He Pūkenga Kōrero: STI Policy and Funding

STI POLICY AND FUNDING STI SERVICE PROVIDERS STI AND RANGATAHI NEET

Current STI policy is derived from three Ministry of Health documents; The Sexual and Reproductive Health Strategy: Phase One (Ministry of Health, 2001), Sexual and Reproductive Health: A Resource Book for New Zealand Health Care Organisations (Ministry of Health, 2003), and the  HIV/AIDS Action Plan (Ministry of Health, 2003). Often overlooked is He Korowai Oranga: Māori Health Strategy (Ministry of Health, 2002), a key policy for all health and disability services, including STI service providers.

While an update of sexual and reproductive health policy is underway now, current policy goals are nonetheless helpful in terms of:

  • supporting funders and STI service providers to use an equity lens to ensure STI services decrease rather than increase health inequities;
  • promoting priority access to STI services for ‘at risk’ groups i.e. rangatahi NEET and takataapui;
  • advocating for young Māori who do not have ready access to services i.e. rangatahi NEET and takataapui;
  • encouraging STI service providers to adopt organisational health literacy approaches in the planning and delivery of services and information resources;
  • incorporating He Korowai Oranga  health systems guide to improving Māori health and realising Pae Ora – healthy Māori futures.


1. ‘Priority Population’ Approach

New Zealand has one of the highest rates of chlamydia in the developed world and rates for gonorrhoea are approximately twice that of Australia and the UK (STI Surveillance Team, 2011, cited in Terry, Braun & Farvid, 2012). Of concern is the evidence indicating the high prevalence of chlamydia and gonorrhoea among young Māori aged 16-24 (Ekeroma, Pandit, Bartley, Ikenasio-Thorpe, & Thompson, 2012; ESR, 2013; Morgan, 2013). Untreated and reoccurring STI create an increased risk of infection and infertility among young people (Morgan, 2013). Those who are particularly vulnerable are rangatahi NEET and takataapui from high deprivation areas of the Waikato for whom access to the internet, mobile phones, the cost of transport, doctor visits and prescription costs may be prohibitive (Robson et al, 2015). Achieving equitable STI outcomes for rangatahi NEET and takataapui requires funders and STI service providers to adopt  a targeted, priority population approach alongside universal approaches.

The funding model is complex. A degree of complexity is required to deliver services to priority groups and to provide universal coverage. [However] the complexity of the SRH sector does not appear to be strategically driven (KPMG, 2013).

The strategy is very clearly saying ‘Improve rural access’ and ‘Improve equity for Māori’; it’s just that they’re saying there’s no money for it.’

[In our strategic framework] we’re looking at commitment from policy and decision makers to assist us with . . . improving sexual and reproductive health equity with a focus on gender and ethnicity.

References
Ekeroma, A., Pandit, L., Bartley, C., Ikenasio-Thorpe, B., Thompson, J. (2012). Screening for sexually transmitted infections in pregnancy at Middlemore Hospital, 2009. New Zealand Medical Journal, 125(1359), 23-30.

ESR. (2013). Sexually transmitted infections in New Zealand 2013: Surveillance report. Porirua, NZ: The Institute of Environmental Science and Research.

KPMG. (2013). Value for money: Review of sexual and reproductive health services. Final Report. Wellington, Ministry of Health.

Ministry of Health. (2014). Equity of Health Care for Māori: A framework. Wellington, NZ: Ministry of Health. Available at http://www.health.govt.nz

Morgan, J. (2013). Epidemiology, screening and treatment of chlamydia trachomatis infection in New Zealand (Doctoral thesis, University of Auckland, New Zealand).

Robson, B., Purdie, G., Simmonds, S., Waa, A., Brownlee, G., Rameka, R. (2015). Waikato District Health Board Māori health profile 2015. Wellington: Te Rōpū Hauora a Eru Pomare.

Terry, G., Braun, V., & Farvid, P. (2012). Structural impediments to sexual health in New Zealand: Key informant perspectives. Sexuality Research and Social Policy, 9, 317-326. doi: 10.1007/s13178-012-0089-y. Retrieved September 2016 from https://www.researchgate.net/publication/230705402_Structural_Impediments_to_Sexual_Health_in_New_Zealand_Key_Informant_Perspectives

2. Primary Care Alliances to Improve Access and Care

The new Youth Systems Level Measures Framework that focuses on youth access to and utilisation of youth-appropriate health services requires DHB-funded primary care services to report across one or more youth health domains. One of the five domains is that young people aged 15 – 24 years manage their sexual and reproductive health safely and receive youth-friendly care in order to improve chlamydia outcomes. The opportunity exists for all STI service providers in the Waikato, regardless of the source of their funding, to form an alliance that identifies shared goals and addresses barriers experienced by rangatahi NEET and takataapui.

Research shows that rangatahi commonly experience a lack of seamless care, integration and navigation (Lawton, Makowharemahihi, Cram, Robson, & Ngata, 2016). An alliance could provide the basis for standardising  ‘seamless care’ across every stage along the care pathway. This is particularly important for rangatahi NEET and takataapui, but is also likely to be true for other young people: from rangatahi accessing testing services; to being tested; if test is positive, their sexual partner or partners being notified; both the rangatahi and their partner/s receiving treatment; both rangatahi and their partner/s practicing safe sex (i.e. using condoms) until they no longer test positive for the infection (to avoid re-infection); and a follow-up check after 3 months.

The people who are most at risk, their lives tend to be more chaotic . . . How that’s reflected in accessing services is that they walk in through the door and say, ‘Can I see someone?’ Impulsivity . . .  And so what we need to do is run a service that can accommodate that. So rather than . . . a service where you have to ring up, be interviewed by someone as to whether or not you fit the criteria for our service, how responsive are we . . . to somebody who just rocks in through the door.

[XX] was the one who started off presenting a few years ago at the Sexual Health conference, that the more steps you put in [to STI treatment] the better the outcomes. And one of the things was to follow up people a week later, after their treatment . . . And then . . . in three months time the person has another check, and that’s actually for re-infection.

Well [prioritising that priority group] is certainly something we keep talking about. I have to say that  . . . people have got to find their way to us, so that’s one of the issues . . . We keep talking about whether we can do some form of video consultations . . . and working with other providers perhaps, if they need the expertise that we work in with them. So those are all the ideas we’ve got.

References

Lawton, B., Makowharemahihi, C., Cram, F., Robson, B., & Ngata, T. (2016). E Hine: access to contraception for indigenous Māori teenage mothers. Journal of Primary Health Care, 8(1), 52-59. Available from http://www.publish.csiro.au/

3. Organisational Health Literacy

Within an organisational approach to health literacy, the objective is to build the health literacy of organisations in order to reduce health literacy demands on people and communities. Most sexual and reproductive health service providers across the country are only just starting to develop their organisational health literacy, particularly with regard to timely, affordable and safe health services for rangatahi (Hunter & Franken, 2012; Jones et al, 2015; Lambert et al., 2014). The government’s Six Dimensions of a Health Literate Organisation (Ministry of Health, 2015) highlights the importance of improving organisation-level health literacy to support better access. Funders and professional organisations are ideally placed to encourage professional development and resources that more closely match the requirements of rangatahi NEET and takataapui.

I despair with how impossible it is to navigate the current system. 

You know, as providers we don’t fully understand [the system], so the patients haven’t got a clue.

I have concern about . . . what is current health literacy amongst this priority group, and the ability to use the tools that [the organisation] is saying are . . . ‘ simple, easy, and exactly what people want’. So will people feel comfortable with it? Do people have smart phones? Do people have broadband access? And enough data? And, and, and . . . ?

References

Hunter, J. & Franken, M. (2012). Health literacy as a complex practice. Literacy and Numeracy Studies 20(1), 25-44.

Jones B., Ingham T. R., Reid S., Davies C., Levack W. and Robson B. (2015). He māramatanga huangō: Asthma health literacy for Māori children in New Zealand. Dunedin, NZ: University of Otago. Available from https://www.asthmafoundation.org.nz/research/

Lambert, M., Luke, J., Downey, B., Crengle, S., Kelaher, M., Reid S., & Smylie, J. (2014). Health literacy: Health professionals’ understandings and their perceptions of barriers that Indigenous patients encounter. BMC Public Health, 14(614). Retrieved from http://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-014-0614-1

Ministry of Health. (2015). Health Literacy Review: A Guide. Wellington, NZ: Author. Available at http://www.health.govt.nz

4. Standarised Access Criteria and Consultation Fees

There are wide variations in terms of availability, quality, costs and access to sexual health services nationwide (KPMG, 2013), and in the Waikato. Research shows that there is a lack of affordable access to health services for rangatahi (Lambert, Luke, Downey, Crengle, Kelaher, Reid & Smylie, 2014). While health literacy has been identified as critical to being able to manage one’s health, there are multiple health systemic barriers that prevent access to STI services. Standardising access criteria and costs for STI testing and treatment is one way that the health system and health providers can improve their own health literacy and in so doing, improve the access of rangatahi NEET and takataapui.

The business of the different costing structures is for us a real hassle, because sexual health clinics are able to provide free services, and we can up to [age] 22, but beyond that we can’t. And so, how do two organisations work together when they’ve got different pricing structures?

So it’s one issue, one consult. And if you want to bring up something else . . . [if] they want an STI check . . . [they have to] either come back [for another appointment], or go to Sexual Health for a free check.

It’s usually 5 dollars for a prescription, but some pharmacies charge more for handling a fax prescription . . . more like 10 or 15 dollars.

It’s ludicrous the GP funding, and I know that the general public doesn’t understand it. I don’t think anyone understands it!

There’s a low cost access practice in Ngāruawāhia. And so you’re a millionaire farmer in Ngāruawāhia and you get pretty much free healthcare.

References

KPMG. (2013). Value for money: Review of sexual and reproductive health services. Final Report. Wellington, Ministry of Health.

Lambert, M., Luke, J., Downey, B., Crengle, S., Kelaher, M., Reid S., & Smylie, J. (2014). Health literacy: Health professionals’ understandings and their perceptions of barriers that Indigenous patients encounter. BMC Public Health, 14(614). Retrieved from http://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-014-0614-1

5. Sexuality Education in School Settings

Access to comprehensive sexuality education programmes that are culturally appropriate and provide accurate information and opportunities for skill-building are critical to reducing the prevalence of STI among rangatahi (Terry et al., 2012; Green, Tipene & Davis, 2016). Schools are an important source of evidence-based sexuality education. School-based programmes that are planned and delivered by a teaching workforce that understands the impact of the social determinants of health and are equipped to engage rangatahi NEET and takataapui into education – incorporating mātauranga Māori informed resources and te reo Māori where appropriate (Lee-Penehira, 2015) – are well placed to strengthen their knowledge. Achieving this vision needs policy and funder advocacy and engagement with the Ministry of Education regarding sexuality education in  Māori- and English-medium school settings.

I think one of the biggest steps this country needs to take is teaching sex[uality] education compulsory at schools. When you sit in a classroom . . . full of your friends and foes and you’re only going into a subject that becomes normal, that generation will then grow up . . . understanding a lot more, a lot faster . . . So the best preventative measure  would be to catch them when they are at school, when they are all together in their peer group, and teach them what it is. That would bring the best outcome.

References

Green, J. A., Tipene, J., & Davis, K. (2016). Mana Tangata Whenua: National guidelines for sexual and reproductive health promotion with Māori. First Edition. Hamilton: Te Whāriki Takapou.

Lee-Penehira, M. (2015). Mouri whakapapa: Repositioning Māori resistance and wellbeing in sexual and reproductive health policy and service provision. A report prepared for the Health Research Council of New Zealand on completion of the Hohua Tutengaehe Postdoctoral Fellowship.

Terry, G., Braun, V., & Farvid, P. (2012). Structural impediments to sexual health in New Zealand: Key informant perspectives. Sexuality Research and Social Policy, 9, 317-326. doi: 10.1007/s13178-012-0089-y. Retrieved September 2016 from https://www.researchgate.net/publication/230705402_Structural_Impediments_to_Sexual_Health_in_New_Zealand_Key_Informant_Perspectives

6. Reduce Health Determinants

Ethnic disparities in the detection of sexually transmitted infections most likely reflect socio-economic factors and issues relating to access to health services (Rose, et al., 2012). There are multiple social and structural barriers that make it difficult for rangatahi to access essential health information and services that would empower them to have a sense of control and practice tino rangatiratanga (self determination) over their own sexual and reproductive wellbeing. He Korowai Oranga: Māori Health Strategy (Ministry of Health, 2002) highlights the need for a cross-sectoral approach to addressing health disparities between Māori and other New Zealanders (Lee-Penehira, 2015).  Advocacy across sectors is essential to reducing socio-economic barriers and addressing the broad determinants of health that act as a barrier to good sexual health and wellbeing for rangatahi NEET and takataapui in the Waikato.

This is where the socio-economic thing comes in: for some people, they would rather walk to the clinic and sit and wait for the next available slot to get the free treatment, versus others who, you know, the petrol cost of coming to see us. And you can hear people doing the sums in their heads.

[X Provider]’s good for low cost access . . . But again, it’s back to: what can you get to? What fits with your hours? What fits with your transport?

References

Lee-Penehira, M. (2015). Mouri whakapapa: Repositioning Māori resistance and wellbeing in sexual and reproductive health policy and service provision. A report prepared for the Health Research Council of New Zealand on completion of the Hohua Tutengaehe Postdoctoral Fellowship.

Ministry of Health. (2002). He korowai oranga: Māori health strategy. Wellington: Ministry of Health.

Rose, S., Bromhead, C., Lawton, B., Zhang, J., Stanley, J., & Baker, M. (2012). Access to chlamydia testing needed for high risk groups: Patterns of testing and detection in an urban area of New Zealand. Australian and New Zealand Journal of Public Health, 36(4), 343-350.

7. National Social Marketing Campaign to Combat Stigma and Discrimination

High levels of stigma and discrimination exist regarding sexual orientation, gender identity and sexual health (NZSHS, 2011). This can be seen as endemic to a society where Māori people and Māori health is problematised by the dominant culture (Lambert, Luke, Downey, Crengle, Kelaher, Reid & Smylie, 2014), and an overall culture of sexual conservatism prevails (Terry et al., 2012). Stigma and discrimination are unacceptable. National social marketing campaigns can have a powerful influence on public awareness and attitudes towards, for example, mental health. A national campaign is needed to combat stigma and discrimination associated with sexual orientation, gender identity and STIs.

People don’t even want to go and get tested because, it’s like they’re ashamed.

You know how people are sometimes, like, I don’t want to go [to sexual health clinic] because someone might think I have an STI or something.

[Getting tested] sounds pretty easy, but going in for it isn’t . . . And that’s just like all the other stigmas of going to get tested for something.

Some places are extremely rude . . . I’ve been to a few places where nurses are just very old school and think that homosexuality can be changed by dating some girl. So those nurses will then be very hard to talk to and be very rude about the whole situation.

References

Lambert, M., Luke, J., Downey, B., Crengle, S., Kelaher, M., Reid S., & Smylie, J. (2014). Health literacy: Health professionals’ understandings and their perceptions of barriers that Indigenous patients encounter. BMC Public Health, 14(614). Retrieved from http://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-014-0614-1

NZSHS (New Zealand Sexual Health Society). (2011). Request for action on the development of a National Sexual Health Strategy and Action Plan (New Zealand Sexual Health Society report to the Ministry of Health on sexually transmitted infections in New Zealand). Wellington: NZSHS. Retrieved from http://nzshs.org/news/policy-submissions/188-development-of-a-sexual-health-strategy-and-action-plan/file

Terry, G., Braun, V., & Farvid, P. (2012). Structural impediments to sexual health in New Zealand: Key informant perspectives. Sexuality Research and Social Policy, 9, 317-326. doi: 10.1007/s13178-012-0089-y. Retrieved September 2016 from https://www.researchgate.net/publication/230705402_Structural_Impediments_to_Sexual_Health_in_New_Zealand_Key_Informant_Perspectives

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