Sydney Sexual Health Centre (SSHC) began a fast-track sexually transmissible infection (STI) screening clinic—Xpress clinic—in December 2010. Xpress is promoted to asymptomatic clients and uses a computer-assisted self-interview (CASI) and self-collection of STI specimens, with limited clinician time. The aim of Xpress is to offer an alternative screening model to the longer, routine care consultation of 30 minutes.
Evaluation has shown that the Xpress clinic has significantly reduced the length of stay and waiting time for clients at SSHC,1 and a client satisfaction study shows a high rate of satisfaction with this service.2 Currently, Xpress is only available to clients who can read and understand a high level of English, and this reduces access for culturally and linguistically diverse (CALD) clients.
Sydney Sexual Health Centre has provided a Multicultural Health Promotion Project and interpreter-assisted language clinics for Chinese-, Korean-, and Thai-speaking sex workers since 1991 because sex workers are advised to attend for routine screening as a priority population of the NSW Sexually Transmissible Infections Strategy3 and CALD populations often experience reduced access to health services. In 2012, the percentage of CALD clients attending SSHC was 13% (n = 1365), 77% of whom were symptomatic. Thirty-seven percent of CALD clients attended a designated language clinic, of whom all but 4 were female.4 Because each language clinic is drop-in only, the wait can be long, and some clients are triaged into the routine clinic because their designated language clinic is full. Using the Xpress screening model with a translated CASI was considered an alternative for Chinese-, Korean-, and Thai-speaking clients to reduce wait times and increase the number of clients who could be seen.
The Xpress model comprises 3 important aspects: a CASI to obtain a risk profile and sexual history on which screening algorithms are built, self-collection of swabs/urine specimens, and not having a physical examination. For the proposed CALD express model, we added an additional aspect—consultation with a nonmedical staff member, in this case a Chinese/Korean/Thai multicultural health promotion officer (HPO) currently employed at SSHC. The HPO role would be to administer the self-collected specimen testing kits and process the client file, in addition to their current sexual health education provision.
The aims of this study were to determine the acceptability of a CALD express clinic model and its individual components among female Chinese, Korean, and Thai clients attending SSHC and to determine differences in acceptability based on language group, new or return client status, sex worker status, clinic visited status (language or general), and age.
This was a cross-sectional survey using a 9-item, tick-box, anonymous questionnaire that included 4 demographic items (first visit, used Xpress previously, age group, and sex worker status) and 5 CALD express service items. Clients were asked to choose 1 only of either 2 or 3 preferences per express question. Surveys were piloted before commencement with 29 language clinic clients. No identifying data were collected. Surveys were numbered to determine the response rate and reception staff monitored potential duplication by asking clients if they had previously completed a survey so that they were not offered another.
Based on the numbers of Chinese, Korean, and Thai clients attending SSHC language and general clinics during the previous 12 months, the numbers calculated to detect a 33% difference between the 3 groups, with 5% error and 80% power, was 144 Chinese, 144 Thai, and 72 Korean clients.
All female Chinese, Thai, and Korean clients attending SSHC from March 2012 were given a questionnaire. Distribution ceased once the required number of participants had been reached, which was September 2012 for Thai clients and November 2012 for Chinese and Korean clients.
Multivariate regression and Pearson χ 2 statistical analyses were conducted using STATA 12 software.
Ethics approval was granted by South Eastern Sydney Local Health District Human Research Ethics Committee (reference no. 12/057).
In total, 388 surveys were distributed and 366 returned, providing a response rate of 94.3%. This comprised a rate of 96% for Thai (n = 149/155), 92% for Chinese (n = 145/157), and 92% for Korean (n = 72/78).
Thirty-five percent (n = 117/339) of respondents were return clients, and 54% (n = 190/353) were sex workers. Of 353 (96%) who answered the question on age, most were 25 to 34 years old (53%; n = 186), followed by 35 to 44 years old (26%; n = 93), 15 to 24 years old (13%; n = 45), and 45+ years old (8%; n = 29).
There were significant differences in the acceptability of the different components of the Xpress model between language groups. For example, just 8.5% of Korean and 14.1% of Chinese women were happy to be seen by an HPO rather than a clinician, compared with 43.2% of Thai (P < 0.001). Similarly, 11.1% of Korean and 12.0% of Chinese women were happy to use a CASI regardless of whether it saved time in clinic, compared with 44.2% of Thai (P < 0.001), and the Thai women were also more accepting of self-swabbing (48.6%) compared with Chinese (23.9%) and Korean (40.9%) women (P < 0.001). No groups wished to forfeit the physical examination, although this was not significant. Further details of differences in acceptability of the components of Xpress are given in Table 1.
After multivariate analysis, the only predictor of willingness to use an express model of service provision remained language group: overall, 67% Thai (odds ratio, 3.74, confidence interval [CI], 2.03–6.89, P < 0.01) and 64% Korean (odds ratio, 3.58, CI, 1.77–7.25; P < 0.01) said that they would use it compared with 35% Chinese. Age, history of sex work, new or returning clients, and general or language clinic attendance did not impact on these choices. The results of multivariate analysis are shown in Table 2.
We believe that this is the first study to be conducted for specific CALD clients as to their preferences for a service delivery model that has been successfully incorporated into use for English-speaking clients.1,2 Our results show that the components of the Xpress model used at SSHC are not the preference for our female Chinese, Korean, and Thai client base, and despite our knowledge that it has the potential to reduce waiting times, clients did not favor reduced waiting time over being physically examined or using a CASI.
Many international studies have demonstrated the feasibility and acceptability of CASI in reporting sexual behaviors and have indicated that a CASI is well accepted.5–7
A study evaluating the cultural acceptability of CASI in collecting data on sensitive HIV risk behaviors in China, India, Peru, Russia, and Zimbabwe reported participant ease in CASI completion and preference for a computer over an interviewer for answering sensitive questions.8 Similar studies have shown successful outcomes using CASI for sexual behavior reporting.9–11
Translated CASIs have also been used successfully in STI studies in the United States; however, they did not report on acceptability for clients, only that translating them for client recruitment was successful.12,13
In contrast, the CASI was not preferred by 2 of our 3 language groups. This is interesting because our anecdotal client feedback is that many of them are wary of using an interpreter at their first visit because of fears around confidentiality, yet they do not wish to provide a sexual health history using a method that would obviate the need for an interpreter. This may be, in part, caused by client fears around the confidentiality of electronic medical records. It may also be, in part, because of the often illegal nature of the work done by many of our CALD clients (eg, working more hours than their visa allows) and fears around information sharing with immigration and police.
Studies from non–English-speaking countries indicate success in using self-collected swabs for STI screening among women and sex workers,14–16 demonstrating that self-collected specimens are acceptable to women across different cultural backgrounds. Our findings support these previous studies in part, in that self-collected swabs acceptability has been demonstrated for women from 2 of our client groups, Korean and Thai. However, acceptability was not demonstrated in relation to the Chinese women attending our center.
Lack of Physical Examination
Some studies have described fast-track services where the physical examination has been omitted, resulting in positive outcomes in terms of clinic capacity.17,18 However, the satisfaction of this aspect of the consultation with the clients in these studies has not been assessed. It has been reported that although clients might find a physical examination more painful and less convenient than self-sampling methods, it is a more trusted method,19 which may explain in part why the Chinese, Korean, and Thai women visiting our clinic consider the physical examination important enough to not wish to lose this aspect of their care. There is no evidence of comparisons between culturally diverse groups with regard to their preference for a physical examination or not.
More research is required to ascertain if this is a belief felt by only our specific language group clients or if it is mirrored in other CALD client populations. It also provides an opportunity to consider what interventions we might undertake to challenge the beliefs clients hold in relation to undergoing a physical examination.
Consulting With a Non-clinician Health Care Worker
The routine model of care in the language clinics at SSHC is consultation with either a doctor (Chinese, Thai, and Korean clinics) or a nurse (Thai clinic only). The existing Xpress clinic is staffed by an enrolled nurse. In the proposed CALD express model, the clients would instead been seen by nonmedical staff, an HPO, because these staff are currently employed to provide education and support for clients. There is limited evidence relating to using nonclinical staff in an express-type clinic. One study used a physician’s assistant, and although their emergency department express clinic was found to be successful, a comparison of clinician or physician’s assistant client preference was not provided.20 There is no evidence comparing provision of a clinical versus an allied health professional in a sexual health clinic setting.
The HPO model was not preferred by Chinese and Korean clients. Although we have established Chinese and Korean HPOs in attendance at each clinic, the Thai program has been running the longest (since 1990; Chinese since 1994 and Korean since 2005). It may be this longevity and the fact that we have a Thai-speaking nurse that has influenced the Thai clients’ preference compared with Chinese and Korean clients. However, other factors that may have contributed include individual experience and cultural factors of which we may not be aware, for example, health, medical, and personal belief systems. Further investigation into the reasons behind these client choices would be a useful addition to the literature.
Our study had some limitations. First, we did not ascertain the reasons behind client preferences but speculate that most of Chinese, Korean, and Thai women coming to SSHC wish to have what they consider to be the best care, namely, a face-to-face consultation with a medical or nursing practitioner and a full examination. Second, these findings do not represent CALD men, other CALD language groups, or those who do not access our clinic. Third, we have not compared our study population with those who may have experience of using an express service and who may have used the individual components; this study is based on what clients say they prefer from a service without having experienced that service. Fourth, we did not ascertain if clients responding to the survey were asymptomatic on the day of attendance. This would have implications for whether or not CALD clients would be eligible for an express service in the first instance.
Strengths of our study were the high response rate and large sample size.
The study used consumer input into the decision-making process for potential clinic reorientation, and we have been able to determine what service model those consumers prefer. Health services need to consider the specific needs of their CALD populations, ideally through surveys such as ours, before implementing potentially costly and resource intensive reorientation. In saying this, given that the Xpress clinic has demonstrated client and clinic benefits,1,2 we are investigating potential HPO-led clinical strategies and have not ruled out reorienting clinical services via development of a CALD express service in the future should client or clinical needs change.
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3. NSW Department of Health. NSW Sexually Transmissible Infections Strategy 2006–2009. Sydney; 2006.
4. Sydney Sexual Health Centre. Multicultural Health Promotion Project Annual Report. 2012. Sydney Sexual Health Centre internal report
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