This is the first qualitative study to examine – from the perspectives of young Aboriginal Australians’ resident in remote Australia, and focussing on gender differences – multiple factors influencing young Aboriginal people’s engagement with clinic-based STI testing. We do so using socio-ecological analysis to highlight the individual, social and health service influences in two contrasting remote settings in the Northern Territory. Our findings illustrate the importance of strong family and community support for health service use, youth-friendly design of health service spaces and appointment procedures, efforts to minimise sexual stigma, and innovative sexual health outreach programs, particularly for young Aboriginal men, to reduce high rates of STIs and enhance engagement in clinic-based STI testing.
At an individual level, young women and men in both settings identified barriers to STI testing linked to limited knowledge and awareness of the transmission and prevention of STIs, and their often asymptomatic nature. Similar findings are reported in studies with other young people in Australia [16,17,18, 22, 29,30,31]. Some participants identified further attitudinal barriers that inhibited or delayed STI testing for symptomatic STIs and a lack of skills to communicate about STIs with health service workers. Among other things, these findings reaffirm the inadequacy of skills-based relationships and sexuality education for young Aboriginal people in diverse settings [15, 17, 22, 24, 32, 33], which is identified as an urgent priority in the latest national strategy .
Beyond the individual level, social connectedness and interaction – especially with friends, peers and family – had divergent effects. In the remote community, women’s nights provided a safe space for young women to interact with older women and share advice about women’s health issues. Such social interactions outside clinic spaces enhanced young women’s individual knowledge and awareness of the issues. However, these informal social support networks also extended into clinic spaces. Accompanied visits to the clinic for women’s health issues – with support from sisters, cousins, aunts, mothers, grandmothers and close friends – enabled young women to gain experience of STI testing procedures under the guise of something else. In this setting, young women’s strong intergenerational, peer and family support networks reduced barriers associated with individual influences, limited the occurrence of social stigma associated with STIs, and enhanced access to and experience within clinic settings.
In contrast, for young people in setting 2, social connectedness and interaction within and outside clinic settings proved to be a barrier to STI testing. Without inter- and intragenerational social support, fear of being seen by, or having to converse with, peers, family or other community members in a clinic waiting room created anxiety and fear of being judged and maligned by peers and family. As reported in other studies in remote and regional Australia [22, 34], teasing, name-calling and gossip within peer networks, and the reputational damage associated with rumours that spread beyond to families were detrimental to STI testing among young people in this setting. Here, the social connections within health service settings led to social processes beyond the clinic which discouraged engagement in clinic-based STI testing.
Health systems delivery influenced young people’s engagement with STI testing. Health promotion outreach strategies – delivered via a partnership between the government clinic and the government-led remote men’s health team – were reported by young men in setting 1 to enhance their willingness to attend the local clinic for STI testing. Ongoing discussion with male health workers during social and sports activities outside the clinic setting, and accompanied visits through the clinic, enhanced social connectedness between young Aboriginal men and male health workers. These strategies brought health services and social influences together and provided opportunities for young men to learn about sexual health issues; experience how to communicate with health professionals; initiate trusting relationships with clinic staff; and become more comfortable accessing formal clinic spaces.
In contrast, young people in setting 2 reported fewer opportunities (outside of a formal, anxiety-provoking clinic visit) to interact with health workers or knowledgeable and supportive friends and family members. As a result, they were not able to acquire the knowledge, language and skills required to negotiate access to a busy, centrally located service in which privacy could not be assured, and lacked both confidence and trust to do so. Nor were they able to acquire the skills to communicate comfortably with other people about issues pertaining to STIs, sexual health and personal sexual practices, for fear of stigmatisation by others. Additionally, in setting 2, the geographical location of the clinic, the nature of the clinic space (i.e. entry points, waiting rooms), appointment procedures (i.e. pre-booked versus drop-in procedures) and waiting times prior to appointments enabled peer and family surveillance of young people’s clinic attendance.Footnote 2 Young Aboriginal people’s fear of lack of confidentiality in health service provision, and concerns about waiting times and interactions with clinic staff have also been documented in other studies [19,20,21, 35]. Here, the exacerbation of social barriers within clinic spaces illustrates the complex challenges of providing private and confidential, but culturally and socially safe clinic-based STI testing.
While our sample of young people was large enough to allow ‘thematic data saturation’ , data collection was limited to a small sample of young people resident in two settings in the Northern Territory. Therefore, care must be taken to not generalise beyond these settings. In addition, information was not captured regarding the reasons why participants declined to participate. Data collection by a range of interviewers may have increased the variation among individual responses, although ‘internal reliability’  was enhanced by interviewers working together during data interpretation and analysis processes to ensure rigour and consistency in data interpretation. Despite these limitations, study findings provide timely insights into the lived experiences of young Aboriginal people and their engagement with STI testing, signalling the range of socio-ecological factors that must be engaged with and addressed if testing is to be a success.
Implications for programmes and services
Given the high prevalence, incidence and poor health outcomes associated with STIs, and the need for extremely high levels of STI testing and treatment in these settings, our findings – when used in collaboration with other available published evidence documenting the expertise of other stakeholders including family members, health workers and policy makers – have implications for strategies designed to enhance young people’s access to STI testing in remote settings. These will help meet priorities identified in the national strategy .
To overcome individual level barriers, action is needed to enhance young Aboriginal people’s communication skills, health seeking practices and understanding of asymptomatic STIs. Culturally responsive comprehensive relationships and sexuality education – in school, clinical, community and peer-based settings , and with a focus on health literacy, interpersonal and negotiation skills to navigate healthy relationships and access health services [37, 38] – would be beneficial, to upscale the limited current provision throughout the Northern Territory.
Action is also required to strengthen social support networks that include peers, families and other community members, and systems of health service provision to enhance young people’s access to and use of health services in remote settings. The women’s nights and the men’s health BBQs illustrate the value of activities that: (i) bring young people together in safe environments to talk about sexual health issues; (ii) involve supportive, trusted and influential family and community members in youth sexual health promotion activities; (iii) ‘nest’ STI-related services within broader systems of support for women’s and men’s health; (iv) enable young people to gain experience communicating with health workers in informal settings beyond the clinic environment. Accompanied clinic visits – with either health workers, friends, or trusted family members – can also facilitate culturally safe STI testing experiences.
There remain challenges to be faced however. These include how to reduce the social risks associated with young people’s clinic attendance, which is essential to the prevention, testing and management of STIs in this population . Several approaches are worthy of further exploration in this regard including: (i) health worker community outreach work and accompanied visits to health services; (ii) the provision of youth-only sessions to limit youth interactions with adult family and community members within the clinic waiting room, and reduce individual risk by facilitating group-based testing; (iii) service re-design research to understand how to eliminate the risky moments of interaction between young and other clients in clinic settings; (iv) messaging about the harms associated with rumour, gossip and reputational damage in communication campaigns.