Barriers and facilitators to knowledge and awareness around sexually transmitted and blood-borne infections (STBBIs)–related preventive measures among Black populations across Canada: a systematic review

Abstract

Objective

The objective of this systematic review was to identify and analyze the barriers and facilitators to knowledge and awareness of sexually transmitted and blood-borne infections (STBBIs) among Black populations in Canada. This review specifically focused on three key areas: general awareness of STBBIs, knowledge of STBBI prevention, and knowledge of STBBI testing.

Methods

A comprehensive search was conducted using five databases: OVID Embase, OVID Medline, CINAHL, and Scopus. A total of 1261 studies were initially identified, with 24 meeting the eligibility criteria, limited to studies published between 1990 and 2023. All eligible studies included in the review underwent quality assessment.

Synthesis

The review identified 57 barriers and 12 facilitators to STBBI knowledge. Key barriers included stigma, cultural norms, inadequate healthcare resources, lack of cultural competence among healthcare providers, and limited access to information and services. Facilitators included access to AIDS Service Organizations, culturally informed dissemination strategies, supportive family and community networks, and effective communication between parents and children. The Social Cognitive Theory (SCT) was used to interpret these findings, focusing on the role of observational learning, self-efficacy, and social support in knowledge acquisition and health-seeking behaviours, and to guide recommendations for future actions.

Conclusion

The findings highlight significant barriers and facilitators to STBBI knowledge among Black populations in Canada. Addressing these barriers and leveraging the identified facilitators, through interventions informed by the SCT, are recommended to improve STBBI knowledge and health outcomes among these communities.

Supplementary information

The online version contains supplementary material available at 10.17269/s41997-025-01069-7.

Introduction

Sexually transmitted and blood-borne infections (STBBIs) pose a significant public health challenge in Canada. The burden of STBBIs, which includes infections such as chlamydia, gonorrhea, hepatitis A, B, and C, HIV/AIDS, and human papillomavirus (HPV), continues to rise, with notable increases observed over the last 10 years (PHAC, 2022). These infections not only cause substantial morbidity and mortality, but also have a significant economic impact on the healthcare system (PHAC, 2021). Recent reports by the Public Health Agency of Canada (PHAC) highlight the urgency of addressing the rising rates of STBBIs in Canada (PHAC, 2022). Despite advancements in medical treatments and prevention strategies, the rates of infections persist, particularly among racialized communities, youth, and young adults. These populations are disproportionately affected by STBBIs, with significant disparities in infection rates compared to other demographic groups (Logie et al., 2016; PHAC, 2022).

Efforts to mitigate the spread of STBBIs have often focused on comprehensive education, awareness programs, and workshops targeting vulnerable populations. These initiatives are instrumental in disseminating crucial information regarding STBBI prevention, transmission, and testing. Importantly, such programs foster a culture of sexual health literacy, empowering individuals to make informed decisions regarding their sexual health (Bajaj et al., 2017; Haghir et al., 2018). Education and awareness workshops have been shown to enhance knowledge, reduce risky sexual behaviours, and increase the uptake of preventive measures, thereby reducing STBBI rates (Laprise & Bolster-Foucault, 2021; Lee-Foon et al., 2022).

However, despite the recognized importance of STBBI education and awareness programs, significant gaps remain in understanding their effectiveness, particularly within specific demographic groups such as Black populations in Canada. A Canadian study showed that HIV rates in Black populations, particularly women, were seven times higher than their counterpart white population (Logie et al., 2016). Another Canadian study showed “50.0% of perinatally HIV-exposed infants were from the Black race/ethnicity, while 23.3% were reported as Caucasian and 18.1% as Indigenous” (Haddad et al., 2018). Certain subpopulations in Canada, including African, Caribbean, and Black (ACB) population, men who have sex with men (MSM), injection drug users (IDUs), and Indigenous peoples, also experience disproportionately high rates of both bacterial and viral STIs, including HIV, herpes, syphilis, and human papillomavirus (HPV). Although there is limited race-based data on STI prevalence specifically within Black populations, another recent study conducted in the Greater Toronto Area (GTA) found that Black women have significantly higher rates of viral STIs such as herpes, cytomegalovirus (CMV), and HPV compared to the general Canadian population (Nelson et al., 2019; Remis et al., 2013). Additionally, the prevalence of HIV, syphilis, hepatitis B, anal HPV, and penal HPV was high in Black men, with an increase among MSM compared to men who have sex with women (MSW) (Nelson et al., 2019).

These statistics reflect a critical health disparity and highlight the importance of targeted interventions within Black communities. Black communities face unique socio-economic and cultural challenges that can influence access to healthcare services, including STBBI education and testing (Lambert et al., 2022). Moreover, research indicates that there are disparities in knowledge and awareness of STBBIs among racial or risk groups, with Black populations often reporting lower levels of sexual health knowledge and awareness (Marshall et al., 2009).

Understanding the barriers and facilitators to knowledge regarding STBBIs among Black populations is essential for developing targeted interventions that address their specific needs and reduce the disproportionate impact of STBBIs within this population (Marshall et al., 2009). In this systematic review, we examine the following research question: What are the barriers and facilitators to STBBI knowledge, specifically regarding awareness, prevention, and testing, within Black populations in Canada? We synthesized existing evidence to provide insights specifically on barriers and facilitators related to three key knowledge types: (1) awareness of STBBIs in general, (2) knowledge on STBBI prevention, and (3) knowledge on STBBI testing. To underpin the study findings, we use the Social Cognitive Theory (SCT), developed by Albert Bandura, which highlights that individuals learn through the interactions between intrapersonal, behavioural, and environmental factors (Gibson et al., 2004; Luszczynska & Schwarzer, 2015). This theory can help explain that lower awareness and knowledge of STBBIs in the Black population may stem from a combination of social norms, observational learning, and environmental factors. These elements interact to shape attitudes and behaviours towards sexual health, ultimately contributing to why these populations are at greater risk of STBBIs. Other theories such as the Health Belief Model, the Theory of Planned Behavior, and the Transtheoretical Model were considered to underpin this study; however, the SCT was the most fitting as it focused on factors influencing one’s knowledge rather than health behaviour. The findings of this review can inform the development of culturally sensitive and effective strategies for STBBI prevention, ultimately achieving the goal of the Pan-Canadian STBBI Framework for action: reducing the health impact of sexually transmitted and blood-borne infections in Canada by 2030 (PHAC, 2018).

Methods

This systematic review is presented according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 (Page et al., 2021). A protocol for this study is registered in the international prospective register of systematic reviews, PROSPERO CRD42023423026 (Girmay et al., 2023).

Search strategy

A comprehensive search was conducted in OVID Embase, OVID Medline, CINAHL, and Scopus, using a search strategy developed by a librarian with input from the first author and the research team. The searches were executed between March 17, 2023, and May 12, 2023. A publication date limit was applied to only retrieve studies published after 1990. The search strings for all databases are provided in Appendix 1. Examples of key terms used to conduct the search include “STBBI,” “STI,” “Knowledge,” “Black,” “Caribbean,” and “African continental ancestry group” which is one of the Medical Subject Headings (MeSH) terms used to describe a subgroup of Black populations in the National Library of Medicine’s controlled vocabulary thesaurus.

Eligibility criteria

The systematic review included articles written in English and published after 1990 (Table 1). Publications needed to be primary research studies (using any type of study design) published in scholarly journals. Publications had to include information or data about at least one of the following outcomes among Black populations in Canada: barriers or facilitators to knowledge around STBBI awareness, prevention, or testing. If the publication included multiple countries or were global in nature, they were eligible if they included disaggregated data for Canada. A detailed summary of the inclusion and exclusion criteria is provided in Table 1.

Table 1.

Summary of inclusion and exclusion criteria

Selection criteria	Inclusion criteria	Exclusion criteria
Publication characteristics
Language	English	Studies written in a language other than English
Publication type	Scholarly journal article	Reference source (e.g., encyclopedia, handbook, textbook), book, book chapter, trade journal article, newspaper article, magazine article, dataset or data table, website, or webpage
		Gray literature
Publication date	Published in the year 1990 and onward	Published before the year 1990
Study design	Primary study (quantitative, qualitative, or mixed-methods design)	Secondary study (review)
Study characteristics
Exposure	Sexually transmitted and blood-borne infections (STBBIs): HIV/AIDS, gonorrhea, chlamydia, hepatitis B, Hepatitis C, epididymitis, genital herpes (HSV), genital warts and human papillomavirus (HPV), mucopurulent cervicitis (MPC), non-gonococcal urethritis (NGU), Pelvic inflammatory disease (PID), syphilis, Trichomonas Vaginitis	All other diseases that are not sexually transmitted and blood-borne infections (STBBIs)
Population	Black communities	Studies that do not include Black communities
Location	Canada	Studies that do not include data from Canada
Outcomes	Barriers related to knowledge and awareness around STBBI prevention and testing	Barriers that are not related to knowledge and awareness around STBBI prevention and testing
	Facilitators related to knowledge and awareness around STBBI prevention and testing	Facilitators that are not related to knowledge and awareness around STBBI prevention and testing

Study selection

The systematic review employed a four-step process to identify studies for inclusion. In the first step, all items retrieved from the database searches were imported into Covidence, a web-based software program that supports citation screening, full-text review, and extraction of study characteristics and outcomes (Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia). The next step involved using Covidence’s automatic deduplication function to remove all duplicates from the database searches. Following the removal of duplicates and a pilot test of the screening guidelines (detailed inclusion and exclusion criteria) to ensure a high level of reviewer agreement, studies were screened in two rounds. During the first stage, two authors independently performed title and abstract screening. In cases where there was insufficient information to draw a conclusion, the study was moved to the second stage of screening for full-text review. A third author resolved disagreements between reviewers. In the second round of screening, the two initial reviewers independently performed full-text screening of the remaining articles. A third reviewer resolved disagreements.

Quality assessment

The selected studies for data extraction underwent assessment using the Mixed Methods Appraisal Tool (MMAT), a critical appraisal instrument designed for systematic reviews encompassing qualitative, quantitative, and mixed methods studies. The MMAT involves a set of criteria to evaluate the methodological quality of these five study types, assigning scores on a scale from 0 (indicating low quality) to 4 (indicating high quality). A detailed breakdown of the tool and its application results is available in Appendix 3. This table presents scores ranging from 0 to 4 for all 23 studies, categorizing them as either low or high quality based on MMAT criteria. The table also outlines the questions used to assess each study’s quality, providing a comprehensive overview of the appraisal process. The assessment process consisted of two rounds of questions for each study. The initial round involved two screening questions related to the research question and data collection. In the subsequent round, each study was categorized into one of five study types (qualitative studies, quantitative randomized control trials, quantitative non-randomized studies, quantitative descriptive studies, and mixed-methods studies) and appraised using the MMAT according to study type. Each author independently appraised each study before collaboratively reaching a consensus during a joint discussion.

Data extraction

Two authors performed a pilot extraction exercise of the following data items from one of the four studies: country of study, study title, year of publication, intervention, study method, study objective, and population, to standardize the data extraction process (Appendix 2). In addition, the outcomes of interest (barriers and facilitators to knowledge around STBBI awareness, prevention, and testing) were also extracted from each article (Tables 2 and 3). Following the pilot extraction exercise, the two authors conducted the data extractions from each article in separate documents independently to minimize bias. The two authors then met to discuss and reach consensus on any discrepancies or differences between their extractions. A third author reviewed the conflicting extractions and resolved any remaining issues to ensure the accuracy and consistency of the final data.

Table 2.

Barriers to knowledge around STBBI awareness, prevention, and testing

	Barrier name(n)	Knowledge type	Representative excerpt	References
1	Disconnect with health care spaces (1)	Awareness, prevention and testing	“… a disconnect with health care spaces, … prevent heterosexual ACB men from openly discussing their vulnerability, testing for HIV, and seeking treatment.” (p. 5)	Antabe et al., 2021
2	Limited awareness of service availability (1)	Awareness, prevention and testing	“…limited awareness of … service availability … prevent heterosexual ACB men from openly discussing their vulnerability, testing for HIV, and seeking treatment.” (p. 5)	Antabe et al., 2021
3	Issues of stigma (1)	Awareness, prevention and testing	“…limited awareness of HIV risks and service availability…issues of stigma … prevent heterosexual ACB men from openly discussing their vulnerability, testing for HIV, and seeking treatment.” (p. 5)	Antabe et al., 2021
4	Cultural norms (1)	Prevention	“…their own cultures of their origins regarding sex negotiations, safer sex practice, discussions around sex and sexuality and related areas, which hugely affect the ability of partners to negotiate on prevention methods, on condom issues … (Interviewee 6, Paragraph 18)” (p. 7)	Amibor & Ogunrotifa, 2012
5	Lack of cultural competence from Health Care Provider (HCP) (1)	Prevention	“…a lack of cultural competence … with the communities being served on the part of HIV-prevention service providers, could often act as a barrier to the uptake of these services by the target populations” (p. 5)	Amibor & Ogunrotifa, 2012
6	Health Care Providers (HCPs) poor identification with community (1)	Prevention	“…poor identification with the communities being served on the part of HIV-prevention service providers, could often act as a barrier to the uptake of these services by the target populations” (p. 5)	Amibor & Ogunrotifa, 2012
7	Lack of healthcare resources (1)	Prevention	“A perceived significant factor that was felt to serve as a barrier to reaching the Afro-Caribbean populations with HIV-prevention services was the issue of a lack of resources.” (p. 7)	Amibor & Ogunrotifa, 2012
8	Low awareness of prevention services (1)	Prevention	“Some heterosexual ACB men who required preventive health services did not know of these services’ existence …” (p. 8)	Antabe et al., 2021
9	Parents imparting knowledge to their children about contraceptive methods with a limited emphasis on STI education and prevention (1)	Prevention	“Sexual health discussions between mothers and their teenagers typically centered on contraceptive methods to avoid pregnancy and seldom, if ever, focused on STIs, which, both parents and youth admitted, were seen as much less of a pressing reality compared to pregnancy.” (p. 4)	Davis et al., 2013
10	Limited access to information about PreP (1)	Prevention	“… access to information about PrEP is limited at the individual level, accessibility issues such as lack of information and location were identified. …” (p. 6)	Etowa et al., 2022a, b (2)
11	Marketing of PrEP/PEP geared towards Caucasian men (1)	Prevention	“Many focus group participants were not aware or did not have direct experience with the use of PrEP/PEP treatments. One of the main reasons why these treatments are not better known in ACB communities is because they were originally marketed as a drug for white gay men.” (p. 6)	Etowa et al., 2022a, b (2)
12	Lack of sexual health knowledge among religious leaders (1)	Prevention	“…lack of information and knowledge about sex, sexuality, and HIV transmission could contribute to misrepresentation and judgment. While talking about the role of religious institutions and leaders in the fight against HIV, participants emphasized the need to be better informed about preventing HIV in general so that they could pass on this knowledge to others.” (p. 1629)	Jangu et al., 2023
13	Religious leaders’ unwillingness to discuss condom use to congregation (1)	Prevention	“…participants suggested that they are unwilling to discuss matters such as condom use in front of their entire congregation, …” (p. 1627)	Jangu et al., 2023
14	Ineffective institutional efforts to disseminate PrEP information (1)	Prevention	“Participants’ responses revealed institutions’ (e.g. sexual healthcare clinics) efforts at disseminating PrEP information had been largely ineffective in reaching them and, in turn, informing their PrEP knowledge. …” (p. 306)	Lee-Foon et al., 2022
15	Delays in getting PrEP knowledge from institutions (1)	Prevention	“… trying to access PrEP knowledge from institutions and delays in getting this knowledge to help reduce their HIV risk.” (p. 307)	Lee-Foon et al., 2022
16	Lack of readily available PrEP information (1)	Prevention	“… trying to access PrEP knowledge from institutions and delays in getting this knowledge to help reduce their HIV risk.” (p. 307)	Lee-Foon et al., 2022
17	Lack of PrEP promotion in sexual and/or primary healthcare settings (1)	Prevention	“PrEP was not a commonly promoted HIV prevention strategy at a place where they frequently sought sexual and/or primary healthcare. Even attempts to advertise PrEP in places frequently accessed by youth failed to provide the information…” (p. 306)	Lee-Foon et al., 2022
18	Perceptions of PrEP cost informs knowledge of PrEP access (1)	Prevention	“… The only thing that really kind of stopped me [using PrEP] was and I didn’t ask about it either, is I thought that … this probably isn’t covered by OHIP [Ontario Health Insurance Plan] or whatever. …So, you know I just didn’t really ask about it because … I don’t have money for this [PrEP]. …” (p. 307)	Lee-Foon et al., 2022
19	PrEP stigma (1)	Prevention	“PrEP stigma … deterred some from enhancing their PrEP knowledge in the virtual world.” (p. 309)	Lee-Foon et al., 2022
20	Sociocultural and structural obstacles (1)	Prevention	“… HIV prevention barriers include sociocultural and struc­tural obstacles to Black women’s engaging with HIV prevention information and services” (p. 832)	Newman et al., 2008
21	Concern of access to safe sex information translating to encouragement for youth to practice sex (1)	Prevention	“In addition, women expressed concern that access to safer sex information was encouraging youth to have sex… ‘Now, because the condom is being introduced, nobody tell the children to have sex, but you find that the majority of young children at an early age is’…” (p.16)	Williams et al., 2009
22	Distrust due to stigma (1)	Awareness	“…the main difficulty is in building trust with the community, because there still is a lot of stigma… that alone may kind of even shut people down from wanting to even engage or talk about the topic or even talk about their risk factors for it (Interviewee 5, paragraph 14)” (p. 6)	Amibor & Ogunrotifa, 2012
23	Inequitable access to health services due to race and racism (1)	Awareness	“Race and racism and these are key issues, which affect people’s abilities to access health care and people’s abilities to access other institutions and other ‘carers’ that would help reduce their risk for HIV” (interviewee, paragraph 19) (p. 7)	Amibor & Ogunrotifa, 2012
24	Lack of cultural sensitivity (1)	Awareness	“I would not be OK if someone specifically walked up to me and [said], hey, here is an HIV thing because you are most likely to be susceptible…I would ask, so you are saying because I am an ACB man and more likely to be susceptible you are just pushing it on me… (FG, 16–24)” (p. 10)	Antabe et al., 2021
25	Lack of cultural competence (1)	Awareness	“I would not be OK if someone specifically walked up to me and [said], hey, here is an HIV thing because you are most likely to be susceptible…I would ask, so you are saying because I am an ACB man and more likely to be susceptible you are just pushing it on me… (FG, 16–24)” (p. 10) “Information dissemination that tends to put ACB men on the spot and overly emphasizing them as especially vulnerable may lead to poor reception of this information and the use of recommended services.” (p. 10)	Antabe et al., 2021
26	Lack of funding for community health programs (1)	Awareness	“ACB men alluded to a lack of funding for social and health programs … that could increase awareness and access to HIV preventive healthcare.” (p. 10)	Antabe et al., 2021
27	Misconceptions about vulnerability (1)	Awareness	“… lingering misconceptions that heterosexuals may be immune to contracting HIV. For instance, given misconceptions about HIV being a ‘gay disease,’…” (p. 6)	Antabe et al., 2021
28	Stigma through information dissemination (1)	Awareness	“…they noted that the stigma associated with these realities also served as a barrier to using health services. In disseminating HIV in- formation…” (p.10)	Antabe et al., 2021
29	Lack of education (1)	Awareness	“…lack of education on HIV transmission work to reduce HIV risk perceptions among some ACB men.” (p. 8)	Antabe et al., 2021
30	Access to information (1)	Awareness	“Access to information for this participant is a key protective asset …” (p. 7)	Antabe et al., 2023
31	Health authorities lack of appropriate health information dissemination through the family system (1)	Awareness	“Some participants blamed the failure of health authorities to appropriately disseminate health information through the family system for some of the sexual and reproductive health challenges in the Black community.” (p. 8)	Antabe et al., 2022
32	Exclusion from the health policy environment (1)	Awareness	“Participants reflected that they have been left out of the health policy environment and observed that their exclusion or marginalization has had adverse repercussions on how health institutions and experts understand Black men’s health….…institutional health literacy constitutes a direct medium to achieving institutional goals, as it requires changing the current deficit approach to an asset-based one that works with the strengths and resilience of Black individuals in HIV information dissemination.” (p. 10)	Antabe et al., 2023
33	Gendered nature of [sexual] health communication by parents (1)	Awareness	“…women, and mothers in particular, identified themselves as the ones who discussed sexual health-related is- sues with their children in the home [33]. One female parent noted, ‘Fathers have a tendency not to talk about too many things. It’s more the mother’….” (p. 3)	Davis et al., 2013
34	Fear of parents’ reaction (1)	Awareness	“Fear and … often the feelings expressed by participants when it came to discussions of sex,… and sexual health… the fear and uncertainty that came with not knowing how their parents might react to their questions…” (p. 4)	Davis et al., 2013
35	Uncertainty of parents’ reaction (1)	Awareness	“…and uncertainty were often the feelings expressed by participants when it came to discussions of sex,… and sexual health… the fear and uncertainty that came with not knowing how their parents might react to their questions…” (p. 4)	Davis et al., 2013
36	Parents’ uncertainty of appropriate sexual health communication (1)	Awareness	“…uncertainty about how best to go about the task of educating their children on a topic that they had received such little advice. What should they say? When should they say it?…” (p. 4)	Davis et al., 2013
37	Parents’ lack of sexual health knowledge (1)	Awareness	“Another participant from the same focus group asked, ‘How can you impart your knowledge, if you don’t have any knowledge?’…” (p. 4)	Davis et al., 2013
38	Inaccurate sexual health information from peers (1)	Awareness	“…to discuss sex and sexual health, a number of participants cited having had discussions with friends that they may not have felt comfortable having with anyone else. In retrospect older participants agreed that the information provided by peers was not always accurate or helpful…” (p. 7)	Davis et al., 2013
39	Parents time constraints (1)	Awareness	“Several of the Black parents explained how they were often too busy working several jobs or long hours at one job, and as a result they had less face-to-face time with their children…” (p. 7)	Davis et al., 2013
40	Lack of HIV awareness among primary health care providers (1)	Awareness	“…. Even when ACB community members had a regular health care provider, the lack of HIV awareness among health providers was a recurring theme….” (p. 5)	Etowa et al., 2022a, b (2)
41	Religious influence on comfort of sexual health discussion (1)	Awareness	“Participants mentioned that often religion influenced how comfortable families were discussing sexual health……A lot of people in the Black family have come from a religion where [HIV] is taboo...” (p. 3527)	Fante-Coleman et al., 2019
42	Discussions of sex being taboo (1)	Awareness	“In instances where discussions about sex did occur, it was often after youth had become sexually active. … One participant stated, ‘I feel like it’s more of a taboo to talk about anything sexual within the family’….” (p. 3527)	Fante-Coleman et al., 2019
43	Lack of information about HIV in Canada (1)	Awareness	“Some participants noted that there was a lack of information about HIV in Canada compared to ‘back home’. …” (p. 720)	Gardezi et al., 2008
44	Lack of sexual health discussion in homes or communities (1)	Awareness	“Both African and Caribbean participants reported that, for the most part, sex, sexuality and physical or psychological health issues were rarely discussed… also impedes access to information about HIV or sexualhealth,…” (p. 721)	Gardezi et al., 2008
45	Misconception of HIV being a ‘‘gay disease’’ (1)	Awareness	“Caribbean participants discussed the belief that HIV is a ‘gay disease’, and the simultaneous denial of homosexuality, as components of HIV denial in their communities. … indicating attitudes that continue to distance HIV from community life.” (p. 722)	Gardezi et al., 2008
46	Religious misconceptions of susceptibility to HIV (1)	Awareness	“There is an assumption that HIV does not infect people who are following their religion. …” (p. 722)	Gardezi et al., 2008
47	Lack of open discussion between parent and child (2)	Awareness	“most participants believed parents found it difficult to engage… some parents had indirect parent-youth sexual health conversations that were often rigid and didactic, leaving young people with little or no input in the conversation.” (p. 1351)	Lee-Foon et al., 2018
			“The parents don’t discuss these affairs directly with their children. The parents need to be open with their children about the effects of HIV and how they can acquire it…” (p. 85)	Ngobi et al., 2020
48	Parents lack of sexual health education/awareness (1)	Awareness	“… the limited exposure to sexual health information many parents received through school or a lack of sexual health conversations with their own parents rendered it difficult to provide sexual health guidance to their own offspring.” (p. 1352)	Lee-Foon et al., 2018
49	Lack of respect when seeking or receiving HIV information (1)	Awareness	“Participants also reported feeling as if they are not treated with respect when seeking or receiving HIV information. …. There is an inherent assumption even if I explain to her I don’t think she’s smart enough to get it, so they just leave you struggling with very limited understanding” (p. 837)	Newman et al., 2008
50	Discomfort talking about sex with parents (1)	Awareness	“most respondents noted that they were uncomfortable talking about sex matters with their parents.” (p. 434)	Omorodion et al., 2007
51	Discomfort talking about sex with HCP (1)	Awareness	“‘Health providers can be judgemental just like parents, so I am uncomfortable talking”(p. 435)	Omorodion et al., 2007
52	Influence of cultural beliefs (1)	Awareness	“Participants who reported that cultural beliefs influenced infant feeding choices (OR = 0.133, p =.004) were less likely to have guideline awareness.” (p. 6)	Phillips et al., 2020
53	Lack of sexual health clinics (1)	Awareness	“Participants highlighted a lack of sexual health clinics in Toronto (Table 1). Moreover, some were difficult to access because they were not ‘on a major transit route.’” (p. 4)	Rana et al., 2022
54	Reluctance to seek information from HIV/AIDS organizations due to homophobia and HIV-related stigma (1)	Awareness	“There was reported reluctance to seek information from HIV/AIDS organizations because of homophobia and HIV stigma…” (p. 16)	Williams et al., 2009
55	Physicians’ difficulty sharing HIV education to patients with presence of parents (1)	Awareness	“The hazards associated with seeking HIV information were echoed by the physician. She recounted the difficulty of educating to young people who were monitored closely by parents and reluctant to ask questions that might imply interest in sex…” (p. 16)	Williams et al., 2009
56	Incomplete health information on available services in Canada (1)	Awareness	“… As one Jamaican man explained: ‘Yes, they tell us about that [HIV/AIDS and STIs], but they don’t tell us where to go here in Canada’…” (p.378)	Narushima et al., 2016
57	Difficulty locating sexual health services (1)	Awareness	“One theme repeated among all focus groups was a ‘lack of knowledge in how to navigate the Canadian/Ontario health system,’ including confusion about their health care coverage and clinic locations…” (p. 379)	Narushima et al., 2016

(n) indicates the number of studies that identified the corresponding barrier name

Table 3.

Facilitators to knowledge around STBBI awareness, prevention, and testing

	Facilitator name(n)	STBBI knowledge type	Representative excerpt	References
1	Access to AIDS Service Organizations (ASOs) (1)	Awareness, prevention and testing	“Connecting ACB men to ASOs [AIDS Service Organizations] had the potential to not only inform them about HIV transmission, but also encourage HIV testing and treatment for those living with the virus” (p. 9)	Antabe et al., 2023
2	Television as a vaccine awareness source (1)	Prevention	"The most common source for acquiring vaccine awareness was television (n = 114, 87%).” (p. 998)	Sadry et al., 2013
3	Visiting sexual health clinics (1)	Prevention	“Having visited sexual health clinics showed a positive association with having correct knowledge of condom[s]” (p. 6)	Etowa et al., 2021
4	Socio-structurally informed dissemination strategies (1)	Prevention	“One participant’s comments highlighted the long-term impact institutions could have on young people’s PrEP knowledge when dissemination strategies were better tailored to the socio-structural factors that impact Black gay, bisexual and other men who have sex with men. …” (p. 307)	Lee-foon et al., 2022
5	Culturally informed dissemination strategies (1)	Prevention	“Following the [Healthy Love Workshop] HLW, participants explained they felt more confident… ‘I got more knowledge in the condom demonstration and especially the female condom use demonstration and safer sex tools…’”. (p. 756)	Logie et al., 2018
6	Sexual health service contact (1)	Awareness	“Knowledge was higher with more health service contact, …” (p. 760)	Mihan et al., 2016
7	Collaborative support of Family and Health Workers on Infant Feeding Guideline (1)	Awareness	“Participants who reported higher functional social support (OR = 1.1, p = 0.034) were more likely to have guideline awareness.” (p. 6) “As agents of functional social support, family members and health workers (e.g., nurses, physicians, social workers, other health care workers) influenced participants’ awareness of infant feeding guidelines and guided them in their infant feeding choices.” (p. 1)	Phillips et al., 2020
8	Health education during pre-departure medical screening (1)	Awareness	“Asked the sources of their knowledge, all groups mentioned that they learned it at the pre-departure medical screening in their home countries… During these medical screenings, sending countries often provide workers with basic health education about HIV/AIDS, STIs, and condom use….” (p. 378)	Narushima et al., 2016
9	Open line of communication (between parent and child) with child (1)	Awareness	“Many of the parents who had established good communication insisted on the importance of laying the foundation for discussions about sexual health by speaking honestly and openly with their children…” (p. 5)	Davis et al., 2013
10	Learning through meetings with peers and community health professionals (1)	Awareness	“…MFWs largely suggested that they would like to learn more information through meeting with fellow MFWs and community health professionals. …” (p. 378)	Narushima et al., 2016
11	Peers as catalyst for parent—child dialogue (1)	Awareness	“For the younger generation, peers also indirectly served as a catalyst for parent–child dialogue in a number of ways. First, some parents noted that because their children were at times attending class alongside classmates with advanced sexual health knowledge or experience at a younger age, they felt it was important to have a frank discussion with their child in order to safeguard them…” (p. 5)	Davis et al., 2013
12	Established communication with primary care physician (1)	Awareness	“Many preferred their primary care physician compared to sexual health clinics because of established and positive patient-physician relationships, which involved active listening and good communication.” (p. 3)	Rana et al., 2022

(n) indicates the number of studies that identified the corresponding facilitator name

Results

From the OVID Medline, OVID Embase, CINAHL, and Scopus databases, the title and abstracts of 1261 studies and the full text of the resulting 71 articles were screened for eligibility. Figure 1 shows the number of studies that passed through each phase of the process. There were 24 publications that met the eligibility criteria, and their data was extracted. The authors reached a consensus on the eligibility of all included studies.

Fig. 1.

PRISMA chart

Study characteristics

Type of study/methods

The 23 articles included in our study used a combination of several methods, including various qualitative (n = 18) and mixed methods (n = 6). Out of the 23 articles included in our study, two were interventional studies, and 21 were non-interventional studies. Both intervention studies used surveys to collect their data. The 21 non-intervention studies used a combination of in-depth semi-structured interviews (n = 11), focus groups (n = 13), surveys (n = 4), and self-administered questionnaires (n = 1).

Year of publication

Our search was limited to studies published between 1990 and 2023. This time limit was set as STBBIs like HIV/AIDS were on the rise in the 1980 s and 1990 s and Canada made significant sexual health awareness efforts in the 1990 s. While there were no studies published between 1990 and 2000, four studies were published between 2001 and 2010, 10 were published between 2011 and 2020, and nine were published between 2021 and 2023 and included in our review. Categorizing into equal year ranges allowed for a clear and consistent overview of research trends, highlighting shifts in the number of publications and focus across the different periods of time.

Participants

Study participants ranged from general African, Caribbean, and Black (ACB) populations to specific stakeholders and key informants that influence the uptake of knowledge of STBBIs. Of the 23 studies, six involved the general ACB population. Eight other studies explored specific ACB populations, where, for example, one study involved gay, bisexual, and other men who have sex with men; five studies looked at heterosexual ACB men; two studies involved ACB women; and two were on ACB youth. Some of these studies expanded on the populations already listed, further including parents of the youth, health and education professionals, health workers, HIV service providers, and policy/decision makers. Three studies looked at specific populations from ACB populations: young heterosexual African migrants from HIV-endemic countries, young Africans living in Windsor, and East African (Ethiopian, Kenya, and Somali) and Caribbean (Guyanese, Jamaican, and Trinidadian) including HIV-positive AC people in communities in Toronto. Two studies looked at populations of a larger racial demographic, where one study explored Caucasian/European, South Asian, East Asian, South-east Asian, Black, Hispanic, and others. Another study looked at care providers who worked with ACB parents and youth. One study also looked at religious leaders of ACB communities. One study looked at mothers living with HIV in North America and Nigeria.

Countries

Twenty-two of the 23 studies in this review focused exclusively on Canada. One of the 23 studies included populations in Canada, the United States, and Nigeria. Most of the studies (n = 21) were conducted in populations across the province of Ontario in Canada; one study was on a population in the province of Nova Scotia. Seventeen of the studies conducted in Ontario involved the cities of Toronto, Ottawa, Windsor, and London.

Mixed-methods appraisal tool

Of the 24 studies based on the MMAT, 23 met the screening criteria, which can be found in Appendix 3. The studies presented a clear research question and gathered the appropriate data that addressed their research questions. The 23 studies also used appropriate measurements and received a high score (high number of “yes” responses). Twenty-one of these studies used a sampling strategy relevant to address the research questions and had a sample representative of the target population. The method of analysis used to answer the research questions was appropriate across the 23 studies, resulting in high scores. One study did not meet the screening criteria, as the study was not a peer-reviewed article.

Study objectives of the selected papers

Of the 23 included studies, some (n = 16) aimed to investigate knowledge and awareness of STBBI prevention, including understanding barriers to access health services and exploring strategies to minimize STBBI. Seven studies focused on identifying barriers and facilitators in STBBI management and the uptake of prevention methods. Some studies (n = 8) also explored interventions to increase STBBI prevention and overcome barriers, such as availability and accessibility in hard-to-reach areas. Three studies evaluated the impact of community engagement initiatives, while 14 studies explored STBBI prevention programs. Finally, six studies examined new or alternative approaches to STBBI prevention methods. Overall, these studies aimed to inform interventions, improve access to services, and reduce STBBI-related disparities within ACB communities.

Types of STBBIs in the selected papers

The 23 studies examined in this review discuss several types of STBBIs. The majority of the studies addressed HIV (n = 21), with six of these also discussing AIDS (n = 2) and STIs broadly (n = 4). One study examined STIs in general, while one specifically addressed HPV (Appendix 2).

Study outcomes

Barriers and facilitators

By extracting and analyzing the data from 23 primary research articles, various barriers and facilitators were identified and are illustrated in Tables 2 and 3, and Fig. 2. Barriers and facilitators were associated with three categories in relation to STBBIs: (1) general knowledge/awareness, (2) knowledge on prevention, and (3) knowledge on testing (Tables 2 and 3). Thirty-seven barriers and seven facilitators were associated with general knowledge/awareness of STBBIs. Eighteen barriers and four facilitators were associated with knowledge on prevention of STBBIs. No barriers and facilitators were associated solely with knowledge on testing for STBBIs. Three barriers and one facilitator were associated with all knowledge types. Below, we present the results around the three categories of knowledge on several STBBIs.

Fig. 2.

Social Cognitive Theory — STBBI knowledge acquisition determinants. The six determinants were chosen for their alignment with SCT, emphasizing how cognitive factors like misconceptions and stigma hinder STBBI knowledge acquisition, whereas positive behavioural aspects, such as open parent–child communication and clinic visits, and environmental factors, like social support and access to health clinics, have positive influence on STBBI knowledge uptake

Barriers for all knowledge types

There are three key knowledge types accounted for in this review: awareness around STBBIs in general, knowledge around prevention of STBBIs, and knowledge around testing for STBBIs. A study by Antabe et al. (2021) identified three barriers to knowledge/awareness, knowledge on testing, and knowledge on prevention: a disconnect with healthcare spaces, limited awareness of service availability, and issues of stigma (Antabe et al., 2021). All three barriers were said to “prevent heterosexual ACB men from openly discussing their vulnerability, testing for HIV, and seeking treatment” (Antabe et al., 2021 p. 5).

Barriers to STBBI awareness

There were 17 studies that highlighted 36 barriers to awareness of STBBIs such as HIV, related to access to healthcare, stigma and cultural beliefs, knowledge and communication gaps, and community and familial relationship dynamics. Access to healthcare services is a major concern, including inequitable access due to race and racism, difficulties locating sexual health services, lack of funding for community health programs, and insufficient HIV awareness among primary health care providers (Amibor & Ogunrotifa, 2012; Etowa et al., 2022a, b; Narushima et al., 2016; Rana et al., 2022). Stigma and cultural beliefs significantly impact awareness, with barriers such as stigma through information dissemination, distrust due to stigma, religious influences making sexual health discussions taboo, and misconceptions about HIV being a “gay disease” (Antabe et al., 2021; Gardezi et al., 2008; Phillips et al., 2020). Knowledge and communication gaps include lack of cultural sensitivity and competence, insufficient education, misconceptions about vulnerability, and the gendered nature of sexual health communication by parents. Additional issues involve fear of parents’ reactions, uncertainty of parental responses, parents’ lack of sexual health knowledge, inaccurate sexual health information from peers, and parents’ time constraints (Antabe et al., 2021; Davis et al., 2013; Fante-Coleman et al., 2019). Family and community dynamics further contribute, including a lack of appropriate health information dissemination through family systems, exclusion from health policy environments, and discomfort in discussing sexual health within families. Additional barriers include a lack of respect when seeking information, difficulty in sharing HIV education with patients in the presence of parents, reluctance to seek information from HIV/AIDS organizations due to homophobia, and the influence of cultural beliefs on HIV awareness and guideline adherence (Lee-Foon et al., 2018; Omorodion et al., 2007; Williams et al., 2009; Phillips et al., 2020). Together, these barriers create a complex array of challenges affecting STBBI knowledge and awareness across diverse Black populations.

Barriers to knowledge on prevention

There were 18 barriers to knowledge on prevention of STBBIs identified in seven studies, particularly encompassing factors such as cultural norms, limitations in the healthcare system, stigma, inadequate communication, and access to information. Cultural norms present significant challenges, as cultural practices related to sex negotiations and safer sex practices can hinder effective communication about prevention methods. For instance, one participant noted how their cultural background impacted their ability to discuss and negotiate condom use (Amibor & Ogunrotifa, 2012). Lack of cultural competence among healthcare providers and inadequate identification with the communities they serve, coupled with insufficient healthcare resources, further obstruct knowledge on HIV prevention. A participant highlighted that the lack of resources significantly impedes reaching Afro-Caribbean populations with prevention services (Amibor & Ogunrotifa, 2012).

Inadequate awareness of prevention services is another barrier, as demonstrated by some individuals who were unaware of available preventive health services (Antabe et al., 2021). Limited emphasis on STI education in parental discussions, focusing predominantly on contraceptive methods to avoid pregnancy, also affects prevention knowledge. One study found that discussions about STIs were often neglected compared to pregnancy prevention (Davis et al., 2013).

Access to specific prevention tools such as pre-exposure prophylaxis (PrEP) is also constrained. Barriers include limited information about PrEP, with marketing primarily targeting Caucasian men, and ineffective institutional efforts to disseminate PrEP information (Etowa et al., 2022a, b; Lee-Foon et al., 2022). As noted, participants felt that institutions’ attempts to spread PrEP information were largely ineffective and perceived PrEP as expensive, with concerns about coverage under health insurance plans (Lee-Foon et al., 2022).

Religious influences add another layer of complexity, with some religious leaders lacking sexual health knowledge and a reluctance to discuss condom use. This gap in knowledge and unwillingness to address prevention methods, such as condom use, further limits effective HIV prevention (Jangu et al., 2023).

Sociocultural and structural obstacles also play a role. For example, concerns that providing safer sex information might be interpreted as encouraging sexual activity among youth can deter parents from discussing prevention (Newman et al., 2008). Similarly, fears that safer sex information could be misunderstood as promoting early sexual activity contribute to reluctance in discussing prevention measures with youth (Williams et al., 2009).

Barriers to knowledge on testing

There were no identified barriers to knowledge exclusively on testing for STBBIs.

Facilitator to all knowledge types

One study identified a facilitator that increases knowledge and awareness, knowledge on testing and prevention of HIV in particular: access to AIDS Service Organizations (ASOs) (Antabe et al., 2023). The study highlights, “connecting ACB men to ASOs [AIDS Service Organizations] had the potential to not only inform them about HIV transmission, but also encourage HIV testing and treatment for those living with the virus” (Antabe et al., 2023, p. 9).

Facilitators to STBBI awareness

There are seven facilitators for STBBI awareness identified across seven studies, encompassing supportive factors within healthcare systems and social networks, such as access to health education, effective communication, and support from peers, family, and community. Access to health education is a critical factor, as demonstrated by Narushima et al. (2016), who found that pre-departure medical screenings for migrant farmworkers often included essential health information about HIV/AIDS and STIs, thereby supporting increased knowledge (Narushima et al., 2016, p. 378). Similarly, Mihan et al. (2016) showed that greater engagement with sexual health care services among ACB youth in Windsor, Ontario, led to improved general sexual health knowledge.

Effective communication with healthcare providers is another important facilitator. Rana et al. (2022) highlighted that interactions characterized by “active listening and good communication” with primary care physicians were preferred and facilitated better knowledge of STIs compared to sexual health clinics (Rana et al., 2022, p. 3). Furthermore, peer and community support play a significant role in enhancing STBBI awareness. Davis et al. (2013) found that peer interactions could indirectly encourage parent–child discussions about sexual health, and open communication between parents and children was crucial for fostering knowledge (Davis et al., 2013, p. 5). Narushima et al. (2016) also noted that learning through meetings with peers and community health professionals contributed positively to STBBI knowledge.

Finally, family and social support are essential facilitators. Phillips et al. (2020) found that mothers living with HIV who received strong support from family and health workers were more likely to be knowledgeable about infant feeding guidelines, underlining the importance of social support in facilitating health knowledge (Phillips et al., 2020, p. 6).

Facilitators to knowledge on prevention

There are several facilitators to increasing STBBI prevention knowledge. A study by Sadry et al. (2013) found that television was an effective source of vaccine awareness for HPV prevention, with 87% of participants acknowledging its role, including a notable proportion of Black women living in Canada (Sadry et al., 2013). Etowa et al. (2021) highlighted that visiting sexual health clinics was a facilitator to increase knowledge on the prevention of HIV and STIs, stating, “having visited sexual health clinics showed a positive association with having correct knowledge of condom[s]” (Etowa et al., 2021, p. 6). Additionally, culturally informed dissemination strategies, such as workshops, were identified as effective in enhancing prevention knowledge for HIV and STIs (Logie et al., 2018), as well as socio-structurally informed approaches (Lee-Foon et al., 2022).

Facilitators to knowledge on testing

There were no facilitators to knowledge exclusively on testing for STBBIs.

Limitations

Throughout the screening process, 24 out of 1261 studies could not be screened for inclusion as they were missing abstracts and full-text articles and could not be found online (Appendix 4). Although libraries were contacted for interlibrary loans on print materials, the articles were also unavailable in print form. A potential limitation is that these articles may contain relevant or important information. Due to limitations in study accessibility, future research can address this gap for a more comprehensive understanding of barriers and facilitators to knowledge around STBBIs among Black populations. Furthermore, there is a notable limitation in the scope of research addressing STBBI knowledge gaps within the Canadian Black population. Specifically, the majority of studies included in this review focus on HIV, with a limited number examining STIs and HPV. This highlights the need for further investigation into the knowledge gaps surrounding other STBBIs, such as chlamydia, gonorrhea, syphilis, HPV, and other STBBIs within the Black population in Canada. Another limitation of this study is that the Black population is portrayed as homogenous, which is not the case. However, distinctions among different subgroups within the Black population across the studies are outlined in the “Results” section under “Participants”.

Conclusion

This systematic review identified multiple barriers and facilitators to knowledge and awareness, knowledge of testing, and knowledge of prevention around STBBIs among Black populations in Canada. Barriers such as stigma, misconceptions, and healthcare system shortcomings limited knowledge acquisition, while facilitators such as exposure to media, culturally sensitive education, and supportive social networks fostered knowledge acquisition. Observational learning supported by role models and community organizations also appeared as effective ways to enhance knowledge and health-seeking behaviours. These findings align with the Social Cognitive Theory (SCT), which emphasizes the role of social influence, observational learning, and environmental factors in shaping knowledge and behaviour.

Among these barriers, environment and structural factors appeared as the most significant hurdle to STBBI knowledge among Black populations in Canada. Structural inequities, such as limited access to healthcare, racial discrimination within the healthcare system, and socioeconomic challenges, were key factors that limit the effectiveness of STBBI education and awareness prevention efforts. For instance, barriers such as disconnect with healthcare spaces, limited awareness of service availability, lack of healthcare resources, inequitable access to health services due to race and racism, and the lack of cultural competence from healthcare providers were central challenges to knowledge acquisition among Black populations in Canada. Furthermore, factors such as the marketing of PrEP/PEP geared towards Caucasian men and the lack of readily available PrEP information and promotion in sexual and primary healthcare settings further exacerbate the issue. These barriers not only impact individuals’ access to necessary resources but also affect their ability to engage in health-seeking behaviours, highlighting the health disparity that disproportionately impacts Black populations in Canada.

In light of the SCT, this study highlights the role of self-efficacy and social support in encouraging STBBI knowledge uptake while recognizing factors posing challenges such as cultural norms and healthcare disparities. Given the central role of environmental and structural factors, policy interventions are essential to address these inequities and improve knowledge and awareness of STBBI prevention among Black Canadians. Policies aimed at increasing access to healthcare services, including culturally competent care and outreach programs, are critical to dismantling the barriers that prevent Black communities from accessing STBBI-related education and awareness. Additionally, addressing the root causes of socioeconomic disparities, such as poverty, unemployment, and inadequate housing, is crucial for creating an environment that supports health equity. Implementing policies that advocate anti-racism and anti-discrimination within healthcare systems is also necessary to ensure that Black populations are supported in accessing care. As a result, interventions informed by the SCT can optimize efforts for knowledge dissemination within Black populations in Canada.

Furthermore, SCT-informed interventions that focus on both self-efficacy and the environmental factors influencing those behaviours can optimize efforts to disseminate knowledge and foster health-seeking behaviours (Bandura,1997; Lo et al., 2013; Ma et al. 2023). Such interventions should include community-based education campaigns, media representations of Black role models, and public health initiatives that specifically target the structural barriers identified in the review. As shown in a recent study, the utilization of the SCT and motivational intervention (MI) approach has been demonstrated to be effective in various health interventions, including those designed to increase fruit and vegetable (F&V) intake and physical activity among African American adolescents (Wilson et al., 2002). Similarly, interventions informed by this theory can optimize efforts to improve knowledge uptake and health outcomes by incorporating elements such as culturally informed media campaigns, where there are Black role models addressing health issues within the Black community. Additionally, community involvement in education interventions, where individuals within the Black community are encouraged to actively engage in efforts to improve knowledge uptake and dissemination within the community, is essential.

In conclusion, this review underscored the importance of addressing the environmental and structural factors that limit STBBI knowledge and awareness in Black populations. It calls for comprehensive policy responses that address these systemic barriers and promote equitable access to education, healthcare, and resources. By integrating SCT with policy-supported interventions that address environmental and structural inequalities, Canada can move closer to reducing the disproportionate impact of STBBIs on Black communities and improving health outcomes for these populations.

Supplementary information

Below is the link to the electronic supplementary material.

Author contributions

Study conception and design: BG and OE. Analysis and interpretation of data: BG and SS. Draft of the manuscript: BG and SS. Critical revision of the manuscript for important intellectual content: BG, DB, and OE. All authors read and approved the final manuscript.

Funding

The authors acknowledge funding support from the Social Sciences and Humanities Research Council of Canada (SSHRC).

Data availability

All data are included in the supplementary files.

Code availability

Not applicable.

Declarations

Ethics approval

Not applicable.

Consent to participate

Not applicable.

Consent for publication

Not applicable.

Conflict of interest

The authors declare no competing interests.