Multi-level interventions to impact incidence and prevalence of sexually transmissible infections (STIs) among First Nations Peoples.

This study aims to reduce the incidence and prevalence of sexually transmissible infections (STIs) in Aboriginal and/or Torres Strait Islander populations by implementing and evaluating community-led, co-designed, multilevel interventions. Our team is well placed to generate evidence to respond to increasing STI rates. The study is founded on evidence that single interventions have not been sufficient to reduce STI prevalence in many Aboriginal and Torres Strait Islander communities, and on the hypothesis that combined interventions have greater potential to impact incidence and prevalence. Our multilevel interventions are conceptualised at four levels: (1) individual; (2) community; (3) health service; and (4) structural/system. Strategies within each level have been co-created with community partners. Strategies across the four levels will be implemented simultaneously during the study period and evaluated individually and collectively. The study will take place in three regions spanning Queensland (Central Queensland and Far North Queensland) and the Northern Territory, building on foundational research by most of the same team. Within each region, we will implement and evaluate multilevel interventions tailored specifically to local contexts. Interventions have been selected through a rigorous co-design process involving Community Advisors and health service partners. Although the exact combination will vary by region, all regions will include interventions from at least three of the following four levels: Level 1: Individual-level interventions – Condom provision and access, and behavioural nudges (aimed at increasing access and use of primary health care services). Male condoms are provided as a free donation from Hero condoms, initially stored at UQ Poche regional offices (Rockhampton and Cairns) then distributed to health facilities for immediate dissemination and through community groups particularly focussing on youth and young men projects. The condom programme follows a plan and is recorded and aligned with the supplier and receiving institution. As and when necessary (depending on demand), the plan is revised. Condom availability is continuous throughout the implementation period (March 2026–June 2028), with monthly monitoring of access point stock levels and stock outs. For the education initiatives this to be set in discussion with Community Advisory Groups, Indigenous Governance Group and respective health facilities (ACCHOs, general practices and government entities) professionals, taking note of lessons learned from previous experience. The core content of this education is sexual wellbeing and correct and consistent use of condoms. The messages are delivered by trained community leaders including peer educators as well as by health practitioners specialising in sexual health. Meetings within the community last approximately one hour and if consent is given by the participants (primarily young men) minuted. Education initiatives fall under both the individual level and community level intervention streams. Katherine West, in particular, has additional region-specific resources regarding the health education component. Content/topics covered: - STI transmission, prevention, and “testing when you feel fine” messaging, awareness of access pathways to health services and in particular, testing. - Correct condom use and protective behaviours; sexual health information tailored for young people, men 15-40, women of reproductive age; and - Stigma/shame reduction messaging embedded in culturally safe communication. In the Katherine West region, for example, additional resources include activity-based education tools, Gender specific forums, animations, posters and print materials and On Country education sessions and information hubs. Mode of Delivery: - Face to face delivery at community activations, sports/carnival events, peer and antenatal outreach sessions. - Clinic based education, through tablets/iPads, posters, opportunistic teaching by clinicians, education package produced by clinician. - Digital education, integrated with the health promotion campaign (videos, microsite, targeted ads). Who will provide the education: - Community Advisors and Aboriginal and/or Torres Strait Islander community engagement officers; - Health service staff (clinicians, nurses, Aboriginal Health Workers); - ACCHO health promotion teams; and - Study coordinators and partner organisations (where relevant and culturally appropriate). Frequency and Duration: - Delivered continuously throughout the implementation phase (Mar 2026–Jun 2028). - Community activations occur periodically, depending on local event schedules (e.g., sports carnivals, community days). - Clinic based education is ongoing as part of routine care. - Digital campaign education runs via scheduled campaign with monthly reporting. Behavioural nudges are developed in part by an independent expert (Ellis-Jones) and ratified by community representatives and health professionals; the emphasis is on testing uptake and regular visits to the health centre. These nudges will run for the life of the study through billboards, posters, flyers and monthly SMS prompts from respective health centres. Behavioural nudges are included across all intervention regions. What Is Involved: - SMS recalls for STI testing and 3-month retesting (60–120 days). Evaluation/Cascade-of-care indicators - Calendar reminders and digital prompts, including direct to person targeted ads (clinic finder links). - Micro incentives for testing attendance (Katherine West only): care kits, shirts, food. Frequency: - SMS recalls follow EMR recall systems and occur routinely as clients become eligible; monitored monthly - Digital prompts follow scheduled campaign flights with weekly internal and monthly external reporting. - Micro incentives offered at each eligible testing episode during implementation. Adherence Monitoring (nudges): - Monthly counts of SMS/email recall volumes, delivery success, and clinic attendance within 30 days of receipt. - EMR prompt coverage for clinician facing nudges (% of consultations triggering prompts). The protocol includes structured adherence monitoring via clinical, behavioural, and process indicators. Condom provision - Monthly recording of: o number of condom access points o stock outs Education initiatives - Event logs documenting: o number of community activations o estimated attendance o education hub interactions Logs of materials distributed: Behavioural nudges - SMS/email recall volumes, delivery success, and attendance within 30 days. - EMR prompt coverage for clinician nudges. Clinical outcomes linked to adherence - Testing coverage, time to treatment, and retesting rates are monitored monthly using EMR data (ATLAS/GRHANITE). Level 2: Community-level interventions – Culturally led health-promotion campaign; peer/antenatal outreach; sports/carnival activations., Campaigns are designed and implemented within the location guided by community peer educators. Ensuring cultural expectancy is met, health promotion proceeds, which can involve, for example, gender specific materials, details of nearest health centre and where and how to get tested for an STI minimising any chance of stigma. Appointed and trained community health educators to deliver health promotion activities. Venues and times will be decided within community structures to ensure best possible uptake of, for example, antenatal outreach. When required sexual health specialists (trained and certified) from local health centres were help deliver the message. This may take place, for example, during work hours. Messaging on sexual health is a constant and core priority of the study, In addition to campaigns, such as the release and promotion of health and wellbeing material, for example at 'footy' or music carnivals the messaging will go on daily at health facilities and community hubs. This will go on for the duration of the study. At sport/carnivals, wherever possible, a stall will be set up complete with posters and supplies of condoms. Merchandise promoting health and wellbeing (designed by local First Nations designer) will be available for handing out to interested parties, notably young people. Reflections through community meetings and discussions with health centre will help in the delivery of this programme and assist in making course corrections as and where necessary. Level 3: Health service-level interventions – Continuous Quality Improvement (CQI) bundles (recall systems, 7-day treatment key performance indicator (KPI), 3-month retest KPI, partner notification prompts; clinician training; point-of-care testing (PoCT; where supported). CQI is facilitated primarily by health centre reports. Data is extracted and analysed (GHRANITE/ATLAS) showing status of sexual health services, uptake and levels of incidence and prevalence. This information demonstrates strengths and weaknesses (for example, visits to a health service, testing requests and positive notifications) and shapes the CQI bundle. Additionally, monthly discourse with health services will include components of CQI and where action needs to be taken. Information about training will be provided to clinicians on a monthly basis. Depending on the type of training required, this will, where possible, be F2F and not time consuming. Information on trainings and by whom to be circulated at a minimum on a quarterly basis. Point-of-care testing involves analysis of samples where healthcare is provided close or near to the patient. PoCT facilitates rapid turnaround of test results and take up of treatment. PoCT is encouraged and supported by this study. Electronic medical records (EMR) are the bedrock for assuring adherence and fidelity. EMR are scrutinised first at the health facility and then by the Poche Atlas team noting and responding to any perceived discrepancy in the data. Level 4: Structural/system-level interventions – After-hours/mobile models; data/policy improvements (GRHANITE/ATLAS feedback loops, dashboards); MenB vaccine. Innovative forms of health care promote after-hours mobile models. This is an example of 'taking health to the people' and not vice-versa, of finding the best place and time to offer services. From ground-truthing work, for example, in Katherine West, Northern Territory, a model will be developed for replication elsewhere on the details and approach of this model. Whereas this service is mobile and by definition limited, test and treat materials will be available for STIs as well as health promotion material and information on nearest health clinic offering full range of primary health care services. This study promotes continual feedback loops for example, health centre reporting, regular meetings (recorded) with community and health professionals on status of services provided. The Community Governance Group, the Community Advisory Groups will take as a core function of their work, deliberations on the success or otherwise of current policy and procedure especially as it relates to First Nations communities. Reporting back to health facilities, and communities by the study team helps establish a firm line of communication on matters affecting policy and procedure - and proposing alternative ways of doing business. Whereas this study is not directly involved in the delivery of the MenB vaccine, given its anticipated impact on outcomes of the programme, close cooperation is established with the University of Adelaide team responsible for its delivery. In particular, details relating to where and when and to whom the vaccine will be administered to allow this study to monitor and see if this has affected incidence and prevalence of STIs in the project areas.