Clinicians’ perspectives on why young Aboriginal people are not testing for sexually transmissible infections in Western Sydney

Introduction

The incidence of sexually transmissible infections (STIs) amongst young Aboriginal people, aged 18 to 29 are significantly higher compared to the rest of the Australian population. ¹ Whilst the impact of STIs varies across the country, it is recognised that STIs more adversely affect Aboriginal people. ¹ The Western Sydney Aboriginal community is large and diverse. For the purpose of this study we focused on the largest urban Aboriginal community in Australia, located in the Sydney Local Government Area (LGA) of Blacktown. ² The recruitment for this study was undertaken at a government run sexual health service that provides services into the western region of Sydney.

Blacktown LGA has a number of key characteristics that result in high rates of STIs, including the young age of the Aboriginal population and the large number of people who live in a small suburban area. ² According to the Australian Bureau of Statistics (ABS), the median age of the population is 21 years compared with the national average of 38 years. ² Due to the young age of the population, it is reasonable to surmise that this group may have a higher number of sexual partners compared to an older population. ³ Additionally, young people are also less likely to engage with public sexual health services which may lead to the exacerbation of poor health outcomes in this Western Sydney community. ⁴

The perspectives of clinicians managing young Aboriginal patients in sexual health services has been previously examined by several researchers in a number of geographic areas.^5–7 McCormack et al. explored how testing for STIs can be integrated into routine primary care screening at Aboriginal Community Controlled Health Services (ACCHS) and reported that, due to the stigma and fears of confidentiality breaches, the most acceptable way to undertake STI screening in a ACHHS was to integrate it into routine service delivery when patients present for other medical consultations. ⁵ ACCHS differ from the Government sexual health service examined in this study because they are health services that are lead by Aboriginal people, usually from the local community they serve ⁵ Other studies sought to understand the perspectives of clinicians through qualitative methods.^6,7 These studies focused on programmatic aspects of sexual health service delivery such as integrating sexual health testing into annual checks as a way of avoiding shame and stigma.

This study builds on existing research by seeking to better understand the perspectives of sexual health clinicians and social workers working in a Local Health District that is home to Australia’s largest urban Aboriginal population. It seeks to understand the unique and varied needs of Aboriginal people in these population dense Sydney suburbs and draw the knowledge and experience of these staff to enable culturally safe service delivery. These perspectives will also provide insight into the beliefs of these staff members and how they approach their work with Aboriginal young people, which may help inform future service design.

Methods

Results

The findings of this study revealed that clinician’s views on this topic fell into three clear themes about Aboriginal health service delivery which included personal, practical, and programmatic. Within these themes there were sub themes that speak to the experience of young people through the lens of experienced sexual health staff. Personal sub themes included the socio-cultural considerations such as discrimination, fear, privacy, social support, and trust. Practical sub themes related to the pragmatic aspects of accessing a clinical service such as clinic building design, opening times, convenience, physical location, and the ease of use of the existing appointment booking system. The programmatic sub themes included Aboriginal involvement in the service, cultural appropriateness, level of community engagement, education, risk perception, and service integration. Table 1 features a content analysis and shows the themes, subthemes, and vignettes that capture the essence of what clinicians emphasized in these interviews.

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Table 1.

Clinician interview themes.

Theme	Subtheme	Quote
Personal	Discrimination	Also, accessing a service that you feel might discriminate against you - or it might not feel as culturally appropriate or - I mean, it wouldn’t be - it wouldn’t be articulated in that way, but they wouldn’t understand, I think, is also a bit of an issue
	Privacy	I remember when I first started there, I was told that confidentiality was a big issue in the Aboriginal population. There was - is - there was a specific Aboriginal medical service based there, but I was told that a lot of the Aboriginal population were reluctant to use it, because they perceived there were confidentiality issues
	Social support	There are - I mean, from the patients that we see in Mount Druitt, there are massive social issues - people dying, people being beaten up - significant issues - not - unable to - drug and alcohol issues as well. Violence, general chaos. It’s - these things can be - these things are pressing concerns, whereas testing for something that you may or may not have - that you might not even know you’re at risk for - it’s not really on the agenda
	Trust	So I suppose first thing would just be to do really with the colonialization and just the idea that it’s a hospital and a government service, and not knowing what might happen, or have had bad experiences with government services in the past, and not been treated with respect because they’re an Aboriginal person. I think that’s still really prevalent
Practical	Clinic building design	I think it’s very clinical, it’s probably a bit too clinical, our clinic. I know a clinic has to be clinical, but you know. The actual waiting room, for example, it’s not very welcoming, it’s not colourful, there isn’t any particularly Aboriginal things there that I’ve noticed anyway. If there are, they’re not very well displayed. Even the counter’s forbidding for some people, I just think that it’s too - what we see as normal, or fine, isn’t necessarily something that is going to fit everyone
	Clinic opening times	Opening hours, asking the community. I think in Mount Druitt specifically, the transient movement of people through the area. So there seems to be a lot of family groups that come and then go to rural areas of New South Wales
	Convenience	Given the transient nature of people and their - and people moving around, well, ideally, you’d have something where people would come to you when they need you, but I think that’s shown time and time again it doesn’t work. So you’d probably need to go somewhere - but you’d need to destigmatise it somehow
	Physical location	I’ve been stunned at how fixed people are into location in that I’ll suggest maybe that people go from Mount Druitt to Penrith for a women’s health service, and they won’t go. They’re like, it’s too far. I’ll just try and find someone local
	Technology	For example, our telephone system is ridiculous. You actually physically have to answer the phone and people have to be put on hold or you have to get called back, which is ridiculous
Programmatic	Aboriginal involvement in service (staffing)	if you have Aboriginal people who are working to service Aboriginal people, then you’re saying, we care - we understand that there’s a cultural sensitivity that, regardless of how many courses I might do, I don’t get. So I think that’s important
	Cultural appropriateness (program aspects)	The other thing is, probably, culturally appropriate information about why they should access. I don’t know whether they actually exist. They may exist in a population that I haven’t seen, but I think - we have - for example, we have culturally appropriate - or not culturally appropriate, but at least in languages - so we have Chinese. We probably have some other languages, but Chinese mainly because that’s our population. I don’t know whether our information leaflets are culturally appropriate for Aboriginal and Torres Strait Island population
	Community engagement	I guess promoting ourselves. You know, I don’t know, increasing our profile. Because we still get people saying, look, we didn’t know you were here, so we still get a lot of that. I guess the groups we’re trying to attract probably communicate with each other, but yeah
	Education	Yeah. Well, I suppose from a health promotion point of view, there needs to obviously be a real focus on getting programs, I think, out away from clinics. If you educate and increase people’s health literacy and their self-determination I think as well, you’re then going to have a group of people that are activated and motivated
	Risk perception	I think maybe they don’t think they’re at risk, although they would be doing things that would put them at risk, but again whether that’s education. I remember there was a lady, she was from… and she’s an Aboriginal worker, she went to - I don’t know if it was… but it was somewhere like that. She said that their sex work practices are completely different from the norm, as in they swap sex for favours, not to earn money so much. It’s very casual and hidden. Casual but secretive, they didn’t identify, but she found out by the way she spoke to them
	Service integration	So well for starters it would have to be a holistic place to gather, so it would have to have other - so I think at the outset it can’t just be a sexual health clinic, because there’s a whole lot less stigma attached to just going into the sexual clinic. It’s also sometimes not a need that everyone identifies as their primary need, but it can come out

The personal aspects discussed reflect a broad range of socio-cultural factors that may stop young Aboriginal people accessing services because of issues that relate to colonization, stigma related to sexual health discussions in the Aboriginal community, and the fear that private matters relating sexual health would not be kept confidential. Practical aspects relating to access are pragmatic considerations that health consumers may consider when they are accessing a health service. Ranging from subtle aesthetic differences in the clinic design to issues such as the opening times, physical location and transport options, and the ease of booking appointments and accessing results. Programmatic aspects are issues that can broadly be addressed through changes in clinical practices, human resource initiatives, health education, and service redesign.

Discussion

Clinicians identified three clear themes which impact on young Aboriginal people engaging with sexual health services. These themes are important because they provide clear guidance to service providers about opportunities to explicitly address concerns and promote timely access and participation. The personal experience of healthcare is something that is impacted by broad socio-cultural factors such as discrimination, privacy, trust, and social support. These themes speak to the historical and contemporary context of Aboriginal communities and how colonialization has impacted their engagement with Government services that include health. The practical aspects of clinic building design, clinic opening times, convenience, physical location, and use of technology all fall into the realm of what contemporary health organizations would deem to come under the umbrella health service planning. All these factors affect how welcoming and easy to use a physical site is and they can be incorporated into the planning for renovations and new building design. The programmatic themes from this study included: Aboriginal Involvement in service (staffing); cultural appropriateness (program aspects); community engagement, education, risk perception, and service integration. These programmatic themes speak to the approach of the service, how it engages with its community and how it improves health literacy within populations that it serves.

Clinicians in our study believed the involvement of Aboriginal people in services contributed to a more inclusive and culturally appropriate service. The study also found that clinicians believed that young Aboriginal people were unaware of the risks of untreated STIs. Clinicians also believed that access barriers to clinical services in Western Sydney will be improved by greater Aboriginal community engagement in service delivery design. This might be achieved through measures that ensure privacy, and by providing comprehensive and appropriate education on the risk of STIs. In addition, there was broad agreement that greater education on the impact of STIs is needed to reduce STI incidence and improve health outcomes for young Aboriginal people. It is well established that development of educational resources would only be successful if co-designed and delivered with the Aboriginal community. ⁸

The findings in our study align with the work of McCormack and colleagues who found that in young Aboriginal people fear, stigma and privacy concerns were keys barriers to partaking in STI testing. ⁵ This study adds to the literature by highlighting that the factors impacting non-participation in sexual health services is multi-dimensional and needs to be addressed through changes in attitudes, places, and processes. The findings of this study provide a public health roadmap for engagement with young Aboriginal people in Western Sydney. Improved engagement will have dramatic implications for health outcomes by providing a model of care that directly aligns with the needs of the service users.

The high number of sub-themes identified under the programmatic theme suggests that there is a significant amount of work that need to be undertaken at the program and policy level to ensure that health organizations present sexual health services that meets the needs of this vulnerable group. The theme captures the important and significant work that needs to be undertaken in areas such as employment of Aboriginal people in clinical services, community education, integration with other services, and STI stigmatization through greater engagement with community members.

The second most important theme according to the number of references in the data relates to personal matters. This is not surprising because wrapped up under the personal theme are issues such as discrimination, privacy, social support, and trust. There is a paucity of data to support the impact that issues surround a health consumers personal experience of things such as discrimination can be a major and enduring barrier to that person accessing a health service, even to the point of adversely affecting life expectancy.

The practical theme speaks to issues that can be largely addressed in the planning and redesign of services. The sub-theme of clinic design and location are matters that may only be addressed in the planning stage of new services however this problem could also be remedied by offering sexual health services in other settings that do meet the practical requirements of health consumers. Other sub-themes such as opening times and technology related to appointment booking and results dissemination are challenges that can be addressed more immediately through a small service redesign or by applying for additional funds to improve service technology. The ability of a health service to address these issues lies largely in its desire to alter existing programs and practices that may be hindering the access of young Aboriginal people. The preference of young people themselves is key to making sure that the service modalities meet their expectations and needs.

Whilst it might appear that the findings have been noted in many journals over decades there are unique perspectives that are not covered by other literature in the area of Aboriginal sexual health. Much of the research commissioned by funders focusses on remote and very remote communities in Australia due to the startlingly high rates of STIs. ⁹ We believe that there is only a small amount of literature that is directly comparable, and we did not want to generalise findings from other parts of Australia that bare very little relevance culturally to this part of western Sydney. The fact that the biggest urban population of Aboriginal people like in the catchment area of this service makes this research worthwhile and the findings relevant to improving outcomes in this and other urban settings. ²

The main limitations of this study are that the data are only from one sexual health clinic and that it was not possible to obtain perspectives from Aboriginal staff as none were employed in the service. Whilst this research adds to the literature and provides useful insights into the perspectives of clinicians, it does not provide information of the direct experience of young people, who are the consumers of the services, or community Elders who are the knowledge holders, and set a tone about what is important in their communities. Further research amongst these two groups will provide a more holistic picture of the scope of the problems and the strategies that may lead to improving health outcomes.

Conclusion

Our study of the perspectives of sexual health clinic-based staff reports important findings that provide specific and pragmatic solutions to making sexual health services more welcoming, accessible, and safe places for young Aboriginal people in Western Sydney and beyond. If timely, effective, and culturally safe initiatives can be implemented it will allow for the acceleration of improvements in health equity. The positive outcomes of such an approach could result in an increase in access, testing, and treatment and therefore contribute to long term health outcomes. Clinicians must challenge themselves to reorient services, so they put the needs of patients at the centre of their approach to sexual health delivery in marginalized communities.

The National Aboriginal and Torres Strait Islander Health Plan 2013–2023 challenges us to think about healthcare delivery through a cultural lens and this study provides the building blocks for a contemporary approach to engagement and service delivery in an area that has been attached to a lot of shame and stigma. ¹⁰ Clinicians have a responsibility to ensure that sexual health services are accessible and culturally appropriate for young Aboriginal people. Aboriginal youth face unique challenges related to sexual health, including high rates of sexually transmitted infections. ¹ These challenges are compounded by historical and ongoing colonization, discrimination, and systemic barriers to accessing healthcare. ¹¹ By improving sexual health services for Aboriginal youth, clinicians can help to address these disparities and promote positive sexual health outcomes. By working collaboratively with Aboriginal communities and youth, clinicians can help to create a more equitable and just healthcare system for all.