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1 Research Open access BMJ Open: first published as 10.1136/bmjopen-2018-026679 on 5 May 2019. Downloaded from Qualitative perspectives on the sustainability of sexual health continuous quality improvement in clinics serving remote Aboriginal Australia communities in 3 1 1,2 1,4 Jenny Brands, Lisa Maher, Gill Schierhout, Praveena Gunaratnam, 7 1,8,9 1 5 6 James Ward, Rebecca Guy, Alice Rumbold, Nathan Ryder, Ross Bailie, 1,12 10,11 1 13 Basil Donovan, John Kaldor, Liz Moore, Christopher K Fairley, 1,14 Stephen Bell Gunaratnam P, To cite: AC t Abstr trengths and limitations of this study s . et al Schierhout G, Brands J, Objectives T o examine barriers and facilitators to Qualitative perspectives on sustaining a sexual health continuous quality improvement ► This is the first qualitative study to document clin- the sustainability of sexual (CQI) programme in clinics serving remote Aboriginal ic-level and regional-level factors influencing up- health continuous quality communities in Australia. improvement in clinics serving take and sustainability of a sexual health continuous Qualita Design tive study. remote Aboriginal communities quality improvement (CQI) programme in govern- Primar s etting y health care services serving remote BMJ Open in Australia. ment-run primary care services serving remote Aboriginal communities in the Northern Territory, Australia. 2019; 9 :e026679. doi:10.1136/ Aboriginal communities in the Northern Territory Seven of the 11 regional sexual health Participants bmjopen-2018-026679 (NT), Australia. tors responsible for supporting the Northern coordina Using in-depth interviews with 7 of the 11 sexual ► Received 14 September 2018 Territory Government Remote Sexual Health Program. health coordinators employed to improve testing Revised 20 February 2019 views conducted Semi-structured in-depth inter Methods and treatment for sexually transmissible infections Accepted 4 April 2019 in person or by telephone; data were analysed using an (STIs) in government-run primary cares services inductive and deductive thematic approach. http://bmjopen.bmj.com/ elicited rich data about the challenges influencing vailability of CQI tools and esults Despite uniform a r sustained use of a sexual health CQI approach to activities, sexual health CQI implementation varied across improve STI testing and treatment rates. the Northern Territory. Participant narratives identified five This is a qualitative study with a small, non-random ► factors enhancing the uptake and sustainability of sexual sample size and as such findings should not be health CQI. At clinic level, these included adaptation of viewed as generalisable to other settings. existing CQI tools for use in specific clinic contexts and risk environments (eg, a syphilis outbreak), local ownership of CQI processes and management support for CQI. At a regional level, factors included the positive framing of CQI n OD IO u t Intr C on 10 May 2019 by guest. Protected by copyright. as a tool to identify and act on areas for improvement, Residents in remote Aboriginal and Torres and regional facilitation of clinic level CQI activities. Strait Islander (hereafter referred to as Three barriers were identified, including the significant ‘Aboriginal’) communities in Australia expe- workload associated with acute and chronic care in rience high rates of sexually transmissible Aboriginal primary care services, high staff turnover infections (STIs), estimated in one large, and lack of Aboriginal staff. Considerations affecting the multi-community study at 10%, 11% and future sustainability of sexual health CQI included the 18%, respectively, for gonorrhoea, chlamydia need to reduce the burden on clinics from multiple CQI 1 © Author(s) (or their and syphilis. Clinical guidelines for these programmes, the contribution of regional sexual health employer(s)) 2019. Re-use communities recommend at least annual coordinators and support structures, and access to and permitted under CC BY-NC. No STI testing, timely treatment, partner noti- use of high-quality information systems. commercial re-use. See rights This stud y contributes to the growing Conclusions fication and regular re-testing, particularly and permissions. Published by 2 3 BMJ. evidence on how CQI approaches may improve sexual those under 35 years old. However, recent health in remote Australian Aboriginal communities. For numbered affiliations see estimates indicate that annual STI testing Enhancing sustainability of sexual health CQI in this end of article. coverage in remote communities is still only context will require ongoing regional facilitation, efforts to 4 20%, with lower rates in men than in women. Correspondence to build local ownership of CQI processes and management Since the 1990s, continuous quality Dr. Stephen Bell; of competing demands on health service staff. au unsw. kirby. [email protected] edu. improvement (CQI) approaches—typically 1 et al . BMJ Open 2019; 9 :e026679. doi:10.1136/bmjopen-2018-026679 GunaratnamflP,

2 Open access in-fly out contracts) with support from resident or visiting consisting of ‘plan-do-study-act’ cycles to monitor the BMJ Open: first published as 10.1136/bmjopen-2018-026679 on 5 May 2019. Downloaded from functioning of organisational systems and identify and general practitioners and other specialist or allied health 5 16 —have been used to improve implement improvements providers. quality and outcomes associated with, for health The setting for this study was the NT government health care 6–10 In Australia, Aboriginal service sector, specifically the NT Government Remote example, chronic disease. Community Controlled Health Services (ACCHS) and Sexual Health Program. This programme coordinates government-run health services providing primary support for sexual health service delivery across both the care to Aboriginal communities have used CQI Top End Health Service (covering approximately 35% health extensively to make evidence-based improvements in clin- of the geographic area and 80% of the population) and 11–13 Central Australia Health Service (65% of the geographic ical care. 19 and Between 2011 area and 20% of the population). 2014, the STIs in Remote commu- ImproVed and Enhanced primary care (STRIVE) nities, s tudy participants trial was conducted in 67 remote communities in the - All sexual health coordinators working in the NT Depart Northern T erritory (NT), Queensland and Western 14 ment of Health (n=11) in 2016 were approached up STRIVE demonstrated that a clinic level Australia. to three times and invited to participate in an in-depth sexual health CQI programme supported by regional 14–16 qualitative interview. This resulted in seven sexual health dedicated sexual health coordinators could improve 15 coordinators providing informed consent to be inter - STI testing rates, with aspects of the CQI programme 16 viewed between March 2016 and January 2017. Of the However, becoming normalised in clinical practice. seven, three worked in Central Australia and four in testing increases were from a low baseline and did not the Top End; six were women; six had worked in their lead to lower STI prevalence over the time frame of the 15 current role for more than 1 , while one had started year trial. the role 8 months prior to the interview but had previ- Elements of the STRIVE CQI approach were incorpo- ously worked in a specialist sexual health clinic for more rated into the NT Government Remote Sexual Health 3 than 1 . Coordinators worked with between 4 and 11 year Program. The programme employs regionally-based services, and one also had a region-wide function. None sexual health coordinators to work with government-run were Aboriginal. primary care services to improve STI testing and treat- ment. Their roles include providing feedback on STI Data collection control through audits and review of clinical data; annual A semi-structured qualitative interview guide was devel- discussions with staff to assess and make recommenda- oped to explore participants’ understandings of CQI for tions for improving clinic-wide systems that support STI sexual health; the post-STRIVE trial transition; factors control (systems assessments); and sexual health educa- 3 influencing the uptake and sustained application of CQI tion and staff training. http://bmjopen.bmj.com/ approaches; and perceptions of the impact of CQI on To gain insight into CQI practice for STI control in sexual health service provision. Interviews lasted between the NT since the STRIVE study finished in 2014, and 80 and 25 - minutes, and were conducted by three inter to explore factors affecting the long-term sustainability viewers (JB, PG, SB) in person (n=2) or by telephone of this approach in government-run health services, we (n=5). conducted qualitative interviews with sexual health coor - dinators. Data were collected as part of a new study called atient and public involvement P STRIVEplus—a long-term observational study of sexual Patients and the public were not involved in this study. and 2019. health CQI in the NT between 2015 on 10 May 2019 by guest. Protected by copyright. r esearch team and reflexivity Interviews were conducted by PG, JB and SB, who had s OD Meth no prior relationship with interviewees in this study. This was a qualitative study using semi-structured, With extensive qualitative research experience, these in-depth interviews. The design, data collection, analysis researchers were able to build rapport and conduct and reporting of this study were conducted in accordance 17 semi-structured interviews with health professionals with the Standards for Reporting Qualitative Research. to elicit deep insight from research participants. The make-up of the research and authorship team also s etting enhanced the credibility of the findings. For instance, all The NT of Australia covers 1.4 million square kilome- interviewers (PG, JB, SB) conducted rigorous qualitative tres, with an estimated resident population of 230 000, analysis to ensure that agreement was sought on the main of whom 26% are Aboriginal (compared with 3% nation- 18 findings from the analysis. All other authors have career ally). Most (79%) Aboriginal residents in the NT live 19 experience in research and clinical practice focussing on in remote areas and are served by two types of primary sexual health CQI in diverse Australians settings, which care services—ACCHS or NT government health services. ensured interpretation of data informed by current and Remote clinics are primarily staffed by Aboriginal health historical sexual health CQI practice and policy in the NT. workers or registered nurses (often on short-term fly 2 BMJ Open 2019; 9 GunaratnamflP, . et al :e026679. doi:10.1136/bmjopen-2018-026679

3 Open access traffic light reports to see whether they’ve got their Data analysis BMJ Open: first published as 10.1136/bmjopen-2018-026679 on 5 May 2019. Downloaded from adult health checks done... we just recently realised Interviews were audio-recorded and transcribed verbatim year olds so there was a gap between the 15 to 24 before uploading into QRS NVivo V.11 for analysis (QRS we’ve gone through the communities and done some International, Melbourne, Australia). A thematic anal- 20 targeted screening. (SHC7, T op End) was used by two team members (PG and ysis approach JB). First, we familiarised ourselves with the data through In contrast, other services were perceived as under - reading and re-reading of transcripts, noting down initial taking less sexual health CQI activity, or as requiring 20 theoretical memos ’ thematic ideas and ‘ as analytical support from a sexual health coordinator to do so. reminders for making links between different findings. They need constant prompts, because what you find Second, a codebook consisting of parent and child nodes is if you go out there, their rates of testing have picked was developed using inductive (codes from initial reads up. That’s what happens, when you go out and give of the interview data) and deductive (codes from existing them some education, their testing will pick up. You literature and the discussion guides) data categorisation can’t take your eye off the ball. (SHC5, Top End) techniques. Third, all transcripts were coded systemati- cally, while reviewing and editing the codebook according Higher levels of sexual health CQI capability were to the data. attributed to greater managerial support, and CQI data and activity being used to identify and act on areas for improvement. r esults u nderstanding of sexual health CQI The two [clinics] that I’m thinking of that do well Participants consistently described CQI for improved is because their clinic manager is really on to it and sexual health service delivery as an iterative, ongoing made it a priority. They’ve been around for a while, process used to assess current performance of a service, those clinic managers. (SH2, Central Australia) identify strengths and weaknesses, design strategies to improve performance and review data to evaluate the CQI activities, tools and related actions for STI control impact of those strategies. Incorporation of the STRIVE CQI approach into the You make a plan, you do the intervention, then you sexual health coordinators’ roles included the use of 14 16 review what you’ve done, and then you act and im- specific tools—described in detail elsewhere —partic- prove the deficiencies, or you go with the strengths ularly in relation to increasing testing. In summary, these and try and address the weaknesses. (SH3, Central tools included audits, systems assessments, data review Australia) and action plans to identify specific activities to improve gaps in service delivery. In addition, ‘traffic light reports’ All participants felt that CQI activities could lead to a http://bmjopen.bmj.com/ is a management tool used by the NT government which care by helping staff to higher quality of sexual health draws automated extraction of data from the Primary understand who is at risk and to identify gaps in service Care Information System (PCIS) used by government delivery. They also felt that the data collected for sexual services to report quarterly on selected clinical perfor - health CQI could drive improvements by allowing services mance indicators. One participant noted that visual data to see how they compare and to gauge their performance reports were particularly appreciated by clinic staff. independent of targets. I’ve done the stats, my system assessments tools ... The clinics don’t know the other clinics on [the list]. that’s a very powerful tool because the clinic will sit on 10 May 2019 by guest. Protected by copyright. They just see where they rank and it makes it pretty back and go, ‘oh, wow’... They’ll look at the spider evident of how well they’re doing... and just focus- graphs and they really get into that visual stuff to find ing the discussion on missed opportunities. (SH2, out their strengths and weaknesses and how they can Central Australia) improve. (SH5, Top End) Participants felt the CQI process should identify simple Current sexual health CQI practice but reproducible actions to improve care. To increase Sexual health coordinators reported varying levels of testing and re-testing, some participants cited specific sexual health CQI engagement and capability in the actions including integration of sexual health into routine services they worked with. At one end of the spectrum adult health checks, the use of recalls and reminder cards were services which regularly reviewed data and deployed and prompts embedded in the electronic health informa- strategies to address gaps and improve key indicators, tion system. such as STI testing. For these services, capability in sexual health CQI appeared to be part of a broader capability Now that sexual health is integrated into the adult and interest in improving performance across different health check, through the men’s and women’s checks, aspects of care: that has been the single most [important change]. Putting in recalls for sexual health in PCIS has ac- [Certain services are] always working to their perfor - tually improved it. Making sure that I’m auditing so mance indicators... they’re always checking on the 3 2019; 9 :e026679. doi:10.1136/bmjopen-2018-026679 GunaratnamflP, . et al BMJ Open

4 Open access that we know if somebody’s not being followed up. much time depending what’s going on in the com- BMJ Open: first published as 10.1136/bmjopen-2018-026679 on 5 May 2019. Downloaded from Then we ask the hard questions why and follow that munity or in the clinic. (SH5, Top End) through. (SH7, Top End) Some participants reported the substantial work in There’s things like putting recalls on for test for re-in- surveillance and response as a result of an outbreak fection, using the STI template which is embedded in of infectious syphilis, ongoing since 2013 in remote 23 PCIS and things like that as a prompt to help better However, one participant felt communities in the NT. sexual health delivery. (SH4, Top End) the outbreak increased the perceived importance of sexual health and the use of CQI to drive STI testing and One participant reported that services engaged in activ- follow-up. ities such as regular monitoring of individual migration within and between communities, in order to be more We have ... reports where we can pull out who in the care. responsive to their clients’ needs for sexual health community hasn’t had an STI check in the last 12 While this element of patient-centred care does not fit the months, and who hasn’t had a syphilis check. Those definition of CQI, the co-ordinator considered this to be have been extremely valuable... It gives [clinic man- closely related to a CQI activity that helps to identify gaps agers] a focus, like it gives them people that they in service delivery. can actually go and [test], rather than saying, ‘Look, you’ve only tested 40% of your people’ (SH2, Central [Service staff] know to keep an eye out for those peo- Australia) ple that have been out in the long grass [away from community for a period of time] and coming back to community. That’s that undercurrent of stuff that Lack of staff and staff turnover goes on that we talk about and make sure you’re Staff shortages and high staff turnover were mentioned by checking, that sort of non-documented CQI that you most participants as presenting a significant challenge to do without doing CQI. (SH7, Top End) ongoing quality sexual health CQI. I will go [to a clinic] and do the action plan, and then Some participants reported that tools such as the I’ll go back the next time and there’ll be new staff, STRIVE systems assessment required adaptation for and they won’t know what you’re talking about. (SH5, ongoing use. One co-ordinator noted the increased Top End) demand for this type of assessment across different aspects of care, and reluctance among clinic managers to One participant reported that the lack of Aboriginal allow staff to participate in what, during the STRIVE trial, health staff increasingly affects the ability to provide were perceived to be lengthy assessment meetings. high-quality, culturally appropriate health services. It was perceived as important to recruit, train and support Now every program in the NT has a systems assess- http://bmjopen.bmj.com/ younger Aboriginal community members to work in ment attached to it. When we went to do it [systems health services, particularly as community members who assessment] last year my boss said to me ‘No, we’re have been performing these functions retire. not’, they kept cancelling it. And I said ‘Look, why don’t we do it, why don’t you allow us to have half You’re finding less and less Indigenous staff in the an hour?’ And they said ‘Yeah, alright, we can let you health centres. Less [Aboriginal] health practitioners. have half an hour’. And in that time we did the system New [non-Aboriginal] staff, even if they’re good and assessment. It was quick and really targeted. (SH7, conscientious and want to do everything right, still Top End) have difficulty with communication, going to differ - on 10 May 2019 by guest. Protected by copyright. ent areas. They don’t know the people. Some of them aren’t there long enough to build up that rapport Current challenges to implementation of CQI for sexual health with people and get their trust. (SH6 Top End) Prioritisation of sexual health CQI The significant workload associated with acute and 5 21 22 meant chronic conditions in the patient population Future considerations in sexual health CQI primary care staff were not able to prioritise sexual health. Local ownership of CQI processes This impacted both on sexual health activities within daily Some participants believed that, while coordinators facil- clinic practice, and on the time available for CQI during itated the process, sexual health CQI processes should sexual health coordinator visits. ultimately be owned by staff and managers at primary care services; and could be used to advocate for addi- Clinics are bombarded by everything. ...STIs, I mean tional resources to improve sexual health service delivery. it’s mostly asymptomatic, probably not going to cause too much trouble... it’s not a huge priority in engage- [Our role is] a facilitation role. You’re allowing that ment in Indigenous people. (SH2, Central Australia) information and asking the right questions to draw out more answers, being a bit directive but allowing When I’m out in the community I’ll give a talk, de- the clinicians to come up with it themselves so they pending on how much time I have. Sometimes I’m have ownership of it. (SH4, Top End) really pressured for time, they’ll only allocate me so 4 2019; 9 :e026679. doi:10.1136/bmjopen-2018-026679 GunaratnamflP, . et al BMJ Open

5 Open access I mean health nowadays is so changeable, you know If sexual health isn’t a priority because they’ve only BMJ Open: first published as 10.1136/bmjopen-2018-026679 on 5 May 2019. Downloaded from had one staff and they’re doing emergencies all day, - we’re coming up with different testing abilities, differ they can turn around to management and say, ‘Yeah, ent... I think you have to have an information system sure, give me more bloody staff’, and it’s a tool for that can keep up, be flexible and that can change. them too. (SH3, Central Australia) PCIS was a bit difficult at times to navigate around and get things changed. (SH1, Central Australia) The level of facilitation required from sexual health coordinators to sustain sexual health CQI was perceived One participant stressed that information management by some participants as dependent on the clinic and systems should not just produce aggregated reports but clinic manager. also have capacity to be used to support clinicians in indi- vidual patient management, by allowing clinic staff to For some communities [clinics] I don’t think they identify which patients were not being followed up for need it [facilitation and support to conduct CQI] as treatment or recalled for re-testing, for example. much as others, and again, I think that’s really de- pendent on the actual community [clinic] and on the You can turn around and you can say, ‘Right, well this clinic manager. (SH2, Central Australia) is the reason that we’re not performing because half the people aren’t actually living in the community’... we should be able to get a list of the patients easily Competing CQI demands and be able to go out to the clinics and give them Participants discussed the tension between maintaining information, and if need be, do the targeted quality sexual health-specific CQI efforts or integrating them audits that can actually drill in and make clear chang- 13 24 into broader CQI practices. es. (SH3, Central Australia) Everyone works and audits and does their quality im- provement in such silos that there really seems to be no integration of services talking to each other. (SH2, Central Australia) IO uss C s I n D Our study contributes to existing research on sexual Some participants reported that separating sexual 11 16 21 25 26 health and CQI in remote Australian settings health CQI from broader CQI efforts creates confusion by identifying factors at clinic and Territory levels that and increases the burden on services involved in multiple both improve and impede the uptake and sustainability systems and processes. However, most participants also of sexual health CQI practices. felt that sexual health-specific CQI, integrated within At the clinic level, an important factor perceived as existing primary care systems and processes, was critical enhancing the uptake and sustainability of sexual health to ensure sexual health is addressed. Without specific http://bmjopen.bmj.com/ CQI was the adaptation of STRIVE CQI tools and reports processes, sexual health could easily be overlooked due to for use in specific clinic contexts, and for responding to other service priorities, and because of patient and health a risk environment such as the syphilis outbreak. The worker discomfort. need for adaptation of CQI activities to ensure they are I do think having a dedicated sexual health team continually fit for purpose has been documented else- 7 27 looking at CQI does bring it into focus and I think where. This study also identified activities that are not certainly does engage practitioners to reflect on, you traditionally defined as clinical CQI, such as monitoring know, how well they do incorporate sexual health movement between and within communities, but which on 10 May 2019 by guest. Protected by copyright. practices into their everyday practice. (SH1, Central assisted service practitioners with monitoring progress Australia) and implementing new strategies to improve sexual ...it’s like a big shame job for everyone. Like clini- health outcomes. cians are uncomfortable to do it, patients are uncom- Two other clinic-level factors that support the imple- fortable, so I think it needs to be highlighted. (SH4, mentation and sustainability of sexual health CQI Top End) included local ownership of, and management support for, these processes. However, these were enabled by two regional level factors. The first was regional facilitation of Information systems and CQI ongoing clinic-level sexual health CQI by sexual health Understanding and communicating service activity data coordinators which helped to raise the profile of sexual was perceived by participants as central to motivating health within services, including with managers. Previous action to improve service delivery. The current patient research has illustrated the pivotal role of a regional information management system used by government sexual health coordinator function in effective STI inter - health services in the NT was perceived to have improved, 16 28 ventions in remote Aboriginal communities. The particularly with respect to automated reporting. second was the positive framing of CQI as a tool to iden- However, some participants suggested that the system tify and act on areas for improvement. At the Territory could be simpler and more responsive to changes in clin- level, ongoing general CQI implementation in the NT is ical guidelines. 5 9 GunaratnamflP, et al . BMJ Open 2019; :e026679. doi:10.1136/bmjopen-2018-026679

6 Open access benchmarking to motivate action and improvement attributed to high levels of policy support compared with BMJ Open: first published as 10.1136/bmjopen-2018-026679 on 5 May 2019. Downloaded from 27 other states in Australia. by allowing services to compare themselves to others is 6 11 16 31 32 similar to findings from other research. The Our study also identified factors that impede the current information system used by government clinics implementation and sustainability of sexual health CQI. 5 16 21 22 partici- As identified in other Australian studies, was perceived to be largely supportive of CQI efforts, pants described how the significant demands of acute including the regular review of data, though simplifica- tion and ongoing flexibility were recommended. This and chronic care on Aboriginal primary care services points to the need for an evolving and responsive health render sexual health CQI a relatively low priority. As has 29 targets could be used to occurred with chronic disease, information system. encourage a greater focus on sexual health. Exploring s tudy limitations team structures and work-flow strategies which allow suffi- 30 There are several limitations to this study. First, this is a to reduce the likelihood cient focus on preventive care qualitative study with a small, non-random sample size, of sexual health being continually overshadowed by more and as such findings should not be viewed as generalis- immediate priorities has also been suggested as a strategy 31 able to all remote settings. Despite the small sample size, to deal with this challenge. 33 —the degree to which findings can ‘external validity’ Workforce shortages and high staff turnover were be generalised across diverse settings within the NT— also described as limiting ongoing staff participation in was enhanced by interviewing the majority (7 of 11) of sexual health CQI activities, which in turn inhibits the employees responsible for supporting sexual health CQI sustainability of sexual health CQI at a regional level. care services in within government-led primary health The lack of experienced Aboriginal health staff was high- this region. It was also enhanced through data interpre- lighted as particularly problematic, due to the strength of tation processes that involved researchers and clinicians community relationships and trust that Aboriginal health 22 31 with ongoing involvement and interest in CQI, who were These issues workers and practitioners can build. able to reflect critically on the findings in the context of have been documented elsewhere as barriers to the provi- current and historical sexual health CQI practice and care sion of quality care in services that provide health 16 21 25 31 policy in the NT and other settings in Australia. to Aboriginal populations, and may be particu- Second, the data collection strategies—involving three care. larly important in delivery of quality sexual health interviewers, and conducting interviews both in person Strategies to address barriers to Aboriginal workforce and by telephone—may have increased the variation participation have the potential to have positive effects among individual responses. However, ‘internal reli- on sexual health CQI in these communities and should 33 was enhanced by interviewers working together ability’ be supported. to ensure rigour and consistency in data analysis and agree- Finally, our findings point to three considerations ment about the presentation of research findings. Third, affecting the future sustainability of sexual health CQI. http://bmjopen.bmj.com/ given the focus on government-run services, findings may First, while coordinators explained that sexual health-spe- 5 21 22 not be generalisable to ACCHS. As part of STRIVEplus, cific CQI ensured a focus on this difficult health area, further qualitative research focused on Territory-level they acknowledged the need to reduce the burden on key informants and health service staff, across both the clinics from multiple CQI programmes. Ongoing moni- government and the community-controlled sectors, will toring of recently available Territory-wide sexual health address these gaps. indicators will help understand if this type of measure is sufficient to increase the perceived importance of sexual health and STI control within primary health care clinics. on 10 May 2019 by guest. Protected by copyright. IO lus O C n C n However, there is also a need to identify which specific CQI is only one of several strategies needed to reduce high CQI tools and activities could be incorporated into STI incidence and prevalence among Aboriginal Austra- generic CQI processes to ensure that sexual health is not lians in remote communities. To ensure sustainability at overlooked. the service and state level, sexual health CQI activities Second, findings stress the important contribution of require responsive and efficient information systems, regional sexual health coordinators and support struc- - and, in the context of high staff turnover, a regional coor tures to ongoing service improvements and CQI partic- dination function. Strategies to address barriers to the ipation in the NT, particularly in the context of high uptake and sustainability of sexual health CQI must be staff turnover. Re-assessment of how support for sexual developed and evaluated to reduce the high burden of health CQI is funded and managed may be indicated, disease associated with STIs in this population. and whether this is incorporated within infectious disease surveillance and response, as is largely the case now, or Author affiliations more broadly as part of primary care service development. 1 Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia Third, access to and use of high-quality information 2 The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, systems and data was seen as a major strength of sexual Australia 3 health CQI, which in turn increases the sustained Menzies School of Health Research, Brisbane, Queensland, Australia 4 Burnet Institute, Melbourne, Victoria, Australia use of sexual health CQI into the future. The use of 6 BMJ Open 2019; 9 :e026679. doi:10.1136/bmjopen-2018-026679 GunaratnamflP, . et al

7 Open access 5 8. Gr ol R, Grimshaw J. From best evidence to best practice: University Centre for Rural Health, The University of Sydney, Lismore, New South BMJ Open: first published as 10.1136/bmjopen-2018-026679 on 5 May 2019. Downloaded from Lancet effective implementation of change in patients' care. Wales, Australia 6 2003;362:1225–30. South Australian Health and Medical Research Centre, Adelaide, South Australia, . Systematic review of eund M, Campbell EM, et al 9. McElwaine KM, Fr Australia interventions to increase the delivery of preventive care by primary 7 Robinson Research Institute, University of Adelaide, Adelaide, South Australia, 2016;11:50. Implement Sci care nurses and allied health clinicians. Australia 10. T ricco AC, Ivers NM, Grimshaw JM, . Effectiveness of quality et al 8 improvement strategies on the management of diabetes: a School of Medicine and Public Health, University of Newcastle, Newcastle, New systematic review and meta-analysis. Lancet 2012;379:2252–61. South Wales, Australia 9 et al dner KL, Dowden M, Togni S, Gar 11. . Understanding uptake of Pacific Clinic Newcastle, HNE Sexual Health, Newcastle, New South Wales, continuous quality improvement in Indigenous primary health care: Australia lessons from a multi-site case study of the Audit and Best Practice 10 Melbourne Sexual Health Centre, Melbourne, Victoria, Australia for Chronic Disease project. Implement Sci 2010;5:21. 11 Central Clinical School, Monash University, Melbourne, Victoria, Australia . Continuous quality et al Gibson-Helm ME, T eede HJ, Rumbold AR, 12. 12 improvement and metabolic screening during pregnancy at primary Sydney Sexual Health Centre, Sydney, New South Wales, Australia 13 health centres attended by Aboriginal and Torres Strait Islander Aboriginal Medical Services Alliance Northern Territory, Darwin, Northern Territory, Med J Aust 2015;203:369–70. women. Australia Allen and Clarke. Evaluation of the Norther 13. n Territory Continuous 14 Centre for Social Research in Health, UNSW Sydney, Sydney, New South Wales, Quality Improvement (CQI) Investment Strategy: Summary report. Australia Department of Health, Canberra 2016. ard J, McGregor S, Guy RJ, et al . STI in remote communities: 14. W improved and enhanced primary health care (STRIVE) study protocol: PG, GS, JB and SB designed the study. PG, JB and SB conducted Contributors a cluster randomised controlled trial comparing 'usual practice' STI data collection. PG, JB and SB undertook analysis of the data. PG, GS and SB led care to enhanced care in remote primary health care services in on drafting of the manuscript. All other authors (LM, RB, JW, RG, AR, NR, CKF, BD, BMC Infect Dis Australia. 2013;13:425. LM, JK) assisted with interpretation of data and review of successive drafts of the A pragmatic stepped wedge . et al ard J, Guy RJ, Rumbold AR, 15. W manuscript. All authors read and approved the final manuscript. cluster randomised trial of continuous quality improvement strategies to improve the control of sexually transmissible infections in remote The STRIVEplus study is funded through a National Health and Medical Funding Australian Aboriginal communities. forthcoming . Research Council Partnership Grant (APP1060471). et al . Perspectives of primary health care Hengel B, Bell S, Garton L, 16. staff on the implementation of a sexual health quality improvement The funder played no role in design or implementa tion of this study. Disclaimer program: a qualitative study in remote aboriginal communities in The authors have ongoing involvement in Aboriginal health, Competing interests Australia. BMC Health Serv Res 2018;18:230. sexual health and CQI in Australia, as researchers, clinicians and policymakers. et al . Standards for reporting 17. O'Brien BC, Harris IB, Beckman TJ, Acad Med qualitative research: a synthesis of recommendations. Not required. Patient consent for publication 2014;89:1245–51. e A thics approval pproval was obtained from Central Australian Human Research Australian Bur 18. eau of Statistics. 2016 Census QuickStats - Northern Territory, 2016. (validated 9 August 2018). http:// quickstats. Ethics Committee (HREC 15–298) and the Human Research Ethics Committee of 2016/ getproduct/ censusdata. abs. gov. au/ census_ services/ census/ the NT Department of Health and the Menzies School of Health Research (HREC opendocument. quickstat/ 7? 2015–2374). Norther 19. n Territory Department of Health. 2016-17 Annual Report: NT Not commissioned; externally peer reviewed. Provenance and peer review health. . digitallibrary Health, 2017. (verified 29 January 2018). http:// nt. . prodjspui/ 1417. au/ gov handle/ 10137/ Data sharing statement Not a pplicable as this is a qualitative research. 20. Strauss A, Corbin J. Basics of qualitative research . Thousand Oaks: Sage, 1990. Open access This is an open access article distributed in accordance with the . Reasons for delays in treatment 21. Hengel B, Maher L, Garton L, et al http://bmjopen.bmj.com/ Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which of bacterial sexually transmissible infections in remote Aboriginal permits others to distribute, remix, adapt, build upon this work non-commercially, communities in Australia: a qualitative study of healthcentre staff. and license their derivative works on different terms, provided the original work is Sex Health 2015;12:341–7. properly cited, appropriate credit is given, any changes made indicated, and the use Newham J, Schierhout G, Bailie R, 22. . 'There's only one enabler; et al creativecommons. licenses/ 0/. 4. nc/ by- org/ is non-commercial. See: http:// come up, help us': staff perspectives of barriers and enablers to continuous quality improvement in Aboriginal primary health-care Aust J Prim Health settings in South Australia. 2016;22:244–54. 23. Bright A, Dups J. Infectious and congenital syphilis notifications associated with an ongoing outbr eak in northern Australia. Commun C r eren es e F 2016;40:E7–10. Dis Intell Q Rep 1. Silver BJ, Guy RJ, W and H, et al . Incidence of curable sexually 24. The Lowitja Institute. Recommendations for a National CQI transmissible infections among adolescents and young adults in on 10 May 2019 by guest. Protected by copyright. orres Strait Islander Health, 2014. Framework for Aboriginal and T remote Australian Aboriginal communities: analysis of longitudinal main/ internet/ gov. au/ (verified 29 January 2018). http://www. health. clinical service data. 2015;91:135–41. Sex Transm Infect atsih. framework- cqi- content/ nsf/ publishing. Central Australian Rural Practitioners Association. CARP 2. A Standard . Evaluating the effectiveness of a et al Schierhout G, Hains J, Si D, 25. Treatment ManualAlice Springs: Central Australian Rural Practitioners multifaceted, multilevel continuous quality improvement program in Association Inc. 2017. 7th edn. validated 29 January 2018. https:// primary health care: developing a realist theory of change. Implement remotephcmanuals. com. www. au/ html home. 2013;8:119. Sci Centr e for Disease Control DoH, Northern Territory. NT Guidelines 3. dner K, Bailie R, Si D, Gar 26. . Reorienting primary health care for et al for the Management of Sexually Transmitted Infections in the Primary addressing chronic conditions in remote Australia and the South Health Care Setting . 4th edn: Department of Health, 2016. validated Pacific: review of evidence and lessons from an innovative quality gov. digitallibrary. health. nt. au/ prodjspui/ handle/ 29 Jan 2018. http:// Aust J Rural Health 2011;19:111–7. improvement process. 699 10137/ . Exploring Systems That et al oods C, Carlisle K, Larkins S, 27. W and H, Ward J, . Patient, staffing and health et al Hengel B, W 4. Support Good Clinical Care in Indigenous Primary Health-care centre factors associated with annual testing for sexually Services: A Retrospective Analysis of Longitudinal Systems Sex Health transmissible infections in remote primary health centres. Assessment Tool Data from High-Improving Services. Front Public 2017;14:274–81. Health 2017;5. . Indigenous health: effective and et al 5. Bailie RS, Si D, O'Donoghue L, et al ard JS, Smith KS, . The impact of sexually Guy R, W 28. sustainable health services through continuous quality improvement. transmissible infection programs in remote Aboriginal communities in 2007;186:525–7. Med J Aust 2012;9:205–12. Australia: a systematic review. Sex Health oving the quality of health care in the 6. Ferlie EB, Shortell SM. Impr . Follow-up of Indigenous- et al Bailie J, Schierhout GH, Kelaher MA, 29. United Kingdom and the United States: a framework for change. specific health assessments - a socioecological analysis. Med J Aust 2001;79:281–315. Milbank Q 2014;200:653–7. . Achieving change in primary , Ong BN, et al Lau R, Stevenson F 7. . Clinic predictors of better et al gis S, Matthews V, Nattabi B, Gir 30. care--causes of the evidence to practice gap: systematic reviews of syphilis testing in Aboriginal primary health care: a promising reviews. Implement Sci 2016;11:40. 7 GunaratnamflP, et al . 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8 Open access . Responses of Aboriginal and oods CE, Matthews V, et al 32. Larkins S, W Aust J Prim opportunity for primary health care service managers. BMJ Open: first published as 10.1136/bmjopen-2018-026679 on 5 May 2019. Downloaded from Torres Strait Islander Primary Health-Care Services to Continuous 2018:350. Health 2015;3:288. Quality Improvement Initiatives. Front Public Health et al . Improving preventive health 31. Bailie J, Matthews V , Laycock A, 33. Bryman A. Social Research Methods . 5th edn. Oxford University care in Aboriginal and Torres Strait Islander primary care settings. Press: Oxford, 2016. Global Health 2017;13:48. http://bmjopen.bmj.com/ on 10 May 2019 by guest. Protected by copyright. 8 GunaratnamflP, :e026679. doi:10.1136/bmjopen-2018-026679 9 2019; BMJ Open . et al

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