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

James Ward,Nathan Ryder,Basil Donovan,Belinda Hengel,Debbie Taylor-Thomson,Amalie Dyda,Steven Skov,Christopher K Fairley,Lisa Maher,Janet Knox,Jacqueline Mein,Matthew Law,John Boffa,Donna Ah Chee,Skye Mcgregor,Linda Garton,Elizabeth Moore,Carole Reeve,Hamish Mcmanus,Handan Wand,John Kaldor ,Bronwyn Silver ,Alice Rumbold ,Rebecca Guy ,Strive Investigators

doi:10.1016/s2214-109x(19)30411-5

Abstract

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. 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. 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). 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. Australian National Health and Medical Research Council.

Highlights

The remote communities of central and northern Australia are the traditional homelands of Aboriginal people, who have lived in such environments for over 40 000 years, maintaining cultures that are among the longest surviving globally
Evidence before this study Before commencing the STRIVE trial, we published a review of available literature that had investigated the effect of sexually transmissible infection (STI) programmes based on increased testing and treatment through primary health-care services in remote Aboriginal communities in Australia
The programme was based on components deemed necessary to control STIs in the primary health-care setting and the trial aimed to increase testing coverage and timely treatment for C trachomatis, N gonorrhoeae, and T vaginalis, consistent with clinical guidelines,9 among people aged 16–24 years who are at the highest risk of STIs

Summary

Introduction

The remote communities of central and northern Australia are the traditional homelands of Aboriginal people, who have lived in such environments for over 40 000 years, maintaining cultures that are among the longest surviving globally. Of approximately 700 000 Aboriginal people in Australia, an estimated20% live in remote and very remote communities. Evidence before this study Before commencing the STRIVE trial, we published a review of available literature that had investigated the effect of sexually transmissible infection (STI) programmes based on increased testing and treatment through primary health-care services in remote Aboriginal communities in Australia. We did an international review of STI quality improvement interventions, and found that two previous trials had been done, one in Tanzania and one in Peru, that had investigated STI quality improvement strategies on a large scale. These trials found an improvement in STI prevalence, but were in settings very different to remote Australian communities. The stepped-wedge design seemed to be the most practical and ethical approach for investigating the implementation of a large-scale quality improvement strategy for STI control because it allowed all participating sites to receive the intervention

Methods

Results

Conclusion