfected but we also want your partner to get the screening and treated because he might have something else.
SN2, male, London, young people’s clinic
I would think I like to give people the opportunity to refer themselves [perform patient referral]. I think the outcome is better for them.
HA8, female, large southern town, GUM clinic
I think they normally find that interaction [with the HA] quite helpful, to have that input, because that’s what they want for that situation [patient referral] but they might not necessarily have the skills.
HA7, male, south coast city, GUM and community clinic
Provider referral
All practitioners reported using provider referral to some extent, with some using it by choice and experience rather than as a clinic-endorsed practice. This was typically seen as more appropriate for casual or unknown partners, or for young patients who did not want to reveal their identity to partners within their social group. Greater uptake of provider referral was reported for students, women and particularly gay men, and it was seen as more suited to certain population contexts and types of infections, particularly the blood-borne viruses HIV and hepatitis B and C.
Some practitioners chose to use provider referral to achieve a perceived better outcome rather than negotiating with an unwilling patient to undertake notification themselves, although some felt uncomfortable that provider referral took away patients’ autonomy and choice.
Mostly we favour a provider referral just to take on ourselves and hopefully it’s going to take a better outcome as a result.
HA7, male, south coast city, GUM and community clinics
I would not say that the culture of my clinic was necessarily provider referral. That’s for me . . . because I know that I can get everything done.
HA2, female, London, GUM clinic
I know the main aim is that the partner is notified, but I tend to give people the benefit of the doubt and hope they will do a patient referral. And I find it made me a little bit uncomfortable from just taking away someone’s independence and choice.
HA8, female, large southern town, GUM clinic
Different population contexts and infection types
The provider referrals, I think, are by far . . . this is also an urban [city] clinic, so by far the preferred. I tend to do those [provider referral] more for the blood-borne infections, particularly with MSM.
HA2, female, London, GUM clinic
We have a high student population so we get quite good outcomes from provider referral.
HA1, female, northern city, community clinics
You can sometimes get [women] to look at the bigger picture and say, ‘But he might be infecting other women and you do not want other women to be in the same situation you are.’
HA3, female, London, GUM clinic
Contract referral
Practitioners reported using contract referral most often for patients with HIV infection or in other circumstances where protection of vulnerable patients was seen as a priority.
We do [offer contract referral] and it’s usually with HIV-positive patients. That’s the primary focus.
HA5, male, London, GUM clinic
Contract referrals, the only time that I know that it’s been used in my clinic has been around HIV patients and usually that process has begun as generated by the HIV team staff.
HA2, female, London, GUM clinic
[Contract for] HIV I think and ones with syphilis, geriatric with syphilis. We have used it a few times with HIV, with people who will not disclose their status but continuously put their partner at risk.
SN1, female, southern town, GUM clinic
Sometimes there’s vulnerability issues with the young person. There’s some child protection stuff. So quite often [we are] contracting with them that they need to do it by this amount of time or legally we would want to step in.
SN2, male, London, young people’s clinic
Theme 2: scenario building
Practitioners invested considerable time and effort in helping patients deal with difficult questions that disclosure might raise within the partnership, such as infidelity. Practitioners used motivational interviewing and challenged patients’ blocking strategies, helping patients to build scenarios and enabling them to project into the future and identify any anticipated regret. Practitioners also suggested creative solutions to introduce the subject to partners or elicit telephone numbers for previous partners.
When you do those patient referrals, sometimes [the patients] want to do them but they do not necessarily know the best ways. So I always say, ‘Have you thought about how you might bring the subject up?’ or ‘You might want to say . . .’
HA7, male, south coast city, GUM and community clinics
It’s our job to help you so it’s not about forcing you to do anything; it’s just working with you really. Obviously you can choose to tell them yourself but obviously you have been a bit worried about that. What we can do is we can let them know on your behalf if it helps?
HA4, female, London, GUM clinic
Is it possible to say, ‘Look, if we are going to be starting to think about trying for a baby maybe I’d better go for a sexual health check up, and check that I have not got anything before we start because I’ve had sex with people before you?’
HA3, female, London, GUM clinic
The first thing people often say is ‘Hang on a moment, why did you not tell me?’ And that creates a whole other dynamic for you.
HA5, male, London, GUM clinic
Approach it very calmly, say that in your history, ’cos it’s a new relationship, as someone that you like to consider your sexual well-being so actually while you were away you decided to have a check up. And then you can decide what you want to tell him the outcome of that was . . . would you rather he found out from a third party or from you?
HA5, male, London, GUM clinic
And it’s a fairly new relationship, so I do not think that it’s without . . . I do not think it’s outside the expected realm that this is a possibility in a new relationship that an infection could be there. You would not actually have to disclose that . . . he knew you had a previous partner just before him, you would not really have a reason to have to tell him there was any overlap at all. He would not gain anything from knowing that.
HA2 female, London, GUM clinic
You can just maybe talk to some work guys, just to get his phone number. Just say he owes you £5, track him down like that.
HA4, female, London, GUM clinic
Creative solutions
What do you think about maybe telling him you have been to the GP, you had thrush or a urinary infection; something like that? And your GP has suggested that you both either go to your GP or both go to the local clinic and have a full check up?
HA3, female, London, GUM clinic
Theme 3: movement between strategies
Although practitioners were able to define the three distinct PN methods, it emerged through role play that there was often a fluid movement between methods as a response to individual patient need. This movement between strategies was enacted through either a follow-up call to check on progress (usually 2 weeks) or a shorter check-back call (2 days) for patients who needed time to consider their options. A time frame for the call was agreed with the patient at the initial consultation.
I can give you a little while to think about it, a couple of days, and then give you a ring back and see how you are feeling about it.
HA1, female, northern city, community clinic
Delayed provider referral
Practitioners often held the offer of provider referral in reserve at the initial consultation and proposed it only during the agreed follow-up call if it became clear that the patient had been unable or unwilling to broach PN with a partner. Practitioners considered this delayed provider referral as normal practice and did not distinguish it from an immediate offer of provider referral. However, they acknowledged that delayed provider referral was sometimes clearly inappropriate, for example when the patient was unwilling to attempt a patient referral first.
Everyone would be followed up and it’s on that follow-up call for, say, chlamydia, 2 weeks down the line, to actually talk to them and reassess the situation. If then they have had problems you do provider referral.
HA8, female, large southern town, GUM clinic
In some cases, practitioners suggested that patients who were initially undecided about provider referral took extra time to decide. Practitioners negotiated a time frame to check back with the patient, allowing them time to absorb information and consider implications already discussed.
We do when there’s a fragility, a psychological vulnerability around the impact of that diagnosis. But I can sense that actually it’s important that they do tell their partner, they want to tell their partner but, actually, they just cannot quite work it out at this point and they need more time to absorb it and think about it. So often I will say to them, ‘Well, why don’t we set a timeframe here . . . If I follow you up, maybe by that point you’ll have got to this stage,’ and then I follow them up.
HA5, male, London, GUM clinic
Theme 4: contract or delayed provider referral?
Participants did not regard contract referral as normal practice for common bacterial STIs. Discussions across the day demonstrated some ambiguity and inconsistency around what constituted a contract referral. Some practitioners described contract referral as an agreement made with the patient that they would follow them up within a set time frame to check their progress, and that this agreement constituted a contract.
So they are expecting a call, so in effect that’s a kind of contract that we will [follow up]. I’m not saying you have got to do it by this time, but I’m definitely going to follow you up.
HA8, female, large southern town, GUM clinic
We tell all our patients that we will call them in a couple of weeks’ time just to see how they are and we wrap it round saying, ‘Did you have any problems after the tablets? Were you okay?’ But we always tell them [in advance] and say, ‘And then we can see how you’re getting on with telling your partners.’ So, in a way, the contract referrals are implicit in the normal way that we work because of the checking we do at 2 weeks. If they have not been able to do it then, then we’ll [offer provider referral].
HA3, female, London, GUM clinic
However, this is not contract referral as previously defined (see ). The practitioner has not agreed with the patient that their partner will be notified directly by the practitioner if they have not attended by a certain time. Instead they have agreed a follow-up call to check on progress. The key difference is that the patient still must agree to provider referral, rather than this having already been agreed or contracted. An indication of whether contract referral has taken place is whether the practitioner collected partner details during the initial conversation for subsequent use if needed. Three of ten practitioners said they would initially request partners’ names so that they could refer to them clearly in conversation with the patient, but none would ask for further partner contact details until an offer of provider referral had been accepted.
Findings in relation to published literature
We found conflicts between practice and guidance. Contract referral as presented in the SSHA manual states:
A hybrid approach may be employed where an initial patient referral is followed up by a provider referral after an agreed period of time, if the contact has not attended.
(p. 20)64
This implies that a contract is made with the patient during the initial consultation that the practitioner will contact a partner directly if they have not attended by an agreed period of time – no questions asked.
However, guidance for patient referral states:
It is important to negotiate a back-up plan during the first interview, if possible (for example, ‘If he’s not been within x days/weeks should I contact him directly, or speak to you again? . . . Is it ok to ring you? . . .’)
(p. 32)64
If the patient agrees to the practitioner contacting the partner directly as a back-up plan, this would constitute a contract referral as defined earlier in the manual. If the patient agrees to be called back and subsequently takes up the offer of provider referral, this would fall under ‘provider referral’ in the guidance, despite differing from a provider referral agreed at the initial consultation. Confusingly, some participants described this incorrectly as ‘contract referral’, even though there was no initial agreement for the practitioner to contact the partner directly.
If a separate category of delayed provider referral was introduced into the guidance this could clarify between a provider referral offered initially and one offered as part of a back-up plan, as is common practice. This would help practitioners to accurately categorise this type of PN offer as a ‘delayed provider referral’ and not as a ‘contract referral’.
Guidance also recommends that for patient referral:
A follow-up interview may be necessary if there is no record of the contact having attended. The purpose of this is to check progress, gather any additional data and repeat the offer of provider referral if the index patient is having difficulty. There is evidence that many patients who initially opt to inform their own partners subsequently agree to provider referral at follow-up interviews.
(p. 32)64
The guidance to ‘repeat the offer of provider referral’ at the follow-up call suggests that an offer of provider referral should have already been made at the initial planned patient referral consultation.
These ambiguities seem to occur as a result of attempting to use distinct definitions for PN methods in the guidance to describe the fluid PN strategy adopted by many practitioners in practice. Some practitioners said they found the term ‘contract’ unhelpful, as its meaning overlaps with negotiating a provider referral, which was closer to how they saw their work.
