Publications by authors named "Bronwyn Silver"

23 Publications

  • Page 1 of 1

The Adaptation of a Youth Diabetes Prevention Program for Aboriginal Children in Central Australia: Community Perspectives.

Int J Environ Res Public Health 2021 Aug 31;18(17). Epub 2021 Aug 31.

Menzies School of Health Research, Charles Darwin University, Casuarina 0810, Australia.

This study reports on integrating community perspectives to adapt a family-focused, culturally appropriate behavioural intervention program to prevent diabetes among Aboriginal children (6-11 years) in Central Australia. A participatory action research approach was used to engage a range of service providers, cultural advisors, and family groups. Appropriateness, acceptability, content, and delivery of a prevention program within the Central Australian context were discussed through a series of workshops with twenty-five service providers and seven family groups separately. The data obtained were deductively coded for thematic analysis. Main findings included: (i) the strong need for a diabetes prevention program that is community owned, (ii) a flexible and culturally appropriate program delivered by upskilling community members as program facilitators, and (iii) consideration of social and environmental factors when implementing the program. It is recommended that a trial of the adapted prevention program for effectiveness and implementation is led by an Aboriginal community-controlled health service.
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http://dx.doi.org/10.3390/ijerph18179173DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8430517PMC
August 2021

Improving systems of prenatal and postpartum care for hyperglycemia in pregnancy: A process evaluation.

Int J Gynaecol Obstet 2021 Jul 31. Epub 2021 Jul 31.

Division of Wellbeing and Preventable Chronic Disease, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia.

Objective: To identify successes to date and opportunities for improvement in the implementation of a complex health systems intervention aiming to improve prenatal and postpartum care and health outcomes for women with hyperglycemia in pregnancy in regional and remote Australia.

Methods: A qualitative evaluation, underpinned by the RE-AIM framework (reach, effectiveness, adoption, implementation, maintenance), was conducted mid-intervention. Semi-structured interviews were conducted with the participants, who included clinicians, regional policymakers and managers, and study implementation staff.

Results: Interviewees (n = 45) reported that the early phase of the intervention had resulted in the establishment of a clinician network, increased clinician awareness of hyperglycemia in pregnancy, and improvements in management, including earlier referral for specialist care and a focus on improving communication with women. Enablers of implementation included existing relationships with stakeholders and alignment of the intervention with health service priorities. Challenges included engaging remote clinicians and the labor-intensive nature of maintaining a clinical register of women with hyperglycemia in pregnancy.

Conclusion: The early phase of this health systems intervention has had a positive perceived impact on systems of care for women with hyperglycemia in pregnancy. Findings have informed modifications to the intervention, including the development of a communication and engagement strategy.
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http://dx.doi.org/10.1002/ijgo.13850DOI Listing
July 2021

Evaluating antimicrobial prescribing practice in Australian remote primary healthcare clinics.

Infect Dis Health 2021 Aug 17;26(3):173-181. Epub 2021 Mar 17.

Centre for Remote Health, Flinders University, Corner Simpson & Skinner Streets, Alice Springs, 0870, Northern Territory, Australia; University of Queensland Centre for Clinical Research, Royal Brisbane & Women's Hospital Campus, Building 71/918, Herston, 4092, Queensland, Brisbane, Queensland, Australia; Pharmacy Department, Alice Springs Hospital, Gap Rd, Alice Springs, 0870, Northern Territory, Australia. Electronic address:

Background: Inappropriate antimicrobial prescribing contributes to the emergence of antimicrobial resistance. Gaps exist in the understanding of antimicrobial prescribing in the remote setting. We aimed to assess adherence to guidelines and appropriateness of antimicrobial prescribing in Central Australia.

Methods: A retrospective study assessing antimicrobial prescriptions in ten Aboriginal clinics (three in remote communities and seven in regional centre) using a validated evaluation tool. Antimicrobials prescribed between 1 January-31 December 2018 were randomly selected for inclusion into the study. The main outcome measures were the rates of guideline adherence and inappropriate prescribing.

Results: A total of 180 prescriptions were included (96.1% Aboriginal, 32.2% male). Ninety-nine (55.0%) prescriptions were written by general practitioners (GPs), 57 (31.7%) by nurses and 24 (13.3%) by others. Forty-three (25.7%) assessable prescriptions were deemed inappropriate and 75 (44.4%) did not adhere to guidelines. Prescriptions written by GPs were less likely to adhere to guidelines, particularly GPs located in remote communities. The most common reasons for inappropriate prescribing were incorrect dosage/frequency and antimicrobial not indicated. Skin and soft-tissue infection was the commonest indication, with 29 of 41 (70.7%) prescriptions deemed appropriate. Prescriptions for lower respiratory-tract infection had the lowest rate of appropriateness, with one of seven prescriptions deemed appropriate (14.3%). Antimicrobials with the lowest rate of appropriateness were ciprofloxacin, amoxicillin-clavulanate and cefalexin, at 50%, 56%, and 62%, respectively.

Conclusion: A quarter of antimicrobial prescriptions written in select remote central Australian Aboriginal primary healthcare clinics were deemed inappropriate. The implementation of a comprehensive antimicrobial stewardship program is recommended.
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http://dx.doi.org/10.1016/j.idh.2021.02.001DOI Listing
August 2021

Adverse pregnancy and neonatal outcomes associated with systematic review and meta-analysis.

Sex Transm Infect 2021 03 12;97(2):104-111. Epub 2021 Jan 12.

Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland.

Objective: To examine associations between (NG) infection during pregnancy and the risk of preterm birth, spontaneous abortion, premature rupture of membranes, perinatal mortality, low birth weight and ophthalmia neonatorum.

Data Sources: We searched Medline, EMBASE, the Cochrane Library and Cumulative Index to Nursing and Allied Health Literature for studies published between 1948 and 14 January 2020.

Methods: Studies were included if they reported testing for NG during pregnancy and compared pregnancy, perinatal and/or neonatal outcomes between women with and without NG. Two reviewers independently assessed papers for inclusion and extracted data. Risk of bias was assessed using established checklists for each study design. Summary ORs with 95% CIs were generated using random effects models for both crude and, where available, adjusted associations.

Results: We identified 2593 records and included 30 in meta-analyses. Women with NG were more likely to experience preterm birth (OR 1.55, 95% CI 1.21 to 1.99, n=18 studies); premature rupture of membranes (OR 1.41, 95% CI 1.02 to 1.92, n=9); perinatal mortality (OR 2.16, 95% CI 1.35 to 3.46, n=9); low birth weight (OR 1.66, 95% CI 1.12 to 2.48, n=8) and ophthalmia neonatorum (OR 4.21, 95% CI 1.36 to 13.04, n=6). Summary adjusted ORs were, for preterm birth 1.90 (95% CI 1.14 to 3.19, n=5) and for low birth weight 1.48 (95% CI 0.79 to 2.77, n=4). In studies with a multivariable analysis, age was the variable most commonly adjusted for. NG was more strongly associated with preterm birth in low-income and middle-income countries (OR 2.21, 95% CI 1.40 to 3.48, n=7) than in high-income countries (OR 1.38, 95% CI 1.04 to 1.83, n=11).

Conclusions: NG is associated with a number of adverse pregnancy and newborn outcomes. Further research should be done to determine the role of NG in different perinatal mortality outcomes because interventions that reduce mortality will have the greatest impact on reducing the burden of disease in low-income and middle-income countries.

Prospero Registration Number: CRD42016050962.
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http://dx.doi.org/10.1136/sextrans-2020-054653DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7892372PMC
March 2021

Working with Aboriginal young people in sexual health research: a peer research methodology in remote Australia.

Qual Health Res 2021 01 3;31(1):16-28. Epub 2020 Oct 3.

University of Queensland, Brisbane, Queensland, Australia.

In a context of ongoing colonization and dispossession in Australia, many Aboriginal people live with experiences of health research that is done "on" rather than "with" or "by" them. Recognizing the agency of young people and contributing to Aboriginal self-determination and community control of research, we used a peer research methodology involving Aboriginal young people as researchers, advisors, and participants in a qualitative sexual health study in one remote setting in the Northern Territory, Australia. We document the methodology, while critically reflecting on its benefits and limitations as a decolonizing method. Findings confirm the importance of enabling Aboriginal young people to play a central role in research with other young people about their own sexual health. Future priorities include developing more enduring forms of coinvestigation with Aboriginal young people beyond data collection during single studies, and support for young researchers to gain formal qualifications to enhance future employability.
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http://dx.doi.org/10.1177/1049732320961348DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7750674PMC
January 2021

Young Aboriginal people's sexual health risk reduction strategies: a qualitative study in remote Australia.

Sex Health 2020 08;17(4):303-310

Kirby Institute for Infection and Immunity in Society, UNSW Sydney, Level 6, Wallace Wurth Building, UNSW Sydney, Sydney, NSW 2052, Australia; and Burnet Institute, Melbourne, Vic. 3004, Australia.

Background Surveillance data indicate that Aboriginal and Torres Strait Islander young people are more likely than their non-Indigenous counterparts to experience sexually transmissible infections (STIs) and teenage pregnancy. Despite increasing emphasis on the need for strengths-based approaches to Aboriginal sexual health, limited published data document how young Aboriginal people reduce sexual health risks encountered in their everyday lives.

Methods: In-depth interviews with 35 young Aboriginal women and men aged 16-21 years in two remote Australian settings were conducted; inductive thematic analysis examining sexual health risk reduction practices was also conducted.

Results: Participants reported individual and collective STI and pregnancy risk reduction strategies. Individual practices included accessing and carrying condoms; having a regular casual sexual partner; being in a long-term trusting relationship; using long-acting reversible contraception; having fewer sexual partners; abstaining from sex; accessing STI testing. More collective strategies included: refusing sex without a condom; accompanied health clinic visits with a trusted individual; encouraging friends to use condoms and go for STI testing; providing friends with condoms.

Conclusion: Findings broaden understanding of young Aboriginal people's sexual health risk reduction strategies in remote Aboriginal communities. Findings signal the need for multisectoral STI prevention and sexual health programs driven by young people's existing harm minimisation strategies and cultural models of collective support. Specific strategies to enhance young people's sexual health include: peer condom distribution; accompanied health service visits; peer-led health promotion; continued community-based condom distribution; enhanced access to a fuller range of available contraception in primary care settings; engaging health service-experienced young people as 'youth health workers'.
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http://dx.doi.org/10.1071/SH19204DOI Listing
August 2020

Young Aboriginal people's engagement with STI testing in the Northern Territory, Australia.

BMC Public Health 2020 Apr 6;20(1):459. Epub 2020 Apr 6.

Kirby Institute for infection and immunity in society, Level 6, Wallace Wurth Building, UNSW Sydney, Sydney, NSW, 2052, Australia.

Background: Australian surveillance data document higher rates of sexually transmissible infections (STIs) among young Aboriginal people (15-29 years) in remote settings than non-Aboriginal young people. Epidemiological data indicate a substantial number of young Aboriginal people do not test for STIs. Rigorous qualitative research can enhance understanding of these findings. This paper documents socio-ecological factors influencing young Aboriginal people's engagement with clinic-based STI testing in two remote settings in the Northern Territory, Australia.

Methods: In-depth interviews with 35 young Aboriginal men and women aged 16-21 years; thematic analysis examining their perceptions and personal experiences of access to clinic-based STI testing.

Results: Findings reveal individual, social and health service level influences on willingness to undertake clinic-based STI testing. Individual level barriers included limited knowledge about asymptomatic STIs, attitudinal barriers against testing for symptomatic STIs, and lack of skills to communicate about STIs with health service staff. Social influences both promoted and inhibited STI testing. In setting 1, local social networks enabled intergenerational learning about sexual health and facilitated accompanied visits to health clinics for young women. In setting 2, however, social connectedness inhibited access to STI testing services. Being seen at clinics was perceived to lead to stigmatisation among peers and fear of reputational damage due to STI-related rumours. Modalities of health service provision both enhanced and inhibited STI testing. In setting 1, outreach strategies by male health workers provided young Aboriginal men with opportunities to learn about sexual health, initiate trusting relationships with clinic staff, and gain access to clinics. In setting 2, barriers were created by the location and visibility of the clinic, appointment procedures, waiting rooms and waiting times. Where inhibitive factors at the individual, social and health service levels exist, young Aboriginal people reported more limited access to STI testing.

Conclusions: This is the first socio-ecological analysis of factors influencing young Aboriginal people's willingness to undertake testing for STIs within clinics in Australia. Strategies to improve uptake of STI testing must tackle the overlapping social and health service factors that discourage young people from seeking sexual health support. Much can be learned from young people's lived sexual health experiences and family- and community-based health promotion practices.
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http://dx.doi.org/10.1186/s12889-020-08565-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7137447PMC
April 2020

Strategies to improve control of sexually transmissible infections in remote Australian Aboriginal communities: a stepped-wedge, cluster-randomised trial.

Lancet Glob Health 2019 11;7(11):e1553-e1563

Kirby Institute, UNSW Sydney, Sydney, NSW, Australia.

Background: Remote Australian Aboriginal communities have among the highest diagnosed rates of sexually transmissible infections (STIs) in the world. We did a trial to assess whether continuous improvement strategies related to sexual health could reduce infection rates.

Methods: In this stepped-wedge, cluster-randomised trial (STIs in remote communities: improved and enhanced primary health care [STRIVE]), we recruited primary health-care centres serving Aboriginal communities in remote areas of Australia. Communities were eligible to participate if they were classified as very remote, had a population predominantly of Aboriginal people, and only had one primary health-care centre serving the population. The health-care centres were grouped into clusters on the basis of geographical proximity to each other, population size, and Aboriginal cultural ties including language connections. Clusters were randomly assigned into three blocks (year 1, year 2, and year 3 clusters) using a computer-generated randomisation algorithm, with minimisation to balance geographical region, population size, and baseline STI testing level. Each year for 3 years, one block of clusters was transitioned into the intervention phase, while those not transitioned continued usual care (control clusters). The intervention phase comprised cycles of reviewing clinical data and modifying systems to support improved STI clinical practice. All investigators and participants were unmasked to the intervention. Primary endpoints were community prevalence and testing coverage in residents aged 16-34 years for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis. We used Poisson regression analyses on the final dataset and compared STI prevalences and testing coverage between control and intervention clusters. All analyses were by intention to treat and models were adjusted for time as an independent covariate in overall analyses. This study was registered with the Australia and New Zealand Clinical Trials Registry, ACTRN12610000358044.

Findings: Between April, 2010, and April, 2011, we recruited 68 primary care centres and grouped them into 24 clusters, which were randomly assigned into year 1 clusters (estimated population aged 16-34 years, n=11 286), year 2 clusters (n=10 288), or year 3 clusters (n=13 304). One primary health-care centre withdrew from the study due to restricted capacity to participate. We detected no difference in the relative prevalence of STIs between intervention and control clusters (adjusted relative risk [RR] 0·97, 95% CI 0·84-1·12; p=0·66). However, testing coverage was substantially higher in intervention clusters (22%) than in control clusters (16%; RR 1·38; 95% CI 1·15-1·65; p=0·0006).

Interpretation: Our intervention increased STI testing coverage but did not have an effect on prevalence. Additional interventions that will provide increased access to both testing and treatment are required to reduce persistently high prevalences of STIs in remote communities.

Funding: Australian National Health and Medical Research Council.
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http://dx.doi.org/10.1016/S2214-109X(19)30411-5DOI Listing
November 2019

Adverse pregnancy and neonatal outcomes associated with a systematic review and meta-analysis protocol.

BMJ Open 2018 11 28;8(11):e024175. Epub 2018 Nov 28.

Public Health Interventions Research Group, Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia.

Introduction: Several bacterial sexually transmitted and genital mycoplasma infections during pregnancy have been associated with poor pregnancy and perinatal outcomes. Comprehensive and systematic information about associations between sexually transmitted infections (STI) and genital infections in pregnancy and adverse perinatal outcomes is needed to improve understanding about the evidence for causal associations between these infections and adverse pregnancy and neonatal outcomes. Our primary objective is to systematically review the literature about associations between: (1) in pregnancy and preterm birth; (2) in pregnancy and preterm birth; (3) and/or in pregnancy and preterm birth.

Methods And Analysis: We will undertake a systematic search of Medline, Excerpta Medica database and the Cochrane Library and Cumulative Index to Nursing and Allied Health Literature. Following an initial screening of titles by one reviewer, abstracts will be independently assessed by two reviewers before screening of full-text articles. To exclude a manuscript, both reviewers need to agree on the decision. Any discrepancies will be resolved by discussion, or the adjudication of a third reviewer. Studies will be included if they report testing for one or more of during pregnancy and report pregnancy and/or birth outcomes. In this review, the primary outcome is preterm birth. Secondary outcomes are premature rupture of membranes, low birth weight, spontaneous abortion, stillbirth, neonatal mortality and ophthalmia neonatorum. We will use standard definitions, or definitions reported by study authors. We will examine associations between exposure and outcome in forest plots, using the I statistic to examine between study heterogeneity. Where appropriate, we will use meta-analysis to combine results of individual studies.

Ethics And Dissemination: This systematic review of published literature does not require ethical committee approval. Results of this review will be published in a peer reviewed, open access journal.

Prospero Registration Number: CRD42016050962.
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http://dx.doi.org/10.1136/bmjopen-2018-024175DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6278811PMC
November 2018

Feasibility of Implementing Infant Home Visiting in a Central Australian Aboriginal Community.

Prev Sci 2018 10;19(7):966-976

Central Australian Aboriginal Congress Aboriginal Corporation, Alice Springs, Northern Territory, Australia.

The Australian Nurse-Family-Partnership Program, an adaption of the Olds' Nurse-Family-Partnership (NFP), commenced in Alice Springs in 2009 (Central Australia FPP), aiming to improve the health and social outcomes of Aboriginal mothers and infants. This study explores the feasibility of NFP implementation in a remote Australian Aboriginal community. Feasibility was defined by programme uptake by eligible women, retention in the programme, actual vs. scheduled visits and extent of programme content delivery. Programme uptake was established from pregnancy data in the patient Clinical Information System and programme referrals to December 31, 2015. Rates of withdrawal, retention and content delivery were derived from FPP data and compared with published NFP data. Modified Poisson regression was used to identify client characteristics associated with retention beyond the child's first birthday. There were 469 valid referrals (43% of eligible pregnancies) and 299 women with at least one completed home visit by December 31, 2015. Of these, 41% completed the programme to the child's second birthday and 53% beyond the child's first birthday. Dominant reasons for leaving were "moved out of service area" (35%) and "declined further participation" (35%). There was a statistically significant positive association for programme retention with later gestational age at referral (RR = 1.27, p value = 0.03). A high proportion (75%) of scheduled visits was achieved and high delivery of programme content (80%). Central Australia FPP is the first implementation of the NFP model in a remote Aboriginal community. This study found that it can be implemented successfully in this setting. Outcome evaluation is needed to test achievement of hypothesised benefits.
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http://dx.doi.org/10.1007/s11121-018-0930-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6182376PMC
October 2018

Perspectives of primary health care staff on the implementation of a sexual health quality improvement program: a qualitative study in remote aboriginal communities in Australia.

BMC Health Serv Res 2018 04 2;18(1):230. Epub 2018 Apr 2.

Kirby Institute, UNSW Sydney, Wallace Wurth Building, Kensington, NSW, 2052, Australia.

Background: Young people living in remote Australian Aboriginal communities experience high rates of sexually transmissible infections (STIs). STRIVE (STIs in Remote communities, ImproVed and Enhanced primary care) was a cluster randomised control trial of a sexual health continuous quality improvement (CQI) program. As part of the trial, qualitative research was conducted to explore staff perceptions of the CQI components, their normalisation and integration into routine practice, and the factors which influenced these processes.

Methods: In-depth semi-structured interviews were conducted with 41 clinical staff at 22 remote community clinics during 2011-2013. Normalisation process theory was used to frame the analysis of interview data and to provide insights into enablers and barriers to the integration and normalisation of the CQI program and its six specific components.

Results: Of the CQI components, participants reported that the clinical data reports had the highest degree of integration and normalisation. Action plan setting, the Systems Assessment Tool, and the STRIVE coordinator role, were perceived as adding value to the program, but were less readily integrated or normalised. The remaining two components (dedicated funding for health promotion and service incentive payments) were seen as least relevant. Our analysis also highlighted factors which enabled greater integration of the CQI components. These included familiarity with CQI tools, increased accountability of health centre staff and the translation of the CQI program into guideline-driven care. The analysis also identified barriers, including high staff turnover, limited time involved in the program and competing clinical demands and programs.

Conclusions: Across all of the CQI components, the clinical data reports had the highest degree of integration and normalisation. The action plans, systems assessment tool and the STRIVE coordinator role all complemented the data reports and allowed these components to be translated directly into clinical activity. To ensure their uptake, CQI programs must acknowledge local clinical guidelines, be compatible with translation into clinical activity and have managerial support. Sexual health CQI needs to align with other CQI activities, engage staff and promote accountability through the provision of clinic specific data and regular face-to-face meetings.

Trial Registration: Australian and New Zealand Clinical Trials Registry ACTRN12610000358044 . Registered 6/05/2010. Prospectively Registered.
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http://dx.doi.org/10.1186/s12913-018-3024-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5879735PMC
April 2018

Patient, staffing and health centre factors associated with annual testing for sexually transmissible infections in remote primary health centres.

Sex Health 2017 06;14(3):274-281

Kirby Institute, UNSW Australia, Wallace Wurth Building, Kensington, NSW 2052, Australia.

Background: In high-incidence Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) settings, annual re-testing is an important public health strategy. Using baseline laboratory data (2009-10) from a cluster randomised trial in 67 remote Aboriginal communities, the extent of re-testing was determined, along with the associated patient, staffing and health centre factors.

Methods: Annual testing was defined as re-testing in 9-15 months (guideline recommendation) and a broader time period of 5-15 months following an initial negative CT/NG test. Random effects logistic regression was used to determine factors associated with re-testing.

Results: Of 10559 individuals aged ≥16 years with an initial negative CT/NG test (median age=25 years), 20.3% had a re-test in 9-15 months (23.6% females vs 15.4% males, P<0.001) and 35.2% in 5-15 months (40.9% females vs 26.5% males, P<0.001). Factors independently associated with re-testing in 9-15 months in both males and females were: younger age (16-19, 20-24 years); and attending a centre that sees predominantly (>90%) Aboriginal people. Additional factors independently associated with re-testing for females were: being aged 25-29 years, attending a centre that used electronic medical records, and for males, attending a health centre that employed Aboriginal health workers and more male staff.

Conclusions: Approximately 20% of people were re-tested within 9-15 months. Re-testing was more common in younger individuals. Findings highlight the importance of recall systems, Aboriginal health workers and male staff to facilitate annual re-testing. Further initiatives may be needed to increase re-testing.
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http://dx.doi.org/10.1071/SH16123DOI Listing
June 2017

High chlamydia and gonorrhoea repeat positivity in remote Aboriginal communities 2009-2011: longitudinal analysis of testing for re-infection at 3 months suggests the need for more frequent screening.

Sex Health 2016 11;13(6):568-574

South Australian Health and Medical Research Institute, PO Box 11060, Adelaide, SA 5001, Australia.

Background Extremely high rates of diagnosis of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) have been recorded in remote communities across northern and central Australia. Re-testing at 3 months, after treatment administered, of CT or NG is recommended to detect repeat infections and prevent morbidity and ongoing transmission.

Methods: Baseline CT and NG laboratory data (2009-2010) from 65 remote health services participating in a cluster randomised trial was used to calculate the proportion of individuals re-tested after an initial CT or NG diagnosis at <2 months (not recommended), 2-4 months (recommended) and 5-12 months and the proportion with repeat positivity on re-test. To assess if there were difference in re-testing and repeat positivity by age group and sex, t-tests were used.

Results: There was a total of 2054 people diagnosed with CT and/or NG in the study period; 14.9% were re-tested at 2-4 months, 26.9% at 5-12 months, a total of 41.8% overall. Re-testing was higher in females than in males in both the 2-4-month (16.9% v. 11.5%, P<0.01) and 5-12-month (28.9% v. 23.5%, P=0.01) periods. Women aged 25-29 years had a significantly higher level of re-testing 5-12 months post-diagnosis than females aged 16-19 years (39.8% v. 25.4%, P<0.01). There was a total of 858 people re-tested at 2-12 months and repeat positivity was 26.7%. There was higher repeat NG positivity than repeat CT positivity (28.8% v. 18.1%, P<0.01).

Conclusions: Just under half the individuals diagnosed with CT or NG were re-tested at 2-12 months post-diagnosis; however, only 15% were re-tested in the recommended time period of 2-4 months. The higher NG repeat positivity compared with CT is important, as repeat NG infections have been associated with higher risk of pelvic inflammatory disease-related hospitalisation. Findings have implications for clinical practice in remote community settings and will inform ongoing sexual health quality improvement programs in remote community clinics.
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http://dx.doi.org/10.1071/SH16025DOI Listing
November 2016

Community and clinic-based screening for curable sexually transmissible infections in a high prevalence setting in Australia: a retrospective longitudinal analysis of clinical service data from 2006 to 2009.

Sex Health 2016 04;13(2):140-7

The Kirby Institute, UNSW Australia (University of New South Wales), Sydney, NSW 2052, Australia.

Unlabelled: Background In response to the high prevalence of sexually transmissible infections (STIs) in many central Australian Aboriginal communities, a community-wide screening program was implemented to supplement routine primary health care (PHC) clinic testing. The uptake and outcomes of these two approaches were compared.

Methods: Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) community and clinic screening data for Aboriginal people aged 15-34 years, 2006-2009, were used. Regression analyses assessed predictors of the first test occurring in the community screen, positivity and repeat testing.

Results: A total of 2792 individuals had 9402 tests (median: four per person) over 4 years. Approximately half of the individuals (54%) were tested in the community and clinic approaches combined, 29% (n=806) in the community screen only and 18% (n=490) in the clinic only. Having the first test in a community screen was associated with being male and being aged 15-19 years. There was no difference between community and clinic approaches in CT or NG positivity at first test. More than half (55%) of individuals had a repeat test within 2-15 months and of these, 52% accessed different approaches at each test. The only independent predictor of repeat testing was being 15-19 years.

Conclusions: STI screening is an important PHC activity and the findings highlight the need for further support for clinics to reach young people. The community screen approach was shown to be a useful complementary approach; however, cost and sustainability need to be considered.
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http://dx.doi.org/10.1071/SH15077DOI Listing
April 2016

Reasons for delays in treatment of bacterial sexually transmissible infections in remote Aboriginal communities in Australia: a qualitative study of healthcentre staff.

Sex Health 2015 Aug;12(4):341-7

Kirby Institute, UNSW Australia, Wallace Wurth Building, Sydney, NSW 2052, Australia.

Unlabelled: Background Remote Aboriginal communities in Australia experience high rates of bacterial sexually transmissible infections (STIs). To control the transmission and decrease the risk of complications, frequent STI testing combined with timely treatment is required, yet significant delays in treatment have been reported. Perceived barriers to timely treatment for asymptomatic patients in remote communities were explored.

Methods: A qualitative study was undertaken as part of the STRIVE (STIs in Remote communities, ImproVed and Enhanced primary health care) project; a cluster randomised controlled trial of a sexual health quality improvement program. During 2012, we conducted 36 in-depth interviews with staff in 22 clinics in remote Australia.

Results: Participants included registered nurses (72%) and Aboriginal health practitioners (28%). A key barrier to timely treatment was infrequent transportation of specimens to laboratories often hundreds of kilometres away from clinics. Within clinics, there were delays checking and actioning test results, and under-utilisation of systems to recall patients. Participants also described difficulties in physically locating patients due to: (i) high mobility between communities; and (ii) low levels of community knowledge created by high staff turnover. Participants also suggested strategies to overcome some barriers such as dedicated clinical time to follow-up recalls and taking treatment out to patients.

Conclusions: Participants identified barriers to timely STI treatment in remote Aboriginal communities, and systems to address some of the barriers. Innovative strategies such as point-of-care testing or increased support for actioning results, coupled with incentives to individual patients to attend for results, may also assist in decreasing the time to treatment.
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http://dx.doi.org/10.1071/SH14240DOI Listing
August 2015

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.

Sex Health 2015 Mar;12(1):4-12

Kirby Institute, UNSW, Australia, Sydney, NSW 2052, Australia.

Unlabelled: 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.
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http://dx.doi.org/10.1071/SH14080DOI Listing
March 2015

Incidence of curable sexually transmissible infections among adolescents and young adults in remote Australian Aboriginal communities: analysis of longitudinal clinical service data.

Sex Transm Infect 2015 Mar 4;91(2):135-41. Epub 2014 Nov 4.

The Kirby Institute, UNSW Australia (University of New South Wales), Sydney, New South Wales, Australia.

Objectives: To undertake the first comprehensive analysis of the incidence of three curable sexually transmissible infections (STIs) within remote Australian Aboriginal populations and provide a basis for developing new control initiatives.

Methods: We obtained all results for Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and Trichomonas vaginalis (TV) testing conducted during 2009-2011 in individuals aged ≥16 years attending 65 primary health services across central and northern Australia. Baseline prevalence and incidence of all three infections was calculated by sex and age group.

Results: A total of 17 849 individuals were tested over 35 months. Baseline prevalence was 11.1%, 9.5% and 17.6% for CT, NG and TV, respectively. During the study period, 7171, 7439 and 4946 initially negative individuals had a repeat test for CT, NG and TV, respectively; these were followed for 6852, 6981 and 6621 person-years and 651 CT, 609 NG and 486 TV incident cases were detected. Incidence of all three STIs was highest in 16-year-olds to 19-year-olds compared with 35+ year olds (incident rate ratio: CT 10.9; NG 11.9; TV 2.5). In the youngest age group there were 23.4 new CT infections per 100 person-years for men and 29.2 for women; and 26.1 and 23.4 new NG infections per 100 person-years in men and women, respectively. TV incidence in this age group for women was also high, at 19.8 per 100 person-years but was much lower in men at 3.6 per 100 person-years.

Conclusions: This study, the largest ever reported on the age and sex specific incidence of any one of these three curable infections, has identified extremely high rates of new infection in young people. Sexual health is a priority for remote communities, but will clearly need new approaches, at least intensification of existing approaches, if a reduction in rates is to be achieved.
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http://dx.doi.org/10.1136/sextrans-2014-051617DOI Listing
March 2015

Coinfection with Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis: a cross-sectional analysis of positivity and risk factors in remote Australian Aboriginal communities.

Sex Transm Infect 2015 May 28;91(3):201-6. Epub 2014 Oct 28.

The Kirby Institute, University of New South Wales, Sydney, Australia.

Objectives: To determine the co-occurrence and epidemiological relationships of Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and Trichomonas vaginalis (TV) in a high-prevalence setting in Australia.

Methods: In the context of a cluster randomised trial in 68 remote Aboriginal communities, we obtained laboratory reports on simultaneous testing for CT, NG and TV by nucleic acid amplification tests in individuals aged ≥16 years and examined relationships between age and sex and the coinfection positivity. ORs were used to determine which infections were more likely to co-occur by demographic category.

Results: Of 13 480 patients (median age: 30 years; men: 37%) tested for all three infections during the study period, 33.3% of women and 21.3% of men had at least one of them, highest in patients aged 16-19 years (48.9% in women, 33.4% in men). The most frequent combination was CT/NG (2.0% of women, 4.1% of men), and 1.8% of women and 0.5% of men had all three. In all co-combinations, coinfection positivity was highest in patients aged 16-19 years. CT and NG were highly predictive of each other's presence, and TV was associated with each of the other two infections, but much more so with NG than CT, and its associations were much stronger in women than in men.

Conclusions: In this remote high-prevalence area, nearly half the patients aged 16-19 years had one or more sexually transmitted infections. CT and NG were more common dual infections. TV was more strongly associated with NG coinfections than with CT. These findings confirm the need for increased simultaneous screening for CT, NG and TV, and enhanced control strategies.

Trial Registration: Australian and New Zealand Clinical Trials Registry ACTRN12610000358044.
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http://dx.doi.org/10.1136/sextrans-2014-051535DOI Listing
May 2015

Trichomonas vaginalis as a cause of perinatal morbidity: a systematic review and meta-analysis.

Sex Transm Dis 2014 Jun;41(6):369-76

From the *Epidemiology and Health Systems Division, Menzies School of Health Research, Darwin, Northern Territory, Australia; †The Kirby Institute, University of New South Wales (UNSW) Australia, Sydney, New South Wales, Australia; and ‡Robinson Institute, The University of Adelaide, Adelaide, South Australia, Australia.

Trichomonas vaginalis is the most common curable sexually transmissible infection worldwide, with high rates in women of reproductive age. There have been inconsistent findings about the impact of infection and its treatment in pregnancy. We conducted a meta-analysis to determine the association between T. vaginalis and perinatal outcomes. Electronic databases were searched to May 2013. Included studies reported perinatal outcomes in women infected and uninfected with T. vaginalis. Meta-analysis calculated a pooled relative risk (RR) and 95% confidence interval (CI) using either a fixed- or random-effects model. Study bias was assessed using funnel plots. Of 178 articles identified, 11 studies met the inclusion criteria. The study populations, outcomes, and quality varied. T. vaginalis in pregnancy was associated with an increased risk of preterm birth (RR, 1.42; 95% CI, 1.15-1.75; 9 studies; n = 81,101; I = 62.7%), preterm premature rupture of membranes (RR, 1.41; 95% CI,1.10-1.82; 2 studies; n = 14,843; I = 0.0%) and small for gestational age infants (RR, 1.51; 95% CI,1.32-1.73; 2 studies; n = 14,843; I = 0.0%). Sensitivity analyses of studies that accounted for coinfection with other sexually transmissible infection found a slightly reduced RR of 1.34 for preterm birth (95% CI, 1.19-1.51; 6 studies; n = 72,077; I = 11.2%), and in studies where no treatment was confirmed, the RR was 1.83 (95% CI, 0.98-3.41; 3 studies; n = 1795; I = 22.3%). Our review provides strong evidence that T. vaginalis in pregnancy is associated with an increased risk of preterm birth. Based on fewer studies, there were also substantial increases in the risk of preterm premature rupture of membranes and small for gestational age infants. Further studies that address the current gaps in evidence on treatment effects in pregnancy are needed.
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http://dx.doi.org/10.1097/OLQ.0000000000000134DOI Listing
June 2014

STI in remote communities: improved and enhanced primary health care (STRIVE) study protocol: a cluster randomised controlled trial comparing 'usual practice' STI care to enhanced care in remote primary health care services in Australia.

BMC Infect Dis 2013 Sep 9;13:425. Epub 2013 Sep 9.

Baker IDI, Alice Springs, Northern Territory 0870, Australia.

Background: Despite two decades of interventions, rates of sexually transmissible infections (STI) in remote Australian Aboriginal communities remain unacceptably high. Routine notifications data from 2011 indicate rates of chlamydia and gonorrhoea among Aboriginal people in remote settings were 8 and 61 times higher respectively than in the non-Indigenous population.

Methods/design: STRIVE is a stepped-wedge cluster randomised trial designed to compare a sexual health quality improvement program (SHQIP) to usual STI clinical care delivered in remote primary health care services. The SHQIP is a multifaceted intervention comprising annual assessments of sexual health service delivery, implementation of a sexual health action plan, six-monthly clinical service activity data reports, regular feedback meetings with a regional coordinator, training and financial incentive payments. The trial clusters comprise either a single community or several communities grouped together based on geographic proximity and cultural ties. The primary outcomes are: prevalence of chlamydia, gonorrhoea and trichomonas in Aboriginal residents aged 16-34 years, and performance in clinical management of STIs based on best practice indicators. STRIVE will be conducted over five years comprising one and a half years of trial initiation and community consultation, three years of trial conditions, and a half year of data analysis. The trial was initiated in 68 remote Aboriginal health services in the Northern Territory, Queensland and Western Australia.

Discussion: STRIVE is the first cluster randomised trial in STI care in remote Aboriginal health services. The trial will provide evidence to inform future culturally appropriate STI clinical care and control strategies in communities with high STI rates.

Trial Registration: Australian and New Zealand Clinical Trials Registry ACTRN12610000358044.
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http://dx.doi.org/10.1186/1471-2334-13-425DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3847940PMC
September 2013

Frequent occurrence of undiagnosed pelvic inflammatory disease in remote communities of central Australia.

Med J Aust 2012 Dec;197(11):647-51

Epidemiology and Health Systems, Menzies School of Health Research, Alice Springs, NT, Australia.

Objective: To assess the extent of diagnosed and undiagnosed pelvic inflammatory disease (PID) in Aboriginal women in remote central Australia.

Design, Setting And Subjects: Retrospective cross-sectional study in five remote central Australian primary health care centres. Medical records of all resident Aboriginal women aged 14-34 years were examined. Data were from presentations with documented lower abdominal pain, excluding other causes, for 2007-2008.

Main Outcome Measures: PID investigations undertaken, PID diagnoses made, recommended treatment, and presentations meeting the guideline criteria for diagnosing PID based on pelvic examination, symptom profile or history.

Results: Of 655 medical records reviewed, 119 women (18%) presented 224 times with lower abdominal pain. Recommended investigations to diagnose PID were infrequently undertaken: bimanual examination (15 cases [7%]); testing for gonorrhoea and chlamydia (78 [35%]); and history taking for vaginal discharge (59 [26%]), intermenstrual bleeding (27 [12%]) and dyspareunia (17 [8%]). There were 95 presentations (42%) consistent with guidelines to diagnose PID, most (87 [39%]) based on symptom profile and history. Of these, practitioners made 15 diagnoses of PID, and none had the recommended treatment documented.

Conclusion: Pelvic inflammatory disease occurred frequently among Aboriginal women in central Australia during the study period but was vastly underdiagnosed and poorly treated. Undiagnosed or inadequately treated PID leads to poorer reproductive health outcomes in the long term. Increased awareness of PID symptoms, diagnosis and treatment and a revision of the guidelines is needed to improve detection and management of PID in this high-risk setting.
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http://dx.doi.org/10.5694/mja11.11450DOI Listing
December 2012

Improving adherence to guidelines for the diagnosis and management of pelvic inflammatory disease: a systematic review.

Infect Dis Obstet Gynecol 2012 29;2012:325108. Epub 2012 Aug 29.

The Kirby Institute, University of New South Wales, Sydney, NSW 2052, Australia.

Background: Evidence suggests adherence to clinical guidelines for pelvic inflammatory disease (PID) diagnosis and management is suboptimal. We systematically reviewed the literature for studies describing strategies to improve the adherence to PID clinical guidelines.

Methods: The databases MEDLINE and EMBASE, and reference lists of review articles were searched from January 2000 to April 2012. Only studies with a control group were included.

Results: An interrupted time-series study and two randomised controlled trials (RCTs) were included. The interrupted time-series found that following a multifaceted patient and practitioner intervention (practice protocol, provision of antibiotics on-site, written instructions for patients, and active followup), more patients received the recommended antibiotics and attended for followup. One RCT found a patient video on PID self-care did not improve medication compliance and followup. Another RCT found an abbreviated PID treatment guideline for health-practitioners improved their management of PID in hypothetical case scenarios but not their diagnosis of PID.

Conclusion: There is limited research on what strategies can improve practitioner and patient adherence to PID diagnosis and management guidelines. Interventions that make managing PID more convenient, such as summary guidelines and provision of treatment on-site, appear to lead to better adherence but further empirical evidence is necessary.
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http://dx.doi.org/10.1155/2012/325108DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3437626PMC
December 2012

The impact of sexually transmissible infection programs in remote Aboriginal communities in Australia: a systematic review.

Sex Health 2012 Jul;9(3):205-12

Kirby Institute, University of New South Wales, Sydney, NSW, Australia.

Objective: To systematically review evaluations of the impact of sexually transmissible infection (STI) programs delivered by primary health care services in remote Aboriginal communities.

Methods: PubMed, Google Scholar, InfoNet, Cochrane Controlled Trials Register, Australian New Zealand Clinical Trial Registry, conference proceedings and bulletins were searched to April 2011 using variations of the terms 'Aboriginal', 'programs' and 'STI'. The primary outcome of interest in the review was the change in bacterial STI infection prevalence in the target age group assessed through cross-sectional screening studies over a 5-year period or more. The characteristics of the primary health care service, STI programs and other clinical service outcomes were also described.

Results: Twelve reports described four distinct STI programs in remote communities and their impact on STI prevalence. In the Anangu Pitjantjatjara Yankunytjatjara (APY) lands of northern South Australia, there was a reduction in the age-adjusted chlamydia and gonorrhoea prevalence by 58% and 67%, respectively (1996-2003). In the Tiwi Islands of Northern Territory (NT), chlamydia and gonorrhoea positivity decreased by 94% and 34%, respectively (2002-2005). In the Ngaanyatjarra Lands of Western Australia, crude chlamydia and gonorrhoea prevalence decreased by 36% and 48%, respectively (2001-2005), and in the central Australian region of NT, there was no sustained decline in crude prevalence (2001-2005).

Conclusion: In three of the four programs, there was some evidence that clinical best practice and well coordinated sexual health programs can reduce STI prevalence in remote Aboriginal communities.
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http://dx.doi.org/10.1071/SH11074DOI Listing
July 2012
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