title: Barriers and facilitators of sexually transmissible infection testing in remote Australian Aboriginal communities: results from the Sexually Transmitted Infections in Remote Communities, Improved and Enhanced Primary Health Care (STRIVE) Study.
abstract: Background Remote Australian Aboriginal communities experience high rates of bacterial sexually transmissible infections (STI). A key strategy to reduce STIs is to increase testing in primary health care centres. The current study aimed to explore barriers to offering and conducting STI testing in this setting.
  
  
  METHODS
  A qualitative study was undertaken as part of the STI in Remote communities, Improved and Enhanced Primary Health Care (STRIVE) project; a large cluster randomised controlled trial of a sexual health quality improvement program. We conducted 36 in-depth interviews in 22 participating health centres across four regions in northern and central Australia.
  
  
  RESULTS
  Participants identified barriers including Aboriginal cultural norms that require the separation of genders and traditional kinship systems that prevent some staff and patients from interacting, both of which were exacerbated by a lack of male staff. Other common barriers were concerns about client confidentiality (lack of private consulting space and living in small communities), staff capacity to offer testing impacted by the competing demands for staff time, and high staff turnover resulting in poor understanding of clinic systems. Many participants also expressed concerns about managing positive test results. To address some of these barriers, participants revealed informal strategies, such as team work, testing outside the clinic and using adult health checks.
  
  
  CONCLUSIONS
  Results identify cultural, structural and health system issues as barriers to offering STI testing in remote communities, some of which were overcome through the creativity and enthusiasm of individuals rather than formal systems. Many of these barriers can be readily addressed through strengthening existing systems of cultural and clinical orientation and educating staff to view STI in a population health framework. However others, particularly issues in relation to culture, kinship ties and living in small communities, may require testing modalities that do not rely on direct contact with health staff or the clinic environment.
authors.affiliation: Apunipima Cape York Health Council, Cairns, PO Box 12045, Earlville, Qld 4870, Australia.
authors.forename: Belinda
authors.initials: B
authors.lastname: Hengel
authors.affiliation: Kirby Institute, UNSW, Australia, Sydney, NSW 2052, Australia.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Guy
authors.affiliation: NT Department of Health, Sexual Health and Blood Borne Virus Unit, Darwin, NT 0810, Australia.
authors.forename: Linda
authors.initials: L
authors.lastname: Garton
authors.affiliation: Baker IDI, PO Box 1294, Alice Springs, NT, 0871, Australia.
authors.forename: James
authors.initials: J
authors.lastname: Ward
authors.affiliation: Menzies School of Health Research, PO Box 41096, Casuarina, Darwin, NT 0811, Australia.
authors.forename: Alice
authors.initials: A
authors.lastname: Rumbold
authors.affiliation: Menzies School of Health Research, PO Box 41096, Casuarina, Darwin, NT 0811, Australia.
authors.forename: Debbie
authors.initials: D
authors.lastname: Taylor-Thomson
authors.affiliation: Menzies School of Health Research, PO Box 41096, Casuarina, Darwin, NT 0811, Australia.
authors.forename: Bronwyn
authors.initials: B
authors.lastname: Silver
authors.affiliation: Kirby Institute, UNSW, Australia, Sydney, NSW 2052, Australia.
authors.forename: Skye
authors.initials: S
authors.lastname: McGregor
authors.affiliation: Kirby Institute, UNSW, Australia, Sydney, NSW 2052, Australia.
authors.forename: Amalie
authors.initials: A
authors.lastname: Dyda
authors.affiliation: Lismore Sexual Health Service, NSW Health, Sydney, NSW 2480, Australia.
authors.forename: Janet
authors.initials: J
authors.lastname: Knox
authors.affiliation: Kirby Institute, UNSW, Australia, Sydney, NSW 2052, Australia.
authors.forename: John
authors.initials: J
authors.lastname: Kaldor
authors.affiliation: Kirby Institute, UNSW, Australia, Sydney, NSW 2052, Australia.
authors.forename: Lisa
authors.initials: L
authors.lastname: Maher