Understanding the role of patient communication protocols in sexually transmissible infections point-of-care testing among Aboriginal and Torres Strait Islander peoples in remote communities: a qualitative study

Introduction

Untreated sexually transmissible infections (STIs), such as Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG), can result in severe health consequences, including pelvic inflammatory disease, infertility,¹ and increased risk of HIV.² The asymptomatic nature of many STIs, and shame and embarrassment,³ can inhibit sexual healthcare engagement. Timely access to testing and treatment are crucial to reducing STI transmission.⁴

The Australian STI Management Guidelines for use in Primary Care Settings (Aboriginal and Torres Strait Islander peoples) recommend that people living in remote, higher-prevalence communities who are sexually active, aged 15–35 years, and are not in a monogamous relationship, undergo STI testing every 6–12 months.⁵ However, recent survey findings of young Aboriginal and Torres Strait Islander peoples, aged 16–29 years, indicate low uptake of testing, with 36% of participants reporting never having undergone STI testing.⁶

Aboriginal Community Controlled Health Centres (ACCHSs) are culturally safe primary care services, which operate in communities across Australia with high Aboriginal populations. An ACCHS is a primary healthcare service initiated and operated by the local Aboriginal community to deliver holistic, comprehensive, and culturally appropriate health care to the community that controls it, through a locally elected Aboriginal Board of Management.⁷ In remote settings, accessing sexual health care can be challenging, particularly in communities where choice of healthcare providers is limited (e.g. in remote settings, which may only have one health service),⁸ and culturally appropriate gender-sensitive health care may not always be available due to staff shortages.⁹ Remote Australian health care is also characterised by high turnover of staff, and is often reliant on locum staff using a fly-in/fly-out model, which can create barriers in developing rapport and building support and engagement with community members.^10–12 Additionally, this model is often focused on acute and triaged care patients, leaving little resourcing for preventive health care.

Shame and stigma can underpin sexual healthcare engagement,¹³ particularly among young Aboriginal and Torres Strait Islander peoples.¹⁴ Patients in smaller communities are more likely to know personnel working at the health service and may be less likely to attend for STI-related reasons due to concerns about confidentiality. Research has found that in remote settings, lack of symptoms and lack of awareness of STIs inhibited health-seeking from patients (individual level), while concerns of shame and embarrassment of being seen to be accessing a health service (social and health service levels) further limited patient access for sexual health care.¹⁴ Additionally, the limited availability of services, and subsequent lack of choice of services, can exacerbate barriers, such as confidentiality concerns. These findings suggest the critical need for healthcare providers to be skilled in comfortably and appropriately engaging Aboriginal and Torres Strait Islander peoples in discussions about sexual health, including offering STI testing.

In regional and remote Australia, there are multiple factors that contribute to delays in the diagnosis and treatment of STIs. These factors include geographical distance from diagnostic laboratories (whereby infrequent planes may be required to transport specimens), constrained health service capacity to locate and recall patients for treatment due to workforce shortages (patient recall can be difficult and may require outreach support by the health service),¹⁵ and a highly mobile young population.¹⁶ Point-of-care (POC) testing, that is, testing which is completed outside of a laboratory and conducted at or near the patient, can reduce health costs and waiting times, facilitate timely diagnoses and treatment accuracy, and facilitate patient follow-up.¹⁷ The Test Treat ANd GO (TTANGO) program supports the delivery of integrated molecular STI POC testing in more than 70 remote and regional primary care services in six jurisdictions across Australia. Trained healthcare providers conduct molecular POC tests (for CT/NG) onsite, with laboratory-comparable results available in 90 min.¹⁸ This program was initiated as a randomised trial (TTANGO 2013–2015),¹⁹ with findings rapidly translated and scaled up into a sustained national program (TTANGO2 2016–2019; TTANGO3 2020-current).²⁰

Drawing on interviews with trained STI POC operators within the period of TTANGO2 implementation, this study seeks to understand the ways in which healthcare providers engage Aboriginal and Torres Strait Islander peoples for STI testing using POC diagnostics and how these engagement practices align with patient and cultural safety for patients in order to overcome known barriers to STI testing.

Methods

Healthcare personnel were recruited from seven primary care clinics participating in the TTANGO2 program in 2018. Clinics were located in remote and regional areas across four jurisdictions within Australia, including the Northern Territory, Queensland, South Australia, and Western Australia. Most of the clinics are ACCHSs, with one clinic governed by a state health department. Clinics primarily serviced Aboriginal and Torres Strait Islander patients in small, geographically isolated, and remote communities. Detailed information about clinic site selection for this qualitative study has been previously reported.²¹ Clinics were purposefully selected from within the TTANGO2 program to include those with ‘high’ (n = 3) and ‘low’ use of STI POC testing (n = 4). Clinics were categorised based on the number of STI POC tests performed in the previous 12 months. ‘High’ testing clinics were defined as those which conducted >150 STI POC tests over the previous year and consistently reported >10 STI POC tests per month; ‘low’ testing clinics were defined as those with <150 POC tests over the previous year and consistently reported ≤10 STI POC tests per month.²¹ Although we employed a metric to assess clinics as either ‘high’ or ‘low’ performing of STI POC testing, assessment of clinics by a single domain is not indicative of a clinic’s overall performance in other healthcare delivery/service domains.²²

Purposive sampling²³ was undertaken to recruit comparable personnel (e.g. Clinic/Practice Managers, Aboriginal Health Workers/Practitioners (AHWs/AHPs), nurses) from each of the seven selected clinics. The TTANGO2 Program Coordinator contacted Practice Managers/Clinic Coordinators at each of the clinics for a list of potential healthcare personnel participants at their respective clinic. The interviewer (LL) then contacted potential participants directly; one nurse declined to participate (reason not provided).

The interview guide was developed by the study authors with input from both the TTANGO2 Investigator and Executive Groups (with the former comprised of study investigators and the latter comprised of study investigators, representatives from state/territory Aboriginal health peak bodies and representatives from state/territory health departments). Participants were asked to reflect on their experiences relating to their use of STI POC testing, normalisation of STI POC testing, cultural and community acceptability of STI POC testing, sustainability of STI POC testing, and personal individual demographic characteristics.

Nearly half of interviews were conducted in person (nine interviews across two clinics), with the remainder completed over the phone (11 interviews across five clinics). Participants were not remunerated. Interviews were audio-recorded and transcribed verbatim.

Deidentified transcripts were uploaded to NVivo 12 qualitative software (QSR International). An initial round of deductive coding was conducted (LL) and informed by the interview guide. Following this, topic summaries informed a secondary round of inductive coding (RM and LL) to synthesise themes within the nodes relevant to patient communication protocols.²⁴ The first author (RM) is a respected Aboriginal man who has been engaging and consulting with Aboriginal and Torres Strait Islander communities across Australia for more than two decades. LL is an experienced qualitative health researcher working in infectious diseases in key settings. During analysis, RM applied a cultural lens, reflecting Indigenous ways of knowing, being, and doing when reviewing the data.²⁵ During the inductive coding process, RM and LL iteratively discussed themes within the data. Through this reflective process, patient communication protocols were found to encompass how patients were offered testing (within the context of POC testing), how patients were followed up (delivering results), and contact tracing strategies.

All participants had completed STI POC training as part of the TTANGO2 program. The participants’ staff roles and whether they worked at a ‘high’/’low’ STI POC testing clinic are presented alongside participant quotes. ‘Management’ refers to all managerial positions held by participants within this study (i.e. Service Coordinators, Practice Managers, and Clinic Managers). ‘Nurses’ includes Enrolled Nurses and Remote Area Nurses. AHWs and Aboriginal Health Practitioners AHPs are combined into AHWs/AHPs. While some participants did not have direct patient-engagement roles, it is likely their management duties within the services influenced healthcare personnel adoption and implementation of STI POC testing, or they were aware of strategies utilised by healthcare personnel to engage patients in STI testing.

All participants received a participant information statement and consent form and provided signed consent prior to interview.

Results

Twenty healthcare personnel who received POC operator training as part of the TTANGO2 program participated in a semi-structured interview. Participants included AHWs/AHPs (n = 8), Nurses (n = 7), Coordinators (including chronic disease and sexual health) (n = 2), and Managers (n = 3).

Themes relating to healthcare workers’ implementation of STI POC testing and broader sexual health engagement centred on various aspects (and timepoints) of STI-related patient communication protocols, including offering testing (inclusive of opportunistic), patient follow-up (i.e. providing results to patients), and concerns relating to contact tracing. Personnel identified patient shame and concerns of confidentiality as underpinning many aspects of patient communication protocols. This suggests that healthcare providers’ understanding of local cultural knowledge and cultural safety, relevant to patient communication protocols and patient-provider relationship building, likely influence patient uptake of comprehensive STI testing.

Discussion

The language used during healthcare engagements underpinned all aspects of STI testing (whether specifically offering POC testing or not), including the framing of offering testing (whether opportunistic or risk-based), making a plan with the patient for same-day follow-up for test results, and mitigating concerns of contact tracing. The importance of sensitive language around offering STI POC testing was viewed by several participants as fostering patient safety and facilitating care engagement. Healthcare workers identified the role of offering a POC test opportunistically as overcoming patient barriers through normalising testing and communicating the benefits of POC testing (e.g. rapid results). Discussions around POC testing were viewed as beneficial in facilitating conversations about STIs, including risks, testing, and treatment. However, some personnel described missed opportunities for patient education of STI risks and transmission. Shame, stigma, and confidentiality were regarded as the primary barriers to uptake of STI testing, though this was often viewed in the absence of normalising language to offer testing. Our findings suggest that STI POC testing, when offered in a culturally informed and culturally safe way can assist with overcoming known barriers to sexual healthcare engagement and foster participation in STI testing in remote Aboriginal and Torres Strait Islander communities.

Shame in the context of sexual health requires a holistic approach that considers the individual needs and experiences of patients, as well as the broader social and cultural contexts in which health care is delivered.²⁶ While participants described being aware that this barrier existed among patients in the communities in which they worked, only some healthcare personnel purposefully sought out strategies to mitigate this barrier for patients. This included provision of opportunistic STI POC testing and considered use of language (e.g. ‘offer that PCR test and explain that you test for everything’), rather than explicitly identifying the STIs being tested for (e.g. NG, CT), or focusing on risky behaviour. Opportunistic testing has been found to reduce shame associated with STIs, particularly among Aboriginal men presenting at health services.²⁷ Young Aboriginal peoples have reported that inclusion of opportunistic STI testing into routine health care or health checks reduces barriers through normalising testing.²⁸ However, it was viewed by some healthcare personnel that patient concerns regarding confidentiality continued to impede care engagement.⁹

Shame in a healthcare setting can significantly impact patients’ willingness to seek care and disclose sensitive information,²⁹ further amplifying the importance of offering testing through use of normalising language. Healthcare workers can create a safe and non-judgmental environment where patients feel comfortable discussing sexual health. As evident in the data presented, this involves adopting an empathetic and accepting attitude, using inclusive language, and respecting patient autonomy and confidentiality.

Primary healthcare personnel in remote communities often have not received formal sexual health training.⁹ This can result in a lack of knowledge on the part of the healthcare provider as to when to offer testing (e.g. opportunistically or risk-based) and, consequently, much of the workforce may lack the awareness or appropriate language to offer testing in a culturally appropriate way. Ultimately, this lack of training likely hinders pathways to testing and treatment. A targeted intervention, such as STI POC testing, in which health staff aim to ‘test everyone’ attending the clinic or test everyone in the community within a short time frame¹⁶ and using appropriately trained staff, may mitigate some of these barriers. However, this would require a rollout of workforce training to upskill healthcare workers to effectively offer testing in a way that would encourage uptake by patients. The inclusion of culturally informed training on how to offer an STI test, incorporating culturally appropriate language, would enhance POC operator training.

Some participants reported that discussion of the STI POC test provided a starting point for dialogue with patients about their sexual health, thereby providing a pathway for sexual health education conversations. This aligns with ‘best practice’ research for patient-centred communication whereby providing information, supporting patients in decision-making, and enabling disease and treatment-related behaviour, enhances quality of care and improves patient outcomes.³⁰ As such, discussing available healthcare interventions with patients may provide multiple benefits, including reducing barriers to care while simultaneously empowering patients about their medical decision-making and autonomy in a culturally safe way.

Patient communication protocols were not limited to the clinical setting but often were extended into the community when returning results following POC testing. Although 90 min is regarded as ‘timely’ compared to an average of 10 days for CT/NG if relying on laboratory test results,²⁰ the experiences in remote communities concerning confidentiality considerations are complex, and suggest that some patients may still prefer to leave the clinic as soon as possible to protect their privacy; preferring to be located shortly thereafter in their community or by phone. A desire not to wait in healthcare services for STI POC test results is not unique to people in remote communities, with research suggesting that reduced wait time will better enhance the optimisation of POC testing as a diagnostic tool for reducing STI prevalence and transmission.³¹ Thus, patient engagement regarding follow-up was still regarded as a critical piece to the testing puzzle. Healthcare workers demonstrated engagement strategies that sought to develop healthcare patient-provider relationships built on trust and time spent with individuals and in the community.

Healthcare providers reflected on patient concerns about their confidentiality for STI testing and partner notification in the event of a positive result. Confidentiality concerns are routinely raised as a barrier to sexual healthcare engagement among Aboriginal and Torres Strait Islander peoples.^9,14,32,33 For example, although a benefit of STI POC testing has been deemed as enhancing timeliness of partner notifications,³⁴ the realities of partner notification are often nuanced and are further complicated in smaller communities. Healthcare providers demonstrated their capacity to understand the subtleties of partner notification and to engage in discussions with patients that prioritised patient safety while also facilitating clinical responses to partners requiring screening.

A systematic review found the four primary barriers to sexual health care included (1) cultural and societal views relating to sexual health; (2) stigma, discrimination and embarrassment; (3) lack of training and education among healthcare providers; and (4) quality of clinician-patient relationships.³⁵ This suggests that the successful strategies for patient communication protocols relating to sexual health identified in this paper may be applicable or transferable to other population groups.

A key limitation of this study is the absence of patient perspectives, which hinders a comprehensive understanding of patient experiences, preferences, and barriers to sexual healthcare engagement. Patient perspectives are crucial for identifying gaps in service provision, addressing cultural sensitivities, and tailoring interventions to meet the needs of Aboriginal and Torres Strait Islander communities. The current study’s focus on healthcare personnel perspectives narrows the scope of inquiry. However, our findings are consistent with the literature, including patient-focused studies, in relation to barriers to sexual healthcare engagement among Aboriginal and Torres Strait Islander peoples.³³ Future research should engage Aboriginal and Torres Strait Islander peoples about the preferred language and approaches for being offered STI (POC) testing to foster greater testing uptake.

Conclusion

STI POC testing has previously been found to be acceptable among healthcare workers and patients within Aboriginal and Torres Strait Islander healthcare services.²¹ Our findings indicate that patient safety is an important component of sexual healthcare engagement in Aboriginal and Torres Strait Islander communities, and language used by healthcare providers, particularly in relation to offering STI testing, can influence patient uptake of sexual health care. Integrating STI POC testing in routine/holistic health care, such as opportunistic testing, can reduce shame and may allow for greater uptake of STI testing. However, same-day results may still require patient follow-up within the community (as preferred by the patient); appropriate follow-up should continue to ensure patient confidentiality is prioritised. Additionally, explanations of STI POC testing can help reduce patient-related barriers, such as shame and stigma, while also providing an opportunity for health education. Offering STI POC testing in a culturally safe and competent manner has the potential to increase the sexual healthcare engagement of Aboriginal and Torres Strait Islander peoples living in remote communities.