Barriers and facilitators to sexually transmitted infections testing in Indigenous populations

Abstract

Background: Indigenous people are disproportionately affected by sexually transmitted and blood-borne infections in Canada. Considering the historical trauma and systemic inequities resulting from colonization, Indigenous people may face distinct barriers to sexually transmitted infection (STI) testing, such as mistrust of healthcare systems and culturally unsafe services in ways that differ from other equity seeking groups.

Objective: To identify the barriers and facilitators to STI testing in Indigenous populations in Canada and comparable high-income countries.

Methods: OVID Medline (1950–), OVID PsycInfo (1872–) and EBSCO Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1937–) were searched from their inception until December 2024. The Joanna Briggs Institute (JBI) guidance, including the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews, was used throughout. Relevant data were extracted into a data extraction table for analysis.

Results: A total of 240 articles were retrieved from the three databases and only 13 articles were included in the final review. Multiple barriers and facilitators were identified. Common barriers include stigma, cultural and religious norms, general lack of knowledge about STI and testing, service limitations, lack of privacy of the design of testing facilities, and shame and discrimination. Common facilitators were 1) provision of culturally sensitive and appropriate care, sexual health and STI education, 2) inclusion of STI testing to the general routine community-based health screening program and 3) incorporation of STI testing into Indigenous wellness programs and services offered by Indigenous service/wellness centers.

Conclusion: Common barriers and facilitators were easily themed using the determinants of health framework. Most of the barriers and facilitators were directly or indirectly linked with the respective Indigenous cultures, which varied with each community.

Introduction

Sexually transmitted infections (STIs) are primarily spread through vaginal, anal, or oral sex without barrier-type protection ^{Footnote 1} and include chlamydia, gonorrhea, syphilis and HIV infection ^{Footnote 2}. When left untreated, STIs can result in infertility, pelvic inflammatory disease, cardiovascular and neurological complications, and even premature death ^{Footnote 1}. They also carry significant social and economic consequences, such as stigma, emotional distress, loss of productivity and increased healthcare costs ^{Footnote 3}.

In Canada, sexually transmitted and blood-borne infections (STBBI) have risen sharply in recent years. National data show a 109% increase in infectious syphilis between 2018–2022 ^{Footnote 4}, and Ontario has seen gonorrhea and infectious syphilis rates double and triple, respectively ^{Footnote 5Footnote 6}. Indigenous populations are disproportionately affected by STIs ^{Footnote 7Footnote 8}. In January 2025, Indigenous Services Canada issued an alert over rising syphilis cases in First Nations communities. Although STI testing is one of the four key pillars to addressing STBBI in Canada ^{Footnote 7Footnote 9}, evidence suggests low STI testing uptake among Indigenous population. For instance, over one-quarter (27.9%) of First Nation youth aged 12–17 years old reported being sexually active, yet only 9.6% had ever been tested for an STI, and just 6.8% had been tested for HIV ^{Footnote 10}.

A preliminary literature search on Medline revealed limited current evidence syntheses on this topic. The only identified systematic review was published over a decade ago, was focused solely on HIV testing, and was not specific to Indigenous peoples ^{Footnote 11}. Considering the historical trauma and systemic inequities resulting from colonization ^{Footnote 12Footnote 13}, Indigenous peoples may face distinct barriers to STI testing, such as mistrust of healthcare systems and culturally unsafe services. Understanding the factors influencing STI testing uptake among this subpopulation is critical for developing targeted, community-informed strategies to improve STI testing and outcomes. As such information is not readily accessible to stakeholders, the findings of this review may offer valuable evidence to support governments, public health organizations, and other relevant stakeholders working with Indigenous populations in informed decision-making, strategic planning, and the development of targeted surveys for similar research in Indigenous communities.

A scoping review approach was selected for this topic as it allows for systematic and comprehensive mapping of available evidence on barriers and facilitators to STI testing among Indigenous populations, and incorporates diverse study designs/methods such as quantitative, qualitative studies, Indigenous research methodologies ^{Footnote 14Footnote 15Footnote 16}. This study focuses on Canada and three comparable high-income countries (Australia, New Zealand and the United States), which share similar colonial histories and ongoing health disparities among Indigenous populations ^{Footnote 17}.

Objective

The objective of this study is to identify the barriers and facilitators to STI testing among Indigenous populations in Canada and comparable high-income countries.

Research question

What are the barriers and facilitators of STI testing among Indigenous populations in Canada and comparable high-income countries?

Inclusion criteria: Using the population, concept, context framework

The population of interest included any named Indigenous peoples (First Nations, Inuit, Métis, American Indian/Alaska Native, Aboriginal and Torres Strait Islander, Māori and Pacific/Indigenous Pacific peoples) of any age, as well as healthcare workers and stakeholders serving Indigenous communities. Both adolescents and adults were included. The concept focuses on the uptake of STI testing. The context or setting includes barriers and facilitators to STI testing within community, primary care, sexual health, hospital, and outreach settings in both remote and urban areas in high-income countries. These countries were selected for their high-income status and shared histories of colonization and systemic marginalization of Indigenous populations. The types of evidence included were empirical studies (qualitative, quantitative and mixed-methods) along with program evaluations and interventional studies (including experimental and quasi-experimental designs). Grey literature was excluded because empirical studies are based on observable data and are more likely to have undergone a peer-review process, enhancing objectivity and accuracy compared with grey literature, which is not typically peer reviewed and may introduce bias.

Methods

This scoping review adapted the Joanna Briggs Institute (JBI) ^{Footnote 16} including the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews ^{Footnote 18} and was conducted in consultation with a hospital librarian.

Information sources and search strategy

An initial limited search in Medline and Google Scholar was conducted to identify key words and to derive Boolean operators, truncations and index terms in the relevant articles, which were used to develop a full search strategy as applicable. OVID Medline, OVID PsycInfo and EBSCO Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched from their inception to December 15 or 16, 2024, combining concepts related to barriers and facilitators to health care access and delivery, STI (including HIV, chlamydia, gonorrhea and syphilis), and testing or screening practices such as point-of-care testing. Terms related to Indigenous populations were also included using modern and outdated terminology as keywords to facilitate retrieval. The main concepts (health care access, STI, testing, barriers, facilitators, Indigenous populations) were searched utilizing a mix of controlled vocabulary and keywords with phrase searching and truncation and combined using the Boolean operator "AND". Results were limited to English-language publications (Appendix, Supplemental material, List 1). Backward citation was done for the reference list of all the articles included in the review to retrieve additional relevant articles.

Selection process and data charting

Following the search, all identified citations were imported to Zotero (a citation management software) and duplicates were removed. Screening and data extraction were performed by a single reviewer. Screening was two staged; title/abstract followed by full-text review based on predefined inclusion/exclusion criteria (Figure 1). A data extraction table was developed to collate relevant information, including study characteristics, population details, study methods, STI focus and identified barriers and facilitators (Appendix, Supplemental material, Table S1). Critical appraisal is generally not required for scoping reviews and was not undertaken as our focus was to map existing evidence rather than assess risk of bias. Descriptive analysis, using counts and percentage, was used to summarize study characteristics and identify patterns across the articles. Barriers and facilitators of STI testing uptake were ranked by the frequency of their mention in the studies and further themed using the determinants of health framework. This framework explores the broad spectrum of personal, social, economic, and environmental factors that influence health at both individual and population levels ^{Footnote 19}. Findings were organized and interpreted around three key determinants: culture; education; and access to care. This approach allowed for systematic identification and synthesis of themes across studies, highlighting how structural and social contexts influence STI testing uptake.

Figure 1 - Text description

This table shows the search records obtained from three databases: OVID Medline, OVID PsycINFO, and EBSCO CINAHL. The 43 duplicates were removed from the results with 197 records screened. From the 197, 173 records were excluded for various reasons including: non-indigenous population groups (n=40), off topic (n=73), outside the scope of STI contraction (n=38), health surveillance (n=12), geography not comparable (n=5), and vaccination or screening focus (n=5). Twenty-four reports were accessed for eligibility with 13 were included in the review. Reasons for exclusion of fully screened at second stage screening included: non-Indigenous or mixed population samples (n=4), healthcare provider perspectives rather than Indigenous (n=2), conditions outside scope if STI contraction (n=2), treatment or service delivery unrelated to uptake (n=2), geographic context outside of scope (n=2). One report was gathered via backward citation searching.

Results

Search result

The initial search identified 240 articles. After screening using the inclusion criteria, 12 articles were selected. A backward citation search identified one more study, to make the final review articles 13 (Figure 1).

Data analysis

Thirteen studies were included in this scoping review (Table 1), with the majority conducted in Australia (54%) and Canada (23%). The objectives of all the studies focused on Indigenous populations, and most (77%) included exclusively Indigenous participants. For studies including healthcare providers or related professional, participants were mostly serving Indigenous communities and/or have good knowledge about Indigenous people. Study populations varied by age and gender, with most employing qualitative (62%) or mixed methods (23%). Only one study assessed STI re-testing ^{Footnote 20}. Nearly 40% addressed chlamydia and gonorrhea, while studies focused solely on HIV (30%) were conducted in Canada and the United States ^{Footnote 21Footnote 22Footnote 23Footnote 24}. Majority of the studies (92%) examined both barriers and facilitators of STI testing across Indigenous populations (Table 2).

Identified barriers and facilitators were themed using components of the determinants of health framework ^{Footnote 19} and ranked according to the frequency of mention across the 13 studies (Table 3).

High ranked barriers were linked by theme into three groups: 1) culture-stigma ^{Footnote 22Footnote 23Footnote 25Footnote 26Footnote 27Footnote 28Footnote 29Footnote 30}, cultural and religious norms ^{Footnote 20Footnote 22Footnote 24Footnote 28Footnote 31Footnote 32}; 2) sexual health education, poor sexual health knowledge ^{Footnote 20Footnote 23Footnote 26Footnote 28Footnote 30}; and 3) access to suitable healthcare services, limited-service availability ^{Footnote 25Footnote 27Footnote 28Footnote 32}, discriminatory staff attitudes, lack of privacy ^{Footnote 20Footnote 27Footnote 30Footnote 31} and feelings of shame or embarrassment during testing ^{Footnote 20Footnote 22Footnote 28Footnote 30}.

Low ranked barriers include perceived lack of anonymity ^{Footnote 22Footnote 24Footnote 25}, fear of testing positive ^{Footnote 22Footnote 24Footnote 25}, denial and ignoring symptoms ^{Footnote 25Footnote 32}.

High ranked facilitators were linked by theme into three groups: 1) culture-cultural sensitivity and culturally appropriate sexual health information and services including training providers in Indigenous practices and gender-aligned services ^{Footnote 20Footnote 21Footnote 22Footnote 25Footnote 27Footnote 28Footnote 31}; 2) sexual health education-peer- and community-led sexual health education, multigenerational programs and outreach via social networks were recommended strategies ^{Footnote 22Footnote 23Footnote 28Footnote 29Footnote 30}; and 3) access to suitable healthcare services- and access-enhancing strategies included skilled and Indigenous health workers ^{Footnote 24Footnote 26Footnote 28}, integration of STI testing into routine community ^{Footnote 26Footnote 28Footnote 29Footnote 31} or routine Indigenous wellness programs ^{Footnote 21Footnote 22Footnote 23Footnote 28}.

Low ranked facilitators include free transport, flexible testing (online, home or pharmacy) ^{Footnote 28}, discreet self-test kits and electronic reminders ^{Footnote 23}.

Discussion

The scoping review identified multiple barriers and facilitators to STI testing in Indigenous populations. Barriers to STI testing included stigma, lack of sexual health education and access to suitable healthcare services, influenced by cultural and religious norms and context. Common facilitators to STI testing included cultural sensitivity, culturally appropriate care, sexual health education and access to suitable healthcare services. Other facilitators included strategies to promote STI testing, including such as training healthcare providers in cultural competencies, providing gender-aligned care and incorporating STI testing into community-based health check programs.

Barriers

Culture and sexual health education: Stigma emerged as the most frequently reported barrier, aligning with previous research ^{Footnote 20Footnote 25Footnote 32Footnote 33Footnote 34Footnote 35}. It is often perpetuated within communities by family and peers ^{Footnote 20} and stemmed largely from cultural and religious norms ^{Footnote 22Footnote 25Footnote 36} and poor sexual health literacy ^{Footnote 21Footnote 24Footnote 25Footnote 27Footnote 29}. Cultural beliefs discouraging open discussions about sexual health, particularly with healthcare providers, further reinforced this barrier ^{Footnote 22}. The absence of formal sexual health education in schools and limited parental guidance also restricted young people's awareness of STI prevention and testing ^{Footnote 29}.

These findings highlight the complex interplay between culture, stigma and education, underscoring the need for interventions guided by frameworks such as the root cause analysis model ^{Footnote 37} to address underlying social determinants of stigma.

Access to suitable healthcare services: Access-related barriers were also prominent, including service limitations, lack of privacy, and feelings of shame or embarrassment when interacting with healthcare workers. Restricted service hours, particularly in rural and remote settings ^{Footnote 38}, along with perceived discriminatory attitudes among staff ^{Footnote 28}, discouraged health care engagement and contributed to delayed or forgone care ^{Footnote 39}. The physical design of facilities also influenced testing behavior. For instance, shared waiting rooms for men and women deterred Indigenous men from seeking STI testing due to fears of being perceived by their female counterparts as weak or unwell ^{Footnote 25}. Shame and embarrassment were linked to previous negative healthcare experiences ^{Footnote 22}, difficulty communicating symptoms ^{Footnote 27}, lengthy pretest assessments ^{Footnote 22}, and close community ties between patients and Indigenous healthcare workers ^{Footnote 24Footnote 25}.

The findings have important clinical implications as stigma and lack of education can lead to delayed diagnosis and treatment of STIs, impacting individual health outcomes. Addressing these barriers is crucial to prevent severe health consequences and improve overall community health. From a public health perspective, low STI testing rates in Indigenous populations can contribute to the spread of STIs and outbreaks in communities. Though less frequently reported, factors such as lack of motivation ^{Footnote 22}, denial and symptom neglect ^{Footnote 21Footnote 27} also affected testing behaviors.

Facilitators

The most frequently identified facilitator was cultural sensitivity and culturally appropriate care, consistent with previous studies ^{Footnote 20Footnote 25Footnote 32Footnote 33} and aligned with national reconciliation efforts ^{Footnote 40}. Key strategies to promote cultural safety include training healthcare providers in Indigenous teachings and spirituality ^{Footnote 22}, ensuring gender-aligned care ^{Footnote 20Footnote 25Footnote 26}, and providing separate waiting areas for men and women ^{Footnote 25}.

Enhance sexual health education was also critical. Recommended approaches included peer-based and community education programs ^{Footnote 26}, intergenerational education integrating Indigenous wellbeing models ^{Footnote 24Footnote 29}, and outreach through kinship and social networks ^{Footnote 22Footnote 27Footnote 29}, emphasizing the importance of tailoring strategies to local contexts ^{Footnote 29}.

Improving access to suitable healthcare services was another major facilitator. This involved employing skilled healthcare providers and Indigenous health workers ^{Footnote 19Footnote 21Footnote 29}. This is corroborated by a study that concluded that Indigenous health workers were found to be impactful in facilitating culturally appropriate care for cardiac inpatient ^{Footnote 41}. Conversely, this review also showed that respondents from remote communities perceived STI testing with an Indigenous health worker as a barrier due to lack of anonymity ^{Footnote 23Footnote 25Footnote 32}. Other factors under this theme include integrating STI testing into community health checks ^{Footnote 21Footnote 26Footnote 29Footnote 32} and Indigenous wellness programs ^{Footnote 20Footnote 22Footnote 24Footnote 29}, and normalizing testing as part of Indigenous holistic wellness ^{Footnote 29Footnote 42}.

Other supportive measures include providing free or flexible testing options (online, home or pharmacy), free transport, discreet packaging for self-test kits, and electronic recall systems ^{Footnote 20Footnote 29Footnote 32}. Although less frequently mentioned, these strategies may hold greater importance in specific community contexts.

Tailored interventions, such as culturally sensitive care and increased access to healthcare services, can help improve STI testing uptake and reduce the burden of STIs in Indigenous communities.

Strengths

This scoping review systematically maps barriers and facilitators to STI testing among Indigenous populations in high-income countries. Its rigorous approach facilitates transparent study selection and data extraction and analysis. Including qualitative and mixed-methods studies provided rich insights into cultural, structural and educational influences on STI testing.

Limitations

This scoping review included primarily qualitative studies across diverse Indigenous populations, limiting generalizability. Restriction to English-language publications and variability in study designs hindered direct comparisons. Intervention effectiveness was not assessed, and potential selection bias exists as only a single reviewer conducted the search and analysis of this review.

Applications and future directions

This scoping review may be useful to governments, public health organizations, and other relevant stakeholders working with Indigenous populations for decision-making, planning or to further guide and contribute to the development of focused survey for similar research in Indigenous communities of interest. Further primary research or a systematic review could deepen our understanding of this topic.

Conclusion and recommendations

This review underscores the critical need to address cultural barriers and improve access to culturally appropriate healthcare services to enhance STI testing among Indigenous populations. Promoting cultural safety, respecting Indigenous values in care delivery, and offering comprehensive sexual health education are essential to reducing stigma and encouraging timely testing.

Based on the evidence reviewed, STI testing programs should focus on building cultural competence among healthcare providers, offering gender-aligned care, and linking testing to community-based health activities. Working directly with communities and completing situational assessments can help ensure that interventions are relevant and effective. Improving access, such as through free transportation, discreet self-testing options, and better use of electronic health records, may also support higher testing uptake. Together, these approaches can help reduce barriers and promote more equitable STI testing for Indigenous populations.

Authors' statement

BO — Conceptualization, methodology, formal analysis, writing–original draft, visualization
CS — Conceptualization, supervision, writing–review & editing
AC — Methodology, validation, writing–review & editing

Competing interests

None.

ORCID numbers

Amanda Caputo — 0000-0002-5117-1411

Acknowledgements

The authors gratefully acknowledge the supports provided from NOSM University library team.

Funding

This work was not funded.

Appendix

Supplemental material is available online: https://osf.io/7e4px

List S1: Database search strategies

Table S1: Data extraction table for barriers and facilitators of sexually transmitted infections testing in Indigenous populations (data extracted from 13 relevant studies)

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