NWT pilot project identifies and overcomes key barriers to care delivery
In 2021, the Northwest Territories (NWT) had syphilis rates seven times higher than the national average. This prompted an evaluation of how to improve syphilis response. The Public Health Agency of Canada says infectious syphilis rates have grown across the country over the past decade, with the national rate increasing from 5.1 per 100,000 in 2011 to 24.7 per 100,000 in 2020. Infection rates remain higher for males than females, but from 2016 to 2020 female rates of infection increased by a whopping 773 per cent, narrowing the gender gap and indicating that the demographics of transmission are changing.
Stephanie Gilbert is an Inuk and a registered nurse working in the NWT who has spent much of her career in community health nursing. “When we knew we were experiencing unprecedented rates of syphilis, we had to look at our own sexually transmitted and blood borne infection (STBBI) epidemiology data to get an idea of what was happening,” she says. “The data was telling us that the classically ‘high risk’ clients of the past are actually not who we are seeing present to the health-care system and being diagnosed with syphilis. Our system needed to respond and adapt.”
This meant revamping how services were delivered, including making changes in conventional clinics and doing a test run of a pop-up clinic. Both efforts were aimed at ensuring services matched the needs of the population and overcame barriers to accessing care.
Changing the way STBBI services are delivered required a paradigm shift in the way NWT nurses viewed infection risk, including how they identified who should be assessed for syphilis in their outreach work. The nurses, alongside a health promotion team, wanted to test and treat as many people as possible and allocate their resources in the most impactful way. After the health promotion team gathered feedback from stakeholders and the public about barriers to STBBI testing, the message was clear: decrease wait times, increase access, provide confidential care but permit support persons or partners, and increase feelings of safety.
People were having to wait weeks to book an appointment in a clinic, but that did not suit their needs; STBBI tests were often needed immediately. Having appointments readily available would allow clients to access assessments, testing and treatment quickly. For the conventional clinic, the solution was to change the types of appointments from booked appointments to same-day and evening appointments. The trial of a pop-up clinic (discussed below) also helped alleviate wait times.
Confidentiality and stigma
People expressed concerns about confidentiality and the stigma that accompanies STBBI testing. These concerns had to be at the forefront of the process. According to a recent report, 50 per cent of Canadians indicated that they had never been tested for an STBBI. Reasons included difficultly talking about STBBIs, fear of a positive result or being judged, stigma associated with STBBIs, concerns over privacy, and a lack of an established relationship with the health-care provider. However, it’s well known that bringing a support person increases the chances of clients accessing STBBI care.
“Fighting stigma and working within the colonial harms that we as Indigenous people have experiencedwhile also maintaining confidentiality is a priority not just for STBBIs, but for health and wellness. Changing our care delivery models took a lot of thought, discussion and planning amongst our STBBI subject matter experts,” Gilbert says. “First and foremost, it requires practitioners to be aware of colonial history, and it requires them to form a relationship with the client based on informed consent. The practitioner has to be transparent with the client about the safety and privacy of all interactions.”
Wait times and confidentiality were not the only hurdles impairing testing, however. It was also vital to consider the racism and discrimination that Indigenous people experience when accessing care and social services. This consideration was especially important when it came to revamping how sexual health care is offered.
Gilbert explains that this requires co-creating safe spaces with Indigenous clients to address the colonial legacy of being shamed, harmed and even punished because Indigenous views and beliefs around sex and sexuality differed from that of the church and other colonial structures. Moreover, in residential schools there is a documented history of sexual and physical assault on Indigenous children that has direct impacts on sexuality, sexual health, and consent.
Gilbert says that nurses and other health-care workers must acknowledge this history and consider them in approaches to care for sexual health and STBBIs.
“Sex, in the context of residential schools, was a violent act,” Gilbert says. “All of this is hard to discuss and is complicated — but knowing that, we must consciously co-create safe spaces for all clients to discuss their sexual health so that if persons are not ready to discuss sex and sexual health openly, they may feel more confident with our consistent support. We also cannot continue to endorse shame around sex either, perpetuating those colonial harms. It becomes a balance.”
This meant being mindful that every Indigenous person has the potential to carry colonially impacted views about sex and health care and are still healing from that. To address these valid concerns, the key principles of the Trauma- and Violence-Informed Care Toolkit, developed by the Public Health Association, were used to shape the care that the team would provide.
Improving access and changing attitudes
In direct response to the feedback and the epidemiological data, the conventional clinic changed the way appointments are booked and how the schedule is structured. Access to services — including completion of STBBI assessments and symptom review, collection of specimens, and provision of treatment, advice, and follow-up care — was greatly improved. Having an open schedule and extended hours meant flexible options for clients.
A pop-up clinic was planned and offered on World Aids Day, December 1, 2022. It became the highlight of one approach to improve access to sexual health care.
The pop-up clinic was preceded by weeks of creative outreach messaging that not only started the conversation around sex, but redefined the view of STBBI testing. Instead of testing being something that “risky” people do, it was described as a normal process that is a part of self-care — like getting tested for strep throat. This communications approach appeared on government websites and printed invitations, which carried messages such as “we are all sexual beings” and “we all deserve access to testing.” The printed materials were handed out in care packages to community members via street outreach.
Volunteers from non-government organizations walked the streets and engaged the public. Gilbert did radio interviews and other team members were interviewed by the CBC’s The National. Social media influencers were enlisted to generate buzz about the clinic and provide a tour of the space the day before it opened, demonstrating how privacy was not being sacrificed and that there was no shame in being tested.
The pop-up clinic was very welcoming, with lots of signs and posters and people walking around chatting to clients. Friends or partners could go through the clinic together so that support systems were in place, and if someone came alone, staff members made the effort to provide them with whatever support was required.
Everyone followed the same four-step care path without deviation:
- Registration: Staff obtained the patient’s contact information and consent to care and explained what to expect throughout the clinic, including basics about the testing and specimen collection process. This allowed clients to make informed decisions about whether or not to proceed. The process was heavily advertised in advance, which made clients more open to coming to the clinic.
- Testing: The testing station had a point-of-care test that tested for syphilis and HIV. Staff also collected confirmatory serology, but no results were provided at the time to allow for privacy.
- Results: This was a private one-on-one session with a sexual health nurse who would talk about harm reduction, safer sex practices, and anything else that clients needed. To ensure confidentiality, nothing personal or private was discussed until clients reached this point in the clinic. If needed, treatment could be provided immediately on-site.
- Follow-up booking: People could also be booked in for followup appointments to avoid barriers to any other care they required. The ability to fast-track clients to booked appointments for their needs was reported as a bonus in the project feedback.
An advantage to this pop-up clinic is the ability to streamline the process and stations to allow the equivalent of a week’s worth of appointments in one day, using around the same number of staff that would run a conventional clinic. But while the pop-up clinic was very successful, there will always be a need to have booked, walk-in and same day appointments in a one-on-one setting with a health-care provider.
The right clinic at the right time and place
When asked about expected outcomes, Gilbert states: “we hope that this messaging and these clinic styles will decrease stigma and access barriers and will increase acceptance of testing by persons who either have not been tested before or are not testing as frequently as would be recommended, and in particular — to see what kinds of clinics work best for STBBI testing in our communities.”
Given the national rates of syphilis, the NWT will continue to periodically use the pop-up clinic model as well as offer conventional clinics with walk-in and same-day appointments. Both approaches will ensure clients have increased access to meet their care needs. The team hopes that other practitioners will provide STBBI care using a trauma-informed approach, consider various scheduling and appointment styles, and reorient their understanding of risk.
Emily Durant, MN, RN, is the provincial transfusion coordinator for Nova Scotia Health. When she is not developing educational resources for nursing students and professionals, you can find her writing health content for her freelance business www.frontline2freelance.com or hiking trails around Halifax.