This article, which reports on the development of a sexual health service for university students, begins with a literature review covering the subject area.
ABSTRACT
Moore, S. (2007) Developing a sexual health service for students. www.nursingtimes.net
This article identifies aspects of sexual health and related health policy that are particularly relevant to the student population. It focuses on how sexual health provision was developed and improved in a student health centre on a university campus.
This article, which reports on the development of a sexual health service for university students, begins with a literature review covering the subject area.
Sexual health in theUK
The primary route of transmission of sexually transmitted infections (STIs) is through sexual contact (Adler, 2005). According to the Health Protection Agency (2006), there were 790,443 new STI diagnoses in the UK in 2005, a 63% increase on 1996 figures. The UK has the highest rate of STIs in Western Europe - especially among young people (Metcalfe, 2004).
According to Hayter (2005), sexual and reproductive ill health create a number of public health concerns. STIs can have long-term effects on reproductive health - for example chlamydia infection is a leading cause of infertility in women (Baird et al, 2002). According to the Medical Foundation for Aids and Sexual Health (2005), the consequences of not proactively addressing sexual health with clients can often be sexual ill health that may have been prevented.
However, sexual health is not just about disease. Department of Health statistics (DH, 2007) show that 193,000 abortions were performed in England and Wales in 2006. Of these, 3,184 were within the area covered by the University of Surrey's local primary care trust and the highest proportion were in the 18-24-year age group. The NHS funded 87% of the abortions; this clearly represents an enormous cost that, in many cases, could have been avoided.
Sexual health is an area in which health promotion is essential. NICE (2007) guidance on reducing STIs and unplanned pregnancy advises a proactive approach. It states: 'One to one interventions are an important element of modern sexual health services and are part of the strategy to prevent STIs and under-18 conceptions. As such, they should be integral to the routine care provided by both primary care and contraceptive services.'
In 2002 the DH launched The National Strategy for Sexual Health and HIV (DH, 2002), which encourages a shift towards management of STIs in primary care in England. This initiative has received around £47.5 million in funding and the targets set included:
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Cutting the rates of newly acquired HIV and gonorrhoea by 25% by 2007;
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Reducing waiting times to no more than 48 hours for a genitourinary medicine (GUM) appointment by 2008;
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Reducing the under-18 conception rate by 50% by 2010;
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Reducing the prevalence of undiagnosed STIs and HIV;
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Offering 15% of people aged 15-24 a chlamydia screening test by 2008.
In addition to this strategy, a national chlamydia screening programme began in England in 2003.
The national strategy describes three levels of service provision: level 1 is provided by GPs, level 2 involves a partnership between family planning clinics, GUM clinics and GPs; and, level 3 is provided by GUM clinicians in the GUM clinic setting.
Student health
Student health in the UK has not been widely researched so it was difficult to obtain up-to-date and university population-specific information within a literature review. However, more general information is also pertinent to this group.
The majority of students on campus are young and will often be away from parental care or their country of origin for the first time. Starting university may also be the time when some young adults have their first sexual experience.
Risky behaviour such as unsafe sex is more likely when people are intoxicated and this will affect the transmission and spread of STIs. Massey (2005) concluded that financial hardship, student accommodation, mental health and poor nutrition - including binge drinking - have an adverse effect on students' health. The findings of Lowe et al (2004) supported this; they state that 'excess alcohol consumption has been implicated in unsafe sex and the spread of sexually transmitted infections'. A European study by Bendtsen et al (2006) found that 40% of women and 56% of men at a Swedish university admitted to being intoxicated at least weekly, and 20% of women and 50% of men reported experiencing alcohol-related blackouts.
Lowe et al (2004) found that 39% of those involved in a study undertaken in a London-based GUM clinic attended after alcohol-related sexual contact. Common reasons cited were being drunk and having sexual contact that would otherwise have not occurred, and alcohol consumption that resulted in sex without a condom.
The need for a sexual health service
The University of Surrey has a high number of international students, many of whom go from living with their extended family, often in one house, to living independently at university. Information from patients attending the student health service suggests that this often gives them the freedom to form sexual relationships for the first time. This group needs to be reached proactively as not only are they at risk from STIs but are at a higher risk than other age groups of having an abortion.
Some overseas students arrive in the UK with pre-existing STIs, including HIV. With testing and screening not always so readily available or accessible in their own countries, they may pass on infection unintentionally due to being unaware that they have any infection. Clearly this poses a risk in transmission and without screening will increase the rates of STIs in the UK - HIV infection is already rising fastest in young heterosexuals (HPA, 2006).
Developing the service
I took up the post of clinical nurse lead in the student health centre in December 2005. The university campus has over 13,000 students, many of whom are away from home for the first time.
At this time the health centre ran a nurse triage service, through which patients would be seen by a member of the nursing team and given an appointment to see a doctor if necessary. Although the nurses worked under patient group directives, these were limited and, while including emergency contraception, they did not include ongoing contraceptive needs. Condoms were available free from reception to all students.
The health centre did not offer a sexual health service and patients were referred elsewhere for screening when needed. This could mean a delay in screening and treatment or that students did not attend for screening at all. This could, potentially, increase the spread of STIs should students continue to be sexually active while waiting for screening. Despite having two family planning trained nurses who worked independently at other clinics, there was no family planning clinic on campus and students still had to be seen by a doctor.
One of the first changes I made was to close an out-of-hours nursing service that was costly to run and under-used. This restructuring enabled improvements to be made to the current day-time service. Savings made were used to expand the nursing team.
From my experience, I thought that students would be more likely to attend for screening and treatment if a service was provided on campus. This view was reinforced by attendance at other clinics, such as smoking cessation and weight management clinics, which are run on site.
The first step in developing a sexual health service for the student population was to consult with the local genitourinary consultant. The result of this process was the implementation of an outreach service at the student health centre run by the local genitourinary clinic.
The clinic was set up to provide full sexual health advice, prevention and screening for students who were both symptomatic and asymptomatic. The clinic is staffed by staff from both the university and the genitourinary medicine clinic (GUM) and is offered once a week. Eight to ten patients can be seen during this clinic time.
Patients are seen by a GUM consultant or, in their absence, a GUM nurse specialist. The GUM staff are supported during clinics by one nurse from the student health centre, which provides an opportunity to learn and develop skills. The clinic is run in the health centre in rooms away from the main area in a quiet and student-friendly setting. At times of higher demand, students can also be seen in the GUM clinic that is nearby.
The service provided at the university health centre during the outreach GUM clinic is a level 2 service, as outlined in the National Strategy for Sexual Health and HIV (DH, 2002). All areas of sexual health and contraception are addressed with clients who present for screening and treatment.
By working in collaboration with the GUM specialist team the practice nurses in the student health centre are continuing to develop the skills required to offer level 1 screening whenever a client presents through the triage system with a sexual health related problem or question. This again improves access for the student population to sexual health services.
Evans (2006) argued that practice nurses have a duty of care to prepare themselves to provide proactive sexual health advice as part of their role in holistic care. Challinor (2006) supported this by stating that practice nurses have a privileged and enviable role in their ability to influence lifestyle and health choices and must educate and give advice on the consequences of sexual activity.
A further commitment was made to improving sexual health by the government with the public health white paper
Choosing Health: Making Healthy Choices Easier (DH, 2004). This identified chlamydia as a new priority area. According to the Health Protection Agency
[ref here?], chlamydia is the most common sexually transmitted infection in the UK; if untreated, it can damage the reproductive system. It is known as 'the silent disease' because it can develop without symptoms, only revealing itself when complications develop. For this reason it is essential that patients are screened and treated early to protect their fertility. This will have an additional benefit in reducing the cost to the NHS for fertility treatments. The health centre is involved in the Surrey Chlamydia Screening Programme and self-testing kits are available for students.
The key issues outlined above clearly highlight the need for a proactive, easily accessible sexual health service to be provided at the university health centre. There has not yet been an audit of the service but clinics are fully booked two weeks in advance with many patients still being seen at the local GUM clinic if appointments are not available at the university clinic.
Further developments
I have also worked with the doctors and contraceptive nurses to develop patient group directives in order for them to offer a family planning clinic. A nurse prescriber has been trained in contraception and a walk-in family planning clinic was developed and is now held every Monday. In the first year of the service the clinic has seen 1,050 patients, 514 more than the previous year.
The student health centre now runs a travel health clinic, which is busy all year round. The clinic is used by students who travel abroad as tourists and on study placements, and by international students travelling home to visit family and friends. A study by Hawkes et al (1994) in two London GUM clinics found that 12% of STIs were acquired abroad. This figure is likely to be higher now as travel abroad has continued to increase.
Finney (2003) found that 32% of a group of medical students had sexual intercourse with a new partner while on holiday. Holmes (1999) states that the risk of STIs due to sexual intercourse on holiday is potentially increased through exposure to new sexual networks, the rate at which partners are changed while away, lack of condom use and consumption of alcohol.
I noticed that men are less likely to attend the health centre for assessment and treatment and usually only attend when they are unwell. Boyle et al (2004) supported this with their research, which consistently showed that men engage in fewer health-promoting behaviours and have less healthy lifestyles than women.
This is an area of the service that needs to be developed. When women attend the family planning clinic it provides an opportunity for both the patient and the nurse to discuss all aspects of sexual health. However, there is no specific service on offer in the student health centre in which men are offered the same proactive approach to sexual health. It is important to offer a male-focused clinic - if men do not present for sexual health screening there is an increased risk of the spread of asymptomatic STIs.
Moore and Topping (1999) found in a descriptive survey of 203 male undergraduates and postgraduate students that few men had any knowledge of the symptoms of testicular cancer and few were found to perform testicular examination regularly. According to Cancer Research UK (2007), the cancers that young and middle-aged men are most likely to develop are testicular and melanoma; however, if detected early, they are highly curable
By providing a male-focused health clinic at the university the team would be able to take a proactive approach to addressing men's health issues. It is well known that men are reluctant to attend health centres and I am keen to take the following different approaches to encourage them to attend:
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Offering a weekly clinic for 'Well Men' checks;
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Updating the health centre website with a men's health page;
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Writing a feature article on men's health for the student newspaper twice a year.
Each of these approaches would cover the following information:
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Sexual health;
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Promoting safe sex;
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Sexual health screening;
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Psychosexual issues;
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Information on where to access further information;
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Travel health;
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Diet, nutrition and exercise;
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Testicular examination;
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Mental wellbeing.
Conclusion
The changes to the service provided in the student health centre have led to the provision of a holistic and proactive sexual health service. The service utilises the skills and expertise of a local GUM clinic in order to provide level 2 sexual health provision in the primary care setting. The service aims to provide advice, screening and treatment for both STIs and unplanned pregnancies in order to tackle the high rates among the student population.
The service takes into account all factors that impact on the spread of STIs and associated health problems, such as cultural beliefs, overseas travel and alcohol use linked to risky behaviour. While the new, innovative service has not yet been audited, its success is shown by the demand from students for appointments for both the GUM and the family planning clinic.
A key objective in developing the service is to formalise a training programme for university nursing staff, setting key objectives and learning outcomes. Currently staff rotate each week, which means that they may only spend one day per month working alongside the GUM team. In the future, a week-long training session in the GUM setting could be developed in order to consolidate and build on skills. This would expand the current service and ensure that staff are able to offer advice, treatment and screening outside of the clinic times if need be. This would also involve level 1/opportunistic screening.
Looking ahead, there is a need and demand to expand on the current service. Formalising a training programme for the health centre staff would enable them to make better use of opportunistic screening. The development of a well-man clinic would provide an opportunity to tackle men's health issues proactively, an area that is often ignored by both male patients and health professionals.
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