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

James Ward, Rebecca J. Guy, Alice R. Rumbold, Skye McGregor, Handan Wand, Hamish McManus, Amalie Dyda, Linda Garton, Belinda Hengel, Bronwyn J. Silver, Debbie Taylor-Thomson, Janet Knox, Basil Donovan, Matthew Law, Lisa Maher, Christopher K. Fairley, Steven Skov, Nathan Ryder, Elizabeth Moore, Jacqueline Mein & 5 others Carole Reeve, Donna Ah Chee, John Boffa, John M. Kaldor, STRIVE Investigators

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Abstract

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.

LanguageEnglish
Pagese1553-e1563
Number of pages11
JournalThe Lancet Global Health
Volume7
Issue number11
DOIs
Publication statusPublished - 1 Nov 2019

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Infection
Primary Health Care
Population Density
Population
Trichomonas vaginalis
Intention to Treat Analysis
Neisseria gonorrhoeae
Chlamydia trachomatis
Reproductive Health
Random Allocation
New Zealand
Information Systems
Registries
Biomedical Research
Language
Regression Analysis
Research Personnel
Clinical Trials
Delivery of Health Care
Health

Bibliographical note

Copyright the Author(s) 2019. Version archived for private and non-commercial use with the permission of the author/s and according to publisher conditions. For further rights please contact the publisher.

Cite this

Ward, James ; Guy, Rebecca J. ; Rumbold, Alice R. ; McGregor, Skye ; Wand, Handan ; McManus, Hamish ; Dyda, Amalie ; Garton, Linda ; Hengel, Belinda ; Silver, Bronwyn J. ; Taylor-Thomson, Debbie ; Knox, Janet ; Donovan, Basil ; Law, Matthew ; Maher, Lisa ; Fairley, Christopher K. ; Skov, Steven ; Ryder, Nathan ; Moore, Elizabeth ; Mein, Jacqueline ; Reeve, Carole ; Ah Chee, Donna ; Boffa, John ; Kaldor, John M. ; STRIVE Investigators. / Strategies to improve control of sexually transmissible infections in remote Australian Aboriginal communities : a stepped-wedge, cluster-randomised trial. In: The Lancet Global Health. 2019 ; Vol. 7, No. 11. pp. e1553-e1563.
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title = "Strategies to improve control of sexually transmissible infections in remote Australian Aboriginal communities: a stepped-wedge, cluster-randomised trial",
abstract = "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.",
author = "James Ward and Guy, {Rebecca J.} and Rumbold, {Alice R.} and Skye McGregor and Handan Wand and Hamish McManus and Amalie Dyda and Linda Garton and Belinda Hengel and Silver, {Bronwyn J.} and Debbie Taylor-Thomson and Janet Knox and Basil Donovan and Matthew Law and Lisa Maher and Fairley, {Christopher K.} and Steven Skov and Nathan Ryder and Elizabeth Moore and Jacqueline Mein and Carole Reeve and {Ah Chee}, Donna and John Boffa and Kaldor, {John M.} and {STRIVE Investigators}",
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Ward, J, Guy, RJ, Rumbold, AR, McGregor, S, Wand, H, McManus, H, Dyda, A, Garton, L, Hengel, B, Silver, BJ, Taylor-Thomson, D, Knox, J, Donovan, B, Law, M, Maher, L, Fairley, CK, Skov, S, Ryder, N, Moore, E, Mein, J, Reeve, C, Ah Chee, D, Boffa, J, Kaldor, JM & STRIVE Investigators 2019, 'Strategies to improve control of sexually transmissible infections in remote Australian Aboriginal communities: a stepped-wedge, cluster-randomised trial', The Lancet Global Health, vol. 7, no. 11, pp. e1553-e1563. https://doi.org/10.1016/S2214-109X(19)30411-5

Strategies to improve control of sexually transmissible infections in remote Australian Aboriginal communities : a stepped-wedge, cluster-randomised trial. / Ward, James; Guy, Rebecca J.; Rumbold, Alice R.; McGregor, Skye; Wand, Handan; McManus, Hamish; Dyda, Amalie; Garton, Linda; Hengel, Belinda; Silver, Bronwyn J.; Taylor-Thomson, Debbie; Knox, Janet; Donovan, Basil; Law, Matthew; Maher, Lisa; Fairley, Christopher K.; Skov, Steven; Ryder, Nathan; Moore, Elizabeth; Mein, Jacqueline; Reeve, Carole; Ah Chee, Donna; Boffa, John; Kaldor, John M.; STRIVE Investigators.

In: The Lancet Global Health, Vol. 7, No. 11, 01.11.2019, p. e1553-e1563.

Research output: Contribution to journalArticleResearchpeer-review

TY - JOUR

T1 - Strategies to improve control of sexually transmissible infections in remote Australian Aboriginal communities

T2 - The Lancet Global Health

AU - Ward, James

AU - Guy, Rebecca J.

AU - Rumbold, Alice R.

AU - McGregor, Skye

AU - Wand, Handan

AU - McManus, Hamish

AU - Dyda, Amalie

AU - Garton, Linda

AU - Hengel, Belinda

AU - Silver, Bronwyn J.

AU - Taylor-Thomson, Debbie

AU - Knox, Janet

AU - Donovan, Basil

AU - Law, Matthew

AU - Maher, Lisa

AU - Fairley, Christopher K.

AU - Skov, Steven

AU - Ryder, Nathan

AU - Moore, Elizabeth

AU - Mein, Jacqueline

AU - Reeve, Carole

AU - Ah Chee, Donna

AU - Boffa, John

AU - Kaldor, John M.

AU - STRIVE Investigators

N1 - Copyright the Author(s) 2019. Version archived for private and non-commercial use with the permission of the author/s and according to publisher conditions. For further rights please contact the publisher.

PY - 2019/11/1

Y1 - 2019/11/1

N2 - 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.

AB - 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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