BARRIERS TO SEXUALLY TRANSMITTED INFECTIONS TESTING IN YOUNG
MEN WHO HAVE SEX WITH MEN: AN INTEGRATIVE REVIEW

by

Allyssa Sy

University of Northern British Columbia, 2011

PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF
THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SCIENCE IN NURSING
FAMILY NURSE PRACTITIONER

UNIVERSITY OF NORTHERN BRITISH COLUMBIA

August 2020

© Allyssa Sy, 2020

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Abstract
Sexually transmitted infections (STIs) are an increasing public health problem that affects all

populations regardless of race or gender. Despite general increased prevalence, specifically
young men who have sex with men (YMSM), between the ages of 15-26, are a high risk group
accounting for 53% of all new cases. National and provincial guidelines recommend increased
STI testing in YMSM in comparison to their female and non-MSM counterparts to reduce

overall STI rates and prevent potential negative health outcomes. Although these guidelines
exist, testing in this population remains low. This integrative literature review explores the

barriers experienced by YMSM when accessing STI testing and informs strategies whereby
Nurse Practitioners could optimize sexual health care in this population. A systematic search of
the literature identified 11 key articles. These were analyzed using the Critical Appraisal Skills

Programme tools, the Mixed Methods Appraisal Tool, and Scale for the Assessment of Narrative
Review Articles. Three key themes emerged from the literature and are explored in detail:

personal barriers, system-level barriers, and healthcare provider barriers. Recommendations
based on the above themes with respect to facilitating sexual health education in YMSM and

related practice improvement in NPs are identified. Normalization of sexual health through a life
course approach and areas for further research are also highlighted.

Keywords: young men who have sex with men, sexually transmitted infections, sexually
transmitted disease, barriers, healthcare provider, primary care provider, nurse practitioner,

integrative review.

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TABLE OF CONTENTS

Abstract

11

Table of Contents

iii

List of Tables

v

List of Figures

vi

Acknowledgements

vn

Chapter 1

Introduction

1

Chapter 2

Background
Prevalence of Sexually Transmitted Infections
Young Men who have Sex with Men at Risk
Neurocognitive Development
Risk Taking Behaviours
Learning
Disclosure of Sexual Orientation
Stigma and Discrimination
Sexual Health Literacy
Delivery of Sexual Health Information
Role of Nurse Practitioners in Sexual Health

4
4
6
7
8
8
9
10
11
12
13

Chapter 3

Methods
Search Strategy
Preliminary Search
Inclusion and Exclusion Criteria
Search Results and Data Evaluation
Data Analysis

16
16
16
18
19
22

Chapter 4

Findings
Personal Barriers
Limited Knowledge of Sexually Transmitted Infections
Lack of Perceived Vulnerability
Fears Related to Testing
System Level Barriers
Testing Site Identifiability and Accessibility
Confidentiality and Anonymity
Health Provider Related Barriers
Negative Judgement and Attitudes

24
26
26
29
31
32
32
34
36
36

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Chapter 5

Discussion and Recommendations
Impact of Knowledge on Fears
Sexually Transmitted Infections Testing Sites
Concerns over Disclosure of Sexual Orientation
Anticipated Stigma from Healthcare Providers
Recommendations for Nurse Practitioners
Increase Provider Confidence in Sexual Health Discussions
Continuing Professional Development
Collaboration
Youth Friendly Sexual Health Services
Promote Confidentiality
Build Trusting Relationships
Normalize Sex

39
39
42
43
44
46
47
48
48
49
50

Limitations

56

Recommendations for Future Research

58

52
52

Conclusion

60

References

61

Appendix A

Evaluation of Checklists and Scales

70

Appendix B

Literature Matrix

74

V

List of Tables
Table 1

Search Terms and MeSH Headings

17

Table 2

Inclusion and Exclusion Criteria

19

Table 3

Recommendations for Nurse Practitioners

54

vi
List of Figures

Figure 1

Prisma Diagram Outlining the Search Strategy

21

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Acknowledgements
I would like to first thank my supervisory committee, Dr Caroline Sanders and Rosemary

Graham, for your contributions to this project. Your support and feedback enhanced my critical
thinking in order to make this project a success.

Thank you to Nathaniel Roxas, for your love, support, and advice as I wrote this paper.
Your endless encouragement means the world me to me and I still hear your voice telling me
‘keep going, you can do it, love is life’ during hard times. The joy you instill in me resonates

and I laugh every time. Thank you to my gracious friends who supported me along the way
through messages, voice notes, and memes that generated so many smiles.
Finally, and most importantly, thank you to the young men who participated in these
studies so that individuals like myself can learn, grow, and be humble. Your resilience and

bravery are inspirational.

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Chapter 1 : Introduction
Sexually transmitted infections (STIs) are an increasing public health concern in Canada.
According to the Public Health Agency of Canada (PHAC, 2017), rates of STIs such as

gonorrhea, chlamydia, and syphilis have significantly increased by 1.5 times since 2014.
Although STIs are prevalent in all populations, young men who have sex with men ( YMSM)
between the ages of 15-26 years of age have been identified as having a disproportionate burden

of STIs, accounting for 53% of all new cases ( Centers for Disease Control and Prevention

[CDC], 2018; PHAC, 2017 ). Increased risk of STIs in YMSM aged 15-26 is a result of a variety
of factors. This age group represents a time of transition, exploration, and maturity consequently
influencing the decision-making surrounding sexual behaviours and completion of STI testing

(Chokprajakchad et al., 2018; Fisher et al., 2018; Kotchick et al., 2001; Phillips et al., 2015;

Shannon & Klausner, 2018 ). Moreover, feelings of personal resiliency and invincibility in this
age group reduce personal perception of STI risk (Chokprajakchad et al., 2018; Shannon &

Klausner, 2018). In addition to these factors, lived negative experiences with the healthcare
system contribute to increased STI risk. Young MSM have often experienced discrimination,

stigma, and negative judgement linked to their sexual orientation and sexual habits fostering
mistrust in others, including health care providers (HCP; Fisher et al., 2018). These

vulnerabilities further perpetuate challenges of navigating a complex healthcare system to seek
sexual health related care because of previous mistreatment and discrimination within the
healthcare system.

Due to the aforementioned risk factors, YMSM represent a population that demonstrate

significant benefit from accessing STI testing. In efforts to reduce STI rates in YMSM, early
screening and testing guidelines, recommendations, and national programs emphasize increased

2
testing frequency with the goal of early identification and treatment (CDC, 2015; PHAC , 2020;
World Health Organization [WHO], 2020). For example, all men who have sex with men

engaging in unprotected sex are recommended to complete STI testing every three to six months,

in comparison to the annual testing frequency in their non-MSM counterparts (CDC, 2015 ).

Despite the importance of STI testing, rates remain low in YMSM which impacts the overall
physical and psychosocial health and well-being of this population ( e.g. sepsis, infertility,
rejection, and isolation). Literature indicates lower testing rates are related to various elements,

including stigma associated with infections (Barbee et al., 2015; Carter et al., 2010;
Chokprajakchad et al., 2018; Delany-Moretlwe et al., 2015; Fisher et al., 2018; Shannon &
Klausner, 2018), lack of HCP knowledge (Adam et al., 2011; Cordova et al., 2018; Dorsen &
Devanter, 2016; Fisher et al., 2018; Kitts, 2010), and individual unwillingness to test. While the

literature has captured various reasons highlighting lack of testing in YMSM, barriers continue to
exist that prevent this population from accessing STI testing as evidenced by a plateau of low
testing rates (Barbee et al., 2015; CDC , 2018). Due to their disproportional representation,
YMSM have been chosen as the topic of this project .

In order to foster positive health outcomes in YMSM, identification of barriers that
prevent STI testing in this population is critical. Therefore, a review of the literature was
conducted guided by the research question: “What are the barriers experienced by young men

who have sex with men when accessing sexually transmitted infections testing?” The purpose of
this paper is to inform primary care practice by exploring the barriers experienced by YMSM

aged 15-26 accessing STI testing. By identifying factors hindering testing experienced by
YMSM, quality improvement changes can be implemented in order to create an inclusive

environment to increase uptake of STI testing. For the purpose of this literature review, YMSM

3
are defined as young men who engage in sexual activity with other males and men who also self-

identify as gay, homosexual, or bisexual.

The barriers revealed in this paper will also inform how Nurse Practitioners (NPs) can
facilitate and improve YMSMs’ testing experience. As primary care providers frequently in
contact with vulnerable populations such as YMSM, NPs are in an ideal position to help address

the low testing rates in STIs and assist in early detection of infection, thus, preventing
transmission and complications in those who are affected. Nurse Practitioners are health

professionals trained at the graduate level to provide primary care services to all populations and
are guided by professional standards to promote provision of safe care (BCCNP, 2020). Nurse

Practitioners also play a large role in providing evidence-based information to their patients in
order to foster positive health outcomes (BCCNP, 2020). Lastly, NPs are key stakeholders in
reducing STI related stigma as a means to promote trustworthy healthcare environments and
advocate for vulnerable populations.

To answer the research question, an integrative review of the literature was performed.
The following section will address the background of the components of the research question.

This will be followed by the search strategy for this integrative review and presentation of the
key findings. Finally, a discussion of the themes with recommendations and potential strategies
for NPs to optimize STI testing in YMSM will be presented.

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Chapter 2: Background

According to the World Health Organization (2020), over one million STIs are acquired
daily with an increasing prevalence across the globe. Between 2005 and 2007, rates of STIs
have increased from 4.1% to 11.5% annually in individuals aged 15-26 (WHO, 2020). Young
men who have sex with men account for 53% of new STI cases compared to their non-MSM

counterparts (WHO, 2020 ). Sexually transmitted infections are largely preventable through
screening, diagnosis, treatment and management (CDC, 2015; PHAC, 2020; WHO, 2020).

Assessing for STI risk factors, such as number of partners and sexual practices, is considered an

essential component in improving the overall sexual health in YMSM. Facilitation of testing is
among one of the first steps NPs can take towards decreasing the disproportionate burden of
STIs in YMSM.

In this chapter, an overview of STIs in YMSM will be presented focusing on the
prevalence and the impacts of infections as a growing health burden. Following this, exploration
of risk factors in YMSM will be discussed. Next , disclosure of sexual orientation and the

impacts on YMSMs’ overall health will be explored. A brief overview highlighting the
significance of stigma and discrimination will be presented. The influence of sexual health
literacy in YMSM and its impacts on STI risk will then be discussed. Finally, discussion
surrounding the role of the NP in facilitating sexual health services to YMSM will also be

provided.
Prevalence of Sexually Transmitted Infections

Broadly defined as pathogens, including bacteria , viruses, and parasites that are known to
be transmitted via sexual contact , STIs are an increasing global public health concern imposing
major health and economic burdens (WHO, 2020 ). Sexually transmitted infections affect all

5

populations and can potentially lead to unfavorable long-term individual psychosocial and
physical health outcomes when left untreated (CDC, 2015). While many STIs are considered

curable (syphilis, gonorrhea, and chlamydia), with minimal long term sequalae, others such as
hepatitis, herpes simplex virus, human papilloma virus, and HIV are not curable and are
managed through modified treatments (WHO, 2020).

The incidence of STIs in YMSM including syphilis, gonorrhea, and HIV, is significantly

higher compared to men who have sex with women ( CDC, 2018). The higher incidence of STIs
in YMSM may be related to multiple factors, including risky sexual behaviours (e.g. condomless

insertive and receptive anal intercourse, substance use, alcohol use) and various sexual
characteristics (PHAC , 2020). For example, the increased number of sexual partners, coupled
with anonymous encounters influences YMSMs probability of exposure to STIs (CDC, 2015).

Moreover, the asymptomatic nature of STIs further contributes to the increased risk of
transmission amongst the YMSM population (CDC, 2015; PHAC , 2017; WHO, 2020).

In the United States Sexually Transmitted Diseases Surveillance Report conducted by
the CDC ( 2018), YMSM accounted for 68.2% of all reported syphilis cases in comparison to
non-MSM identifying population groups. Gonorrhea rates are steadily increasing in YMSM

from 10% in 2001 to 38.5% in 2017 (CDC, 2018). Reasons for this dramatic incidence of

gonorrhea is unclear, however; it is suggested that improved surveillance due to changes in
health seeking behaviour of YMSM is a primary reason for increasing gonorrhea rates (CDC,

2018). Similarly, in Canada, syphilis and gonorrhea rates are significantly higher in males
(PHAC , 2017 ). Males aged 20-26 account for an increase of 68% of syphilis rates since 2017
and carry majority of the burden in Canada (89% or 3,622 cases annually; PHAC, 2017 ). In

addition to syphilis, males also have the highest rates of gonorrhea accounting for 65% of all

6
cases (18,734 cases) in Canada (PHAC, 2017). Unlike the United States CDC Surveillance

Reports however, the Canadian Surveillance Reports on STIs do not emphasize specific cases in
YMSM. Despite this, the incidence of STIs are significant in this demographic group and

highlight young men, and perhaps YMSM, are at an increased risk of STIs overall. Comparable
statistics are displayed in British Columbia, in which YMSM carry the highest rates of gonorrhea
( 80.8% ) and syphilis (30.7%; British Columbia Center for Disease Control [BCCDC], 2017 ).

Left untreated, STIs can cause several health related complications including urethral
strictures, epididymitis, genital malignancies, enteritis, colitis, proctitis and arthritis secondary to

gonorrhea and chlamydia (CDC, 2015). Concurrent STIs also increase the risk of HIV or

hepatitis leading to possible liver failure, malignancy, or encephalitis (BCCDC , 2017; CDC ,

2015). Although global and national initiatives are in place to decrease STIs globally, rates
continue to increase, which reflects ineffective prevention, screening, and testing strategies. This

highlights the need for improvement and expansion of STI prevention services to YMSM in

order to reduce overall STI rates.

Young Men who have Sex with Men at Risk
As mentioned previously, increasing rates of STIs in YMSM propelled creation of

national guidelines to effectively screen, treat , and manage infections in this population.

Evidently, annual testing rates for rectal and urethral STIs in YMSM decreased from 13.78% to
8.5% in the last few years (Feinstein et ah , 2018). Understanding this decline in testing rates is

complex yet it highlights that understanding the various factors which continue to contribute to
STI transmission among YMSM is an ongoing concern.
A plethora of variables contribute to the increased risk of STIs and declining testing rates

in YMSM. For example, biological factors (neurocognitive development, decreased risk

7

perception, beliefs of invincibility ) and certain sexual characteristics (concurrency and
anonymity of sexual partners, substance use, unprotected receptive and insertive anal sex)

contribute to STIs in this population (Kotchik et al., 2004). Stigma and discrimination towards
MSM in general in both social and healthcare settings contribute to the declining rates of STI

testing. As a result, YMSM fear how family members and HCPs will perceive their sexual

choices and sexual orientation (Chokprajakchad et al., 2018; Coker et al., 2010; Cordova et al.,

2018; Everett et al . , 2014; Kotchick et al., 2001; Shannon & Klausner, 2018; Vasilenko et al.,
2018). These worries ultimately prevent or delay YMSM from engaging in sexual health
services, potentially fostering overall decline in health status. Complexities in sexual health
literacy— the capacity and skills to understand sexual health information to access related
services —also contribute to risks of infection in YMSM (Easton et al., 2010). Limited sexual

health literacy has been determined to delay or prevent engagement in sexual health services
because of both functional literacy impairments and social determinants that influence sexual

health seeking.
Neurocognitive Development

In order to understand reasons behind sexually risky behaviours in YMSM, it is crucial to
understand the neurodevelopmental processes that influence decision making. Neurocognitive

development of younger individuals, has been identified as a significant cause of sexual
behaviour due to the continuing development and maturation of their cognitive decision making

(Kotchick et al., 2001; Spear, 2013). Young MSM are not beyond exception, in which
hormonal, physical, and neurological changes are closely related to risk taking behaviours,

cognitive learning, and emotion (Kotchick et al., 2001; Spear, 2013). As young people progress

towards adulthood, self -regulatory processes in their prefrontal cortexes continue to develop

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leading to fluctuations in inhibitory control (Spear, 2013). In addition to the effects of the

developing brain on risk taking and learning, development of sexual orientation is also impacted
through neurocognitive means. According to Bosse and Chiodo (2016), development of sexual

orientation is a fluid process that consists of exploration, episodes of curiosity, and uncertainty

before final development. The emphasis on a fluid and dynamic intellectual and emotional
process towards sexual orientation is important, as it highlights heightened experimentation for
young MSM during an important period of their lives (Bosse & Chido, 2016).

Risk Taking Behaviours
Considering the continued maturation of the pre-frontal cortex during the pubertal years,
increased vulnerability and decisions to engage in risky behaviours are often driven by

impulsiveness and the need for reward (Spear, 2013). Sexual sensation seeking, or the need to
engage in varying sexual stimulation, is also driven by the neurocognitive changes in YMSM
(Kotchick, et ah , 2001; Spear, 2013). An immature prefrontal cortex reduces inhibitions causing

unsafe behaviours, such as condomless sex, despite the potential understanding of associated

dangers. While experimentation and exploration are part of normal growth and development,
these cognitive changes place YMSM at greater vulnerability of STIs.

Learning

In addition to the neurocognitive development of the brain impacting risk taking
behaviours in YMSM, developing brains are also responsible for the uptake and retention of
information. Not surprisingly, sexual health literacy, which includes the skills to understand and

determine health decision making is predictably influenced by developing brains. Primarily
contributed to the immaturity of the frontal lobe, brain functions in YMSM largely rely on other

processes to assist with learning and knowledge retention ( Spear, 2013 ) . The frontal lobe is

9
responsible for processing higher functionality including reasoning, problem solving, memory,
planning and executive functions (Spear, 2013). Until full maturation of the frontal lobe
(approximately at age 25) alternative brain functions including the prefrontal cortex, supports
decision making in young people (Spear, 2013). Due to the involvement of additional parts of
the brain to assist with learning, young individuals in general lack impulse control, demonstrate
more erratic and risky behaviours, and often control decision making through emotions rather

than logical processes (Spear, 2013). These factors strongly affect the ability for YMSM to learn
and absorb information which limits their sexual health literacy and health decision making.

Disclosure of Sexual Orientation

In order to reduce STIs in YMSM, tailored sexual health recommendations for YMSM
include a myriad of services to prevent additional sexual health outcomes such as concurrent

HIV or hepatitis infection (CDC, 2015; PHAC, 2020 ). In order to receive the full panel of
recommended sexual health related services specific to this population (e.g. more frequent
testing, publicly funded vaccinations) , disclosure of sexual orientation to HCPs is critical .
Disclosure of sexual orientation is associated with improved overall health outcomes, including

sexual health (Bosse & Chiodo, 2016; Singh et al., 2018 ). Aside from health improvement,
disclosure of sexual orientation in the healthcare setting facilitates a more complete panel of STI
services, provides a better picture of individual health risks, and prompts timely and efficient

referrals if necessary (Singh et ah , 2018). More importantly, non-disclosure results in missed

opportunities to provide holistic and comprehensive care in YMSM, which ultimately fosters
poorer health outcomes (Bosse & Chido, 2016; Durso & Meyer, 2013; Singh et ah , 2018).
The factors associated with disclosure of sexual orientation, however; are complex in
YMSM. According to Harper et ah , ( 2016), YMSM considering disclosing their sexual

10

orientation will only do so within societal systems that they consider to be safe and inclusive.
These may include family, friend groups, school settings, or health care environments where

safety and acceptance are expected (Harper et ah , 2016). In actuality, disclosure of sexual
orientation frequently results in violence, micro-aggressions, and exclusion of YMSM (Harper et

ah , 2016 ). These negative consequences more commonly prevent disclosure over fears of
expulsion and rejection (Harper et al., 2016; Singh et ah , 2018). Additional factors including

internalized homophobia, fears of being mistreated, or beliefs that sexual orientation are not
important to health are also prominent predictors of non-disclosure in YMSM (Durso & Meyer,

2013).
As a young, vulnerable population group, access to sexual health care services is critical
to maintaining overall health and well-being. Driven by multiple factors, however; disclosure of

sexual orientation remains low (Durso & Meyer, 2013; Singh et al., 2018 ). Creating
environments where YMSM feel comfortable in disclosing their sexual orientation may assist in

improvement of sexual health outcomes and reduction of STIs.
Stigma and Discrimination

Stigma related to STIs is particularly detrimental to YMSM due to the associated
negative physical and mental associated outcomes. Stigma is a complex social phenomenon in

which individuals are devalued and discredited because of certain qualities or traits (Goffman,

1963; Maclean, 2018). According to Ford et al., (2013), historical efforts to reduce rates of STIs
emphasized risky sexual behaviours are detrimental to families, relationships, and communities,
thereby, perpetuating negative beliefs associated with sex and homosexuality in society today.

Sexually transmitted infections were portrayed as consequences of immoral behaviour, such as

11

promiscuity and prostitution, which led to delays in sexual health care seeking, STI testing, and

prevention (Ford et al., 2013; MacLean, 2018).

The poor provision of sexual health care related services has been evidenced to be a
consequence of stigma and is a significant barrier to seeking health care in non-heterosexual

populations (Maclean, 2018; Puckett et al., 2017). Gay men were viewed as sexually
promiscuous and transmitters of STIs and HIV which encouraged negative beliefs towards this

population group (Brown et al., 2017; Chokprajakchad et al., 2018; Everett et al., 2014; Kitts,
2010; Kotchick et al., 2001). Both STI and homosexual related stigma created challenging social
conditions for YMSM, such as discrimination, isolation, and rejection from others, and thus,
prevented YMSM from accessing healthcare services and disclosing sexual orientation (Durso &
Meyer, 2013; Singh et al., 2018; Maclean, 2018; Puckett et al., 2017). These adverse health

consequences not only physically impact YMSM (e.g. STIs, HIV, hepatitis), but also place them
at risk of increased depression and suicide, substance use, and lower social supports (Puckett et

al., 2017 ). In addition to the neurodevelopmental complexities experienced by YMSM, stigma
related to sexual activity and sexual orientation causes further difficulty in navigation of sexual

related services.

Sexual Health Literacy
Health literacy extends beyond the cognitive ability of an individual and is shaped by
changing individual, social, and structural elements which influence health seeking behaviours.
Sexual health literacy (SHL) is defined as the cognitive skills and social factors which influence

individual ability to access and understand information which promote and maintain sexual
health ( Easton et al., 2010). Lower SHL not only impacts the knowledge required to access

sexual health services but plays a role in negative health related sequalae. As evidenced by the

12
literature, limited SHL is associated with poorer health outcomes and inadequate management of
STIs (Ontario HIV Treatment Network, 2015). Alongside additional social vulnerabilities

experienced by YMSM (e.g. age, stigma, poor access to health services) , SHL greatly impacts
the ability for YMSM to access, interpret, and act on the abundance of information presented

regarding STIs and sexual health.
Delivery of Sexual Health Information
Sexual health literacy encompasses more than individual ability to understand and

process information; facilitating this information is the shared responsibility of information

providers. The effectiveness of how STI prevention is communicated by information providers
significantly influences decision making in YMSM (Easton et al., 2010). Public health

messaging used to educate and inform YMSM about sexual health continues to be a challenge

and impacts SHL in YMSM. For example, presentation of the rapidly changing scientific
evidence in sexual health makes it difficult for producers of public health messaging to maintain
relevance. These continuously evolving messages makes it challenging to interpret in YMSM
communities as it becomes unclear what resources are accurate and reliable (Fleary et al., 2018).

Changing sexual health related material ultimately can overwhelm these young men which
further prevents them from accessing care. Moreover, presentation of medical material is often

standardized (e.g. in English, Grade 6 level reading, presented via technology) without
accounting for the different social and cultural aspects that may affect YMSMs’ health literacy.

In addition, traditional sexual health information is primarily presented through formal

educational institutions with a diverse student group (Fleary et al., 2018; Ford et al., 2013 ).
Educational guidelines focus on the provision of comprehensive sexual health care including STI

prevention information and linking youth to appropriate STI testing services ( Sex Information

13

and Education Council of Canada [SIECCAN], 2019). However, within these guidelines, little
attention is placed on health literacy and modification of sexual health delivery amongst different

population groups. Varying learning styles in the classroom leads to unequal understanding of
information consequently contributing to the limited comprehension of sexual health in YMSM
(Fleary et al., 2018; Ford et al., 2013; Kotchick et al., 2001; Pharr et al., 2016 ). Furthermore,

educational guidelines provide little information on sexual orientation which is a critical factor in
a maturing non-heterosexual male.

Additional information providers, such as HCPs are also crucial in improving and
supporting health literacy, however; various factors significantly affects the modalities sexual
health delivery is completed. Rapidly evolving evidence surrounding sexual health further leads
to dissemination of differing health messages creating inconsistencies which can be challenging

for YMSM to comprehend (Dorsen & Devanter, 2016; Ford et al., 2013). Furthermore, time
constraints in a clinic setting may make it difficult for HCPs to comprehensively assess STI risk

and establish rapport with YMSM. For example, limited time during clinical visits prevents the
opportunity for YMSM to ask questions. In addition, conversations regarding the ability for
YMSM to access resources within their communities and homes are often missed in these visits,

which is a critical factor in the comprehensive understanding of sexual health in YMSM.

Role of Nurse Practitioners in Sexual Health
Nurse Practitioners play a critical role in the reduction of STIs in YMSM in the primary
care setting. Primary care is an important concept within the public health care system and is

significant for disease prevention and health promotion (Government of Canada, 2018 ). Primary
care encompasses a variety of services that can be accessed directly by patients who are seeking

healthcare needs, including STI testing ( Government of Canada, 2018 ). Nurse Practitioners, who

14
are often situated in primary care settings, provide several aspects of primary care including

health promotion and preventative health care services (BCCNP, 2020). As health professionals
who undergo advanced training to be competent in broader medical skill sets, NPs have a larger
scope of practice which make them well-situated to care for the sexual health needs of YMSM.

More specifically, the NP scope includes provision of various healthcare services such as the
administration and ordering of screening and diagnostics tests, prescribing medications, and

referral to specialists for further care if needed (BCCNP, 2020). It is important to note that
Registered Nurses in British Columbia who have completed a STI management certification
program approved by the Nurses and Nurse Practitioners of British Columbia (NNPBC) are also

capable of assessing, diagnosing, and treating STIs ( NNPBC , 2020). In comparison to NPs,
however, Registered Nurses are limited in scope as primary care providers and cannot prescribe

beyond curable STIs, such as chlamydia and gonorrhea, without the direction of a physician or
NP ( NNPBC, 2020). For these reasons, NPs are better positioned to care for YMSM with STIs

and overall primary care needs.

In addition to providing sexual health and primary care needs to YMSM, NPs also play a
larger role in the creation of inclusive environments to foster better health outcomes in this

population through reduction of STI related stigma. Nurse Practitioners not only need to be

alerted to how personal conduct can be stigmatizing to YMSM, but use individual capacities to
guard against, and counteract stigma through normalization of sex in the clinical environment.

By providing safe, trusting care towards YMSM, not only can NPs work towards uptake of STI
services and decrease the burden of STIs, they can also advocate for the health of YMSM and
normalize sex without judgement. Nurse Practitioners have the scope of practice, competency,

skills, and the opportunities to be part of system-level changes to better the overall health of

15
YMSM. By answering the question “what are the barriers experienced by young men who have

sex with men when accessing sexually transmitted infections testing?” can NPs act towards
reducing the vulnerabilities and disparities experienced by this population group.

In the context of this review, HCPs will refer to all providers in primary care including
NPs. The follow section will discuss the search methods that were undertaken to select the most
relevant literature in order to answer the research question.

16

Chapter 3: Methods
In order to answer the question “what are the barriers experienced by young men who

have sex with men when accessing sexually transmitted infections testing?, ” an integrative
literature review was conducted. The integrative literature review encompasses the inclusion of

diverse research methodologies which allows for a comprehensive analysis of a healthcare
phenomenon (Whittenmore & Knafl, 2005). Following the integrative review approach outlined
by Whittenmore and Knafl ( 2005), an extensive search of the literature was performed. In this

chapter, the search strategies, inclusion and exclusion criteria, preliminary search, evaluation of
the studies, and data analysis strategies will be discussed.

Search Strategy
In order to ensure the literature was the most relevant to the research question, multiple

eligibility requirements, including inclusion and exclusion criteria were utilized. All types of
studies (e.g. focus groups, cross-sectional studies, qualitative studies, quantitative studies) were

included in the search as long as the studies maintained relevance to the research question and
were evidence-based, peer-reviewed articles. Various electronic databases were used to conduct

the literature search including Cumulative Index to Nursing and Allied Health Literature
(CINAHL ), MEDLINE, PsychINFO, and Google Scholar. These databases were chosen for

their relevant and current literature pertaining to the fields of primary care, medicine, and
psychology (Bordens & Abbott, 2018). Google Scholar was also used to ensure no pertinent
articles to the research question were neglected.
Preliminary Search

For the preliminary search, the network method was used to identify applicable keywords
to guide the literature search. The network method is the use of the reference list in a relevant

17
paper to establish and trace other relevant articles pertaining to a specific topic (Timmins &
McCabe, 2005). The initial paper used in the network method to guide the literature search was

the article “Barriers to bacterial STI testing of HIV-infected men who have sex with men

engaged in HIV primary care” by Barbee et al., (2015). This article was used to gather keywords
to guide the preliminary search. The keywords used in the preliminary search included ‘STI

testing,’ ‘barriers to STI testing,’ ‘gonorrhea,’ ‘ chlamydia,’ and ‘HIV care.’

The aforementioned keywords were used as MeSH headings to complete an initial search
of the literature in the databases . Due to the vast quantity of articles (23,412 publications),

additional MeSH headings were added to narrow down articles relevant to the research question.
The use of Boolean operators such as AND, OR, and NOT were used in the literature search
when appropriate. For example, men who have sex with men OR MSM OR YMSM were used
to include the common abbreviation for MSM in literature. Table 1 provides the MeSH terms

used for this literature search.

Table 1

Search Terms and MeSH Headings
Search Terms and MeSH Headings

Young OR youth OR adolescent OR teen* OR young adult AND men who have sex with men
OR MSM
Sexually transmitted infections* OR sexually transmitted disease* OR STI* OR gonorrhea OR
chlamydia OR HIV AND testing OR screening
barriers OR testing OR barriers OR barriers to testing OR barriers AND facilitators
Primary care OR healthcare* OR provider* OR healthcare provider*

18
Inclusion and Exclusion Criteria

The next step towards the search strategy was narrowing the number of articles to be

reviewed based on a set of inclusion and exclusion criteria. The focus of the research question
was inclusive to YMSM between the ages of 15-26 years old accessing STI testing. Young

MSM who accessed HIV testing was also included in the search as HIV is categorized as a STI

and to ensure inclusion of robust literature relevant to the research question (CDC, 2018 ).

Inclusion criteria also included explicit experiences of STI testing from the perspectives of
YMSM and not HCPs as HCP perspectives of barriers may be vastly different . Studies which

included perspective of both YMSM and HCPs were included. All study methodologies (e.g.
qualitative studies, quantitative studies) were included if they were relevant to the research
question. Searches were limited to peer-reviewed studies between 2009 and 2020, however;
older articles were included if they provided additional pertinent findings to the research

question. Non-English literature was excluded because no reliable translation services were
readily available . Articles that included female participants were also included if a significant

portion of the data included YMSM. Articles that discussed facilitators to STI testing
exclusively was excluded, however; articles that included both barriers and facilitators to STI
testing were included. Studies conducted outside of Canada and United States were considered
if the study was conducted in a countiy having similar healthcare systems to Canada (e.g.

provision of healthcare, access to services, costs) to ensure relevancy. Table 2 provides a
summary of the inclusion and exclusion criteria used to guide the literature search.

19

Table 2
Inclusion and Exclusion Criteria

Inclusion Criteria

Exclusion Criteria

Young, adolescent, and youth populations

Adult populations

Identify as male who has sex with men, gay,
bisexual, or homosexual

Participants do not identify as men who have
sex with men

Between 15-26 years of age

<15 years of age and >26 years of age

Perspectives from young men who have sex
with men

Perspectives outside of young men who have
sex with men ie ) healthcare providers

STI or HIV testing services

Not accessing STI testing or HIV services

Focuses on barriers to STI testing services

Studies exclusively focused on facilitators

Inclusive of all peer-reviewed study
methodologies

Non-peer reviewed literature, grey literature,
discussion posts, editorials, newspaper or
magazine publications, opinion pieces

Publications in English

Publications in any language aside from
English

Relevant title and abstract

Irrelevant titles and abstracts

Publications conducted in North America,
Western Europe, Australia , New Zealand

Studies conducted outside of identified
countries

Search Results and Data Evaluation
After using MeSH terms to conduct the literature search and the application of the
inclusion and exclusion criteria , PsychINFO generated 348 articles, MedLine generated 164

articles, and CINAHL generated 158 articles. Literature was selected using a strict process that
included assessment of all articles for relevancy to the research question and appropriateness to

clinical practice. Initial review of all articles was completed by assessing the titles of each article

20
to ensure that the article was relevant to the research question. Articles that included a

combination of terms such as barriers, men who have sex with men, young men who have sex

with men, facilitators and barriers, healthcare attitudes, or experiences were selected for review
for relevancy to the research topic. This yielded a total of 47 articles from CINAHL, 23 articles
from MEDLINE , and 12 articles from PubMed. The abstracts from this list of articles were
reviewed for appropriateness to the research topic and were removed if inapplicable. After in-

depth review of the abstracts, twenty articles were collected for critical appraisal. Figure 1
outlines the full search strategy from the four databases, including the total number of results

obtained.
Critical appraisal of research is a systematic process involving careful examination of the

literature to assess strengths and limitations, bias, reliability and relevancy to practice (Gray,
Groves, & Sutherland, 2017 ). Twenty remaining articles were evaluated using various tools in

accordance to the research methodology. The Critical Appraisal Skills Programme (CASP)

checklists were used for qualitative studies, quantitative studies, and systematic reviews while
the Mixed Method Appraisal Tool ( MMAT) was used to evaluate mixed method studies. Lastly,
the Scale for the Assessment of Narrative Review Articles ( SANRA) was used to evaluate the
narrative review. The purpose of using the CASP, MMAT, and SANRA checklists on the

articles is to ensure that the content is relevant, evidence-based, and reliable in order to be used
as key pieces in the integrative literature review (CASP, 2019; MMAT, 2018; SANRA, 2019).

These tools are included in Appendix A. After appraisal of the final 20 articles, 11 studies were
chosen as the primary studies for analysis in this literature review. Careful cross examination
was completed on all 11 studies to ensure no duplicity of articles and that no relevant articles
were excluded.

21

Figure 1

Prisma Diagram Outlining the Search Strategy’

a
2

2
£

-

(n

CINAHL
2009- 2019
( n =158 )

MedLine
2009-2020

Psychlnfo
2009- 2020

= 348)

(n

= 164)

01

d

V

Articles screened
( n = 82)

WJ

a
Ol

Ol

£

Records excluded (abstract
relevance)
( n = 20 )

Records excluded (inclusion and
exclusion criteria )
( n = 36 )
2 r_

Full-text articles assessed for
eligibility
( n = 20 )

£
2

3
3

Studies included in
qualitative synthesis
( n = 3)
ir

d
Ol
d
3

w

Studies included in
quantitative synthesis
( n = 3)

I
Studies included in
mixed methods
synthesis
( n = 2)

Reviews (Systematic ,
Narrative)
(n = 2)

Adapted from PRISMA Flow Diagram (2015)

22

Data Analysis
According to Whittemore and Knafl (2005), data analysis is essential in the integrative
review process to summarize common themes associated with the research question to inform
conclusions and support decision making. Data analysis occurs in four stages: data reduction,

data display, data comparison, and conclusion drawing and verification (Whittemore & Knafl,

2005).
Data Reduction

Data reduction is the process of data extraction and categorization of themes, patterns,

and relationships (Whittemore & Knafl, 2005 ). This was completed by reviewing the chosen
articles for this integrative literature review and becoming familiarized with emerging patterns.

In this review, articles were organized by barriers to STIs in YMSM.

Data Display
Patterns that emerged in the reduction of data were organized and presented in a matrix to

easily identify themes and subthemes within the literature (Whittemore & Knafl, 2005). Factors
addressing barriers to STI testing in YMSM were derived from the 11 articles and displayed in
the literature matrix. Other pertinent features of the literature including methodology, study

purposes, participant demographics, and strengths/limitations were also included in the literature

matrix (Appendix B).

Data Comparison
Data within the matrix was compared and contrasted to critically examine overarching

barriers experienced by YMSM when accessing STI screening in the data comparison stage.
This stage allows for critical analysis and interpretation across the relevant studies to provide a

23

detailed account of the data while also presenting interpretation of the data.. The results of the
data analysis are presented in the Findings chapter.

Conclusion Drawing and Verification
This final stage in data analysis aims to move from data interpretation to “higher levels of

abstraction (Whittemore & Knafl, 2005, p. 551 ).” The discussion chapter of this paper presents
the process of higher level abstraction of the literature. The significant themes and contradictory

findings are explored and recommendations for both future research and NP practice will be
discussed. Strategies to reduce barriers to STI testing in YMSM will also be explored in the

discussion chapter in order to improve the healthcare needs of YMSM. The following chapter
will present the analysis of the pertinent literature.

24
Chapter 4: Findings
The purpose of this integrative literature review was to understand the barriers

experienced by YMSM when accessing STI testing by critically examining the data through the
11 studies chosen for this literature review. Data analysis was guided by the research question:

“ what are the barriers experienced by young men who have sex with men when accessing
sexually transmitted infections testing !" This chapter focuses on the overarching themes and
subthemes that emerged from the 11 studies relevant to this research question.
The 11 studies comprised of a broad range of methodologies. Three of the studies used
to gather data were characterized as qualitative studies and included the use of focus groups
(Datta et al., 2018; Pharr et ah , 2016) , and field observation accompanied by in-depth interviews

(Goldenberg et al., 2008). Four studies were characterized as quantitative studies and comprised
of surveys as a means to gather data (Adam et al., 2011; Barbee et al., 2015; Fisher et al., 2018;

Phillips et al., 2015). Two mixed methods studies (de Visser & O’Neill, 2013; Mimiaga et al.,

2007) , one systematic review (Delany-Moretlwe et al., 2015) , and one narrative review ( Yeung
et al., 2015 ) were also included to answer the research question. Cross examination of both the

systematic review and narrative review was completed to ensure no duplication of studies.

Geographical location of the studies were considered in order to ensure the findings for

this literature review were similar to the Canadian healthcare system. Five of the studies were
conducted in the United States (Barbee et al., 2015; Fisher et al., 2018; Mimiaga et al., 2007;

Pharr et al., 2016; Phillips et al., 2015), two were conducted in the United Kingdom (Datta et al.,

2018; de Visser & O’Neill, 2013), one was conducted in Canada ( Goldenberg et al., 2008 ), and
one study was conducted in Australia (Adam et al., 2011 ). The systemic review included data

25

from all these countries (Delany-Moretlwe et al., 2015) and the narrative review included studies
from Australia, New Zealand, Ireland, and the United Kingdom (Yeung et al., 2015).
Results of the literature analysis identified three overarching themes representing the
barriers experienced by YMSM when accessing STI testing. These themes included 1) personal

barriers, 2 ) system-level barriers, and 3 ) healthcare provider related barriers. These three themes
were derived from the studies’ results and will be used to organize findings in upcoming

sections. Each theme comprised of sub-themes that were interpreted from the nine primary
studies (Adam et al., 2011; Barbee et al., 2015; Datta et al., 2018; de Visser & O’Neill, 2013;

Fisher et al., 2018; Goldenberg et al., 2008; Mimiaga et al., 2007; Pharr et al., 2016; Phillips et
al., 2015 ) and two review studies’ results (Delany-Moretlwe et al., 2015; Yeung et al., 2015).
Several studies in this literature review exclusively explored barriers to HIV testing, however;

considering HIV is categorized as a STI the findings will be consolidated in this chapter (Barbee
et al., 2015; Pharr et al., 2016; Phillips et al., 2015).

Stigma was a common phenomenon throughout all of the findings and is explicitly
defined as an “attribute that is deeply discrediting” and reduces an individual “from a whole

person to a tainted, discounted one ( Goffman, 1963 , p. 3 ).” In this literature review, stigma was
a prominent factor, in which YMSM held strong fears of societal attitudes and potential

discrimination from seeking or completing STI testing. As mentioned previously, negative
associations attributed to STIs and homosexuality are key components of testing behaviour,

particularly the belief that one is undesirable and promiscuous because of their sexual activity

and orientation. In the upcoming sections, stigma will be highlighted throughout the
aforementioned themes as influential factors impacting testing in YMSM. This next section will
examine personal barriers as an influential factor to testing.

26

Personal Barriers
For the purpose of this integrative literature review, personal barriers were preconceived

perceptions, feelings, attitudes, or behaviours that influenced YMSM in accessing STI testing.
Personal barriers were dominant in 10 studies throughout the analysis and appeared to be a
significant barrier to STI testing (Adam et al., 2011; Datta et al , 2018; de Visser & O’Neill,

2013; Delany-Moretlwe et al., 2015; Fisher et al., 2018; Goldenberg et al., 2008; Mimiaga et al.,
2007; Pharr et al., 2016; Phillips et al. , 2015; Yeung et al., 2015 ) . This theme is relevant to the
research question because in order to best meet the needs for YMSM , understanding the

psychological barriers that influence test seeking decisions is critical. The following section will
focus on three sub-themes: a) limited knowledge of STIs, b) lack of perceived vulnerability, and
c) fears related to testing.

Limited Knowledge of Sexually Transmitted Infections
Limited knowledge surrounding STIs were identified in four studies as personal barriers

for YMSM (Adam et al., 2011; Goldenberg et al., 2008; Pharr et al., 2016; Yeung et al., 2015 ) .
Authors concluded little knowledge of risk factors, symptoms, testing sites, treatments, and
testing consequences were deficits experienced by YMSM consequently acting as obstacles to
STI testing (Adam et al., 2011; Goldenberg et al., 2008; Pharr et al., 2016; Yeung et al., 2015).

In a qualitative focus group study (n=25), Goldenberg et al., (2008) identified YMSM aged 15-

24 sought sexual health information through friends, family, or media sites of which reliability of
the information provided could not be determined. Authors of this study concluded inconsistent

and inaccurate STI information perpetuated poor individual STI knowledge, especially the
importance of testing, which subsequently limited STI testing attendance in YMSM (Goldenberg
et al., 2008). Similar conclusions were found in the narrative review by Yeung et al., ( 2015) in

27
which young people in general were unfamiliar with trustworthy and accurate sexual health
resources leading to their limited knowledge of STIs in general. Analysis indicated young

people were unfamiliar with what STIs were, especially chlamydia, which consequently
diminished their motivation to seek STI information ( Yeung et al., 2015). Yeung et al., (2015 )

also identified young people obtained inaccurate STI information, facilitating overall incorrect
and inconsistent messaging about testing.

Analyses from the narrative review by Yeung et al., ( 2015) aligned with the
aforementioned findings concluded by Goldenberg et al., (2008), where limited appropriate STI
information hindered access to STI testing. It is important to note in both studies the processes
used to determine the reliability and accuracy of the resources YMSM used were not discussed

(Goldenberg et al., 2008; Yeung et al., 2015). This factor solicits careful interpretation of this

finding as it is unclear in the studies if knowledge deficits in YMSM surrounding STIs were
caused exclusively by unreliable resources or additional alternative factors not explored in the

literature.

In addition, the overall invisibility of STI related resources emphasized in the study by
Goldenberg et al., (2008) may be facilitated by the remote oil and gas community the study was
conducted in. This was also identified as a study limitation where authors concluded lack of
information distribution in remote and rural communities was a common phenomenon and may
have contributed to the limited STI information in this community (Goldenberg et al., 2008).
Overall, inadequate knowledge distribution in remote locations may indicate the greater need for

sexual health information dissemination to improve the health of local communities.
Conversely, analysis from the qualitative study by Pharr et al., (2016) demonstrated
YMSM understood STI risks factors, transmission, and prevention, however; lacked awareness

28

regarding the importance of testing. As the majority of the participants in this study acquired

sexual health education in school settings, it was speculated limited testing awareness was

specifically due to the abstinence based nature of sexual health curriculums (Pharr et al., 2016).
Authors determined locally provided sexual health education curriculums in Clark County,

Nevada were not comprehensive which contributed to the lack of knowledge surrounding STI
testing in general ( Pharr et al., 2016 ). This specific finding may be limited to the educational
curriculums in Clark County, Nevada where the study was conducted. There were unclear

expectations of sexual health education by instructors in Nevada, therefore; this finding should
be interpreted with caution. In general, Pharr et al. (2016) suggested enhancing specificity in
STI education, such as when to access testing, is important in improving STI knowledge.

In contrast to previous studies, the cross sectional study by Adam et al., (2011) concluded
YMSM had a greater understanding of STI related knowledge compared to their heterosexual

counterparts. Using a quantitative survey, 1100 young people between the ages of 16-26 with
varying sexual orientations, including MSM, completed a survey consisting of STI related

questions such as knowledge of symptoms, knowledge of transmission, consequences of testing

and treatment ( Adam et al., 2011). Analyses highlighted YMSM specifically had greater
understanding of STI symptoms, testing consequences, and STI treatment (Adam et al., 2011).

Therefore, authors inferred the higher degree of STI knowledge in YMSM indicated a weak
connection between STI knowledge and STI testing (Adam et al., 2011). Young MSM having
greater STI knowledge contradicted the previous conclusions evidenced by Goldenberg et al.,

(2008), Pharr et al., (2016), and Yeung et al., (2015 ) in which limited STI resources determined
STI knowledge in YMSM. Cautious interpretation of the findings by Adam et al. should be

conducted as studies failed to identify reasons for differences in uptake of STI knowledge

29
between heterosexual and non-heterosexual populations. This suggests there are additional

factors that influence STI knowledge in YMSM that have yet to be explored in the literature.

Although there were inconsistencies in the findings pertaining to limited knowledge
surrounding STIs, it is apparent YMSM require reliable and evidence based sexual health
information to facilitate STI testing. These findings highlight the need for review of current STI
related resources YMSM are currently using to ensure reliability and accuracy of the material.

Lack of Perceived Vulnerability
For the purpose of this literature review, perceived vulnerability reflects the personal risk
of YMSM acquiring STIs. Upon analysis of the data, six studies concluded lack of perceived
vulnerability to STI infection hindered YMSM from seeking STI testing (Adam et al., 2011; de
Visser & O’Neill, 2013; Delany-Moretlwe et al., 2015; Mimiaga et al., 2007; Pharr et al., 2016;

Phillips et al., 2015 ).
In the mixed methods study conducted by de Visser and O’Neill (2013), data analyses

emphasized young people who perceived a low likelihood of infection were less motivated to
access STI testing. A connection between monogamous relationships or belief that having one

partner resulted in lower risk sexual activity, equated protection against STIs and therefore,
determined testing was unnecessary (de Visser & O’Neill, 2013). In the systematic review by

Delany-Moretlwe et al., (2015), gaps in healthcare services for young populations including HIV
and STI testing were explored. The authors of this study concluded perceived vulnerability to
STIs was strongly influenced by limited sexual health related education (e.g. risk factors,

transmission; Delany-Moretlwe et al., 2015). These findings suggest that low perceived risk of
STI acquisition may be closely related to limited STI knowledge as mentioned in the previous

section. It is important to note that demographic profiles collected across this systematic review

30

broadly encompassed young persons of differing socioeconomic status which may have

influenced the findings. Populations of differing socioeconomic statuses may have considerably

distinct factors influencing health literacy and thus, generalizability of the findings to all YMSM
maybe be limited (Delany-Moretlwe et al., 2015).

While low perceived risk of STIs was also a significant finding in the study by Mimiaga
et al., (2007), authors also hypothesized that younger MSM (<20 years of age ) were at greater

risk of STI acquisition as they perceived themselves as having less health risks overall compared
to their older counterparts (>20 years of age ). Data collection in this study confirmed this

hypothesis, in which younger MSM (<20 years of age) believed in greater protection against
STIs and therefore, engaged in higher risk sexual activity (e.g. condomless sex, multiple sexual

partners) subsequently increasing their risk of infection.

In the study by Adam et al., (2011 ), younger MSM (<18 years of age) perceived
themselves to be at lower risk of STIs in comparison to their non-heterosexual counterparts.

This specific finding is interesting as it infers younger non-heterosexual men believe themselves
to have greater protection against STIs in comparison to their heterosexual counterparts. There

was no indication in this study as to why non-heterosexual men had perceptions of lower risk

which may highlight a knowledge gap between heterosexual and non-heterosexual males. In the

previous two studies, authors concluded younger MSM identified themselves as having greater
invincibility to STIs possibly as a result of several factors, such as their age, physical resilience,
and decreased sexual inhibitions (Adam et al., 2011; Mimiaga et al., 2007).

In summary, the six studies appear to indicate younger aged MSM believe themselves to
have decreased risk of STI infection. Moreover, it appears there is a close correlation between

31
STI knowledge and perceived risk. There is a clear need for educational sexual health material

tailored to younger MSM in order to foster knowledge and promote testing in this population.

Fears Related to Testing
A multitude of fears (fear of testing positive, fear of negative reactions from peers and

family, fear of medical procedures, and fear of negative attitudes from medical staff ) were
identified in seven studies as obstacles to STI testing in YMSM (Adam et al., 2011; Datta et al.,

2018; de Visser & O’Neill, 2013; Fisher et ah , 2018; Mimiaga et ah , 2007; Pharr et ah , 2016;
Phillips et ah , 2015 ). Throughout these seven studies, STI related stigma was an underlying

influence on the aforementioned fears experienced by YMSM prior to accessing testing and
played a significant role as a barrier to testing (Adam et ah , 2011; Datta et ah , 2018; de Visser &
O’Neill, 2013; Fisher et ah , 2018; Mimiaga et ah , 2007; Pharr et ah , 2016; Phillips et ah , 2015).

Worries over shame and embarrassment if YMSM tested positive for STIs for example, was

highlighted in de Visser and O’Neill’s (2013 ) study as a deterrent to testing.
Fears of unknown medical procedures associated with STI testing was also a common
theme that emerged in the data analysis. Assumptions that STI testing was intrusive and painful
were associated with reduced rates of STI testing in young individuals (Adam et ah , 2011).

Similar results were presented in the study by Mimiaga et ah , (2007 ), in which participants

postponed STI testing after assuming mandatory and invasive urogenital swabs were required.

In the seven studies, negative assumptions regarding testing procedures appeared to be
related to knowledge deficits in both STIs and testing consequences in YMSM. The literature

evidently highlighted negative emotions contribute to decisions to seek out STI testing.
Misguided fears stresses the need to reduce the concerns and anxieties surrounding STI testing in
YMSM to foster their confidence to access testing.

32

System Level Barriers
System level barriers are considered gaps or inadequacies in healthcare systems that

prevent accessibility for populations. System level barriers were prominent throughout all 11
studies and implies constraints which prevent STI testing in YMSM (Adam et ah , 2011; Barbee
et ah , 2015; Datta et ah , 2018; de Visser & O’Neill , 2013; Delany-Moretlwe et ah , 2015; Fisher

et ah , 2018; Goldenberg et al., 2008; Mimiaga et ah , 2007; Pharr et ah , 2016; Phillips et ah ,

2015; Yeung et al . , 2015). In the literature, these system level constraints that will be discussed
in the upcoming sections include a) testing site identifiability and accessibility and b)

confidentiality and anonymity.

Testing Site Identifiability and Accessibility
Testing site identifiability and accessibility refers to the lack of clarity surrounding

geographical testing locations and the various challenges in accessing these sites. According to
several studies, little information about STI testing site availability were detennined as barriers
to STI testing for YMSM (de Visser & O’Neill , 2013; Delany-Moretlwe et al., 2015; Goldenberg
et al., 2008; Mimiaga et al., 2007; Pharr et al., 2016; Yeung et al., 2015). More specifically ,

unclear testing site locations were identified as a deterrent to testing and ultimately decreased

young peoples’ motivation to seek and subsequently access STI testing (de Visser & O’Neill,

2013; Mimiaga et al., 2007). Additional barriers such as long distance travel to testing sites, lack
of transportation to get there, or costs associated with travel were also determined as obstacles to
STI testing (Goldenberg et al., 2008; Pharr et al., 2016; Yeung et al., 2015). It is important to

note however, that factors influencing the aforementioned obstacles to testing sites were not

addressed in majority of the studies (de Visser & O’Neill, 2013; Delany-Moretlwe et al., 2015;
Mimiaga et al., 2007; Pharr et al., 2016; Yeung et al., 2015). These pieces of information are

33

relevant as various socioeconomic factors may have contributed to YMSMs’ inability to access
STI testing sites. Conversely, in the study by Goldenberg and authors (2008), rurality played a

large role in physical distance between work sites and STI testing locations and therefore,
hindered STI testing.

Characteristics of service delivery including unknown or conflicting clinic times of
operation, such as during school or work hours, appointment booking procedures, costs of

services, or long wait times for walk in STI testing clinics, were also determined as hindrances to
STI testing for YMSM (de Visser & O’Neill, 2013; Delany-Moretlwe et al., 2015; Goldenberg et

al., 2008; Mimiaga et al., 2007; Pharr et al., 2016; Yeung et al., 2015). While these studies took
place in varying countries, STI testing services offered in Canada are generally free of cost,
therefore; it can be inferred that costs associated with testing may not be a barrier specific to the

Canadian healthcare system.
Two studies identified uncomfortable testing environments as barriers to STI testing in
YMSM (Delany-Moretlwe et al., 2015; Pharr et al . , 2016 ). Authors highlighted YMSM

demonstrated decreased willingness to test after experiencing crowded testing sites and

unfriendly mannerisms from HCPs (Delany-Moretlwe et al., 2015 ; Pharr et al., 2016). These

experiences acted as barriers to subsequent STI testing (Pharr et al., 2016). Lack of service
integration, such as the availability to discuss other health related subjects and conflicting

operational times were also considered not ‘youth friendly’ to YMSM (Delany-Moretlwe et al.,

2015). In particular, YMSM stressed feeling rushed and pressured to complete their sexual
health visit without the opportunity to discuss other health concerns (Delany-Moretlwe et al.,

2015). Moreover, Delany-Moretlwe et al., (2015 ) identified a combination of both restricted
times of operation, such as during school hours, in association with non-youth friendly

34
environments further discouraged young people from attending STI testing centres. These

findings may indicate additional considerations are required in order to assist YMSM in
accessing STI clinics easily to facilitate testing.

Confidentiality and Anonymity
Concerns over confidentiality and anonymity when completing STI testing was a

significant finding in all eleven studies ( Adam et al., 2011; Barbee et ah , 2015; Datta et al., 2018;

de Visser & O ’Neill, 2013; Delany-Moretlwe et al., 2015; Fisher et al., 2018; Goldenberg et al.,
2008; Mimiaga et al. , 2007; Pharr et al., 2016; Phillips et al., 2015; Yeung et al. , 2015). In

particular, YMSMs’ primary concerns over being ‘outed’ for their sexual orientation was a
prominent finding which significantly influenced their decisions to access testing (Adam et al.,

2011; Barbee et al., 2015; Datta et al., 2018; Fisher et al., 2018; Pharr et al., 2016; Phillips et al.,
2015). In two studies conducted by Pharr et al., (2016) and Mimiaga et al., (2007) authors
identified concerns over positive results as a strong emotional barrier to STI testing as YMSM

feared negative consequences associated with testing. More specifically, these negative
consequences were defined as rejection from parents, partners, and peers (Mimiaga et al., 2007;

Pharr et al., 2016).

In the statistical analyses conducted in the quantitative study by Phillips et al. , (2015 ),
authors determined younger MSM (ages 14-15) had greater worries of non-consensual disclosure

of sexual orientation compared to their older counterparts (>16 years of age). Authors inferred

younger MSM (<14 of age) had increased fear of disclosure and parental rejection due to overall
reliance on parents for transportation and knowledge seeking (Phillips et al., 2015). Disclosure

of sexual activity and sexual orientation to parents would place YMSMs’ needs at jeopardy, and
therefore, deterred YMSM from accessing STI testing (Phillips et al., 2015).

35

Due to YMSMs’ fears of having their sexual orientation disclosed, other studies also
concluded concerns over confidentiality and anonymity were extremely important to YMSM

(Barbee et al., 2015; Datta et ah , 2018; Fisher et ah , 2018; Pharr et ah , 2016; Phillips et ah ,

2015). Amongst YMSM that had regular health care providers, more than half of YMSM
(69.2% of 198 YMSM ) avoided discussions regarding STI related concerns with their regular

HCP over concerns that their regular HCP would disclose their sexual orientation to others
(Fisher et ah , 2018). Similarly, the study by Barbee et ah , ( 2015) identified young men wanted

anonymous STI testing outside of their regular healthcare clinic. Participants attached to a health

clinic frequently accessed services for non-STI related concerns but explicitly chose to seek
sexual health related services elsewhere (Barbee et ah , 2015 ). In spite of this unique finding,
authors failed to discuss the rationale for participants seeking sexual health related services at a

different location.
Physical environments of testing sites also perpetuated YMSMs’ beliefs of lack of
confidentiality, anonymity, and disclosure of sexual orientation. Crowded waiting rooms, which
were considered ‘ unfriendly and non-youth friendly’ in the previous section, also contributed to

the perception of little privacy and anonymity (Delany-Moretlwe et ah , 2015 ; Pharr et ah , 2016).

Moreover, these environments were also viewed as homophobic and participants feared the

negative associated social stigma if their sexual orientation was unwillingly or unknowingly
disclosed (Datta et ah , 2018; de Visser & O’Neill, 2013).
The beliefs that non-consensual disclosure of sexual orientation in YMSM will occur in

clinic settings infers little understanding of confidentiality rights and highlight the importance of
explicit conversations of confidentiality in the healthcare setting. Discussions about

36
confidentiality rights are evidenced to be crucial in the healthcare environment when working

with YMSM.

Healthcare Provider Related Barriers
Health care providers, including NPs, are often the first individuals to interact with
YMSM , therefore; it was not surprising that HCP related factors were a significant barrier when

accessing STI testing (Adam et al., 2011; Datta et ah , 2018; Goldenberg et ah , 2008; Pharr et ah ,

2016; Yeung et ah , 2015). For the purpose of this literature review, HCPs are considered
primary care clinicians that provide sexual health related interventions, including STI testing, to
YMSM. While the studies chosen for this literature review do not explicitly focus on NP

interactions with YMSM, lessons learned from experiences between HCPs and YMSM can be

implemented to build trusting and meaningful patient and NP relationships in the future.

Negative Judgement and Attitudes
Five studies revealed perceived judgement and negative attitudes from HCPs as the most
significant challenges YMSM faced when sharing beliefs about STI testing ( Adam et ah , 2011;
Barbee et ah , 2015; Datta et ah , 2018; Goldenberg et ah , 2008; Pharr et ah , 2016; Yeung et ah ,

2015). For YMSM that have previously accessed STI testing, authors identified participants
avoided future testing due to prior negative experiences with HCPs and thereby anticipated

similar interactions during subsequent testing (Adam et ah , 2011). Similarly, testing naive
YMSM anticipated judgement and negative attitudes from HCPs making them apprehensive and

resistant to accessing any initial STI testing (Adam et ah , 2011).

Descriptions of uncomfortable interactions with HCPs were revealed in studies and also
consequently deterred YMSM from STI testing (Adam et ah , 2011; Datta et ah , 2018; Pharr et

ah , 2016 ). Perceived judgement from HCPs towards YMSM were described as uncomfortable

37
encounters that prevented future STI testing (Datta et al., 2018; Pharr et ah , 2016). More

specifically, participants perceived interview questions, such as number of partners (Datta et ah ,

2018) , or non-verbal behaviours from providers such as ‘disapproving looks’ (Pharr et ah , 2016)
as uncomfortable and judgemental. Comparatively, asking participants to complete STI testing

when not initiated by YMSM was considered judgemental (Yeung et ah , 2015 ). Visible provider
discomfort in taking sexual health histories ( lack of eye contact, lack of opportunities to ask STI

related questions, being denied STI testing when participants explicitly requested) were all
viewed as negative and judgemental attitudes by participants (Goldenberg et ah , 2008). These

negative experiences may be contributed to the overall stigma associated with sex in general
which further fostered perceived negative interactions from HCPs in YMSM. These character
traits exhibited by HCPs, was considered stigmatizing and contributed to fears of being judged in
YMSM seeking STI testing (Delany-Moretlwe et ah , 2015). Furthermore, YMSM were revealed
to experience internalized stigma - negative attitudes towards self as a result of stigmatizing

attitudes held by society - as a result of negative interactions with HCPs (Delany-Moretlwe et
ah , 2015).

Although additional HCP related factors other than those reviewed may impact testing in
YMSM, the five studies summarized clearly identify HCP attitudes play a significant role in the

uptake of STI testing in this population. In order to promote STI testing, reassurance from HCPs
surrounding STIs in general for YMSM may be a key component in reducing their fears of STI

testing while fostering positive health outcomes.
To summarize, this analysis has provided a critical review of 11 studies identified to
answer the research question: “what are the barriers experienced by young men who have sex

with men when accessing sexually transmitted infections testing?” Critical data analysis revealed

38
three themes: 1) personal barriers, 2) system-level barriers, and 3) healthcare provider related
barriers. The following chapter will include discussion and recommendations on how the

findings from this integrative review can be put into NP practice to reduce the barriers to STI
testing in this population.

39
Chapter 5: Discussion and Recommendations
In this chapter, analyses of the 11 studies in the findings will be discussed. After
examination of the literature, three interrelated themes affected the decision making of YMSM
when accessing STI testing. Personal barriers, system-level barriers, and healthcare provider

related barriers were the obstacles experienced by YMSM when accessing STI testing and
contributed to the continued stigmatization towards STIs in general. This upcoming section aims
to discuss the findings from the previous 11 studies followed by recommendations for NP

practice.
Impact of Knowledge on Fears
Personal barriers experienced by YMSM analyzed in the studies, primarily encompassed
anxieties and fears over STI testing. Seven of the studies indicated many of these concerns were

subsequently due to a lack of awareness and understanding of what STIs were and its’ overall
psychological and physical health implications (Adam et ah , 2011; Datta et ah , 2018; de Visser
& O’Neill , 2013; Fisher et ah , 2018; Mimiaga et ah , 2007; Pharr et ah , 2016; Phillips et ah ,

2015). According to Shepherd and Smith ( 2017 ), lack of understanding of a particular health
condition and its’ consequences, such as STIs, drives fear-based behaviour and consequently
decreases the likelihood to seek assistance. This is mostly due to inaccurate assumptions,
concerns, or ‘fears of the unknown’ that drive a belief that negative events will occur if

assistance is sought. Analysis of the studies in this integrative review highlighted that fears
decreased the motivation in YMSM to test and was a significant emotional barrier.

Young MSMs’ knowledge deficits in sexual health further decreased the perceived risk of
STIs despite YMSM engaging in risky sexual behaviours (Adam et al., 2011; de Visser &
O’Neill, 2013; Delany-Moretlwe et al., 2015; Mimiaga et al., 2007; Pharr et al. , 2016; Phillips et

40
al., 2015 ). Ultimately, YMSM who lacked STI knowledge were unaware of the risk factors and

consequences of testing. As such, seven studies indicated greater efforts were required in

providing information to YMSM to encourage and empower their decision making around sexual
health (Adam et al., 2011; Datta et ah , 2018; de Visser & O’Neill, 2013; Fisher et ah , 2018;
Mimiaga et ah , 2007; Pharr et ah , 2016; Phillips et ah , 2015 ).

Despite evidence indicating the importance of education and its’ role in reducing fears

related to STI testing, the seven studies failed to provide recommendations to facilitate sexual
health knowledge in YMSM. Moreover, inconsistencies in the findings infers additional

variables, such as learning styles or socioeconomic factors, may impact knowledge surrounding
STIs in YMSM. Contrary to three studies which identified limited STI knowledge as a barrier to

testing (Goldenberg et ah , 2008; Pharr et ah , 2016; Yeung et ah , 2015), the study by Adam et ah ,
(2011 ) highlighted young non-heterosexual men had greater knowledge in comparison to their
heterosexual counterparts. The inconsistency regarding sexual health knowledge between nonheterosexual and heterosexual males indicates further research is recommended to better
understand the differences in STI related information uptake between these two population

groups. Customizable sexual health education is also recommended to facilitate STI knowledge

in YMSM to accommodate differing learning needs. For example, educational sexual health

sessions led by other YMSM could be used to support different YMSMs’ learning styles.
Furthermore, to reduce the anxieties related to STI testing in YMSM, education which considers
their historical disparities are critical. According to the SIECCAN (2019), YMSM as part of the

larger LGBTQ community describes feelings of exclusion in sexual health education in

comparison to their heterosexual counterparts. In order to gain the same health benefits as their
heterosexual peers, diversifying discussion about sexual health and STIs with age-appropriate

41
and medically accurate information is crucial. Tailoring education to be inclusive of YMSM
would considerably reduce the fear-based barriers to testing. This would foster inclusivity for

YMSM within sexual health education , while also facilitating access to appropriate information
to enable them to develop the confidence and strategies to seek out STI testing.

Consideration of sexual health education delivery methods are necessary to better
understand the factors which impact sexual health knowledge uptake in YMSM. Historically,

sexual health education including STIs is delivered in the classroom setting through formal
lectures (SIECCAN, 2019 ). This type of teaching potentially impedes knowledge uptake and

translation of sexual health concepts as YMSM do not find it engaging or meaningful to
themselves (Leung et al., 2019, SIECCAN, 2019). As a means to mitigate these sexual health

knowledge deficits in YMSM, modifying traditional lecture-style methods with contextual
teaching may be beneficial for YMSMs’ understanding. Contextual teaching and learning is a
method in which subject matter is presented in relation to real-word situations, thereby allowing

learners to make connections between knowledge and personal experiences (Leung et al., 2019).
The connection between these factors allows YMSM to generate understanding of a concept that
is meaningful to themselves, thus; increasing their likelihood of implementing learned
information in their everyday lives. For example, contextual teaching strategies such as

presentation of common scenarios (e.g. occurrence of unprotected sex) and encouraging YMSM
to articulate their subsequent actions fosters opportunities to discuss risk, safety, and importance

of STI testing. This example of contextual teaching and learning allows YMSM to discover a
more practical application of sexual health content and thus, promote independent decision-

making around STI testing.

42
Sexually Transmitted Infections Testing Sites
System-level barriers inhibit population groups from adequate access to services (Adam
et al., 2011; Barbee et al., 2015 ; Datta et al., 2018; de Visser & O’Neill, 2013 ; Delany-Moretlwe
et al., 2015; Fisher et al., 2018; Goldenberg et al., 2008; Mimiaga et al., 2007; Pharr et al., 2016;

Phillips et al., 2015; Yeung et ah , 2015). After review of the literature, it is clear there are still
unmet needs facing YMSM accessing STI testing at the organizational level. As evidenced by

several authors, the accessibility and identifiability of STI testing clinics (e.g, physical locations
of the testing site ) were considered barriers (Adam et al., 2011; Barbee et al., 2015; Datta et al.,

2018; de Visser & O’Neill, 2013; Delany-Moretlwe et al., 2015; Fisher et al., 2018; Goldenberg
et al., 2008; Mimiaga et al., 2007; Pharr et al., 2016; Phillips et al., 2015; Yeung et al., 2015 ).

Despite this prevalent finding, there was a lack of discussion pertaining to specific reasons
YMSM were unable to access testing site information. Various factors, such as signage, may

have influenced YMSMs’ inability to seek out clinics, however; this was not explored in the

articles reviewed. Goldenberg et al., (2008 ) were the only researchers that explained limited
accessibility to STI testing sites. In particular, the lack of access and identification of testing
sites was concluded to be compounded by rurality and the remote location this study was
conducted in (Goldenberg et al., 2008). Two studies emphasized certain characteristics of STI
testing sites (e.g. crowded waiting rooms, times of operation, non-youth friendly testing site
locations) were also considered barriers to STI testing in YMSM (Delany-Moretlwe et al., 2015;

Pharr et al., 2016). Interestingly, the studies failed to identify what components would be

considered ‘youth-friendly ’ within a STI testing environment. This would have been pertinent
information to include in the literature to determine what services could be acceptable to YMSM
to promote comfort and inclusivity. The lack of specific information provided indicates

43
additional quality improvements are needed to tailor sexual health services to YMSM to increase
STI testing uptake.

Difficulty accessing information regarding STI testing sites was an interesting finding as
several resources currently exist that can readily offer this information. The trending use of
technology, social media, schools, or clinic websites would have provided adequate information
to YMSM, however ; the use of such means was not discussed in any of the literature and was a

significant limitation to the studies. This specific finding ( clinic accessibility and identifiability)
clearly indicate additional research is needed to assess explicit factors acting as barriers to
seeking STI testing information in YMSM.

Concerns over Disclosure of Sexual Orientation
Concerns over lack of confidentiality and anonymity, more specifically, worries over

non-consensual disclosure of sexual orientation to others was also analyzed as a prominent

barrier to testing in the literature (Adam et al., 2011; Barbee et ah , 2015; Datta et ah , 2018; de
Visser & O’Neill, 2013; Delany-Moretlwe et ah , 2015; Fisher et ah , 2018; Goldenberg et ah ,

2008; Mimiaga et ah , 2007; Pharr et ah , 2016; Phillips et ah , 2015; Yeung et ah , 2015). As

previously noted, disclosure of sexual orientation is directly con-elated with the improvement of
overall sexual health and well-being (Bosse & Chiodo, 2016; Singh et ah , 2018). Although
evidence indicates the importance of disclosing sexual orientation in healthcare settings, the
findings analyzed from the literature clearly identifies the fear of negative consequences play a
role in YMSMs’ decision making and subsequently seeking out STI testing. In the review and
wider literature, characteristics of YMSM who were comfortable disclosing their sexual
orientation were those who had supportive families, friends, and communities or were connected
to the larger LGBTQ community (Durso & Meyer, 2013; Singh et ah , 2018). Evidently, further

44
creation of supportive environments for YMSM to comfortably disclose their sexual orientation
is recommended to better the overall health of this population.

All eleven studies indicated YMSM had concerns regarding confidentiality and nonconsensual disclosure of sexual orientation, however; no mention of whether explicit
conversations regarding confidential care between HCPs and YMSM were explored. While the
BCCNP (2020) expects nursing professionals to routinely uphold confidentiality rights by

safeguarding personal and health information, it is evident that YMSM are not assured they will

receive confidential care from HCPs. This specific finding highlights YMSM do not have a clear

understanding of confidentiality. This also indicates HCPs need to explicitly provide clarity to
YMSM about their rights and when confidentiality may be breached (e.g. in case of harm to self
or others). A limitation in eleven of the studies is failure to mention whether the significance of

this specific barrier would have decreased if confidentiality rights were explicitly discussed

during healthcare visits. Therefore, discussions about confidential care at every healthcare visit
is recommended for HCPs to reassure YMSMs’ confidentiality is maintained (Barbee et al.,

2015; Fisher et al., 2018; Pharr et al., 2016).

Anticipated Stigma from Healthcare Providers
Although there are several methods to reduce personal and system-level barriers to STI
testing in YMSM, the literature consistently indicated that STI testing habits in YMSM were
strongly impacted by interactions with HCPs. The literature analyzed in this integrative review

highlighted perceived judgement and negative attitudes from HCPs fostered anticipated stigma
from YMSM which prevented this population group from accessing testing (Adam et al., 2011;
Barbee et al., 2015; Datta et al., 2018; Goldenberg et al., 2008; Pharr et al., 2016; Yeung et al.,

2015). Anticipated stigma in YMSM often occurs from previously lived experiences of

45
discrimination subsequently triggering negative feelings preventing this population from
accessing future care (Brown et al., 2017).

The studies also identified certain mannerisms (e.g, disapproving looks, lack of eye
contact, asking sexual health related questions) as negative judgement from HCPs towards

YMSM ( Adam et al., 2011; Barbee et al., 2015; Datta et al. , 2018; Goldenberg et al., 2008; Pharr
et al., 2016; Yeung et al., 2015). Interestingly, two studies exclusively identified participants felt

judged when HCPs asked questions about sexual activity when not initiated by YMSM

themselves (Datta et al., 2018; Yeung et al., 2015). The inconsistencies between these two

studies compared to the others, may suggest that personal feelings of perceived negative attitudes
and feeling judged from HCPs is not a generalizable barrier to the broader YMSM population. It
can be argued that each individual HCP experience is unique and elicits different emotions, and

therefore, may not be a consistent barrier for all YMSM seeking STI testing.

Alternatively, the broader literature indicates HCPs that exhibited certain characteristics
(e.g. confidence in sexual health history taking, openness and willingness to discuss sexual habits

and sexual orientation, and compassionate, non-judgemental attitudes) were described as

facilitators to testing and increased YMSMs’ willingness to disclose sexual orientation (Datta et
al., 2018; Fisher et al., 2018; Mimiaga et al., 2007; Yeung et al., 2015). While these findings

clearly identify what is required from HCPs to foster a safe and trusting environment for STI
testing, YMSM continue to encounter negative experiences with HCPs. This is a critical finding

in the literature since it identifies HCPs need to be both reflective and reflexive in the clinical
setting and thereby make adjustments that can result in YMSM feeling safe in STI testing

settings.

46
Barriers continue to limit practice, as HCPs emphasize various factors that prevent them

from discussing sexual health related concerns in the healthcare setting (Dorsen & Devanter,

2016). Various reasons such as feeling unprepared to discuss sexual health concerns or limited
STI knowledge, have been identified as barriers to discussing sexual health with YMSM (Carter
et ah , 2014; Dorsen & Devanter, 2016). Improving comfort levels in sexual health discussions in

is recommended so HCPs can confidently assess, treat, manage, and thereby increase STI testing

in YMSM. In the upcoming section, recommendations for NPs to reduce the aforementioned
barriers to STI testing will be provided.

Recommendations for Nurse Practitioners
As evidenced by this literature review, current sexual health services are failing to meet

the STI testing needs of YMSM due to complex psychosocial, sociocultural, and systemic

factors. While stigma was emphasized as a primary influence on the decision making processes
of YMSM when seeking sexual health services, discussions surrounding eradicating stigma at a
systemic level and changing cultural norms is beyond the scope of this paper. Nevertheless, the
results of this integrative review indicate continued front line gaps in the delivery of sexual

health services. As primary care providers routinely interacting with YMSM, NPs have an
important role to play in tailoring the care they provide to optimize sexual health and overall

needs for this population.
Based on the aforementioned results, a set of recommendations has been generated to
assist NPs in supporting YMSM to reduce the barriers they experience when accessing STI
testing. These recommendations in addition to detailed strategies to implement these
recommendations in the primary care setting will be presented in Table 3.

47
Increase Provider Confidence in Sexual Health Discussions
The BCCNP (2020) indicates NPs have the responsibility to provision safe, competent,

and ethical care to their patients. Nurse Practitioners need to modify care appropriately for the
sexual health needs of YMSM through initiation of sexual health discussions. Young MSM may
feel embarrassed or fearful to initiate these conversations with HCPs regarding their sexual
health and behaviour. Therefore, NPs must be well prepared in order to ease this embarrassment

and facilitate open conversation about sexual health related subjects. However, most HCPs feel
ill-equipped to have conversations around sexual health and therefore, avoid the topic leading to
noncomprehensive visits with YMSM (Dorsen & Devanter, 2016).
Improving confidence and individual NP comfort during sexual health discussions is
critical for the overall sexual health and well-being of YMSM . Healthcare provider discomfort

when conducting these conversations is linked to a lack of sexual health education or limited

experience in discussing sexual health and sexuality (Dorsen & Devanter, 2016). Therefore, NP

educational programs need to be responsive and aim to incorporate both comprehensive sexual
health management and effective communication strategies so NPs can confidently initiate

sexual health conversations with all individuals, including YMSM. For new NPs with little
experience in sexual health management approaches, such education and training shifts the focus

towards comprehensive sexual healthcare while assisting to increase comfort levels when
discussing sexual health.
Nurse Practitioners are also responsible for their own learning needs and seeking out

alternative activities to meet them throughout their practice (BCCNP, 2020). In doing so, NPs
can continuously improve and take action to provision most appropriate care for their patients
(BCCNP, 2020). For practicing NPs who may not be comfortable in initiating sexual health

48
discussions with YMSM , mentorship programs are useful to improve their confidence levels.

Mentorship is a mutually beneficial relationship where a more experienced and knowledgeable
NP supports the maturation of less experienced one (BCCNP, 2020). Novice NPs can partner
with experienced NPs in sexual health to learn how to initiate sexual health related conversations
to foster confidence and independence. Expert NPs in the field can also benefit from a

mentorship program as they are contributing to the profession and the overall health and wellbeing of YMSM.

Continuing Professional Development
Nurse Practitioners have the professional responsibility to continuously undergo

professional development (e.g. professional conferences) to provide the most relevant sexual
healthcare services to YMSM (BCCNP, 2020). Nurse Practitioners can take part in developing

policies and programs within their respective health authorities and regulatory bodies to ensure
all NPs working in sexual health provide care using evidence based medical knowledge. This
can be achieved by partnering with leadership and regulatory bodies to monitor professional

development through completion of mandatory sexual health related practice hours. To maintain
current knowledge and ensure YMSM are receiving the most relevant sexual health services, all

NPs in the clinical setting need to be familiar with current national and provincial STI guidelines
to guide their practice in sexual health.

Collaboration
The role of the NP is to reduce the negative health outcomes in YMSM through

collaboration with other professionals and resources to meet overall patient needs (BCCNP,

2020). Collaboration goes beyond the consultation of medical specialists, but also includes a

partnership with other providers and resources to meet the sexual health care needs of YMSM

49
and to reduce any negative STI related health outcomes. To do so, NPs need to be aware of

support groups and local community resources as complementary services for referral purposes

for the overall care of YMSM.
An example of NPs collaborating with additional supports is the inclusion of peer

mentors, in which individuals with lived experiences provide expertise to another, in their

practice. This recommendation is based upon the findings that YMSM with prior testing

experience expressed positive outlooks on subsequent STI testing and were more likely to
encourage peers to access sexual health services (Adam et ah , 2011; de Visser & O’Neill, 2013;

Mimiaga et al., 2007; Yeung et al., 2015). Young role models have the capacity to act as

powerful and persuasive influences to reduce STI related fear while also fostering sexual health
knowledge (Spear, 2013; Vasilenko et al., 2018). Moreover, peer mentors would also serve to
pass on valuable lessons regarding emerging sexual emotions and gender identity in YMSM.
The collaborative efforts between both NPs and peer mentors would serve to better the care and

well-being of YMSM. Nurse Practitioners can also partner with peer mentors through outreach
programs to bring sexual health related services to YMSM who cannot attend clinics, or formally

attending educational institutions to provide information and resources regarding STI testing
sites.

Youth Friendly Sexual Health Services
Ensuring that sexual health services are youth friendly and accessible for YMSM is a
critical component to increasing STI testing as evidenced by the findings (Adam et al., 2011;

Barbee et al., 2015; Datta et al., 2018; de Visser & O’Neill, 2013; Delany-Moretlwe et al., 2015;
Fisher et al., 2018; Goldenberg et al., 2008; Mimiaga et al., 2007; Pharr et al., 2016; Phillips et

al., 2015; Yeung et al., 2015). Nurse Practitioners need to promote the adoption of youth

50

friendly sexual health services by advocating for them within each health care setting and

facilitating their implementation. Timely services, hours of operation conducive to youth (e.g
after school hours or weekends), closer proximity of sexual health clinics to schools, and clear

signage tailored to youth are essential to make sexual health services accessible and identifiable
to YMSM.

Nurse Practitioners also have the professional duty to direct and participate in the

ongoing evaluation of healthcare services after implementation to improve the patient care

experience (BCCNP, 2020). By collaborating with both organizational leadership and YMSM,
NPs can facilitate necessary improvements to ensure youth-friendly sexual health services. For

example, NPs can initiate quality improvement strategies, such as focus groups, in which YMSM
are invited to discuss improvements to the clinic and sexual healthcare service delivery. This

would promote inclusivity and encourage YMSM to take part in their own sexual health while
also ensuring youth friendly services for YMSM. Additional methods to include YMSM in the
enhancement and improvement of youth-friendly sexual health services can include informal
evaluation forms or comment boxes readily available in the clinic setting.

Promote Confidentiality
As demonstrated by the literature, concerns over non-consensual disclosure of sexual

orientation was a prominent barrier to YMSM from accessing STI testing (Adam et al., 2011;
Barbee et al., 2015 ; Datta et al., 2018; de Visser & O’Neill, 2013; Delany-Moretlwe et al., 2015;
Fisher et al., 2018; Goldenberg et al., 2008; Mimiaga et al., 2007; Pharr et al., 2016; Phillips et

al., 2015; Yeung et al., 2015). Compromising confidentiality strongly affects YMSMs’ trust in
the healthcare system and therefore, indicates they will be less likely to access a sexual health
service. Moreover, they are unlikely to be honest when asked about sexual health related

51

questions which ultimately jeopardizes the provision of appropriate sexual health services. All
nursing professionals, including NPs, have an ethical responsibility to protect and maintain
confidentiality rights for all of their patients (BCCNP, 2020). Nurse Practitioners need to
employ different strategies to emphasize the confidentiality rights of YMSM to make them feel

comfortable to discuss their sexual health needs. Having explicit conversations about
confidential care during healthcare visits is imperative to reassure YMSM that their health visits

will not be discussed with others. Additional approaches to promote confidentiality can include:
adding signage or posters identifying confidentiality and anonymity around the clinic, displaying

options for communication on intake forms (e.g. “ How would you like us to get in touch with

you?”), or giving YMSM the option to use aliases or alternative names. Nurse Practitioners who
are unfamiliar with discussing confidentiality with YMSM in sexual health would benefit from a

skilled preceptor in the field to learn effective strategies to explain legal rights of confidentiality
to YMSM. Moreover, NPs need to familiarize themselves with Canadian Laws regarding

confidentiality through their respective resources to competently discuss confidential care with
YMSM.

For YMSM who prefer not to attend a physical clinic environment for confidentiality
reasons, alternative STI testing methods should be implemented and offered by the NP.

Programs such as GetCheckedOnline piloted by the BCCDC offer free of cost, anonymous,
confidential, and accessible means of STI testing through an internet based testing service

(Gilbert et ah , 2019). Nurse Practitioners can offer this as an alternative testing method for
YMSM while also increasing uptake and frequency of testing leading to timely diagnosis and

management. The test results are returned to the NP without the patient needing to physically

52

attend a sexual health clinic, thus, confidentiality and anonymity concerns are largely eliminated
and greater control over health is facilitated.
Build Trusting Relationships

The BCCNP (2020) emphasizes therapeutic relationships between patients and providers
are built on trust , respect , and placing the needs of the patient first . Despite this practice

standard, YMSM often feel stigmatized and judged from HCPs when seeking STI testing as
evidenced in this literature review ( Adam et ah , 2011; Barbee et al., 2015; Datta et al., 2018;

Goldenberg et al., 2008; Pharr et al. , 2016; Yeung et al., 2015) . Reducing the anticipated stigma
from HCPs is critical as a means to fostering meaningful connections and positive relationships
between NPs and YMSM (Datta et al., 2018; Fisher et al., 2018; Mimiaga et al., 2007; Yeung et

al., 2015). An abundance of literature indicates HCPs who are confident, open, and initiated

sexual health conversations were perceived by YMSM as competent and capable providers, and
increased YMSMs’ likelihood to engage in sexual health services (Datta et al., 2018; Fisher et

al., 2018; Mimiaga et al., 2007; Yeung et al., 2015 ). Therefore, taking the time to ask specific
sexual health questions at every visit and listening to the stories of YMSM and their STI testing
concerns, are crucial in fostering therapeutic relationships.

Normalize Sex
A growing body of evidence endorses a modified way to view health and well-being
through a life course approach (Halpem, 2010; Kuruvilla et al., 2017). In contrast to traditional
disease-oriented approaches in healthcare, where the focus is on one intervention for a single
condition at a single point in life, sexual health across the life course focuses on the promotion of
sexual health and well-being through life stages. For YMSM, sexual activity has generally been
a disapproving behaviour, including the acquisition of STIs or multiple sexual partners, which

53

has led to fears of discrimination and judgement (Ford et al., 2013; MacLean , 2018). However,

if societal acceptance normalizes sex as a central component to general well-being and that
young people are safe to explore their sexual orientation , identity , and behaviour, this will

ultimately contribute to positive health outcomes in YMSM.
Nurse Practitioners play a vital role in the life course approach, as discussions between
NPs and YMSM in the healthcare setting would focus on healthy sexual behaviours and not

abstinence. Formal educational programs need to include life-course approach and theory in
curricula for NPs to familiarize themselves with this concept before practice . These changes in
formal education would encourage NPs to be more confident in discussing sexual health with
YMSM across the lifespan. Nurse Practitioners can also assist in normalizing sex in the practice

setting in a variety of ways. Asking about sexual activity during every visit, discussing risk
factors associated with sexual activity, and providing education regarding safe sex to prevent
STIs (e.g. condom use ) are all significant examples NPs can employ in their practice. Ensuring

that resources are readily available if YMSM need them, such as having condoms available in
the clinic, can also be a strategy NPs can utilize to foster normalization of sex.

In summary, NPs are uniquely positioned to provide a panel of STI services for YMSM
through a variety of means. By continuing education to maintain the most relevant and current

sexual health information, NPs can also share evidence-based material through collaboration
with others and with YMSM themselves. Nurse Practitioners are also important stakeholders in

changing the stigmatizing landscape surrounding STIs through thoughtful discussions and

normalization of healthy sexuality with YMSM. These actions will further foster trusting
relationships between NPs and YMSM, while also reducing the barriers experienced by YMSM

54
when accessing STI testing. The recommendations for NPs mentioned above are presented in
Table 3.

Table 3
Recommendations for Nurse Practitioners
Recommendations for Nurse Practitioners
Increase Provider Confidence with Sexual Health Discussions

• Liaise with educational institutions to redesign educational curricula to include effective
•
•

communication strategies and comprehensive sexual healthcare management for all
population groups, including YMSM
Be responsible for learning needs and seek out alternative learning strategies to meet
these needs if feeling unprepared to have sexual health conversations with YMSM (e.g.
seeking out a mentor )
Participate in mentorship programs to NPs and provide experiences for them to increase
comfort levels in discussing sexual health with YMSM

Continuing Professional Development

• Continue professional development to maintain current evidence based practice in sexual
•
•

health through a variety of means ( e.g. conferences, lectures )
Liaise with health authorities and regulatory bodies to implement mandatory professional
development in sexual health for all NPs (e.g. through practice logs or mandatory hours)
Be familiar with relevant STI related clinical practice guidelines (e.g. PHAC, BCCDC
guidelines)

Collaboration

• Collaborate with professionals, resources, and supports to meet the sexual health needs of

•
•
•

YMSM ( e.g peer mentors as a resource to reduce testing fears)
Partner with peer mentors to provide outreach sexual health services for YMSM who
cannot attend clinics
Have knowledge of community resources and supports for YMSM ( e.g. local LGBTQ
groups) and refer as necessary to ensure continuity of care
Attend formal educational institutions (e.g. classroom settings) to discuss STI testing
sites or provide up to date relevant sexual health information

55

Recommendations for Nurse Practitioners
Youth Friendly Sexual Health Services

• Participate in the planning, delivery, and evaluation of youth-friendly clinical sexual
•
•
•

health services
Ensure sexual health services are conducive to YMSMs sexual health by ensuring timely
services, changing hours of operation to after school hours or weekends, and close
proximity to schools
Tailor signage to youth and LGBTQ communities to increase visibility of testing sites
Obtain feedback from YMSM regarding youth-friendly and LGBTQ friendly sexual
health services through quality improvement strategies (e.g. focus groups, evaluation
forms, comment boxes)
Ensuring Confidentiality

• Be familiar with Canadian Laws surrounding confidentiality rights for YMSM
• Add signage or posters around the clinical site ensuring confidentiality in all visits

• Display options for communication on intake forms with various options such as texting
•

•
•
•
•

or email ( e.g. “ /Tow would you like us to get in touch with you?”)
Provide options for YMSM to use aliases or alternative names on intake forms and
medical records
Explicitly discuss confidential care with YMSM in all clinical visits
Explain when confidentiality must be breached to YMSM
Seek assistance from others (e.g. experienced NPs in sexual health) if unfamiliar with
confidentiality discussions
Offer alternative STI testing methods ( e.g. GetCheckedOnline ) for YMSM who have
concerns about confidentiality, anonymity, or have any challenges attending clinic

Building Trusting Relationships

• Build therapeutic relationships with all patients, including YMSM

• Instill a sense of competence and capability in YMSM by initiating sexual health
•
•
•

conversations to build therapeutic relationships (e.g. “ Are you currently sexually active?
Are you thinking of being sexually active?”)
Inquire about sexual orientation, gender identity, and safety at home and at school to
facilitate rapport building
Listen to the experiences of YMSM and testing concerns, make efforts to ease fears and
worries around testing by answering questions and validating their concerns
(e.g. “Tell me what your concerns are around STI testing ”)
Review care options related to sexual health collaboratively with YMSM and respecting
their choices (e.g. treatment options, types of STI tests)

56
Recommendations for Nurse Practitioners

Normalizing Sex

• Advocate for the implementation of life course approach in formal educational curricula

• Ask about sexual health at every healthcare encounter regardless of the visit to normalize
•

•
•
•

•

healthy sexual behaviours
Utilize different communication strategies such as empathy, humour, listening, and
frankness to employ a positive sexual health approach
Offer YMSM an open-door policy to assess for any sexual health concern (e.g. new
sexual partner, symptoms, sexual health related questions)
Offer follow up routine STI testing by using of automatic prompts and reminders in
medical records
Discuss risk reduction methods with YMSM during clinical visits including the use of
condoms (e.g. “How are you protecting yourself against STls? ”)
Ensure condoms are readily available and accessible to YMSM if they require it (e.g. in
clinic washrooms or waiting areas)

Limitations
As with all studies, limitations are common. A major limitation to the articles chosen for

this integrative review were the lack of studies that focused exclusively on YMSM. Studies

which included YMSM encompassed other populations such as young people or broader MSM
populations . Although many findings were applicable to YMSM specifically, these studies may
not have revealed explicit barriers facing this population. Another limitation included the scant

number of Canadian based studies relevant to the research topic. While the geographical
locations of the studies were explicitly chosen for similarities to the Canadian healthcare system,

additional barriers to STI testing influenced by differing system barriers cannot be ruled out. In
addition, studies included small research population sizes which affected the overall

generalizability to the larger YMSM population . Consideration of socioeconomic factors and
recruitment strategies in different countries cannot be ruled out as a cause of the small sample
sizes and may be an area for exploration.

57
Studies chosen for this integrative review and within the broader literature did not

consider the cultural and ethnic backgrounds of YMSM which is a major limitation to the

findings of this review. As cultural complexities impact test seeking behaviours, inclusion of
this criteria may have provided a more robust panel of barriers experienced by YMSM and
further informed the analyses. Cultural and ethnic issues impacting testing experiences was

beyond the scope of this paper but is an important area for further inquiry. Studies focusing on

preventative strategies for STIs (e.g. routine STI screening in HIV positive individuals) were
also not included in this study. This is a significant limitation as STI prevention efforts and
routine testing associated with chronic diseases may have improved access to STI testing and
further informed the findings of this review. In addition, studies focusing on YMSM accessing
HIV preventative medication (pre-exposure prophylaxis or PreP) were not included in this study.

The exclusion of these studies may have limited the findings as STI testing is routinely included
in PreP initiation and continuation. Studies that included PreP access may have encouraged
engagement to overall STI testing services and is an area for future research.

Formal sexual health education in differing countries may also be a limitation which

impacted the sexual health knowledge in YMSM. Additional research in this area is warranted
to ensure no additional educational barriers are in place that may contribute to knowledge

deficits. Moreover, the majority of studies included in this integrative review failed to mention
the gender and sexual orientations of the HCPs who provided sexual health care services to
YMSM. These specific factors may have influenced the comfort levels of YMSM in openly

discussing their sexual health with their primary care providers. In papers which mentioned
healthcare provider attitudes and the impact on the testing experiences of YMSM, there was no
mention of the sexual health educational experiences these HCPs had. More experienced versus

58
novice NPs in sexual health may have contributed to the differing HCP attitudes experienced by
YMSM and may be an area of further research. Lastly , all studies chosen for this literature

review were applicable to primary care practice, however; there was no direct mention of NPs.
This may have affected the application of the findings to NPs specifically. Moreover, in studies

that mention HCPs, no definition of which HCPs were included in studies.

Recommendations for Future Research

In consideration of the limitations of this integrative review, several recommendations for
future research are proposed. Future recommendations for research include:

• Repeating studies on larger population sizes in order to increase generalizability to the
wider YMSM population

• Conducting research on barriers to STI testing in Canada to explicitly identify obstacles
in the Canadian healthcare system

• Identifying the factors which influence difference in sexual health knowledge between
heterosexual and non-heterosexual males

• Completing research focusing on assessment of STI related resources used by YMSM to
ensure validity, reliability, and accessibility of content

• Developing research that is exclusively focused on YMSM, rather than incorporating
population into larger research groups such as MSM and young people

• Completing research determining more specific strategies on how to reduce stigma
towards sex

• Continuing research on the impact of sexual health education in formal educational
institutions and its impacts on YMSM

59

• Completing research on the impact of sexual health experience in HCPs and the effects
on provision of sexual health services

• Completing research focusing on the strategies NPs can employ to reduce STI barriers in
YMSM

60
Conclusion

Sexually transmitted infections is a common global public health concern which

disproportionately affects young men who have sex with men between the ages of 15-26 (CDC ,
2018; PHAC , 2017). This integrative review explored the barriers experienced by YMSM when
accessing STI testing in order to develop greater understanding of the factors which ultimately

influence the decision to test. A systematic search of the literature identified 11 studies.
Analysis of the studies revealed three key themes which inhibited YMSM from accessing testing.

These three themes included: personal barriers (limited knowledge of STIs, decreased perceived

vulnerability to infection, and fears related to testing), system level barriers (identifiability and
accessibility of testing sites, confidentiality and anonymity concerns), and healthcare provider
related barriers (negative attitudes and judgements). Recommendations to improve these barriers
through improvement of education and normalization of sexual activity through the life course
were suggested to reduce these barriers. In addition, areas for further research included

developing research specifically to YMSM rather than as a smaller cohort of the larger MSM
population, and the exploration of specific strategies to reduce the obstacles experienced by
YMSM were highlighted. By recognizing the factors that influence YMSM and acknowledging

the importance of the role HCPs have in optimizing sexual health, NPs can truly reduce the

health disparities experienced by this population group.

61
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70
Appendix A : Evaluation Checklists and Scales
Critical Appraisal Skills Program (CASP) Qualitative Review Checklist

Three broad issues need to be considered when appraising qualitative studies:
• Section A: Are the results of the study valid?
• Section B : What are the results?
• Section C: Will the results help locally?
Section A: Are the results of the study valid?
1. Was there a clear statement of the aims of the research?

Yes

Can’t Tell

No

2. Is the qualitative methodology appropriate?

Yes

Can’t Tell

No

3. Was the research design appropriate to address the aims
of the research?

Yes

Can’t Tell

No

4. Was the recruitment strategy appropriate to the aims of
the research?

Yes

Can’t Tell

No

5. Was the data collected in a way that addressed the
research issue?

Yes

Can’t Tell

No

6. Has the relationship between researcher and participants Yes
been adequately considered?

Can’t Tell

No

Is it worth continuing?

Section B: What are the results?
7. Have ethical issues been taken into consideration?

Yes

Can’t Tell

No

8. Was the data analysis sufficiently rigorous?

Yes

Can’t Tell

No

9. Is there a clear statement of findings?

Yes

Can’t Tell

No

Yes

Can’t Tell

No

Section C: Will the results help locally?
10. How valuable is the research?

(Critical Appraisal Skills Checklist , 2018)

71
CASP Systematic Review Checklist

Three broad issues need to be considered when appraising systematic reviews:
• Section A: Are the results of the study valid?
• Section B : What are the results?
• Section C: Will the results help locally?

Section A: Are the results of the study valid?
1. Did the review address a clearly focused question?

Yes

Can’t Tell

No

2. Did the authors look for the right type of papers?

Yes

Can’t Tell

No

3. Do you think all the important, relevant studies were
included?

Yes

Can’t Tell

No

4. Did the review’s authors do enough to assess quality of
the included studies?

Yes

Can’t Tell

No

5. If the results of the review have been combined, was it
reasonable to do so?

Yes

Can’t Tell

No

6. What are the overall results of the review?

Yes

Can’t Tell

No

7. How precise are the results?

Yes

Can’t Tell

No

8. Can the results to applied to the local population?

Yes

Can’t Tell

No

9. Were all important outcomes considered?

Yes

Can’t Tell

No

10. How valuable is the research?

Yes

Can’t Tell

No

Is it worth continuing?

Section B: What are the results?

Section C: Will the results help locally?

(Critical Appraisal Skills Programme, 2018)

72
Mixed Methods Appraisal Tool
The Mixed Methods Appraisal Tool (MMAT) is a checklist developed to provide quality
appraisal for qualitative and quantitative mixed methods studies ( Hong et ah , 2018).

Screening Questions
1. Are there clear research questions?

Yes

Can’t Tell

No

2. Do the collected data allow to address the research
questions?

Yes

Can’t Tell

No

Can’t Tell

No

Further appraisal may not be feasible or appropriate when
the answer is ‘no ’ or ‘can ’t tell ’
Yes
3. Is there adequate rationale for using a mixed methods
design to address the research question?

4. Are the different components of the study effectively
integrated to answer the research question?

Yes

Can’t Tell

No

5. Are the outputs of the integration of qualitative and
quantitative components adequately interpreted?

Yes

Can’t Tell

No

6. Are divergences and inconsistencies between
quantitative and qualitative results adequately addressed?

Yes

Can’t Tell

No

7. Do the different components of the study adhere to the
quality criteria of each tradition of the methods involved?

Yes

Can’t Tell

No

(Hong et al. , 2018)

73
Scale of Assessment for Narrative Review Articles (SANRA)

The Scale of Assessment for Narrative Review Articles (SANRA) is a checklist developed to
provide quality appraisal for narrative reviews ( Baethge et ah , 2019 ).

1. Justification of the article’s importance for the readership
The importance is not justified

0

The importance is alluded to, but not explicitly justified

1

The importance is explicitly justified

2

2. Statement of concrete aims or formulation of questions

No aims or questions are formulated

0

Aims are formulated generally but not concretely or in terms of clear questions

1

One or more concrete aims or questions are formulated

2

3. Description of the literature search

The search strategy is not presented

0

The literature search is described briefly

1

The literature search is described in detail, including search times and inclusion criteria 2

4. Referencing
Key statements are not supported by references

0

The referencing of key statements is inconsistent

1

Key statements are supported by references

2

5. Scientific reasoning (e.g. incorporation of evidence, such as RCTs in clinical
medicine)
The article’s point is not based on appropriate arguments

0

Appropriate evidence is introduced selectively

1

Appropriate evidence is generally present

2
(Baethge et ah , 2019 )

74

Appendix B : Literature Matrix

Title of Article

Understanding
barriers to STI
testing among
young people:
results from the
online survey
'Getting Down To
If

Australia

Methodology
Authors/Date of
Publication/Study and Methods
Rating
Adam et al., 2011 Cross-sectional ,
quantitative
online survey
CASP Rating: 10
between MayOctober 2010
Males and
females aged
16-26 recruited
through online
sampling
(n= 1 , 658)

Young males
identified as
gay, bisexual,
or having sex
with other men
(28.5%)

Purpose

Key Findings

1) Determine the
sociodemographic,
behavioural, and
psychosocial
factors influencing
young people’s
STI testing in
Australia

1) Majority of participants
understood the risks of STI
transmission, but little
understanding surrounding the
consequences of testing

2) Increase
understanding of
the barriers and
facilitators
impacting STI
testing in young
peoples

3) Critically
examine whether
lack of STI
Online survey = knowledge is not
the only barrier to
32 questions
STI testing
(assessed
vulnerability to
STIs, attitudes
towards testing,
pros and cons

Strengths and
Limitations

Strengths:
1) Recruitment
strategy as a
major strength,
the ability to
reach a large
2) Experience with previous STI number of
testing and of non-heterosexual participants
identify facilitated STI testing
through one
platform
Barriers:
Limitations :
1) Lack of perceived
vulnerability to STI testing and 1) Limited to
decreased perception of
recruitment
contracting STI
through one
social media
2) Concerns of lack of
platform, could
have considered
confidentiality in those who
other platforms
have never tested; fearful that
for participant
guardian or parental consent
recruitment
was required
3) Fears over partner’s reaction,
parent’s reaction, negative staff
attitudes and medical
procedures

2 ) Participant
bias; access to
internet and
computer
applicable to

75

of STI testing,
worries around
STI testing, STI
related shame,
and norms
related to
testing )

4) STI related shame and stigma
negative connotations with
promiscuity, risk taking
behaviour, sexual lability

-

higher
socioeconomic
statuses - data
may be limited
to nonmarginalized or
vulnerable
populations with
no access to
technology
services
3) Unclear
methods on
survey
development

Barriers to
Bacterial STI
Testing of HIVInfected Men who
have Sex with
Men Engaged in
HIV Primary Care
United States

Barbee,
Dhanireddy, Tat,
& Marrazzo, 2015

CASP Rating: 8

Quantitative
method, paper
based surveys
for patients;
online surveys
for providers
Extraction of
lab data to

gather testing
rates in MSM
with the last 18
months

Convenience
sampling,

1) Investigate
barriers to STI
screening from
both patient and
healthcare
provider
perspectives

Patient perspectives:
1) Desired increased anonymity
and confidentiality when
testing—felt the potential to be
‘outed’ when accessing testing

Strengths:
1) Barriers were
extracted from
both MSM and
providers
providing robust
2) Simpler and ‘easier’ access to understanding of
STI testing; ‘easier’ not defined experiences
but assumed as access to more
2) Identify
baseline STI
appointment slots and increased 2) Use of
testing rates
anonymity outside of their usual laboratory data
primary care clinic
to extract
amongst HIV
number of
positive MSM
participants
3 ) Medical procedures—
3) Understand why bloodwork tests for certain STIs testing in an 18
testing wasn’t
but swabs may be necessary and month period

76

recruitment
occurred in an
HIV clinic
Males aged 1849 and health
care providers
recruited
through
convenience
sampling to
take part in an
anonymous 11
question survey
(assessed
sexual risk
behaviours,
reasons for not
accessing STI
services with
their routine
primary care
provider)
Men 18-29
( n=1,456)
Healthcare
Providers
(n=33)

occurring

frequently
4) Develop
interventions to
increase screening

acted as deterrent to testing ( fear convenience and
of pain and invasive procedures) reliability

Provider perspectives:
1 ) lacked knowledge
surrounding STI testing
guidelines and treatment ie )
unsure what swabs to use and
what treatment to provide for
positive result

2) Structural/organizational
barriers—lacked the time to
complete STI screening and
testing, felt uncomfortable with
genital exam or sexual health
history interviews, concerned
they appeared judgemental, not
believing patient was at risk and
therefore, not testing patient

Limitations :
1) Exclusively
HIV infected
MSM
participants—
MSM with no
chronic illness
may experience
different barriers
in comparison

2) Participants
were
specifically
selected to
participate from
HIV specific
clinic
(convenience
sampling)—may
not be
generalizable to
other clinics and
non-HIV MSM

3) Rapid
assessment
using surveys
and unable to

77

assess whether
knowledge of
STIs was a
barrier to testing
as well ( major
barrier in other
studies)

4) Unclear
definitions from
the participants
e.g. “easier
testing”
and what these
mean to the
patient;
subjective
terminology

de Visser &
Identifying and
O’Neill, 2013
understanding
barriers to sexually
transmissible
infection testing
MMAT Scale: 19
among young
people
United Kingdom

Cross sectional
quantitative
survey with

qualitative
analyses
Mixed methods
study; online
questionnaire
then semistructured
interview

1) Identify what
influences STI
testing behaviour
in young people

2) Identify
facilitators and
barriers to STI
testing

Facilitators to testing:
1) First initial sexual encounter
at a younger age

2) Greater number of sexual
partners
3) Recent STI testing (within
one year)

Strengths:
1) Clear
processes
behind
questionnaire
development
and questions
asked

2) Analyses
4) Perceived norm in STI testing combined both
quantitative and
countered stigma - friends and

78

peers ‘normalized’ testing

Sampling of
male and
females aged
17-25, number
of MSM, gay or
bisexual men
were not
identified

Completed
questionnaire
(n= 275),
selected for
interview (n=8)
Questionnaire
adapted from
previous
studies, 7 item
scale assessing
sexual health
services access,
sexual
peimissiveness,
stigma towards
STIs, perceived
susceptibility

qualitative
aspects of study
creating robust

Barriers to testing:
conclusions
1) Low perceived risk, lack of
vulnerability despite sexual
Limitations :
contact- based on personal
perception of what “risk” entails 1 ) Unclear
(assumptions about monogamy
recruitment
and what sexual contact actually strategies,
is)
participants
were self2)Stigma/shame/embarrassment selected
university
a. past negative experience after students may
testing positive deterred future
not be
testing
generalizable to
b. perceived fear and negative
the larger
populations due
assumptions from others for
testing even though this was not to increased STI
rates in
experienced personally
university
students
3 ) Ease of access to testingunsure of locations that offer
2) All
testing and what testing
generally involved; opted no
participants
testing due to lack of knowledge received a
quantitative
4 ) Fear of lack of
survey
confidentiality and anonymity,
identifying
worried about disclosure to
influencers on
STI testing
family and friends that they
accessed STI testing; concerned behaviour; only
about negative consequences
8 participants

—

79

Patient-Provider
Communication
Barriers and
Facilitators to HIV
and STI
Preventive
Services for
Adolescent MSM
United States

Fisher, Fried,
Macapagal, &
Mustanski, 2018

CASP Rating: 11

Quantitative
surveys
Convenience
sampling
(participants
were recruited
from another
project) and
online
recruitment
through
Facebook
advertisements

Total sample
( n=198) of
AMSM aged

14-17
National survey

assessing
AMSM
communication

Identify factors
facilitating and
impending
HIV/STI
preventative health
services in
adolescent MSM
aged 14-17

and judgements of promiscuity

were chosen to
conduct semistructured
interviews- may
not be general
consensus of
testing barriers

Barriers to STI preventative
services:
1) Less sexual experience as a
barrier to STI/HIV screening

Strengths:

2) Fear of stigmatization and
being ‘outed’ for sexual
orientation from HCPs,
concerns over heterosexist bias
in healthcare
3) Anticipated stigma and
concerns over inequitable
treatment for being gay or
bisexual (although never
personally experienced)

1) Focused
exclusively on
adolescent
MSM rather
than grouping
them in with
larger MSM
population or
youth
population

2 ) Clear
methodology
and explanation
of use of Likert
Scales

4 ) Concerns over lack of
confidentiality/anonymity from
HCP, more specifically that
HCP will disclose sexual
orientation or testing results to
parents

Limitations :
1 ) Limited
recruitment;
only recruited
through one
social media

80

with providers,
feelings of
medical
mistrust,
experienced of
minority
discrimination
on 5 point
Likert Scale

Facilitators to STIpreventative
services:
1) HCPs asked about sexual
orientation and sexual habits
with AMSM

2) Highlighting and reiterating
anonymity and confidentiality
increased trusting relationships
between patient and provider—
increased likelihood of STI
testing

Secondary 5
point Likert
scale ( Medical
Mistrust Scale)
also completed
assessing
beliefs of
discrimination
and equity
towards AMSM
from healthcare
providers

Barriers to STI

Goldenberg,

8 weeks of

platform and
previous
projectparticipants may
be used to this
type of question
possibly
affecting
reliability of the
answers
2) Participants
were sampled
from a previous
national survey;
participants are
used to
answering
questions

3) Participant
demographics—
all college/high
school educated,
living at home ;
does not reflect
the experiences
of those with
lower
socioeconomic
status
1) Document

Barriers to testing:

Strengths:

81

testing among
youth in a
Canadian
oil and gas
community
Canada

Shoveller,
Koehoom, &
Ostry, 2008
CASP Rating: 7

periodic
fieldwork and
inclusion of indepth
interviews
Eight weeks of
field work
provided data
which
formulated indepth interview
questions

young peoples
experiences with
STI testing in
oil/gas community

1) Stigma, shame, social
discomfort
a. STI testing viewed negatively
ie) promiscuity, immoral

2) Gather service
providers
perspectives on
sexual health
delivery

2) Concerns about anonymity
and confidentiality especially
due to geographical location of
testing sites (oil and gas
community small)

3) Develop
recommendations

3) Limited information
regarding access to testing and
treatment, unclear what
concerning STI symptoms were,
unsure where to test, unclear
procedures related to STI testing

to increase

Sample males
47% with 8%
identifying
themselves as
participating in
sex with men
Males and
females aged
15-25 were
asked to
participant in
in-depth
interviews
(n=25), 14
service
providers also
participated in
in-depth

accessibility of
STI testing
extraction
communities

1) Captured
unique barriers
in a specific
population
group,
considered
migration and
rurality as an
impact on sexual
health
2) Data
collection
occurred
through four
seasons to
account for
seasonal barriers
ie)

4) Operational barriers a .
inconvenient hours, long wait
transportation in
times
the winter
.
,
unclear
b
appointment process
no walk in process when booked
appointments unavailable
5) Provider related barriers
a. discomfort in taking histories,
rushed history taking—no
attempt to establish rapport and
build trust
b. lack of understanding of STI
prevalence and testing
c. unfamiliar with testing

Limitations:
1) Data relevant
to smaller rural
areas, many not
be generalizable
to larger
populations;
rural barriers
may be different

82

interviews

Specific
interview
domains were
not explicitly
discussed

Men Who Have
Sex With Men:
Perceptions About
Sexual Risk, HIV
and Sexually
Transmitted
Disease Testing,
and Provider

( Mimiaga,

Goldhammer,
Belanoff, Tetu, &
Mayer, 2007 )

MMAT Rating: 15

Mixed methods
study

Identify perceived
barriers to sexually
transmitted
infections and HIV
Respondent
driven sampling screening in
Boston men who
technique
(ongoing
have sex with men
recruitment

procedures and guidelines
d . mistrust of providers as they
were not regular providers of
patients
e . visible discomfort by
providers ( lack of eye contact,
refusal to test patients,
derogatory comments)

Primary reasons for seeking
testing:
1) event driven ie) risky sex,
recent notification of positive
contact
2 ) prevention driven ie) as part
of routine care;
3)socially driven ie ) entering

to urban barriers

2) Participants
were all field
workers in
oil/gas industry,
may have
different
experiences and
circumstances
that are not
relatable to the
larger
population

3) No
discussions on
facilitators to
STI testing or
discussion on
how to improve
despite this
being a study
aim
Respondent
driven sampling
technique seeds may have
potentially
introduced
participant bias
by recruiting

83

Communication

from
participants)

United States

Participantsmales selfidentified as
MSM or gay,
bisexual >18
years of age
Semi structured
interviews with
follow up
quantitative
survey (n=50 )

Interviews
assessed sexual
behaviours,
sexual health
characteristics,
barriers to
testing,
discrimination
from healthcare
providers

new relationship,
encouragement from
community, family and friends,
following peer norms

Primary> reasons for not testing:
1 ) lack of symptoms, perceived
low risk of STI/HIY acquisition,
2 ) dislike of anogenital swabs
3) fear of lack of confidentiality
and anonymity,
4) lack of information regarding
testing
Perceived barriers to testing:
1 ) fear of results
2) denial of risk
3)drugs and alcohol as a barrier
to testing,
4 ) lack of information regarding
testing sites and what treatments
were available,
5) social stigma, discrimination
from HCPs, antigay bias
Ideal STD/HIV testing scenario:
1 ) gay positive, normalized
STD/HIV, culturally competent,
friendly testing environment;
2) compassionate, respectful,
nonjudgmental HCP;
3) anonymous testing- avoid
results and documentation to be

participants who
have increased
knowledge or
previous bias of
STD/HIV
screening

84

accessed by guardians or
parents

Places and people:
the perceptions of
men who have sex
with men
concerning STI
testing: a
qualitative study
United Kingdom

Datta et ah , 2018
CASP Rating: 7

Qualitative,
focus groups
(10 participants
per group)

Recruited 61
males self identified as
MSM or gay,
bisexual; <26
years of age
n=22

Focus groups
explicitly
discussed
experiences of
sexual health
services and
knowledge,
attitudes
towards STIs

Explore
experiences and
views of MSM
attending sexual
health clinics and
their experience of
sexual health
services

Facilitators to accessing care:
1) fear of infection, routine care
and regular check-ups
2) concern over self or partner’s
sexual health; staff qualities professional
3) discreet, and knowledgeable,
non-judgemental
Barriers to accessing care:
1) disclosure of sexual identity,
being ‘outed,’ social risks of
being identified in smaller
communities
2) physical space of the clinic—
location of the clinic or labels
deterred screening
3) perceived negative societal
stereotypes prevent MSM from
accessing sexual health services
ie) promiscuity, deviancy, and
undesirability
4 ) power positions from HCPs,
pressure and negative
stereotypes dissuade MSM from
accessing care

Strengths:
1) Findings were
explicit and
clear, analyses
of the data was
also clear
Limitations :
1) Focus groups
may have

discouraged
open and honest
opinions about
said topics;
participants may
feel fearful or
judged
depending on
their answer
2) Limited
information on
how
development of
focus group
questions
occurred
3) Responses
and experiences

85

Providing
comprehensive
health services for
young key
populations:
needs, barriers,
and gaps, 2015

Sinead DelanyMoretlwe, Frances
M Cowan, Joanna
Busza, Carolyn
Bolton-Moore,
Karen Kelley and
Lee Fairlie

International
including Canada,
United States, and
United Kingdom

CASP Rating: 7

Systematic
reviews of
health services
relevant to
young
populations
including
mental health,
STI

Systematic
search of
electronic
databases
including
PubMed and
Google Scholar
Studies
published from
1990- 2015

Focused on
young
populations
aged 10-24 of
varying

Understanding
what the health
care needs,
barriers, and gaps
are for youth aged
<26

Personal barriers to STI
screening:
1 ) Lower levels of education,
younger age
2) decreased perception of risk
3) lack of sexual experience,
4) internalized stigma - self
endorsement of negative
connotations of gender and
sexual activity
Healthcare provider barriers:
1) Stigma, discrimination by
HCP
2) lack of confidentiality and
privacy
3) Poor attitudes from HCPs, no
discussion surrounding sexual
health/orientation or discomfort
4) Discomfort in discussing
sexual health with adults as
authority figures
Organizational barriers
1 ) Cost, wait times
2) Location of clinic, lack of
transport to get there

may not be
generalizable to
the larger MSM
population given
small sample
size
Strengths:
1) Inclusion of
perceptions of
males of varying
ethnicities,
socioeconomic
groups, and
gender diversity
to obtain robust
literature of
health needs
2) Study aims
were congruent
with study
methodology
Limitations :
1) Use of
PubMed and
Google Scholar
to exclusively
search for
literature may
have limited the
number of
studies included

86

socioeconomic

Systems barriers:
1) Legalities fear that minors
need parental permission for
treatments, procedures;
concerns surrounding disclosing
orientation to peers and parents

statues, gender,
and sexual

—

identity
Number of
young men who
have sex with
men were not
identified

Low Rates of
Human
Immunodeficiency
Virus Testing
Among
Adolescent Gay,
Bisexual, and
Queer Men

United States

Quantitative
Phillips, Ybarra,
Prescott, Parsons,
survey
& Mustanski, 2015
Recruitment

CASP Rating:

through
Facebook
advertising
Males aged 1418 (n=19)

Investigate testing
behaviours and
barriers among
national young
gay, bisexual men

Barriers contributing to low
rates of testing:
1) HIV testing knowledge
influenced testing behaviours
never tested or did not know
where to test

—

2) Fear based barriers:
fear of being positive, fear of
disclosing to family and friends,
fear of losing community and

interpersonal relationships
Nine item scale
adapted from
previous
studies,
domains not
identified in
study

3) Lack of perceived risk
surrounding STIs prevented
testing

in the systematic
review;
alternative
databases such
as Medline
could have been
used
2) Lack of
information
regarding
literature
evaluation tools
for studies
Strengths:
1) Clear
methodology
including data
analyses
2) Focused
exclusively on
adolescent
MSM rather
than grouping
them in with
larger MSM
population or
youth
population
Limitations :
1 ) May not

87

extend to young
men who have
sex with men
that do not
identify as gay
or bisexual

2) Self-reported
data- may be
affected by
personal bias or
may be false
information;
little
information
from researchers
on how this was
prevented

Barriers to HIV
Testing Among
Young Men Who
Have Sex With
Men
(MSM):
Experiences from

Pharr, Lough, &
Ezeanolue, 2016

Qualitative
study

CASP Rating: 8

Focus group
discussions,
participants
n= l l , semi

Understanding the
barriers
experienced by
young MSM when
accessing HIV
testing

Personal factors as barriers to
screening:
1) Low perception of HIV/STI
acquisition

3) No
identification in
the study of
what items or
domains
consisted of in
the study
Strengths:
1) Study
methodology
congruent with
study purpose

2) Lack of
awareness/knowledge about STI 2 ) ) Focused

88

Clark County,
Nevada

structured
interviews
conducted by
two researchers

United States

Sample ( n= l 1),
young gay men
aged 18-24

and HIV testing in general,
aware that infections are spread
sexually but lacking information
regarding the importance of
testing
3) Fear of being positive,
rejection, and disclosure; fear of
‘being outed’ (parents and peers
finding out sexual orientation);
HIV as a gay disease, fear of
rejection from family and
community

4) Lack of self -confidence/selfesteem to search more about
HIV and testing
System level/organizational
factors:
1) Transportation to clinic,
location of clinic, hours of
operation, costs incurred
prevented STI testing

exclusively on
young MSM
rather than
grouping them
in with larger
MSM
population or
youth
population

Limitations :
1) Small sample
size, not
generalizable to
larger MSM
population as
there were only
11 participants
in total in focus
group

2) Authors
failed to provide
2) Stigma ; HIV as a gay disease, further detail
lack of support from community and clarity of
and family
subjective
answers from
participants, ie)
3) Unfriendly testing
environments, unprofessional
lack of self and unfriendly HCPs;
confidence,
disapproval from HCPs
disapproval

89

from HCPs

Narrative review
of the barriers and
facilitators
to chlamydia
testing in general
practice
United Kingdom,
Ireland, New
Zealand , Australia

Yeung, TempleSmith, Fairley, &
Hocking, 2015

SANRA Scale
Rating: 8

Narrative
review of
studies
collected
through six
databases;
studies
conducted in
the UK, Ireland,
New Zealand or
Australia

Participant
demographics,
male and
females aged
15-25 with
differing sexual
identities
including
heterosexual,
gay, bisexual
Number of
males identified
as MSM, gay,
bisexual was
not identified
Systematic

Identify barriers
and facilitators to
chlamydia testing
in primary care
settings from the
patient and general
practitioner level

Barriers to chlamydia testing at
patient level:
1) Perceptions of being
judged—stigma, embarrassment
and questionable morals if
completed testing, testing was
considered dirty and negatively
marked individuals; younger
patients felt uncomfortable
discussing sexual health issues
with GP for perceptions of
above; younger patients had
increased concerns about
confidentiality and privacy
2) Poor knowledge around
STIs—unfamiliar with what
chlamydia was, little knowledge
of risk factors and infection, led
to belief of low infection risk;
lack of accurate infonnation
around testing procedures

—

3 ) Accessibility unaware of
where testing sites were, costs,
feeling rushed during
appointments
Barriers to chlamydia testing at
GP level:

Strengths:
1) Inclusion of
perceptions
young
individuals
varying
ethnicities,
socioeconomic
groups, and
gender diversity
to obtain robust
literature of
health needs
2 ) Study aims
were congruent

with study
methodology
Limitations :
1) Selected
studies limited
to UK, Ireland,
New Zealand,
and Australia—
other barriers in
other countries
were not
addressed

90

search of six
electronic
databases
including:
Medline,
PubMed,
Meditext,
Psychlnfo,
Scopus, Web of
Science
Studies
published
between 19972013

1) Time and workload
constraints—heavy workload ,
lack of time prevented GPs from
addressing sexual health
concerns and testing for
chlamydia, standard
consultation did not allow
sufficient time to introduce
testing and STI education
2) Lack of knowledge and
capacity lack of knowledge,
skill, and awareness around
chlamydia testing, unaware of
risk factors and testing protocols
ie ) urine test for chlamydia,
reported lack of training in
medical school surrounding
STIs in general

—

3) Patient related issues—lack
of funding, resources, and
services contributed to inability
to test or to refer for testing ie)
no printed resources, no
appropriate testing equipment,
legal concerns surrounding
partner notification hindered GP
ability to carry around testing
for patients

4) Fear of appearing
discriminatory

—feared they

2) Attempts to
make selection
process of
papers clear but
explicit search
criteria not
addressed in
paper; possible
for selection
bias and little
generalizability

91

would offend patients if testing
offered, increased sensitivity in
this matter if a different culture
from the GP

Facilitators at the patient level:
1) Normalization of testing—
testing initiated by GP,
reinforced autonomy and shared
decision making over care;
framing testing as preventative
care of benefiting self and
partners, reinforcing privacy
and confidentiality by the GPs
increased trusting relationships
and normalized testing
2) Education—increased
awareness of chlamydia and
testing in general practices and
community leaves patients more
informed to seek health and
testing accordingly, increased
education about chlamydia
when GP initiated the
conversation which allows
patients to feel more prepared
and at ease

3) Access to testing and services
patients more likely to test if
given choices around urine or
swabs; free sexual health testing

-

92

facilitated testing

4) Patient comfort with general
practice preferred health-care
like settings as they felt more
prepared to accept interventions
and sexual health consultations;
younger and same sex as patient
preferred ( perceived to be less
judgemental)

—

Facilitators at the GP level:
1) Remembering to
test/normalization of testingreminders to offer testing to
eligible patients either through
charts or electronic reminders;
non-heteronormative
terminology theorized to reduce
stigma around testing and
sexual habits
2)
Education/awareness/training—
better education, awareness and
training facilitated STI testing
but little evidence and data on
what specific type of education
was needed to impact testing

3) Use of practice staff —clinic
nurses and practice staff as a

93

way to reduce pressures on GPs;
considering nurse-led practice to
facilitate STI testing (reducing
time burden on GPs)

4) Supportive infrastructure—
adequate resources to track
testing histoiy or electronic
computer prompts to test;
adequate supplies of testing kits
such as urine kits and swabs