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Sexually Transmitted Diseases:
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Quality of Sexually Transmitted Infection Clinical Management and Contact Tracing Outcomes in a Remote Area of High Sexually Transmitted Infection Endemicity

Mak, Donna B. MBBS, MPH*†‡; Plant, Aileen J. MBBS, MPH, PhD‡; Bulsara, Max K. BSc, MSc†

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Author Information

From the *Kimberley Public Health Unit (formerly), the †School of Population Health, The University of Western Australia, and the ‡Division of Health Sciences, Curtin University of Technology, Western Australia

The authors thank Graeme Johnson and Rebecca Quake (resident medical officers) who were involved in collection and preliminary analysis of the data. Special thanks to the Kimberley Public Health Unit’s Disease Control team (1997–2002) for their unwavering commitment to STI control.

The views expressed are those of the authors and may not reflect the views of the institutions which they were employed by, or affiliated with, during the writing of this paper.

Correspondence: Donna B. Mak, MPH, 29 Cooper St., Nedlands, WA 6009, Australia. E-mail: makho@bigpond.com

Received for publication October 23, 2003, and accepted March 22, 2004.

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Abstract

Objectives: The objectives of this study were to assess health professionals’ adherence to Western Australian sexually transmitted infection (STI) management guidelines and to document the outcomes of contact tracing in a remote Indigenous setting.

Methods: This article comprises 2 parts: a retrospective clinical audit of quality of clinical STI management and outcomes of contact tracing and an analysis of completeness of relevant laboratory investigations.

Results: Documented clinical STI management of index cases varied from 94% receiving treatment in accordance with the Guidelines, whereas only 48% underwent a clinical examination. Sexual contacts who underwent STI consultation had concordant (30%) and discordant (17%) STI(s). The proportion of patients with STI(s) in whom all appropriate laboratory investigations had been requested increased from 25% in 1998 to 9% to 49% in 2001–2002.

Conclusions: This study demonstrates that quality of clinical STI management comparable to that observed overseas is possible despite the challenges of healthcare delivery in a remote setting.

THE REMOTE KIMBERLEY REGION of far-northern Western Australia has the highest incidence rates of sexually transmitted infections (STIs) in the state and some of the highest reported rates of STIs in Australia, with syphilis being epidemic since August 2000 and gonorrhea and chlamydia being highly endemic.1,2 In 2001, rates of gonorrhea, chlamydia, and infectious syphilis (ie, primary, secondary, and congenital) were 1371, 1011, and 138 per 100,000 person-years, respectively. Fortunately, there have been few notifications of HIV/AIDS as yet, and all these patients contracted their infection outside the Kimberley region.

In 1997, the Health Department of Western Australia distributed the first edition of Guidelines for Managing Sexually Transmitted Diseases, a handbook providing comprehensive coverage of STI clinical management and contact tracing.3 At the same time, prepackaged laboratory investigation kits (including an algorithm of what investigations to offer depending on the patient’s clinical presentation, a laboratory request form, the required swabs, and specimen containers) were introduced and supplied, at no cost, to all Kimberley health services. Prepackaged medications (government-funded) for the empiric treatment of patients with STI presentations, based on a syndromic approach, have been used in the region since the mid-1980s. An updated second edition of the Guidelines was distributed in 2001.4 In recognition of the high STI rates and the cultural, geographic, and workforce issues peculiar to the Kimberley region, a Kimberley Supplement to each edition of the Guidelines was inserted before distribution in the Kimberley region. The Supplement outlined the public health and primary healthcare strategies important for STI/HIV control in areas of high STI endemicity, eg, empiric treatment of gonorrhea or chlamydia (a Kimberley recommendation since the mid-1980s).

Since 1997, in addition to distributing the Guidelines, the Health Department of Western Australia has conducted annual STI staff development workshops to promote use of the Guidelines and improve health professionals’ knowledge and understanding of sexual health and STIs. Workshops have been well attended by a wide cross-section of staff, including medical practitioners, hospital and community health nurses, and Aboriginal health workers, from government and community-controlled health services. Although workshop participants’ evaluations have always been overwhelmingly positive, a previous paper demonstrated that, in 1998–1999, completeness of laboratory investigation was generally poor and not in accordance with the Guidelines with minimum appropriate tests having been requested in only 14.5% of patients presenting for STI clinical management and screening.5 This prompted interventions such as HIV testing by appropriately trained nurses and Aboriginal health workers (introduced in mid-2000), increasing use of problem-based approaches (in accordance with adult learning principles) to staff orientation and education, and development of self-obtained lower vaginal swabs (SOLVS) as an alternative to practitioner-obtained endocervical swabs in certain clinical circumstances.6,7

We aimed to assess whether health professionals working in the Kimberley region in 2001–2002 were observing the HDWA Guidelines for Managing STDs and Kimberley Supplement and to document the outcomes of contact tracing. We also investigated whether the completeness of laboratory investigation of patients with STIs had improved since 1998–1999.

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Setting

The Kimberley region of Western Australia (WA) has a resident population of approximately 32,000 people scattered across an area of more than 420,000 km2. Aboriginal people comprise one half of the resident population. Transport in the region is often difficult as a result of the rugged terrain, cyclones, and flooding. There are 6 towns with populations ranging from 2000 to 10,000 and more than 200 discrete Aboriginal communities ranging in size from just a few families to over 500 people.

Health care is provided predominantly by government and Aboriginal community-controlled organizations. Each of the towns has a hospital and 1 or more primary healthcare services, whereas remote area clinics staffed by resident nurses and Aboriginal health workers are present in less than 15 Aboriginal communities.

Much of the clinical management and contact tracing of patients with STIs, which would be performed by general practitioners (GPs) or specialist sexual health clinics in urban Australia, is undertaken by nurses (predominantly female) and Aboriginal health workers in Kimberley primary healthcare settings. Almost all contact tracing in the Kimberley region is undertaken by primary healthcare staff, because patients very rarely accept the option of notifying their sexual partners. The Kimberley Public Health Unit (KPHU) has statutory responsibility for communicable disease control in the region. Over 70% of STI notifications come from staff employed by the Health Department of WA.8

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Methods

This article comprises 2 parts: a retrospective clinical audit of quality of clinical STI management and outcomes of contact tracing and a logistic regression analysis of completeness of laboratory investigation of patients with STIs.

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Quality of Sexually Transmitted Infection Clinical Management and Outcomes of Contact Tracing

A retrospective review was conducted of the STI clinical management and contact tracing forms used by all Kimberley health professionals for patients presenting with STI symptoms or with a laboratory-confirmed STI. The study population included all patients reported to have a notifiable STI from June 11, 2001, to January 29, 2002, by Health Department of WA-employed staff and whose infection was diagnosed through self-presentation for an STI consultation or through screening conducted as part of routine primary health care, eg, antenatal STI screening, well-person’s screening; these patients were the “index cases.” The sexual contacts they reported were the “sexual contacts.”

Demographic information about index cases and information about the quality of their clinical management and outcomes of contact tracing were collected from standard STI clinical management and contact tracing forms used in health services throughout the Kimberley region. The outcomes of interest were whether the index case’s history (including sexual history) and clinical examination findings had been documented, whether safe-sex counseling had been provided, whether the STI laboratory investigations performed and treatment given were in accordance with the Guidelines, the number of sexual contacts reported, the number of sexual contacts located and investigated, the STIs notified from these sexual contacts, and whether sexual contacts were given empiric STI treatment in accordance with the Guidelines. Data were entered onto a Microsoft Access database and exported to SPSS for analysis.

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Completeness of, and Improvements in, Laboratory Investigation of Patients With Sexually Transmitted Infections

The study population included all patients notified with genital gonorrhea and/or chlamydia in comparison period 1 (March 17, 1998–April 15, 1998, July 2, 1998–July 30, 1998, March 17, 1999–May 3, 1999, and November 1, 1999–November 29, 1999) and comparison period 2 (May 31, 2001–February 14, 2002). Information about patients and outcomes of interest were collected from pathology request forms. Data collection was clustered around times when resources for data collection were available, and these clusters were considered to be representative of the time periods of interest. The outcomes of interest were the STI laboratory investigations requested. A score was allocated depending on whether all appropriate tests had been requested, or if 1 test or 2 or more tests were missing.

Minimum laboratory investigations for patients suspected of having an STI as defined in both editions of the Guidelines were:

1. Urinary gonorrhea and chlamydia nucleic acid test (G&C-NAT), and syphilis, hepatitis B, and HIV serology in males.

2. Urinary G&C-NAT, endocervical swab G&C-NAT, high vaginal swab microscopy, culture and sensitivities (MC&S), and syphilis, hepatitis B, and HIV serology in females.

Hepatitis B was not included when scoring data from comparison period 1 because these data were not collected. G&C-NAT testing of SOLVS was piloted in parts of the Kimberley region in 2000 and made available throughout the region in mid-2001 as an alternative to endocervical swab G&C-NAT, in particular clinical situations.4,7 When scoring data from comparison period 2, SOLVS G&C-NAT and endocervical swab G&C-NAT were treated as equivalent.

Data were entered onto SPSS and logistic regression was used to analyze associations between having had all appropriate tests requested and the following variables: age and sex of the patient, profession of practitioner (medical practitioner, nurse, or Aboriginal health worker), location of the health service (town or remote Aboriginal community), and time period.

In accordance with ethical requirements, access to raw data were limited to DM who generated the data in the course of conducting routine quality assurance on the program for which she held a service responsibility as an employee of KPHU. This ensured confidentiality and privacy of the patients and health services studied.

From June 11, 2001, to January 29, 2002, KPHU had access to STI clinical management and contact tracing forms of patients whose STIs were notified by Department of Health-employed medical practitioners as part of a quality improvement project initiated in response to a syphilis outbreak. The project was overseen by a committee with representatives from KPHU, the Kimberley Division of General Practice, a nongovernment primary healthcare service in the Kimberley region and an independent sexual health physician that performed the functions of an investigation review board.

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Results

Quality of Sexually Transmitted Infection Clinical Management and Outcomes of Contact Tracing
Quality of Sexually Transmitted Infection Clinical Management.

The study population comprised 192 index cases (98 males and 94 females) aged 14 to 51 years (median, 23 years). Three fourths (144 of 192) were less than 30 years old. Ninety-three percent (179 of 192) were Aboriginal, 4% (7 of 192) were non-Aboriginal, and the ethnicity in 3% (6 of 192) was unknown. One hundred twenty-six index cases (66%) had gonorrhea, 87 (45%) had chlamydia, and 25 (13%) had primary or secondary syphilis. There were no cases of donovanosis or HIV. Multiple STIs were common with 42 (22%) and 2 (1%) having 2 and 3 concurrent notifiable STIs, respectively. At presentation, only 54 index cases (28%) were seen by a medical practitioner, 130 (68%) had been seen by a nurse, 6 (3%) by an Aboriginal health worker, and in 2 (1%) the practitioner type was unknown.

The proportions of index cases in whom the correct laboratory investigations were requested and who received appropriate treatment were high, with the exception of endocervical and high vaginal swab testing in females, as shown in Table 1. Documentation of presenting symptoms and presumptive diagnosis, and urinary G&C-NAT, hepatitis B, and HIV testing were more complete in male than female index cases.

Table 1
Table 1
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Outcomes of Contact Tracing.

A total of 354 sexual contacts was reported by the 192 index cases. The number of sexual contacts reported ranged from 0 to 8, with a mean of 1.83 and median of 1. Six percent, 47%, 27%, 10%, and 10% of index cases reported 0, 1, 2, 3, and ≥4 sexual contacts, respectively. There was no difference in the number of sexual contacts reported by males (mean, 1.95; median, 1) and females (mean, 1.74; median, 1) (Kruksal-Wallis chi-square df = 1 = 0.5, P = 0.47). No same-sex sexual contacts were reported.

Forty-eight percent (169 of 354) of reported sexual contacts were located and underwent STI consultation. The number of days between the index case reporting a sexual contact and that sexual contact undergoing STI consultation (infectious days) ranged from 0 to 120 days, with mean of 14 days and median 8 days. Forty percent and 59% of sexual contacts underwent STI consultation within 5 and 10 days, respectively, of being reported by an index case. There were no associations between completeness (Pearson chi-square df = 1 = 2.1, P = 0.15) or timeliness (Kruskal-Wallis chi-square df = 1 <0.01, P = 0.98) of contact tracing and the sex of sexual contacts.

Of the 169 sexual contacts who underwent STI consultation, 51 (30%) had the same STI(s) as their corresponding index case, ie, concordant STI(s) and 29 (17%) had completely different or at least 1 different, ie, fully or partially discordant, STI(s). Outcomes of contact tracing by the STI of the index case are shown in Table 2. Sexual contacts of gonorrhea and chlamydia were more likely to have concordant infection (53% and 52%, respectively) than sexual contacts of syphilis (13%).

Table 2
Table 2
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Completeness of, and Improvements in, Laboratory Investigation of Patients With Sexually Transmitted Infections

The study population comprised 508 people, with 232 and 276 in comparison periods 1 and 2, respectively. There were no significant differences in the sex and age distribution of people in comparison periods 1 and 2 (Pearson chi-square df = 1 = 0.02, P = 0.90 and Pearson chi-square df = 3 = 0.5, P = 0.92, respectively). The proportions of people seen by a nurse, medical practitioner, and Aboriginal health worker were 43%, 57%, and 0%, respectively, in comparison period 1 and 70%, 25%, and 5%, respectively, in comparison period 2 (Pearson chi-square df = 2 = 55.4, P = 0.000). People in comparison period 2 were more likely than those in comparison period 1 to have been seen in a remote area health service (31% vs. 23%) than a town-based health service (69% vs. 77%) (Pearson chi-square df = 1 = 4.24, P = 0.04).

Univariate analysis showed that being male, attending a remote area health service, and being tested in comparison period 2 were positively associated with all recommended tests having been requested (see Tables 3 and 4). However, in a multivariate model, only being male (P = 0.000; odds ratio [OR], 10.942; 95% confidence interval [CI], 6.878–17.407), and being tested in comparison period 2 (P = 0.000; OR, 4.490; 95% CI, 2.829–7.125) were still significantly associated with all recommended tests having been requested. There was no significant interaction between sex and comparison period (P = 0.787; OR, 1.146; 95% CI, 0.427–3.076)

Table 3
Table 3
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Table 4
Table 4
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Discussion

Documented clinical STI management of index cases in the Kimberley region was inconsistent, with 94% receiving treatment in accordance with the Guidelines, whereas only 48% underwent clinical examination. Of the 48% of reported sexual contacts who underwent STI consultation, 30% and 17% had concordant and discordant STI(s), respectively, whereas 53% had no notifiable STIs. The proportion of patients with STI(s) in whom all appropriate laboratory investigations has been requested increased from 25% in 1998–1999 to 49% in 2001–2002.

In 2001–2002, 70% of patients with STI had been seen by a nurse at presentation. The smaller proportions seen by medical practitioners and Aboriginal health workers (25% and 5%, respectively) reflects limited access to medical services and the preference of many Aboriginal patients for STI clinical services to be provided by someone outside of their family/social group.9–11 This underscores the importance of clinical guidelines, standard STI clinical management and contact tracing forms, prepackaged laboratory investigation kits and medications, and standing orders that facilitate and allow appropriately trained nonmedical practitioners to undertake STI consultations, perform laboratory investigations, and administer empiric treatments and safe sex education. This is similar to the syndromic, primary healthcare approach to STI control recommended by the World Health Organization and adopted, with varying degrees of success, in many other underserved settings in Africa and other countries.12–18

The mean number of sexual contacts named by index cases in our study is higher than that reported from other similar settings.9,11 Given that these index cases had 1 or more STIs, it is reasonable to assume that index cases underreported their sexual contacts. Qualitative research involving other Indigenous men indicates that this could be because STI patients and non-Indigenous health staff have different understandings and expectations of the contact tracing process.10 Indigenous men with STIs tended to report casual partners but expected the clinic to perform a checkup on their wife/regular partner even though they had not reported the wife/regular partner as a sexual contact; however, non-Indigenous health staff were unaware of this expectation. Our experience was very similar. Several experienced Aboriginal health workers who were also senior women in their communities stated that when they knew that an index case had not reported his or her spouse/regular partner as a sexual contact, they would discreetly offer that person a checkup and empiric treatment, and the offer would usually be well-received. There seemed to be an unstated mutual understanding of each other’s expectations. However, the covert nature of these expectations and the fear of further marginalizing already-disadvantaged people by openly acknowledging the fact they are disproportionately affected by STIs has made it almost impossible to talk about these issues openly or to tailor health service policy and practice accordingly. This is similar to the dilemma faced by health professionals working in STI control in African-Americans in the Southern states of the United States.19

The prevalences of concordant and discordant STIs observed in this study were slightly higher than, but comparable to, those reported in similar Indigenous (19–33% prevalence of concordant and discordant STIs among sexual contacts of index cases, respectively) and overseas non-Indigenous settings (up to 24% prevalence of STIs where health service staff are responsible for eliciting, locating, and notifying sexual contacts of STI patients).9,11,20 Factors contributing to these high prevalences include the highly infective nature of gonorrhea, chlamydia, and, to a lesser extent, primary and secondary syphilis, the high population prevalence of these STIs in the Kimberley region, and delays in treatment (as indicated by the number of infective days), which result in increased opportunities for STI transmission. These findings support the rationale for offering a full clinical examination and laboratory testing for all STIs and empiric treatment to all reported sexual contacts, and indicate the use of contact tracing within a multistrategy STI control program.

There was no improvement in the proportions of reported sexual contacts who underwent STI consultation (66% and 48% in 1995–1996 and 2001–2002, respectively).21 There was also no improvement in the proportion of reported sexual contacts undergoing STI consultation within 5 and 10 days (44% in 1995–1996 and 40% in 2001–2002, and 66% in 1995–1996 and 59% in 2001–2002, respectively). Given the Kimberley region’s high staff turnover and the sociopolitical and logistic difficulties of contact tracing in a remote, cross-cultural environment, these findings were not unexpected.

Our observation that indicators of the quality of STI clinical management were better in male index cases than their female counterparts was unexpected given the female predominance of the Kimberley region’s health workforce. However, similar findings have been reported from researchers in Botswana who suggested that this could be the result of the traditional acceptability of males changing their sexual partners and the relative ease of male versus female genital examinations.14 Although these factors could also apply in the Kimberley setting, they were not reported in a recent qualitative study of Kimberley health staff and community members.22

The improvements observed in completeness of laboratory testing of patients with STIs between 1998–1999 and 2001–2002 and the fact that syphilis and HIV tests were requested in 91% and 77%, respectively, of Kimberley patients versus 25% and 15% of U.S. Medicaid patients indicates that the challenges of healthcare delivery in a remote, cross-cultural setting do not preclude improvements or achievements in at least some indicators of STI clinical management.23 It would be impossible to quantify the relative of contributions of staff and community education, structural changes (such as increased staffing, particularly in remote communities, prepackaged laboratory investigation kits, and regional guidelines that allow appropriately trained nonmedical health staff to conduct STI consultations and laboratory tests), and the “declaration” of a syphilis outbreak toward these improvements. However, our opinion is that the syphilis outbreak initiated the “sense of urgency” that is a prerequisite for change, and that this, in combination with removing barriers to nonmedical health staff conducting full STI consultations and laboratory testing, and already established STI orientation and ongoing staff education programs resulted in the observed improvements.24 Whether the improvement can be maintained, as the “sense of urgency” decreases over time, remains to be seen.

The unique cultural, demographic, and health workforce mix of the Kimberley region, coupled with its geographic features and low population density, has considerable implications for STI control. This study demonstrates that improvements in the completeness of laboratory investigation of patients with STIs are possible in a remote setting. These improvements were stimulated by a regional syphilis outbreak, starting in August 2000, that resulted in the first case of congenital syphilis in the region since at least 1989.2 In light of this outbreak, the lack of improvement in completeness and timeliness of contact tracing and high prevalences of discordant STIs among reported sexual contacts are extremely concerning because they indicate deficiencies in STI control, which must be improved before the current outbreak can be controlled or further STI outbreaks prevented. The study raises new research questions about inequities in STI management between indigenous males and females. It is difficult to see how this question can be answered or how further improvements in STI control can occur until health professionals and the wider community are able to discuss, openly and honestly, the sexual health issues of disadvantaged groups without fear of further marginalizing these groups of people.

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Statement of Authors’ Contributions

DM conceived the study, collected and supervised collection of the data, performed the statistical analyses, and was involved in writing all sections of the paper. AP contributed concepts to the discussion and was involved in writing of all sections of the paper. MB contributed to the statistical analysis and was involved in writing the results sections of the paper.

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References

1. Lin M, Roche P, Spencer J, et al. Australia’s notifiable diseases status, 2000 Annual Report of the National Notifiable Diseases Surveillance System. Commun Dis Intell 2002; 26:118–203.

2. Mak DB, Marshall LJ. Gonorrhoea, chlamydia and syphilis incidence in the Kimberley. Commun Dis Intell 2003; 27:370–372.

3. Health Department of Western Australia. Guidelines for Managing Sexually Transmitted Diseases. Sydney: Australasian Medical Publishing Co, 1997.

4. Health Department of Western Australia. Guidelines for Managing Sexually Transmitted Infections: A Guide for Primary Health Care Providers. Perth: Public Health Division of the Health Department of Western Australia, 2001.

5. Mak DB, Holman CDJ. STDs aren’t sexy: Health professionals’ lack of adherence to clinical guidelines in an area of high STD endemicity. J Public Health Med 2000; 22:540–5.

6. Knowles M. Andragogy in Action. San Francisco: Jossey-Bass, 1984.

7. Garrow SC, Smith DW, Harnett GB. The diagnosis of chlamydia, gonorrhoea, and trichomonas infections by self obtained low vaginal swabs, in remote northern Australian clinical practice. Sex Transm Infect 2002; 78:278–281.

8. Mak D. Chlamydia and gonorrhoea notifications by practitioner type. Kimberley Public Health Unit Bulletin 2002; Aug:14.

9. Mulvey G, Hart G, Scrimgeour D, Radford A. STD contact tracing and syphilis screening on the Anangu Pitjantjatjara lands in South Australia. Venereology 1995; 8:26–33.

10. Mulvey G, Manderson L. Contact tracing and sexually transmitted disease among Aboriginal men on the Anangu Pitjantjatjara lands. Aust J Public Health 1995; 19:596–602.

11. Fagan P. Sexual health service provision in remote Aboriginal and Torres Strait Islander settings in Far North Queensland: Sexual health symptoms and some outcomes of partner notification. Venereology 2001; 14:55–61.

12. Harrison A, Wilkinson D, Lurie M, Connolly AM, Karim SA. Improving quality of sexually transmitted disease case management in rural South Africa. AIDS 1998; 12:2329–2335.

13. Grosskurth H, Mwijarubi E, Todd J, et al. Operational performance of an STD control programme in Mwanza Region, Tanzania. Sex Transm Infect 2000; 76:426–436.

14. Boonstra E, Lindbaek M, Klouman E, Ngome E, Romoren M, Sundby J. Syndromic management of sexually transmitted diseases in Botswana’s primary health care: quality of care aspects. Trop Med Int Health 2003; 8:601–604.

15. Harrison A, Karim SA, Floyd K, et al. Syndrome packets and health worker training improve sexually transmitted disease case management in rural South Africa: Randomized controlled trial. AIDS 2000; 14:2769–2779.

16. Voeten HA, Otido JM, O’Hara HB, et al. Quality of sexually transmitted disease case management in Nairobi, Kenya: A comparison among different types of healthcare facilities. Sex Transm Dis 2001; 28:633–642.

17. O’Hara HB, Voeten HA, Kuperus AG, et al. Quality of health education during STD case management in Nairobi, Kenya. Int J STD AIDS 2001; 12:315–323.

18. Bryce J, Vernon A, Brathwaite AR, Perry S, Figueroa JP, Emerson RB. Quality of sexually transmitted disease services in Jamaica: evaluation of a clinic-based approach. Collaborative Working Group on Indicators of STD Case Management. Bull World Health Organ 1994; 72:239–247.

19. St. Louis ME, Farley TA, Aral SO. Untangling the persistence of syphilis in the South. Sex Transm Dis 1996; 23:1–4.

20. Macke BA, Maher JE. Partner notification in the United States: An evidence-based review. Am J Prev Med 1999; 17:230–242.

21. Mak D. Kimberley gonorrhoea evaluation, Dec 1995–Feb 1996. Kimberley Public Health Unit Bulletin 1996; May:15–16.

22. Bolger A, Guilfoyle A, Hunter P, Ejai G. How Do We Re-orient STD Services to Ensure That They Are Customer Focussed? Derby: Derby Aboriginal Health Service, 1999.

23. Rust G, Minor P, Jordan N, Mayberry R, Satcher D. Do clinicians screen Medicaid patients for syphilis or HIV when they diagnose other sexually transmitted diseases? Sex Transm Dis 2003; 30:723–727.

24. Kotter JP. Why transformation efforts fail. Harvard Business Review 1995; 73:59–67.

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