'Every strategy needs to be contributing to erasing the stigma': Maori and Pacific young people talk about overcoming barriers to testing for sexually transmitted infections.

BACKGROUND: Maori and Pacific young people are disproportionately impacted by sexually transmitted infections (STIs). Access to STI screening is important to reduce transmission and reproductive health complications. METHODS: Between November 2022 and May 2023, we held four wananga (workshops) with Maori and Pacific participants (15-24years old) to find out what barriers they encounter to STI testing, and hear their ideas about how to overcome these. Participants were recruited via youth-focused community organisations in the Wellington region of Aotearoa New Zealand. Inductive thematic analysis was used to understand data generated from discussions, drawing on Maori and Pacific models of wellbeing to frame themes. RESULTS: Thirty-eight participants were involved in the wananga. Barriers to STI testing related to five themes: (1) differences in cultural values and expression; (2) family/friends; (3) educational gaps; (4) psychological factors; and (5) structural obstacles. Suggested strategies to improve access to sexual health care included the need for free, flexible services, education and health promotion activities to reach young people in their spaces (e.g. church, marae, social media). Participants stressed the need for approaches to be community-based, delivered by trusted individuals using culturally appropriate messages, and saw participation in STI testing as beneficial for whanau/family and communities. CONCLUSIONS: To improve access to STI testing, participants described the need for free services, together with education and health promotion to improve inter-generational sexual health knowledge. Reframing messages around STIs to align with Maori and Pacific models of wellbeing was identified as a way to normalise conversations, in turn reducing the stigma surrounding STI testing.

"It was a very awkward consultation because I didn't know"-general practice staff experiences and challenges in providing healthcare to gender and sexual minority youth in Aotearoa New Zealand.

BACKGROUND: Rainbow young people (RYP; people of diverse genders, sexualities, and variations in sex characteristics) face barriers accessing primary care, often report negative experiences and the need to educate clinicians on rainbow-specific issues. This study explores general practice staff views and experiences of providing care to RYP. METHODS: Three focus groups were held with staff from 5 general practices in an urban area of Aotearoa New Zealand (25 participants in total). Practices were purposively selected to include some known to be more "rainbow-friendly" seeing larger numbers of RYP and some with no particular focus on RYP. All members of each practice were invited to participate, including administration and reception staff. Focus groups were audio-recorded, transcribed, and analysed in NVivo using inductive thematic analysis. RESULTS: Four main themes were identified: (i) Practice experience, (ii) Feeling awkward, (iii) Knowledge and training, and (iv) Structural barriers. Differences were apparent in health provider knowledge, comfort, and experience in providing care to RYP. Participants identified a lack of knowledge and training and wanted more resources and education. Systems limitations were common (e.g. with IT systems for recording gender) and often contributed to awkward clinical encounters. CONCLUSIONS: Participants recognized shortcomings in their training, knowledge, and level of confidence providing care to RYP and expressed a desire to improve their competency. Further work is needed to identify and trial practical strategies that help improve communication skills, knowledge, and the delivery of more equitable healthcare to RYP.

'Be nice to us, we're still learning': an online survey of young people in Hawkes Bay, New Zealand, about unmet need for sexual health care and improving access to services.

Background Young people need equitable access to high-quality sexual and reproductive health care to enjoy good sexual health. Methods This online survey of people aged 15-24years in a defined region of New Zealand asked about unmet need for sexual health care and sought views on improving access to sexual health care. Results Fivehundred participants took part in the study between August and October 2020, of whom 60% were female, 25% were of Maori (indigenous) ethnicity, and 21.4% were gender and/or sexuality diverse. Sixty percent had ever received sexual health care (300/500), and 74.3% received it from a general practice clinic (223/300). Overall, 41% (204/500) reported they needed, but had not received sexual health care in the past ('unmet need'). Reasons for unmet need included being shy, embarrassed or ashamed (74.5%, 152/204), fear of judgment by clinic staff (42.6%, 87/204), cost (32.8%, 67/204), concerns about confidentiality (28.9%, 59/204), and not knowing where to go (24%, 49/204). Maori participants were more likely to report not knowing where to go (32.1% vs 20%, P=0.04). Participants identified the need to reduce stigma, normalise sexual health care, improve convenience, affordability and awareness of services as key to improving access. Reassurance about confidentiality and being treated with kindness, empathy and respect were deemed critical to service acceptability. Conclusions Action is urgently needed at policy, funding and practice levels to improve access to services by: reducing societal stigma, normalising discussions around sexual health, improving affordability and raising awareness of services. Quality improvement is also needed in general practice to ensure young people can routinely access youth-friendly sexual and reproductive health care.

Chlamydia trachomatis and Neisseria gonorrhoeae Retesting and Reinfection Rates in New Zealand Health Care Settings: Implications for Sexually Transmitted Infection Control.

BACKGROUND: Reinfection with chlamydia or gonorrhea is common and can lead to significant reproductive health complications so testing for reinfection after treatment is recommended. This study described retesting and reinfection rates in regions of New Zealand with higher-than-average population rates of chlamydia. METHODS: This retrospective cohort study analyzed chlamydia and gonorrhea testing data from 2 laboratories providing community testing services for 4 higher-rate regions in the North Island of New Zealand. Three years of data were obtained (2015-2017) to include a minimum of 6-month follow-up for all individuals. Retesting and reinfection rates between 6 weeks and 6 months of a positive result were calculated, and time to retesting was plotted using Kaplan-Meier curves. Logistic regression modeling was used to determine the odds of retesting (outcome 1) and reinfection (outcome 2) between 6 weeks and 6 months of follow-up. RESULTS: Overall, 34% (3151/9241) of the cohort was retested within the recommended period, of whom 21% retested positive. Significant differences were observed in the odds of retesting by sex, age band, ethnic group, clinic type, and region (P < 0.01). The odds of a subsequent positive on retesting within 6 months differed significantly by sex, age band, and ethnic group (P < 0.01). CONCLUSIONS: These findings reflect substantial gaps in the delivery of best-practice sexually transmitted infection management in New Zealand. There is a clear need to prioritize the implementation of clinic-level processes to support clinicians in the routine delivery of best-practice sexual health care. These should include routine provision of patient advice about retesting and strategies to promote timely and equitable access to retesting.

Addressing Gaps in the Management of Chlamydia trachomatis and Neisseria gonorrhoeae in Primary Care: Lessons Learned in a Pilot Intervention Study.

BACKGROUND: We aimed to test the acceptability and utility of strategies designed to facilitate the delivery of clinical best practice for patients diagnosed with chlamydia or gonorrhea in primary care. METHODS: A nonrandomized pilot intervention study with a historic control period was run over 9 months in six primary health care clinics (2 youth services, 3 low-fee clinics, and 1 student health service) in Wellington, New Zealand. "Study nurses" in participating clinics oversaw the implementation of strategies designed to facilitate partner notification and follow-up for patients diagnosed with chlamydia or gonorrhea. Clinics chose which of 2 approaches they wished to trial-either managing all study processes themselves or drawing on the assistance of an external specialist sexual health advisor. Outcome measures included acceptability and utility of study processes ascertained via structured interviews with study nurses and collection of clinical data. RESULTS: Outcomes for 287 patients seen during the intervention were compared with 240 historic controls. Participant views on study processes were positive overall, and all clinics intended to continue all or most of the study processes implemented. During the intervention, substantial improvements were observed in documented patient management (sexual history, partner notification, and outcomes, P < 0.05). Increases were observed in percentages of patients reached for follow-up (74% vs. 26% at baseline, P < 0.05) and partners reported to have been notified (79% vs. 23%, P < 0.05). CONCLUSIONS: Nurse-led strategies implemented were deemed acceptable and appeared to facilitate delivery of best practice care for patients diagnosed with bacterial sexually transmitted infections in participating primary care practices.

Retesting and repeat positivity following diagnosis of Chlamydia trachomatis and Neisseria gonorrhoea in New Zealand: a retrospective cohort study.

BACKGROUND: Testing for reinfection at 3 to 6 months following treatment for Chlamydia Trachomatis or Neisseria gonorrhoea is recommended in best practice sexual health management guidelines. This study aimed to describe rates of retesting and repeat positivity following diagnosis of chlamydia or gonorrhoea in a defined geographic region of New Zealand. METHODS: Retrospective cohort study in Wellington, New Zealand involving analysis of laboratory data for chlamydia and gonorrhoea tests performed in primary care and sexual health clinics (July 2012-July 2015). OUTCOME MEASURES: rate of retesting and rate of repeat positivity 6 weeks to 6 months after a positive result (index event). Kaplan-Meier curves were used to plot time from first index event to retest. Logistic regression modelling was used to determine the odds of retesting and repeat positivity between 6 weeks and 6 months of follow-up, adjusting for potential confounders (age, gender, ethnicity and socioeconomic deprivation). RESULTS: Overall 29.4% (1919/6530) of the cohort was retested between 6 weeks and 6 months, with 18% (347/1919) of those retested returning positive results. Lower odds of retesting were observed for males (OR 0.4, 95% CI 0.34-0.48), and individuals of NZ Maori (OR 0.72, 0.61-0.85) and Pacific ethnicities (OR 0.49, 0.39-0.62, reference European). Factors associated with higher odds of repeat positivity on retesting included male gender (OR 2.0, 1.14-2.82), age 15-19 years (OR 1.78, 1.32-2.41, reference 20-24 years), chlamydia/gonorrhoea co-infection (OR 2.39, 1.32-4.35, reference chlamydia only), Maori (OR 1.6, 1.18-2.17) and Pacific ethnicities (OR 1.88, 1.22-2.9, reference European). CONCLUSIONS: We observed low adherence to STI retesting guidelines, and marked gender and ethnic disparities in rates of retesting and repeat positivity. Low retesting rates are suggestive of low levels of awareness of this aspect of patient management, and an absence of a systematic approach to retesting. High rates of repeat positivity reinforce the importance of advising patients about reducing their risk of reinfection, including notification and treatment of all recent sexual partners. Greater priority needs to be placed on increasing retesting and reducing rates of reinfection, with strategies implemented to improve these important aspects of patient care and population STI control.

Chlamydia testing and diagnosis following initiation of long-acting reversible contraception: A retrospective cohort study.

BACKGROUND: Long-acting reversible contraception (LARC) effectively protects against pregnancy but provides no protection against sexually transmitted infections (STIs). AIM: To compare rates of chlamydia testing and diagnosis for women initiating long-acting versus oral contraception. MATERIALS AND METHODS: Retrospective cohort study involving data collection for 6160 women initiating post-abortion contraception at a large New Zealand regional public hospital abortion clinic (2009-2012), with chlamydia testing data obtained from the local laboratory during two-year follow up. Negative binomial regression modelling examined the effect of contraceptive method on two outcome measures: chlamydia testing and chlamydia diagnosis (adjusting for potential covariates of age, ethnicity, past chlamydia infection, pregnancy history) in year one and two of follow up. RESULTS: Two thousand seven hundred and twenty nine women (44%) received a LARC and 1764 (28.6%) were prescribed oral contraception. Adjusted testing rates differed by contraceptive method only in year one (P < 0.01): with higher rates among copper intrauterine device users (relative risk (RR) 1.2, 95% CI 1.06-1.35), and lower rates for implant users (RR 0.84, 95% CI 0.72-0.99) compared with oral contraceptive users (reference group). No significant differences were observed in chlamydia diagnosis rates by contraceptive method (P > 0.05). Younger age, past chlamydia infection, Maori and Pacific ethnicity were associated with higher rates of chlamydia diagnosis (P < 0.01). CONCLUSIONS: Known STI-related risk factors (age, ethnicity, past infection) but not contraceptive method were independently related to rates of subsequent chlamydia diagnosis. This suggests that increased LARC uptake would not occur at the expense of chlamydia control. Regular screening and risk reduction advice (including condom use) are important chlamydia control measures for at-risk groups.

Regional variation in postabortion initiation of long-acting reversible contraception in New Zealand.

OBJECTIVE: To determine whether there is regional variation in the immediate postabortion initiation of long-acting reversible contraception (LARC) in New Zealand. MATERIALS AND METHODS: Retrospective analysis of nationally collected data on receipt of intrauterine and implantable contraception at the time of an abortion, together with demographic characteristics and region of residence for the year 2013. RESULTS: Postabortion LARC initiation varied significantly between the 16 regions of New Zealand, ranging from 32% (95% CI 23.2-42) to 61.4% (95% CI 53.3-69). Implant use ranged from 6.8% to 32.7% across regions, and intrauterine method use ranged from 21.4% to 54.7%. Regional variation in total LARC uptake was most marked for under 20-year-olds (20.3% to 70.9%). The ratio of intrauterine to implant users ranged from 0.7 to 4.1 across regions, with intrauterine methods prescribed two and a half times more frequently nationwide. CONCLUSIONS: These regional differences in postabortion LARC initiation suggest there are between-clinic differences in prescribing. Reasons for these differences need to be examined to identify and address any barriers faced by clinics in the routine provision of postabortion LARC. Equitable access to LARC at the time of an abortion is needed throughout New Zealand to assist women in the prevention of future unintended pregnancies.

Time to second abortion or continued pregnancy following a first abortion: a retrospective cohort study.

STUDY QUESTION: What proportions of women have a second abortion or continued pregnancy within 12-46 months of a first abortion? SUMMARY ANSWER: Estimated return rates for a second abortion were 5, 10.9 and 19.8% at 12, 24 and 46-months, respectively, and rates of continued pregnancy were 5.6, 12.9 and 24.3% at the same intervals. WHAT IS KNOWN ALREADY: Studies attempting to identify women at risk for 'repeat abortion' for intervention purposes have described a range of demographic and behavioural characteristics associated with presentation for more than one abortion, but few have taken timing of abortions into account. STUDY DESIGN, SIZE, DURATION: Retrospective cohort study involving women presenting for a first abortion at a public hospital abortion clinic in New Zealand (2007-2010). PARTICIPANTS/MATERIALS, SETTING, METHODS: Electronically stored records were analysed for women discharged from a public hospital abortion clinic in New Zealand. Outcome measures were the proportion of women having a second abortion or continued pregnancy within 24 months of a first abortion, and characteristics associated with shorter time to subsequent pregnancy. Cox proportional hazards modelling was used to detect factors associated with time to a second abortion or continued pregnancy, and Kaplan-Meier survival analyses were used to estimate time to one of these two pregnancy outcomes. MAIN RESULTS AND THE ROLE OF CHANCE: A total of 6767 women had a first abortion between 2007 and 2010. Some data were missing for 11 women so were excluded from the cohort and analyses. Return rates for a second abortion estimated from survival analyses were 5, 10.9 and 19.8% at 12, 24 and 46 months, respectively. Estimated rates of continued pregnancies were 5.6, 12.9 and 24.3% at 12, 24 and 46 months, respectively. Younger age, non-European ethnicity and greater parity were significantly associated with shorter time to a second abortion and to a subsequent continued pregnancy (P < 0.01 for all factor P-values). Hazard ratios (HR) for a second abortion were highest among those aged 16-19 years (HR 1.6, 95% confidence interval (CI) 1.3-1.9, Reference 20-24), of Pacific Island (HR 1.35, 95% CI 1.1-1.7) or Maori ethnicity (HR 1.26, 95% CI 1.1-1.5, Reference New Zealand European), and with 1 (HR 1.41, 95% CI 1.1-1.7) or 2 (HR 1.41, 95% CI 1.1-1.9, Reference nulliparous) children at the time of the first abortion. Both pregnancy outcomes were observed among 120 women (1.8%), with 60% of these women having a second abortion before the continued pregnancy. LIMITATIONS, REASONS FOR CAUTION: This study was limited to analysis of routinely collected clinical and demographic data for women presenting for abortion over a 4-year period. Conclusions could not be drawn about a wider range of personal and situational factors influencing pregnancy and pregnancy outcomes. Data were drawn from only one clinic but characteristics of the study sample were broadly representative of those reported nationally. Loss to follow-up for women seeking a second abortion elsewhere in the country cannot be ruled out and would serve to underestimate return rates reported here. WIDER IMPLICATIONS OF THE FINDINGS: To date, the most effective public health measure known to reduce abortion return rates within 24 months is the initiation of long-acting reversible contraception (LARC) at the time of an abortion. The high proportion of women seeking a second abortion <4 years after a first abortion (20%) could be significantly reduced by use of LARC, as could unintended pregnancies that are continued soon after a first abortion, particularly among teenaged and young women. Barrier-free access to a range of LARC methods should be prioritized to prevent unintended and mistimed pregnancies. STUDY FUNDING/COMPETING INTERESTS: Funded by a Lottery Health Research Grant and a University of Otago Research Grant. The authors have no competing interests. TRIAL REGISTRATION NUMBER: Not applicable.

Uterine cancer: exploring access to services in the public health system.

BACKGROUND: Maori are the indigenous peoples of New Zealand and experience higher rates of uterine cancer and poorer survival rates. Postmenopausal bleeding (PMB) is the most common presenting symptom for uterine cancer. Prompt investigation is essential with 28 days being viewed as an appropriate time from first medical contact (FMC) to first specialist appointment (FSA). AIMS: To compare access to services for the investigation of PMB between Maori and non-Maori women. MATERIALS AND METHODS: The time interval between FMC to FSA was obtained from medical records for women presenting to gynaecology clinics for PMB. Dates of first bleeding symptoms, knowledge and access issues were collected in a nurse-administered questionnaire. RESULTS: A total of 154 women (n = 27 Maori and 127 non-Maori) participated in the study. 23% of women had their FSA from FMC within 28 days and 67% waited more than six weeks. The 75th percentile was approximately two weeks longer for Maori women. 25% (n = 37) of women were not aware that they needed to see a doctor about PMB, and this was significantly more common for Maori women (44%; 95% CI 25-65) than non-Maori women (20%; 95% CI 13-28; P = 0.011). CONCLUSIONS: The majority of women were not seen for FSA within 28 days of their FMC. Maori women were more likely to experience lengthy delays and to report that they did not know they should see a doctor about PMB. Further investigation into reasons for delays and initiatives to improve access to services and health information appears warranted.