Digital Competencies and Training Approaches to Enhance the Capacity of Practitioners to Support the Digital Transformation of Public Health: Rapid Review of Current Recommendations.

Background: The COVID-19 pandemic highlighted gaps in the public health workforce's capacity to deploy digital technologies while upholding ethical, social justice, and health equity principles. Existing public health competency frameworks have not been updated to reflect the prominent role digital technologies play in contemporary public health, and public health training institutions are seeking to integrate digital technologies in their curricula. Objective: As a first step in a multiphase study exploring recommendations for updates to public health competency frameworks within the Canadian public health context, we conducted a rapid review of literature aiming to identify recommendations for digital competencies, training approaches, and inter- or transdisciplinary partnerships that can enhance public health practitioners' capacity to support the digital transformation of public health. Methods: Following the World Health Organization's (2017) guidelines for rapid reviews, a systematic search was conducted on Ovid MEDLINE, Ovid Embase, ERIC (Education Resources Information Center), and Web of Science for peer-reviewed articles. We also searched Google Scholar and various public health agency and public health association websites for gray literature using search terms related to public health, digital health, practice competencies, and training approaches. We included articles with explicit practice competencies and training recommendations related to digital technologies among public health practitioners published between January 2010 and December 2022. We excluded articles describing these concepts in passing or from a solely clinical perspective. Results: Our search returned 2023 titles and abstracts, of which only 12 studies met the inclusion criteria. We found recommendations for new competencies to enable public health practitioners to appropriately use digital technologies that cut across all existing categories of the core competencies for public health framework of the Public Health Agency of Canada. We also identified a new competency category related to data, data systems management, and governance. Training approaches identified include adapted degree-awarding programs like combined public health and informatics or data science degree programs and ongoing professional certifications with integration of practice-based learning in multi- and interdisciplinary training. Disciplines suggested as important to facilitate practice competency and training recommendations included public health, public health informatics, data, information and computer sciences, biostatistics, health communication, and business. Conclusions: Despite the growth of digital technologies in public health, recommendations about practice competencies and training approaches necessary to effectively support the digital transformation of public health remain limited in the literature. Where available, evidence suggests the workforce requires new competencies that cut across and extend existing public health competencies, including new competencies related to the use and protection of new digital data sources, alongside facilitating health communication and promotion functions using digital media. Recommendations also emphasize the need for training approaches that focus on interdisciplinarity through adapted degree-awarding public health training programs and ongoing professional development.

Missed opportunities to provide sexually transmitted and blood-borne infections testing in British Columbia: An interpretive description of users' experiences of Get Checked Online's design and implementation.

Background: Digital testing services for sexually transmitted and blood-borne infections (STBBIs), such as GetCheckedOnline, experience significant user drop-offs. For example, 32% of GetCheckedOnline users needing testing at account creation do not test, constituting missed opportunities. We explored the influence of users' expectations and experiences of GetCheckedOnline's web design and implementation on missed opportunities. Methods: This interpretive description purposively sampled 14 GetCheckedOnline users who created accounts between April 2022 and February 2023, indicated needed testing at account creation but did not test. We conducted semi-structured interviews and cognitive walkthroughs of GetCheckedOnline on Zoom, exploring participants' expectations and experiences, including problems using the service. Interviews were audio recorded, transcribed verbatim, and analyzed using reflexive thematic analyses. Results: Three themes were identified: (a) transitioning between GetCheckedOnline and laboratory services is a major testing barrier; (b) users' appraisal of their health and social contexts is a determinant of testing through GetCheckedOnline; and (c) tailoring GetCheckedOnline's design and implementation to accommodate varying user needs can promote equitable testing. Health equity issues occurred along sociodemographic gradients as the GetCheckedOnline-laboratory transition was more onerous for older users. Users' appraisal of their testing needs which varied by age and gender, and their assessment of time, and travel requirements for testing in remote communities influenced testing. Learning about GetCheckedOnline from healthcare providers improved testing compared with learning about the service through Google search which raised trust concerns regarding GetCheckedOnline's authenticity. Suggested improvements to promote health equity include personalized education, mail-in testing options, and simpler seamless web experiences. Conclusions: To promote equitable access to digital STBBI testing services such as GetCheckedOnline, we can adapt web-design and implementation to suit user needs and contexts, ensuring simplicity and options for testing that reduce user burdens.

'Sometimes white doctors are not very friendly or inclusive': a Critical Race Theory analysis of racism within and beyond sexual health settings.

Many Two-Spirit, gay, bisexual, transgender, and other queer Black, Indigenous, people of colour in Canada encounter racism when testing for sexually transmitted and blood-borne infections. Our objective in this study was to understand how racism shapes testing experiences for these communities in Ontario, Canada. Four peer researchers conducted recruitment and data collection in consultation with a community advisory board. Focus groups and interviews took place with 21 participants and their narrative accounts were analysed using reflexive thematic analysis. Participants identified three interrelated issues when testing: (1) experiencing judgement and discomfort due to racism; (2) lack of community and cultural indicators in testing spaces; and (3) barriers to accessing testing centres and services. Systemic racism was linked to each of these barriers, including increased distance to testing centres due to racial segregation. Participant accounts signal the need for antiracist testing spaces and practices. Key implications include the need for antiracism training for health service providers and others working with Two-Spirit, gay, bisexual, transgender, and other queer Black, Indigenous, people of colour, and the organisations that serve them, in order to make testing spaces safer. Dismantling systemic racism is imperative to achieve health equity for members of these communities.

Reach of GetCheckedOnline among gay, bisexual, transgender and queer men and Two-Spirit people and correlates of use 5 years after program launch in British Columbia, Canada.

OBJECTIVES: Understanding who uses internet-based sexually transmitted and blood-borne infection (STBBI) services can inform programme implementation, particularly among those most impacted by STBBIs, including gender and sexual minority (GSM) men. GetCheckedOnline, an internet-based STBBI testing service in British Columbia, Canada, launched in 2014. Our objectives were to assess reach, identify factors associated with use of GetCheckedOnline 5 years into implementation and describe reasons for using and not using GetCheckedOnline among GSM men. METHODS: The Sex Now 2019 Survey was an online, cross-sectional survey of GSM men in Canada administered from November 2019 to February 2020. Participants were asked a subset of questions related to use of GetCheckedOnline. Multivariable binary logistic regression modelling was used to estimate associations between correlates and use of GetCheckedOnline. RESULTS: Of 431 British Columbia (BC) participants aware of GetCheckedOnline, 27.6% had tested using the service. Lower odds of having used GetCheckedOnline were found among participants with non-white race/ethnicity (adjusted OR (aOR)=0.41 (95% CI 0.21 to 0.74)) and those living with HIV (aOR=0.23 (95% CI 0.05 to 0.76)). Those who usually tested at a walk-in clinic, relative to a sexual health clinic, had greater odds of using GetCheckedOnline (aOR=3.91 (95% CI 1.36 to 11.61)). The most commonly reported reason for using and not using GetCheckedOnline was convenience (78%) and only accessing the website to see how the service worked (48%), respectively. CONCLUSION: Over a quarter of GSM men in BC aware of GetCheckedOnline had used it. Findings demonstrate the importance of social/structural factors related to use of GetCheckedOnline. Service promotion strategies could highlight its convenience and privacy benefits to enhance uptake.

Perspectives on digital testing services for sexually transmitted and blood-borne infections from Two-Spirit, gay, bisexual, transgender, and other queer Black, Indigenous, people of colour living in Ontario, Canada.

OBJECTIVES: Increased sexually transmitted and blood-borne infections (STBBI) testing can reduce the burden of disease among Two-Spirit, gay, bisexual, transgender, and other queer Black, Indigenous, people of colour (2SGBTQ+ BIPOC). However, this population encounters barriers, such as discrimination, when accessing in-person STBBI testing services. Digital STBBI testing, such as self-testing/collection kits ordered online and digital requisitions, may address some of these barriers. Our aim was to understand acceptability of free digital STBBI testing among 2SGBTQ+ BIPOC living in Ontario, Canada. DESIGN: We approached this analysis using Implementation Science and Critical Race Theory. We conducted interviews and focus groups with 21 2SGBTQ + BIPOC individuals from 2020-2021. Participants were asked about their perceptions of the benefits and drawbacks of digital STBBI testing, populations that would benefit from using these services, and recommendations for how these services may be implemented in Ontario. Interviews and focus groups were transcribed verbatim and analyzed using reflexive thematic analysis. RESULTS: Six themes emerged. Digital STBBI testing services: (1) May reduce oppression experienced by 2SGBTQ + BIPOC when testing in-person; (2) Should address the unique needs that 2SGBTQ + BIPOC experience due to other intersecting identities they possess; (3) Should adapt their services to suit the varying cultural contexts and living circumstances of 2SGBTQ + BIPOC; (4) Should be accessible to 2SGBTQ + BIPOC who hold diverse or no documentation; (5) Should be offered in multiple languages; (6) May be inaccessible to those without Internet access or devices. CONCLUSION: Digital STBBI testing is one strategy that may reduce discrimination experienced by 2SGBTQ + BIPOC when getting tested in-person. However, digital STBBI testing services may not address all the needs of 2SGBTQ + BIPOC. Racism and other forms of oppression embedded into in-person and digital testing services will need to be addressed to meet the needs of this diverse population.

Examining the Influence of Pre-HAART Experiences on Older, Self-Identifying Gay Men's Contemporary Constructions of Quality of Life (QOL).

Some older gay men (50+) experience diminished quality of life (QOL) due to historical and ongoing discrimination in addition to living through a collective trauma-the pre-HAART era of the HIV/AIDS epidemic-characterized by the absence of treatment and rampant discrimination targeting gay men. A growing body of literature, however, illustrates that older gay men demonstrate remarkable resilience but little is known about how QOL is conceptualized and how these conceptualizations are potentially shaped by pre-HAART experiences. The current study drew on constructivist grounded theory methods to examine how QOL is conceptualized in light of the sociohistorical relevance of pre-HAART. Twenty Canadian based gay men aged 50+ participated in semi-structured interviews via Zoom. Ultimately, QOL is understood as experiencing contentment, which is made possible by the development and implementation of three key processes: (1) developing and cultivating meaningful connections, (2) growing into and embracing identity, and (3) appreciating the capacity to do what brings joy. QOL for this group is greatly informed by a context of disadvantage, and the demonstrated resilience warrants further investigation to meaningfully support the overall well-being of older gay men.

Acceptability of an existing online sexually transmitted and blood-borne infection testing model among gay, bisexual and other men who have sex with men in Ontario, Canada.

Objectives: Gay, bisexual and other men who have sex with men (GBM) are disproportionately affected by sexually transmitted and blood-borne infections (STBBI) due to stigma and other factors such as structural barriers, which delay STBBI testing in this population. Understanding acceptability of online testing is useful in expanding access in this population, thus we examined barriers to clinic-based testing, acceptability of a potential online testing model, and factors associated with acceptability among GBM living in Ontario. Methods: Sex Now 2019 was a community-based, online, bilingual survey of GBM aged ≥15. Prevalence ratios (PR) and 95% confidence intervals (95%CI) were calculated using modified Poisson regression with robust variances. Multivariable modelling was conducted using the Hosmer-Lemeshow-Sturdivant approach. Results: Among 1369 participants, many delayed STBBI testing due to being too busy (31%) or inconvenient clinic hours (29%). Acceptability for online testing was high (80%), with saving time (67%) as the most common benefit, and privacy concerns the most common drawback (38%). Statistically significant predictors of acceptability for online testing were younger age (PR = 0.993; 95%CI: 0.991-0.996); a greater number of different sexual behaviours associated with STBBI transmission (PR = 1.031; 95%CI: 1.018-1.044); identifying as an Indigenous immigrant (PR = 1.427; 95%CI: 1.276-1.596) or immigrant of colour (PR = 1.158; 95%CI: 1.086-1.235) compared with white non-immigrants; and currently using HIV pre-exposure prophylaxis (PrEP) compared to not currently using PrEP (PR = 0.894; 95%CI: 0.828-0.965). Conclusions: Acceptability of online testing was high among GBM in Ontario. Implementing online STBBI testing may expand access for certain subpopulations of GBM facing barriers to current in-person testing.

Evaluating the Impact of the COVID-19-Related Public Health Restrictions on Access to Digital Sexually Transmitted and Blood-Borne Infection Testing in British Columbia, Canada: An Interrupted Time Series Analysis.

BACKGROUND: Evidence of long-term impacts of COVID-19-related public health restrictions on digital sexually transmitted and blood-borne infection (STBBI) testing utilization is limited. We assessed these impacts on GetCheckedOnline (a digital testing resource for STBBIs) relative to all STBBI tests in British Columbia (BC). METHODS: Interrupted time series analyses were conducted using GetCheckedOnline program data comparing monthly test episodes (STBBI tests per requisition) among BC residents, stratified by BC region, and testers' sociodemographic and sexual risk profiles, for the prepandemic (March 2018-February 2020) and pandemic periods (March 2020-October 2021). Trends in GetCheckedOnline testing per 100 STBBI tests in BC regions with GetCheckedOnline were analyzed. Each outcome was modeled using segmented generalized least squared regression. RESULTS: Overall, 17,215 and 22,646 test episodes were conducted in the prepandemic and pandemic periods. Monthly GetCheckedOnline test episodes reduced immediately after restrictions. By October 2021 (end of the pandemic period), monthly GetCheckedOnline testing increased by 21.24 test episodes per million BC residents (95% confidence interval, -11.88 to 54.84), and GetCheckedOnline tests per 100 tests in corresponding BC regions increased by 1.10 (95% confidence interval, 0.02 to 2.17) above baseline trends. After initial increases among users at higher STBBI risk (symptomatic testers/testers reporting sexual contacts with STBBIs), testing decreased below baseline trends later in the pandemic, whereas monthly GetCheckedOnline testing increased among people 40 years or older, men who have sex with men, racialized minorities, and first-time testers via GetCheckedOnline. CONCLUSIONS: Sustained increases in utilization of digital STBBI testing during the pandemic suggest fundamental changes in STBBI testing in BC, highlighting the need for accessible and appropriate digital testing, especially for those most affected by STBBIs.

The Red River Cart Model: a Métis conceptualization of health and well-being in the context of HIV and other STBBI.

OBJECTIVES: Métis people experience health inequities and often face discrimination when accessing health services. Métis-specific services are limited, and pan-Indigenous approaches to health services fail to acknowledge heterogenous identities and distinct health needs of the Métis. This study explored a Métis response to HIV and other sexually transmitted and blood borne infections to inform public health services development for Métis people. METHODS: As part of the DRUM & SASH Project, this study used a community-based research approach which privileged Métis knowledges and processes. Three gathering circles were held in Alberta, Canada, with self-identified Métis individuals who had lived experience or intimate knowledge of HIV/hepatitis C or worked in HIV/HCV service provision. The gathering circle process integrated Métis cultural practices in discussions about Métis understandings of health. Gathering circles transcripts were used to inform the description of the model emerging through the dialogue. RESULTS: Twelve diverse Métis people participated in gathering circles. Participants identified 12 determinants of health and well-being grounded in Métis culture and imagery, including Métis medicine bag, fiddle, cart tarp, flag, Capote coat, sash, York boat, moccasins, grub box, weapons, tools, and stove. The Red River Cart Model, a Métis-specific model of health to guide service planning, was created from these discussions. CONCLUSION: The Red River Cart Model provides a holistic view of the determinants of Métis health and has potential as a collaborative client assessment resource for STBBI community health service providers. Additionally, this model may be helpful to other health service providers for developing Métis-specific/informed services and improving cultural safety for the Métis.

RéSUMé: OBJECTIFS: Les Métis font face à des iniquités en santé et sont souvent l'objet de discrimination dans leur accès aux services de santé. Les services centrés sur les Métis sont limités, et les approches panautochtones face aux services de santé ne reconnaissent ni l'hétérogénéité des identités, ni les besoins de santé particuliers des Métis. Notre étude a exploré une intervention métisse face au VIH et à d'autres infections transmissibles sexuellement et par le sang (ITSS) pour éclairer l'élaboration de services de santé publique pour les Métis. MéTHODE: Dans le cadre du projet DRUM & SASH, notre étude a utilisé une méthode de recherche de proximité qui a privilégié les savoirs et les processus métis. Trois cercles de rassemblement ont eu lieu en Alberta, au Canada, avec des personnes s'identifiant comme étant métisses et ayant un vécu ou une connaissance intime du VIH ou de l'hépatite C ou ayant travaillé à offrir des services liés au VIH ou au VHC. Le processus des cercles de rassemblement a intégré des pratiques culturelles métisses dans les discussions des savoirs métis en matière de santé. Les transcriptions des cercles de rassemblement ont éclairé la description du modèle ayant émergé de ce dialogue. RéSULTATS: Douze personnes métisses d'horizons divers ont participé aux cercles de rassemblement. Elles ont défini 12 déterminants de la santé et du bien-être ancrés dans la culture et les images métisses : le sac de guérisseur, le violon, la bâche de charrette, le drapeau, le caban, la ceinture fléchée, la barge d'York, les mocassins, le coffre de nourriture, les armes, les outils et la cuisinière. Le modèle Red River Cart (« charrette de la rivière Rouge ¼), un modèle spécifiquement métis de la santé, a été créé à partir de ces discussions pour guider la planification des services. CONCLUSION: Le modèle Red River Cart présente un portrait holistique des déterminants de la santé des Métis et pourrait être une ressource collaborative d'évaluation des patientes et des patients pour les prestataires de services de santé de proximité liés aux ITSS. Ce modèle pourrait aussi être utile à d'autres prestataires de services de santé pour élaborer des services centrés sur les Métis ou éclairés par la culture métisse et pour améliorer la sécurisation culturelle pour les Métis.

Disruptions of sexually transmitted and blood borne infections testing services during the COVID-19 pandemic: accounts of service providers in Ontario, Canada.

BACKGROUND: Since the onset of the COVID-19 pandemic in March 2020 in Canada, the availability of sexual health services including sexually transmitted and blood-borne infection (STBBI) testing has been negatively impacted in the province of Ontario due to their designation as "non-essential" health services. As a result, many individuals wanting to access sexual healthcare continued to have unmet sexual health needs throughout the pandemic. In response to this, sexual health service providers have adopted alternative models of testing, such as virtual interventions and self-sampling/testing. Our objective was to investigate service providers' experiences of disruptions to STBBI testing during the COVID-19 pandemic in Ontario, Canada, and their acceptability of alternative testing services. METHODS: Between October 2020-February 2021, we conducted semi-structured virtual focus groups (3) and in-depth interviews (11) with a diverse group of sexual health service providers (n = 18) including frontline workers, public health workers, sexual health nurses, physicians, and sexual health educators across Ontario. As part of a larger community-based research study, data collection and analysis were led by three Peer Researchers and a Community Advisory Board was consulted throughout the research process. Transcripts were transcribed verbatim and analysed with NVivo software following grounded theory. RESULTS: Service providers identified the reallocation of public health resources and staff toward COVID-19 management, and closures, reduced hours, and lower in-person capacities at sexual health clinics as the causes for a sharp decline in access to sexual health testing services. Virtual and self-sampling interventions for STBBI testing were adopted to increase service capacity while reducing risks of COVID-19 transmission. Participants suggested that alternative models of testing were more convenient, accessible, safe, comfortable, cost-effective, and less onerous compared to traditional clinic-based models, and that they helped fill the gaps in testing caused by the pandemic. CONCLUSIONS: Acceptability of virtual and self-sampling interventions for STBBI testing was high among service providers, and their lived experiences of implementing such services demonstrated their feasibility in the context of Ontario. There is a need to approach sexual health services as an essential part of healthcare and to sustain sexual health services that meet the needs of diverse individuals.

Assessing the acceptability of dried blood spot testing for HIV and STBBI among Métis people in a community driven pilot project in Alberta, Canada.

BACKGROUND: Little literature exists on culturally grounded approaches for addressing human immunodeficiency virus (HIV) and sexually transmitted and blood-borne infections (STBBI) among Métis people. The goal of this mixed-methods research was to explore the experiences of Métis community members participating in a dried blood spot testing (DBST) for HIV/STBBI pilot for Métis communities in Alberta, Canada, with the aim of assessing the acceptability of this testing method. METHODS: Grounded in community-based and Indigenous research approaches and working in partnership with a Métis community-based organization, data collection included a survey and four gathering circles with Métis DBST recipients at one of two community events, and semi-structured interviews with three DBST providers. RESULTS: Twenty-six of the 30 DBST recipients completed surveys, and 19 DBST recipients participated in gathering circles. Survey results suggest DBST is a highly acceptable STBBI testing method to Métis community members. Thematic analysis of gathering circle and interview transcripts revealed four broad themes related to the participants' experiences with DBST related to its acceptability (i. ease of DBST process, ii. overcoming logistical challenges associated with existing STBBI testing, iii. Reducing stigma through health role models and event-based, and iv. Métis-specific services). CONCLUSIONS: These findings illustrate the potential for DBST to be part of a culturally grounded, Métis-specific response to HIV and STBBI.

Building capacity in quantitative research and data storytelling to enhance knowledge translation: a training curriculum for peer researchers.

BACKGROUND: Many community-based HIV research studies incorporate principles of greater involvement and meaningful engagement of people living with HIV (GIPA/MEPA) by training people with HIV as peer researchers. Unfortunately, there are still some aspects of research (e.g., quantitative data analysis and interpretation) where many projects fall short in realizing GIPA/MEPA principles. To address these gaps, we developed an eight-week training course that aimed to build the capacity of peer researchers around the understanding and interpretation of quantitative data and incorporating lived experience to increase the impact of the knowledge transfer and exchange phase of a study. METHODS: Peer researchers (n = 8) participated from British Columbia, Alberta, and Ontario and lessons learned from the training were implemented throughout the dissemination of research findings from the People Living with HIV Stigma Index study. This paper presents the curriculum and main training components, course evaluation results, and challenges and lessons learned. The manuscript was created in collaboration with and includes the perspectives of both the peer researchers involved in the training, as well the course facilitators. RESULTS: Throughout the course, peer researchers' self-assessed knowledge and understanding of quantitative research and data storytelling improved and, through interactive activities and practice, they gained the confidence to deliver a full research presentation. This improved their understanding of research findings, which was beneficial for discussing results with community partners and study participants. The peer researchers also agreed that learning about integrating lived experience with quantitative data has helped them to make research findings more relatable and convey key messages in a more meaningful way. CONCLUSIONS: Our training curriculum provides a template for research teams to build capacity in areas of research where peer researchers and community members are less often engaged. In doing so, we continue to uphold the principles of GIPA/MEPA and enhance the translation of research knowledge in communities most greatly affected.

Engaging patient groups or community members is commonplace in HIV research where people living with HIV are trained as peer researchers. There are still however some gaps where community members are less engaged, especially in quantitative data analysis. This presents a barrier preventing them from being meaningfully engaged in research about them. To build capacity in these areas, we designed an eight-week online course that taught peer researchers about quantitative data analysis and interpretation with a focus on concepts that would be important for talking about key messages from research findings. This was used to enhance the knowledge translation and dissemination initiatives for the People Living with HIV Stigma Index study­a survey tool containing quantitative measures examining stigma and related health factors. Peer researchers agreed that their knowledge and understanding of the key quantitative data concepts improved significantly throughout the course. This increased understanding helped them discuss quantitative data with community members and study participants, which was important to ensure that research findings reach the affected communities. Peer researchers also agreed that incorporating their new data analysis knowledge with existing lived experience helped them to make findings more relatable and understandable which is critical for translating knowledge to other researchers and policy makers. Overall, our training curriculum gave peer researchers the confidence to talk about quantitative data and improve their capacity to disseminate research. This work also provides guidelines for training peer researchers and ensuring that they are meaningfully engaged in research studies they are a part of.

Cisnormativity as a structural barrier to STI testing for trans masculine, two-spirit, and non-binary people who are gay, bisexual, or have sex with men.

Trans masculine, two-spirit, and non-binary people who are gay, bisexual or otherwise have sex with men (TGBM) are under-tested for sexually transmitted infections (STI) and may face complex, intersectional barriers that prevent them from accessing STI testing. As part of a study on gay, bisexual and other men who have sex with men's (GBM) experiences of current STI testing systems in Ontario, Canada, this paper reports on the findings from TGBM participants' experiences with in-person STI testing in a range of venues (i.e. Family doctors, walk-in clinics, and community-based organizations) to explore testing barriers specific to TGBM. Using a community-based research approach, between June 2020 and December 2021 peer researchers who identified as GBM conducted focus groups and interviews with 38 cis and trans GBM, 13 of whom identified as TGBM. Data were analyzed following grounded theory. When questioned about past experiences with testing, TGBM participants reported several barriers to STI testing within current testing models in Ontario due to cisnormativity and heteronormativity. Cisnormativity is the assumption that everyone identifies as the gender they were assigned at birth, and those who do not are considered "abnormal", while heteronormativity is when it is assumed that everyone is heterosexual. From our research we identified three overarching themes concerning testing barriers among TGBM participants: (1) non-inclusive clinic environments, (2) lack of provider knowledge and competency, and (3) legal documentation. Inherent cis and heteronormativity in healthcare institutions appear to be factors shaping the historical under-testing for STI in the TGBM population. These findings suggest the relevance of implementing trans-specific clinical practices that reduce the stigma and barriers faced by TGBM in STI testing contexts, including: hosting all-gender testing hours, opening more LGBTQ+ clinics, offering training in transgender health to testing providers, and conducting a review of how gender markers on health documents can be more inclusive of trans, two-spirit, and non-binary communities.

Challenges to communicating the Undetectable equals Untransmittable (U=U) HIV prevention message: Healthcare provider perspectives.

"Undetectable equals Untransmittable", or U=U, is a public health message designed to reduce HIV stigma and help communicate the scientific consensus that HIV cannot be sexually transmitted when a person living with HIV has an undetectable viral load. Between October 2020-February 2021 we conducted 11 in-depth interviews and 3 focus groups with diverse HIV/STI service providers (nurses, public health workers, physicians, frontline providers, and sexual health educators) in Ontario, Canada (n = 18). Our objective was to understand how U=U was communicated to sexual health service users in healthcare interactions. Interview questions were embedded in a larger study focused on improving access to HIV/STI testing. Transcripts were transcribed verbatim and analysed following grounded theory. Most providers emphasized the significance of U=U as a biomedical advancement in HIV prevention but had some challenges communicating U=U in everyday practice. We discovered four interrelated barriers when communicating the U=U message: (1) provider-perceived challenges with "zero risk" messaging (e.g., wanting to "leave a margin" of HIV risk); (2) service users not interested in receiving sexual health information (e.g., in order to provide "client centered care" some providers do not share U=U messages if service users are only interested in HIV/STI testing or if other discussions must be prioritized); (3) skepticism and HIV stigma from service users (e.g., providers explained how the hesitancy of some service users accepting the U=U message was shaped by a legacy of HIV prevention messages and persistent HIV stigma); and (4) need for more culturally appropriate resources (e.g., communities other than sexual and gender minority men; non-English speaking service users; that account for broader legal context). We discuss ways to overcome barriers to communicating the U=U message as well as the limitations and potential unintended consequences of U=U framings in the context of unequal access to HIV prevention and treatment.

Educational debt and the gender gap: Understanding factors influencing orthodontists' career decisions.

INTRODUCTION: Orthodontic residents face challenges unparalleled to their predecessors, including competitive marketplaces, rising debt burdens, and changing demographics that have contributed to the shift in initial career choice from owner to employee. We aim to understand factors important to orthodontists at different career stages and the impact on job satisfaction through a sequential mixed methodology study. METHODS: Semistructured interviews were conducted with 25 orthodontic residents and practitioners. A survey was developed from qualitative findings that explored career decision-making of orthodontic residents and practicing orthodontists, with descriptive and bivariate statistical analyses (n = 343 orthodontists and 185 residents). RESULTS: Graduating orthodontic residents are choosing employment over ownership as their initial job, prioritizing high income to offset the educational debt. The majority of residents report thinking about their debt very often to all of the time and find it very to extremely stressful. Current residents have long-term goals of ownership, whereas practicing doctors of both genders became owners at equal frequencies. However, on average, women earn $119,000 less per year and report being the primary family caretaker more often than men. CONCLUSIONS: Excellent patient care, work-life balance, and sufficient income are the most important drivers for career choices and job satisfaction for orthodontists of all ages. Despite debt, most residents and working orthodontists report a high level of job satisfaction and would recommend the field of orthodontics to others.

Accessing needed sexual health services during the COVID-19 pandemic in British Columbia, Canada: a survey of sexual health service clients.

OBJECTIVES: We assessed COVID-19 pandemic impacts on accessing needed sexual health services, and acceptability of alternative service delivery models, among sexual health service clients in British Columbia (BC), Canada. METHODS: We administered an online survey on 21 July-4 August 2020 to clients using a provincial STI clinic or internet-based testing service, GetCheckedOnline, in the year prior to March 2020. We used logistic regression to identify factors associated with having unmet sexual health needs (ie, not accessing needed services) during March-July 2020 and the likelihood of using various alternative service models, if available. RESULTS: Of 1198 survey respondents, 706 (59%) reported needing any sexual health service since March 2020; of these 706, 365 (52%) did not access needed services and 458 (66%) had avoided or delayed accessing services. GetCheckedOnline users (univariate OR (uOR)=0.62; 95% CI 0.43 to 0.88) or clients with more urgent needs (eg, treatment for new STI, uOR 0.40 (95% CI 0.21 to 0.7)) had lower odds of unmet sexual health needs. The most common factors reported for avoiding or delaying access were public messaging against seeking non-urgent healthcare (234/662, 35%), concern about getting COVID-19 while at (214/662, 32%) or travelling to (147/662, 22%) a clinic or lab and closure of usual place of accessing services (178/662, 27%). All factors were positively associated with having unmet sexual health needs, with public messaging showing the strongest effect (adjusted OR=4.27 (95% CI 2.88 to 6.42)). Likelihood of using alternative sexual health service models was high overall, with the most appealing options being home self-collection kits (634/706, 90%), receiving test kits or antibiotics at home (592/700, 85%) and express testing (565/706, 80%). CONCLUSIONS: Of BC sexual health service clients needing services during March-July 2020, many had unmet needs. Offering alternative service delivery methods may help to improve access during and beyond the COVID-19 pandemic.

"Do something with them!": developing "comfortable" engagement with Elders participating in an arts-based sexual health promotion and STBBI prevention workshop for Indigenous Youth in Labrador, Canada.

Although Indigenous Elders were traditionally involved in cross-generational health promotion and education, colonisation disrupted this role. Little research examines the role of Elders in contemporary health promotion for Indigenous youth and few strategies have been identified to engage Elders in health promotion or sexual health education. We explored engagement of Elders through participatory filmmaking in a sexual health and HIV education workshop for youth. Eleven youth and five Elders participated in this 3.5-day workshop. During the workshop, Elders indicated they wanted to make a film and attend a sexual health and HIV education session. Four Elders were interviewed about their experiences. Interview transcripts and the Elders' film were analysed using content analysis. Although Elders initially felt hesitant to engage, the process of participatory filmmaking allowed Elders to co-create an environment for their "comfortable" workshop engagement. Elders' feelings of comfort were created by having control and sense of ownership over their engagement; the presence of youth; peer-based dialogue; inclusion of traditional items; and an Indigenous sexual health educator. Findings suggest participatory filmmaking is a promising approach for engaging and empowering Elders to reclaim traditional roles in sexual health education and health promotion with Indigenous youth.

Partner number and use of COVID-19 risk reduction strategies during initial phases of the pandemic in British Columbia, Canada: a survey of sexual health service clients.

OBJECTIVES: Initial public health guidance related to sex and COVID-19 infection focused on reducing partner number. We characterized individuals having a higher partner number during the initial phases of the pandemic. METHODS: In British Columbia, the initial wave of COVID-19 cases was from March 14 to May 19, 2020, followed by gradual lifting of public health restrictions. We conducted an e-mail survey of existing sexual health service clients during the period of July 23 to August 4, 2020. We used bivariate logistic regression to examine the association between the reported number of sexual partners since the start of the pandemic and key variables (level of significance p < 0.01). RESULTS: Of the 1196 clients in our final sample, 42% reported 2+ partners since the start of the pandemic, with higher odds among participants who were men who have sex with men, and single or in open relationships prior to the pandemic. This group was more likely to perceive stigma associated with having sex during the pandemic, and had the highest use of strategies to reduce risk of COVID-19 infection during sexual encounters (mainly focused on reducing/avoiding partners, such as masturbation, limiting sex to a "bubble", and not having sex). CONCLUSION: Sexual health service clients in BC with 2+ partners during the initial phases of BC's pandemic used strategies to reduce their risk of COVID-19 infection during sex. Our study provides support for a harm reduction approach to guidance on COVID-19 risk during sex, and highlights the need for further research on stigma related to having sex during the COVID-19 pandemic.

RéSUMé: OBJECTIFS: Les premières directives de santé publique sur les rapports sexuels et l'infection par la COVID-19 portaient sur la réduction du nombre de partenaires. Nous avons caractérisé les personnes ayant eu de nombreux partenaires au cours des phases initiales de la pandémie. MéTHODE: En Colombie-Britannique, la première vague de cas de COVID-19 a déferlé du 14 mars au 19 mai 2020, puis a été suivie d'une levée progressive des restrictions sanitaires. Nous avons administré un sondage par courriel auprès d'usagers existants des services de santé sexuelle entre le 23 juillet et le 4 août 2020. Nous avons procédé par régression logistique bivariée pour examiner l'association entre le nombre déclaré de partenaires sexuels depuis le début de la pandémie et certaines variables clés (seuil de signification p < 0,01). RéSULTATS: Sur les 1196 usagers de notre échantillon final, 42 % ont dit avoir eu 2 partenaires ou plus depuis le début de la pandémie, avec une probabilité plus élevée chez les participants qui étaient des hommes ayant des relations sexuelles avec des hommes et ceux qui étaient célibataires ou dans une relation ouverte avant la pandémie. Ce groupe était plus susceptible de percevoir une stigmatisation des relations sexuelles durant la pandémie, et il a présenté l'utilisation la plus élevée de stratégies pour réduire le risque de contracter la COVID-19 lors de rapports sexuels (principalement en réduisant partiellement ou à zéro le nombre de partenaires, p. ex. en se masturbant, en limitant ses partenaires aux membres de sa « bulle¼ ou en s'abstenant de tout rapport sexuel). CONCLUSION: Les usagers des services de santé sexuelle de la Colombie-Britannique ayant eu 2 partenaires ou plus durant les premières phases de la pandémie dans la province ont employé des stratégies pour réduire leur risque de contracter la COVID-19 durant les rapports sexuels. Notre étude confirme la validité d'une approche de réduction des méfaits dans les directives sur le risque de contracter la COVID-19 durant les rapports sexuels et souligne le besoin de pousser la recherche sur la stigmatisation des rapports sexuels durant la pandémie de COVID-19.

Caught between HIV exceptionalism and health service integration: Making visible the role of public health policy in the scale-up of novel sexual health services.

The role of contextual factors for program implementation is well-documented; however, their changing function throughout implementation phases is less established. We conducted an institutional ethnography to understand how structural conditions for scaling up initiatives are shaped by public health policy. We conducted 25 interviews with implementers of a comprehensive sexual health testing service in Canada, 21 meeting observations, and textual analyses of key policies and reports. Our analysis revealed a disjuncture between implementers' task of scaling up programming and the actualities of working within the discursive and material confines of policies premised on HIV exceptionalism and underfunded integrated health services.

Self-rated mental health among sexual health service clients during the first months of the COVID-19 pandemic, British Columbia, Canada.

We investigated self-reported mental health during the first three months of the COVID-19 pandemic (March-May 2020), using a survey of HIV-testing and sexual health service clients from British Columbia, Canada (N = 1198). Over half (55%) reported their mental health as poor at the beginning of the COVID-19 pandemic, more than double that of the general Canadian population in the same time frame (22%). Acknowledging that this burden of poor mental health that is likely to persist in the coming years, we propose that sexual health clinics should facilitate access to mental health supports as a low-barrier point of primary care contact.