Area-based comparison of risk factors and testing rates to improve sexual health care access: cross-sectional population-based study in a Dutch multicultural area

Abstract

Objectives: Areas with high sexually transmitted infection (STI) testing rates may not require additional strategies to improve testing. However, it may be necessary to intervene in areas with elevated STI risk, but with low STI testing rates. We aimed to compare STI-related risk profiles and STI testing rates by geographical area to determine areas for improvement of sexual healthcare access.

Design: Cross-sectional population-based study.

Setting: Greater Rotterdam area, the Netherlands (2015-2019).

Participants: All residents aged 15-45 years. Individual population-based register data were matched with laboratory-based STI testing data of general practitioners (GPs) and the only sexual health centre (SHC).

Outcome measures: Postal code (PC) area-specific STI risk scores (based on age, migratory background, education level and urbanisation), STI testing rates and STI positivity.

Results: The study area consists of approximately 500 000 residents aged 15-45 years. Strong spatial variation in STI testing, STI positivity and STI risk was observed. PC area testing rate ranged from 5.2 to 114.9 tests per 1000 residents. Three PC clusters were identified based on STI risk and testing rate: (1) high-high; (2) high-low; (3) low, independently of testing rate. Clusters 1 and 2 had comparable STI-related risk and STI positivity, but the testing rate differed greatly (75.8 vs 33.2 per 1000 residents). Multivariable logistic regression analysis with generalised estimating equation was used to compare residents in cluster 1 and cluster 2. Compared with cluster 1, residents in cluster 2 more often did not have a migratory background, lived in less urbanised areas with higher median household income, and more distant from both GP and SHC.

Conclusion: The determinants associated with individuals living in areas with high STI-related risk scores and low testing rates provide leads for improvement of sexual healthcare access. Opportunities for further exploration include GP education, community-based testing and service (re)allocation.

Keywords: epidemiology; health services accessibility; public health; registries; sexually transmitted disease.

Figure 1

Plots per postal code area, the greater Rotterdam area, the Netherlands (2015–2019). White dot in the geographical plots represents the central sexual health centre. (A)STI testing rate (per 1000 residents). (B)STI positivity (%): residents with a positive test out of number of residents tested. (C)Mean community STI risk scores based on age, migratory background, education level and urbanisation. (D)Mean community STI risk score versus STI testing rate classified in three clusters. The maps were generated using ggplot in R (version 3.6.2). STI, sexually transmitted infection.