Healthcare-seeking behaviour for sexually transmitted infection testing in New Zealand: A mixed methods study

Sexually transmitted infections (STIs) are a global public health problem. Sequelae for infected individuals can be serious and STIs impose a substantial financial burden on healthcare systems. Duration of infection is one factor influencing transmission rates, and is modifiable through secondary prevention methods, namely ‘test and treat’. For this approach to be effective, at-risk individuals must choose to present for testing. New Zealand provides a useful case-study to investigate healthcare-seeking behaviour for STI testing, as incidence rates of common STIs are especially high. The aims of this thesis were to quantify healthcare-seeking behaviour for STI symptoms and assess the risk of transmission in this period, to identify the barriers to STI testing, to understand the personal drivers for getting an STI test, to examine how STI knowledge is associated with testing behaviour, and finally, to collate and critically evaluate the published evidence regarding the incidence of a lesser known sequela of STI, reactive arthritis. This thesis took a mixed method approach, employing both qualitative and quantitative methods to address the research aims. The results showed that delays in healthcare-seeking for STI symptoms were common among patients attending an inner-city Sexual Health Clinic (SHC). Almost half of people with symptoms waited longer than seven days to seek healthcare, although there were no identified predictors of delayed healthcare-seeking. Around a third of people with symptoms continued to have sex after they first thought they may need to seek healthcare. Among these individuals, infrequent condom use was reported more by those who had sex with existing sexual partners than by those who had sex with new partners. Having sex while symptomatic was statistically significantly associated with delaying seeking healthcare for more than seven days (odds ratio (OR) = 3.25, 95% CI 1.225 – 8.623, p = 0.018). Analysis of qualitative interview data revealed three types of barriers to testing. These were personal (underestimating risk, perceiving STIs as not serious, fear of invasive procedure, self-consciousness in genital examination and being too busy), structural (financial cost of test and clinician attributes and attitude) and social (concern of being stigmatised). This work also revealed several drivers for testing including crisis, partners, clinicians, routines, and previous knowledge. Knowledge of the incidence, asymptomatic nature and sequelae of STIs featured prominently in the explanations of those who undertook routine testing. However, at the same time, many of the participants felt they did not have a good knowledge base and that their school-based sex education had been lacking. STI knowledge was investigated further using quantitative methodology. Levels of STI knowledge were generally good and did not differ between a Student Health Service population and an SHC population. Individuals who had tested before had significantly better knowledge than those who were attending for testing for the first time (U = 10089.500, Z = -4.684, p < 0.001). In addition, total knowledge score was an independent predictor of having had a previous test (OR = 1.436, 95% CI 1.217-1.694, p < 0.001). Reactive arthritis can be triggered by STI, thus STI screening patients who present with reactive arthritis has the potential to identify undiagnosed infection. This thesis provides the first assessment of the international literature regarding the incidence of reactive arthritis after STI. The systematic review found only three published studies which had prospectively examined the incidence of reactive arthritis after STI. The studies reported an incidence of reactive arthritis after STI of 3.0% to 8.1% and were found to be of low to moderate quality. In conclusion, this thesis provides healthcare service providers, policy makers and clinicians with data to inform practice and public health interventions aimed at improving healthcare-seeking behaviour for STI testing. It illustrates that delayed healthcare-seeking for STI symptoms is a common behaviour in New Zealand and could potentially be contributing to STI transmission and downstream burden on the health system. This work provides evidence of the drivers of STI testing that can be promoted, and the barriers that need to be removed. Specifically, improving STI knowledge may positively impact on testing rates. Lastly, this research indicates that there is a need for more studies assessing the incidence of reactive arthritis after an STI.