Correspondence to: Dr Patricia Fagan, School of Population Health and Rehabilitation Medicine, James Cook University, Cairns, QLD 4870; e-mail: firstname.lastname@example.org
Objective: This paper describes the implementation and selected outcomes of the Young Person Check (YPC), a high-coverage screening program in far north Queensland targeting remote youth aged 15–24 years for sexually transmissible infections (STI) and chronic disease risk. The YPC was conducted 19 times in eight discrete remote communities and one community cluster between 2009 and 2012.
Methods: Narrative description of consultation processes, YPC planning, recruitment strategies, logistics, screen design, additional costs and data management; analysis of coverage by location, age group and gender, selected STI management outcomes, and clinic-based STI testing separate from YPCs.
Results: A total of 3,686 episodes of care were delivered, including 3,083 to Indigenous youth aged 15–24 years. Overall coverage of the 15–24 population was 73% for females and 72% for males. Median time to treatment for chlamydia/gonorrhoea cases was 13 days and 63% of cases had at least one contact treated. Clinic-based STI testing did not decrease.
Conclusions: Positive outcomes of the YPC program, including satisfactory participation, rest on a rigorous approach to planning, recruitment and implementation; provision for STI follow-up; and data management.
Implications: Testing and treatment strategies form an important element of efforts to address endemic STI and reduce HIV risk in remote Australian populations. Complementary population testing strategies will continue to be utilised and may contribute, if coverage is satisfactory. Programs such as the YPC should be considered in settings where the conditions outlined here can be met.
Far north Queensland (FNQ) covers more than 130,000 square kilometres and has an estimated Aboriginal and Torres Strait Islander population of 16,337 living in 27 mainland and island communities, and representing about two-thirds of the total population of this remote region.1 The disadvantage experienced by Indigenous Queenslanders in housing, educational attainment and employment is compounded in FNQ by remoteness and limited access to skilled health services.2 Health outcomes are poor with more frequent and earlier onset of diabetes; circulatory system and kidney disease; and extremely high rates of sexually transmitted infection (STI), especially among youth. In the 25–44 age group, mortality from diabetes, cardiovascular and renal diseases stands at 13, 10 and 38 times the Queensland rates, respectively. Annual notifications (between 2004 and 2009) in the 15–24 year age group in FNQ for the two most common STI – chlamydia and gonorrhoea – stood at 8,339 and 2,739 per 100,000, compared with 869 and 44.1 per 100,000, respectively, in their non-Indigenous Queensland counterparts.3–5
STI cause significant morbidity and are associated with a range of negative reproductive health outcomes: pelvic inflammatory disease, tubal infertility, adverse pregnancy outcomes and congenital infection,6,7 all of which are more common in the FNQ population.3,8 A high prevalence of STI also places the population at increased risk from HIV, if exposed.9
Many STI are clinically silent,10 as are the risk factors for chronic disease. This burden of infection and early onset chronic disease has led, over the past 15 years, to an emphasis on screening as an important part of the clinical care that generalist remote primary health care service providers opportunistically offer.11 Screening here refers to the testing of asymptomatic individuals for the earlier detection of common conditions for which there is an intervention.
FNQ patient information system data for 2005 to 2008 and a detailed analysis of service utilisation data for 2010 suggest that this screening resulted in about 45% of the females and 25% of the males aged 15–24 years having at least one test for chlamydia/gonorrhoea each year, with substantially fewer being tested for syphilis.12 There is no evidence available to determine the optimum testing frequency or coverage levels required to reduce the burden of STI in remote Australian populations. However, there are positive reports from similar populations in the Tiwi Islands and the Anangu Pitjantjatjara Yankunytjatjara Lands of northern South Australia, where intensive population-wide screens that regularly achieve 65–75% coverage of the target population are offered each year to complement day-to-day clinic based testing. These reports highlight the potential benefits of this approach, with significant and sustained reductions in prevalence being reported, notably for chlamydia and gonorrhoea.13,14 These strategies are premised on the notion that testing and treating the majority of the at-risk population within a short period interrupts disease transmission. In addition, population-wide screening casts a wide net to encourage those potentially at higher risk and less likely to present for a comprehensive health check to get tested, thus providing the opportunity to tap into the underlying reservoir of infection.
In 2008, the regional Public Health Unit (PHU) discussed the FNQ testing data and these published reports with two District management teams and regional community-controlled health organisations, with a view to developing additional strategies to increase STI testing among remote youth. As a result of these discussions, it was agreed that an intensive screening strategy, called the Young Person Check (YPC), would be jointly implemented. The aim was to attract at least 70% of the resident Aboriginal and Torres Strait Islander population aged 15 to 24 years to each screen event, with a view to increasing testing and high quality treatment for STI. A subsidiary aim was to assess selected chronic disease risk factors among the youth who attended. The strategy was intended to complement, but not replace, primary care activity.
The YPC program was conducted in discrete Aboriginal and Torres Strait Islander locations across a large region of remote north Queensland between March 2009 and May 2012. It was implemented on 19 occasions in eight discrete communities and in one community cluster containing five villages. Four locations hosted a YPC on three occasions, two on two occasions, and three on one occasion. Aboriginal and Torres Strait Islander populations at community level varied from 596 to 2,689, with an estimated total population of 12,638 Indigenous residents, of whom 2,068 were aged 15–24 years, across all the locations.1
This paper describes the YPC program, its implementation and selected outcomes. It illustrates the elements that facilitated high youth participation, enabled comprehensive reporting and ensured satisfactory STI treatment outcomes in this setting.
YPC Program description
Consultation leading up to the first YPC in each location included a community visit with district health partners to meet with Council, health staff and management, and non-government organisations with an interest in youth welfare. If community and local services agreed, the timing of the YPC and likely screen location were decided. Memoranda of Understanding and documents outlining roles and responsibilities for each stakeholder ensured clear communication. Planning began six to eight weeks before each YPC. Local and District health staff and community organisations were represented at the three or four planning teleconferences that the PHU chaired using a standard agenda. After each teleconference an action list was circulated. Provision for staff to complete timely STI follow-up was an essential element.
The recruitment strategy began a few days prior to each YPC. Community-wide saturation advertising with location-specific colourful posters featuring local young people was followed by rigorous implementation of a house-to-house flyer drop by paid local youth supervised by an adult. Peer-aged recruiters were also employed to maximise youth interest during the screen, and personal invitations were delivered in the last few days to those in the target group who had not yet attended. A $20 incentive (phone credit or local store voucher) was offered to each target age-group participant and to those who successfully recruited three other target group members. Finally, all participants were entered into a draw for a mobile device such as an MP3 player or mobile phone.
The YPC process for the participant consisted of: provision of written and verbal information to gain consent; documentation of demographic and contact details; body (height, waist, weight) and blood pressure measurements; and collection of a non-fasting blood and a first catch urine sample. The tests were: random plasma glucose and lipid profile; urinary albumin creatinine ratio; syphilis serology; and polymerase chain reaction urine test for Chlamydia trachomatis, Neisseria gonorrhoea and Trichomonas vaginalis. Testing for hepatitis B virus surface antigen was included later in the program. The screen took about 15 minutes of the person's time.
The screen venue and operation times varied and were flexible with the aim of maximising youth friendliness and avoiding interference with health service activities. A screen day began in the late morning and sometimes extended into the evening to facilitate youth participation. The screening phase was proportional to population size, ranging from four to 18 days. The screen team ideally comprised four to six members and included local health workers, District sexual health staff and the PHU public health nurse (PHN – sexual health). This PHN co-ordinated the YPC team, the screen itself and the data entry, as well as assisting local and district staff to complete STI follow-up.
STI treatments began immediately after the screen period and the YPC was not considered finished until a satisfactory report could be made on treatment outcomes. A single medical officer assessed chronic disease risk and a list of participants requiring further investigation or review was given to the health centre for follow-up. Individuals requiring urgent review were referred from the screen site.
Population coverage by YPC location, age group and gender was calculated. A target group resident was defined as an Aboriginal or Torres Strait Islander individual aged 15–24 years present in the community at any time during the YPC screen period. This number formed the denominator used to determine participation at each YPC. A clinic population list was the starting point to determine the denominator. Local health workers and peer recruiters culled or added to the list prior to the YPC. This became the registration list for participants. In each location, the denominator grew as others attended or were remembered, and was culled as individuals were discovered to be absent. Selected outcomes of the management of the total YPC-diagnosed chlamydia and gonorrhoea cases are reported. Primary care STI-testing data for the two Districts containing seven of the nine screen locations were obtained from the single regional pathology provider (Queensland Health Pathology and Scientific Services) for 2007 to 2011. Annual test numbers over time (separate from YPCs) was assessed for the five communities in these Districts that held more than one YPC, in order to monitor the impact of the YPC on STI testing. Data on the costs of the program that were additional to routine service provision are reported.
For each episode of care, participant information was manually recorded, then entered into a database designed for the purpose and into the local electronic medical record system (if in use). The data were examined for accuracy and consistency and an electronic download of the pathology results at the end of the screen enabled the generation of population level reports. Individual summaries, including recommendations for chronic disease risk follow-up, were generated and filed in the participant's medical record in each location. A population level report of each YPC detailing the screen process, 15–24 age group population coverage, STI epidemiology and treatment outcomes was provided to the local health service and relevant stakeholders within two months of the end of the YPC, accompanied by face-to-face feedback to interested community stakeholders and health staff, if appropriate.
After the first six months, a process evaluation of the YPC program was conducted by an external consultant.15 The adoption of its recommendations refined program processes and presentation, and strengthened communication with primary care providers.
Surveillance for chlamydia and gonorrhoea is conducted in accordance with the provisions of the Public Health Act Queensland (2005). The YPC program was a service initiative developed in partnership with local communities, District management and community-controlled health organisations. Letters of support for the publication of this paper have been provided by the two District managements, the two community-controlled health services and a partner community organisation in the region.
Participation and target group coverage
A total of 3,686 episodes of care were delivered, more than 95% involving Aboriginal and Torres Strait Islander individuals. The age range of participants was 12 to 37 years. Of these, 3,083 episodes (female: 1,615; male: 1,468) were delivered to Aboriginal and Torres Strait Islander youth aged 15–24 years. Approximately one-third (34%) of the episodes of care involved individuals who attended for a YPC on more than one (up to three) occasion. Coverage of the 15–24 population in each location ranged from 50% to 87%, with 13 of 19 events achieving target group coverage of at least 70%, and a further five events achieving 65–69%. On one occasion, participation was well below target at 50% (see Figure 1). Coverage of the 15–19 population was higher, ranging from 56–90%, and at least 70% in 15 of 19 YPCs. Overall participation of the 15–24 age group for all YPCs was 73% for females and 72% for males, while participation of the 15–19 age group was 77% for females and 76% for males.
Outcomes of chlamydia/gonorrhoea management
There were 547 individuals diagnosed with chlamydia and/or gonorrhoea. The median time to treatment from the date of test was 13 days, and 87% were treated within one month of testing. Sixty-three per cent of index cases had at least one contact treated, and 60% of all the contacts named were treated.16
Impact on primary care testing
Figure 2 displays chlamydia/gonorrhoea primary care testing (performed separate from a YPC) over time in the two Districts for the five communities that held more than one YPC. District 1 demonstrated a significant upward trend (p<0.05) while the decrease in District 2 was not statistically significant.
The YPC program was implemented using existing public health, district and local health service staff. One additional PHN position with a significant travel budget co-ordinated the program. Pathology and incentive costs per location varied by population size. The cost of the recruitment strategy, including posters, flyers, resources, advertising and peer recruiter costs, ranged between $3,000 and $15,000, depending on the size of the community.
The resurgence of syphilis in north Queensland;17,18 on-going concerns regarding a generalised outbreak of HIV; and the persisting burden of STI in remote populations require action across a broad front. Global best practice,19 adapted to FNQ, indicates that this includes: community mobilisation around the unacceptability of this situation for Indigenous youth;20 embedding school-based sexuality and relationships education; population-wide sexual health communications campaigns; improvements in condom access;21 and strategies to improve early detection and treatment. In regard to the latter, despite more than a decade of the widespread use of non-invasive specimens, reliable tests and single dose treatments, many questions remain about the adequacy of the existing primary-care-based opportunistic testing strategy. The search for innovative approaches to improve testing and treatment continues22,23 and additional population screening strategies such as the YPC continue to be utilised.
Substantial resources have been directed towards these intensive population screening efforts in Queensland in recent years, but there are few reports on outcomes, including target group participation and STI management, so their effectiveness is difficult to evaluate. Where reported, participation categories vary and are broad. For example, the Well Person Health Check survey in north Queensland (1998–2000) reported 42.5% participation for those aged 15–34 years, but participation of the 15–24 age group is not reported, and is known to have been lower.24 We support the 2012 call of Guy et al. for comprehensive reporting of STI program outcomes and the development of a standard set of indicators to facilitate both reporting and the evaluation of programs.25
The YPC was a service initiative, so attempts to identify important factors for a successful screen event rely on reflection and consensus. Factors considered critical to participation included: community engagement (of community champions, local health staff and peer recruiters); a rigorously implemented advertising and recruitment strategy followed by personal invitation (previously demonstrated to be effective in north Queensland);24 the priority given to a youth-friendly screen experience; and the material incentive ($20 voucher and the draw). Factors thought to have impaired participation included: concurrent important community events (funerals, local festivals); lack of local health staff involvement; and the spread of misinformation regarding the tests within the target group. Large communities that offered distractions and greater employment opportunities sometimes challenged the recruitment effort. Community-controlled health services are well placed to galvanise youth around a YPC, though factors other than governance were thought to be the critical determinants of high participation. Occasionally, despite every effort, the YPC failed to reach a significant majority of local youth. On one occasion, a YPC was aborted on day two when it was clear that community conditions precluded success.
YPC effectiveness has been reproducible and participation was particularly satisfactory in the 15–19 age group where STI notifications are concentrated.26 The YPC program not only increased annual STI testing coverage of youth (especially males) but, importantly, increased the frequency of testing during a life phase that is one of significant STI risk for many.
Northern Territory authorities suspended annual STI screens in 2010, partly in response to reduced STI testing, separate from the screen period.27 The extent to which the YPC may have a negative impact on underlying primary care testing in north Queensland is debatable. The two Districts here (Figure 2) have differing sexual health service arrangements. Difficulties in recruitment to remote settings and variable functionality within District sexual health teams seemed a more dominant influence. However, monitoring underlying STI testing is recommended. Sporadic, as opposed to annual, implementation of well-conducted screens may help guard against this negative outcome.
In one location in 2009, the YPC strategy intervened early and effectively controlled a previously unrecognised outbreak of syphilis. More recently, it demonstrated itself to be a useful tool in assessing the status of outbreaks, as well as providing information on STI prevalence and chronic disease risk.16
In addition to participation, YPC program success must be measured on the outcomes for those with STI and chronic disease risk. The former are satisfactory. Although time to treatment is extended in longer screens (until the treatment phase begins) both the STI treatment and contact tracing outcomes represent a high benchmark for remote practice.28,29 The follow-up of YPC participants with chronic disease risk is currently being reviewed in a separate study, as is the prevalence of chronic disease risk. The epidemiology of the STI found has not been reported here, as this analysis will require further ethics approval.
From a public health perspective, the YPC succeeds where young people and community are comfortable with the process; participation targets are reached; STI management outcomes are of high quality and young people with chronic disease risk are followed up; and the findings are documented. These outcomes rest on a coordinated approach to planning, recruitment, implementation of the screen, follow up of abnormal findings and data management. They also rest on primary care capacity to implement chronic disease risk interventions for identified youth.
The target age group for the YPC did not capture all those at risk for STI, but did reflect the finding from remote populations across Australia that the majority of notifications for chlamydia and gonorrhoea occur in young people aged less than 25 years.4,18 The age group chosen was acceptable to community leaders and balanced the reality of a large remote population with the limited resources available for implementation. The relatively narrow age range also facilitated the development of a service marketing strategy that appealed to youth. The principles guiding the design of the YPC were that it was ‘youth friendly’ and consistent with World Health Organization screen principles.30 Local communities requested the inclusion of chronic disease risk factor assessment and, in some locations, the participating health service provided brief intervention at the screen for those identified. Interrogation regarding sexual health risks or use of tobacco, alcohol and other drugs was not included because of human resource considerations, lack of privacy at the screen sites and the risk of deterring young people from participation.
The sustainability over years of a YPC-type strategy is unknown. In FNQ, participating communities continue to request PHU support to conduct YPCs, but recent structural changes within Queensland Health have made the continuing provision of that support difficult. The additional cost to the health system of conducting a YPC is substantial, but not prohibitive. A further evaluation that includes assessment of chronic disease risk follow-up and cost-effectiveness considerations, in addition to the impact on STI epidemiology and health care provider practice, would be welcomed.
The burden of chlamydia and gonorrhoea,3 the re-emergence of syphilis17 and the risk of HIV represent a challenge to remote health services, and detection and treatment of STI is an essential element of any strategy to address the issue. While high rates of STI remain, health services will continue to seek to complement primary-care-based testing with intensive population-screening strategies. The YPC experience demonstrates that, if carefully planned and continuously evaluated, innovative strategies can engage youth and achieve high youth participation and satisfactory STI treatment outcomes.
Given the added jeopardy to Aboriginal and Torres Strait Islander health outcomes that would accrue if HIV were to gain a foothold among young people in remote populations, rigorously implemented strategies such as the YPC should be considered in settings where the conditions outlined here can be met.
The Young Person Check program was funded through a National Partnership Agreement – Indigenous Early Childhood grant. The authors thank the many individuals and communities who participated in and/or supported implementation of the YPC, including the participants, district health staff and management, and TRS sexual health, data management and public health nutrition staff.