Perspectives of primary health care staff on the implementation of a sexual health quality improvement program: a qualitative study in remote aboriginal communities in Australia

Abstract

BackgroundYoung people living in remote Australian Aboriginal communities experience high rates of sexually transmissible infections (STIs). STRIVE (STIs in Remote communities, ImproVed and Enhanced primary care) was a cluster randomised control trial of a sexual health continuous quality improvement (CQI) program. As part of the trial, qualitative research was conducted to explore staff perceptions of the CQI components, their normalisation and integration into routine practice, and the factors which influenced these processes.MethodsIn-depth semi-structured interviews were conducted with 41 clinical staff at 22 remote community clinics during 2011–2013. Normalisation process theory was used to frame the analysis of interview data and to provide insights into enablers and barriers to the integration and normalisation of the CQI program and its six specific components.ResultsOf the CQI components, participants reported that the clinical data reports had the highest degree of integration and normalisation. Action plan setting, the Systems Assessment Tool, and the STRIVE coordinator role, were perceived as adding value to the program, but were less readily integrated or normalised. The remaining two components (dedicated funding for health promotion and service incentive payments) were seen as least relevant. Our analysis also highlighted factors which enabled greater integration of the CQI components. These included familiarity with CQI tools, increased accountability of health centre staff and the translation of the CQI program into guideline-driven care. The analysis also identified barriers, including high staff turnover, limited time involved in the program and competing clinical demands and programs.ConclusionsAcross all of the CQI components, the clinical data reports had the highest degree of integration and normalisation. The action plans, systems assessment tool and the STRIVE coordinator role all complemented the data reports and allowed these components to be translated directly into clinical activity. To ensure their uptake, CQI programs must acknowledge local clinical guidelines, be compatible with translation into clinical activity and have managerial support. Sexual health CQI needs to align with other CQI activities, engage staff and promote accountability through the provision of clinic specific data and regular face-to-face meetings.Trial registrationAustralian and New Zealand Clinical Trials Registry ACTRN12610000358044. Registered 6/05/2010. Prospectively Registered.Electronic supplementary materialThe online version of this article (10.1186/s12913-018-3024-y) contains supplementary material, which is available to authorized users.

Qualitative perspectives on the sustainability of sexual health continuous quality improvement in clinics serving remote Aboriginal communities in Australia

“…The first was regional facilitation of ongoing clinic-level sexual health CQI by sexual health coordinators which helped to raise the profile of sexual health within services, including with managers. Previous research has illustrated the pivotal role of a regional sexual health coordinator function in effective STI interventions in remote Aboriginal communities 16 28. The second was the positive framing of CQI as a tool to identify and act on areas for improvement.…”

“…The lack of experienced Aboriginal health staff was highlighted as particularly problematic, due to the strength of community relationships and trust that Aboriginal health workers and practitioners can build 22 31. These issues have been documented elsewhere as barriers to the provision of quality care in services that provide health care to Aboriginal populations,16 21 25 31 and may be particularly important in delivery of quality sexual health care. Strategies to address barriers to Aboriginal workforce participation have the potential to have positive effects on sexual health CQI in these communities and should be supported.…”

“…Most (79%) Aboriginal residents in the NT live in remote areas19 and are served by two types of primary care services—ACCHS or NT government health services. Remote clinics are primarily staffed by Aboriginal health workers or registered nurses (often on short-term fly in-fly out contracts) with support from resident or visiting general practitioners and other specialist or allied health providers 16…”

“…Between 2011 and 2014, the STIs in Remote communities, ImproVed and Enhanced primary care (STRIVE) trial was conducted in 67 remote communities in the Northern Territory (NT), Queensland and Western Australia 14. STRIVE demonstrated that a clinic level sexual health CQI programme supported by regional dedicated sexual health coordinators14–16 could improve STI testing rates,15 with aspects of the CQI programme becoming normalised in clinical practice 16. However, testing increases were from a low baseline and did not lead to lower STI prevalence over the time frame of the trial 15…”

The views of New Zealand general practitioners and patients on a proposed risk assessment and communication tool: a qualitative study using Normalisation Process Theory

“…NPT bridges the translational gap between research evidence and practical implementation and is comprehensive, flexible and has a strong focus on participatory co-design [43][44][45][46]. NPT has been used for research involving ethnic minority populations and to explore issues of equity [47][48][49][50]. NPT provides a useful framework for researchers to anticipate implementation issues while designing a complex intervention and its evaluation [44][45][46]51].…”