The importance of promoting good sexual health

by Helen Knox

Speech component of Preventive Health conference - GovNet - June 25th 2009 - copyright Helen Knox

The importance of promoting good sexual health is not just important, it is VITAL

The average cost of contraceptive failure is around £1500. ((DH_081858.pdf))
Contraception services probably save the NHS over £2.5 billion a year. ((DH_081858.pdf))
For every £1 spent on contraception services, £11 is saved. ((DH_081858.pdf))
HIV imposes a significant burden on our healthcare resources at around £580,000,000 a year. ((DH_081858.pdf))
Preventing the onward infection of one case of HIV could save around £0.5 million in health care costs and individual health gains. ((DH_081858.pdf))
The direct costs of treating other STIs cost the health service approximately £165,000,000 a year. ((DH_081858.pdf))

At present, Chlamydial awareness and screening is promoted at the expense of HIV and all the other STIs, about much of which young people, especially in the UK, are ignorant. Although harder to contract than Chlamydia, HIV rates are rising rapidly and it is now, firmly, a heterosexual infection. And, as people travel, don’t think about the risks of sun, sea, sand, sex and ‘sangria’ - and more mixed relationships develop, rates are bound to rise further. We live in a - bacterial and viral - sexual melting pot !

We now have approximately 77,000 HIV positive people in the UK. Since, according to the DH website “it is worth spending between £500,000 and £1m to prevent one case of HIV” - why are we not! From 1985-95, we had ring-fenced HIV money and we got good statistical results. That went, and the emphasis for the next 10 yrs was on cancer.

We NEED greater investment in sexual ill health prevention & contraception education, with improved understanding, than we have nationally - and indeed internationally - to prevent further HIV spread and ‘importation’; to protect us from escalating costs to our already overstretched health service.
What we don’t need is the lip service and a ‘no money’ response to this, as I am finding on an international scale. In the last 10 yrs we have diagnosed 931 cases of HIV in this country, where the presumed place of infection was the Caribbean. From Africa and Eastern Europe the physical and emotional burden from the figures is staggering - and as for the financial, I am sure you can figure out the escalating maths!

The case for the increased role of the school nurse is logical and good, since School Nurses are ideally placed to support young people’s development in this area, but there is a national shortage of them and without considerable training, and experience, those that are in the field are not comfortable or perhaps even interested enough to take on this additional role - confidently and competently.

It is ideal - and lovely in theory - but there are not enough nurses, in general, to make this a safe and sustainable option. Having said that, some are developing their knowledge through courses such as the RCN Sexual Health Skills course - a distance learning course now run by the University of Greenwich. But this type of learning is not the same as hands on experience or tutor led training. School Nurses are better placed than form tutors to teach some of these subjects since the children do not have such a close, daily relationship with them but largely, depending on their personality,
young people see them as a safe figure of authority to turn to.

This is an ever changing field that requires constant updating, to enable them to give safe and effective information and advice to those they tend. This topic and this field of work is NOT for everyone and we should NOT force people to do it if they are not ready, comfortable or willing to do so. It would have been wise if the money given to PCTs and Local Authorities for sexual health work had been ringfenced, not used as a way to prop up other services and balance the books. To me it is as scandalous as the recent MPs expense confusion. If it was given for sexual health work, it should have been used for sexual health work - not anything else.

There have been a considerable number of reinventions of the wheel with this subject and with each new idea comes a whole host of research, focus group discussion and a range of other annoyances that merely waste time and money while someone ticks another box. Local practitioners know their area - listen to them and don’t keep trying to reinvent the wheel. Modernising and integrating services is all very well. It sounds lovely but clinicians should be allowed to do their work, on clinical grounds, in an appropriate way for the patient infront of them, without constant pressure from administrators and statisticians to meet local or national targets - whether the patient needs a swab or not! Instead of number crunching and statistic gathering, commissioners and local authorities should be concentrating on delivering good quality patient care, with staff having enough TIME to see patients in an unhurried way. Then, and only then, do patients relax enough to ask what they really came for and we get the opportunity to extract from them information we need to ensure we look after them properly. They are not numbers they are people - the same with our most precious commodity - our staff. In my professional opinion, staff burn out and low morale within this field has never felt higher - in 20+ years! It is all very well wanting statistics - but at what expense!

Be very careful just how much you ask for. Taking a cheaper staff option to fulfill a quota for someone, somewhere, does not mean the money has been well spent. You get what you pay for in sexual health just as with anything else – and patients need time spent on them - and staff are not robots on a conveyor belt. Providing good advice to people in order to stop the spread of STIs is hard work, as is that of unplanned pregnancy. It involves continuous study to keep up to date and a nonjudgmental attitude, throughout. It is not a subject that can be learnt in five minutes or a task just anyone can do. Although there are text books and courses, there are a lot of STIs and conditions about which only experience can inform and a lot
of cultural customs and practices that only interest, opportunity and experience can teach. As with anything, the sensible teachers - and students - know
what they don’t know as much as what they do. Although less confusing than the ever changing world of contraception, when confronted with the many and varied questions people ask about the different STIs, it takes time and considerable experience to master comprehensive simple enough explanations, that are appropriate for the level of understanding or interpretation that the client infront of you can comprehend. And, as with anything else, very often with this subject ‘it is important to us, but it may not be important to them’ at the time - and we are really up against a kamikaze attitude by people of all ages, when it comes to sexual health. The attitude abounds, of ‘it won’t happen to me but if I catch anything, they’ll be able to cure it, so why take any notice’ or as recently said by a young man under 25 when offered opportunistic chlamydia screening, ‘talk to the chavs, not me’.
Only when it becomes personal do many people start to take protecting their sexual health seriously. Until then, it is not important and, sadly, if they know the basics about protection, they are actually far ahead of the crowd.

We need to do more, in interesting ways that can compete with what already holds people’s attention while remembering that this side of sex is not exactly sexy or something most people want to think about - especially when they are out, to enjoy themselves ! When giving people enough information to make an informed choices about sex it needs to be comprehensive, age and language appropriate, consistent and ongoing - given over many years - and it only starts to mean something to them when it is actually required in practice. But, even then, repetition and further teaching are vital, to sustain
lifelong learning. Information is not always enough to effect behaviour change - understanding and an acceptance that ‘it could happen to me’ are also necessary. And there needs to be easily accessible support available for, and information about, the less savory side of sex - that of child abuse,
genital mutilation, domestic and other violence, drugs, alcohol and other factors that contribute to poor sexual self-esteem and therefore poor sexual self-worth and health, in general. We cannot and should not ask questions about someone’s sexual history or ask them to consider it, without having safety nets in place should they then open up about something unpleasant for the first time. We cannot teach this subject in the community at large without knowing where our local safety nets are situated - and being ready to go the extra mile for the person whose emotions we have just
stirred up or who needs our help and protection. Eliminating the taboo of talking about our personal sexual health is, realistically, impossible en mass, but it can be achieved on a one to one basis, with TIME, care and understanding.

Sadly, we live in an extremely judgmental society, even though, at times we may think we don’t. People will only talk about their personal sexual health when they feel safe, not judged - and in the knowledge that what they disclose will remain confidential. Safe environments and services are around but they can not be bought off the shelf and it takes the right mix of personalities within a non-threatening service to make clients - and staff - feel
supported enough to bring down - and keep down - communication barriers. Part of the problem lies within small communities where everyone
knows the next man’s business - and gossip is rife. Double standards and hypocrisy abound in order to keep up a front for the outside world.
Things go on behind closed doors and are denied to the hilt when the doors are open. Getting patients to open up is definitely an acquired skill and one that can not be learnt from a text book. Take a look around you now... spot the person you would feel comfortable talking to - and definitely spot the person you would not. It is human nature. We will never eliminate the taboo about this subject but with time and experience, we can make people
feel more comfortable.

The economics of prevention make great sense. Having one infection increases the risk of contracting another, tenfold.
... Chlamydia - prevention - approximately 10p
… treatment - approximately 50p
... cost of failure - to detect, treat and contact trace and fertility care - nationally, £££ millions
... Chlamydia - double edged sword - damned if we do screen, damned if we don’t.

Although a national infection, what the screening programme shows is that there are pockets of high infection. Screening is offered proactively or opportunistically and I will let you speak directly with the NCSP stand for more detailed information about it’s effectiveness. What it does not show are the rising pockets of people over the programme’s catchment age who are contracting chlamydia, as shown in clinic results when screening is offered to anyone who wants it, in general. So I see The Programme as just the start.

Internationally:

In some ways we are not doing too badly - in others we are floundering. The United States promoted abstinence for years and has only recently acknowledged that it does not work. They have now concluded that taking a comprehensive approach to sex education is a better way forward.
It is well proven that giving young people more information about sexual and reproductive health subjects before they are sexually active actually delays the onset of such activity rather than encourages it, which is the stance Holland has taken for many years. Uganda was hailed as the most successful sub-Saharan country at reducing its HIV prevalence through a proactive campaign and Thailand had a 100% condom policy amongst sex workers - which had a superb effect. Both are now noticing ‘condom fatigue’ with the increased availability of ARV treatment. Complacency has set in.

And in the Caribbean, for example:

UNFPA is promoting the new Female Condom across 23 LAC countries and reaching out through sports groups.
UNICEF is developing packages for use in schools and is encouraging business to get involved with them to protect the lives of young people.
Caribbean Broadcast Media HIV-AIDS Partnership, is working across 40 countries with its Live-UP campaign.
Food banks are growing. Workplace education is starting.
Stigma and discrimination are still rife but with time and a lot of effort, attitudes are very slowly changing.
Fear – largely through lack of understanding and appreciation - is still a huge factor but not huge enough to encourage condom use
as widely as it should be.
Commercial companies, funding bodies and donor agencies - don’t help when they have an attitude that a market is too small or too
rich in $$$ terms, despite obvious poverty, to support proactive education or even bother to introduce new products proactively to the region, which people would use, if only they were encouraged and able.
Pennies make pounds and people from small regions travel to larger ones, and vice versa, regularly!
Numerous smaller organisations are doing what they can but have to jump through too many hoops and fill in too many forms, to try and receive funding - yet they are the passionate, proactive ones - with the best ideas and the best links, that SHOULD be supported much more readily.
We are losing innovation, enthusiasm and excellent ideas through a ridiculous amount of red tape and nonsense like ‘the funding round is closed’. Well, open it again - we can find money for bombs, we should find money to prevent this worsening health explosion which will cost many times more if not tackled head on and supported properly!

Small organisations are our lifeblood – they get out there and work hard where the larger organisations merely empire build, pay high salaries, have meetings about meetings and still, outside in the street, statistics rise. Grab proactive people by their hand and run with them. This, is life
and death – and prevention is so much cheaper than, often, no cure. When you leave here, today, get out there and make a difference
– and please, do your bit to really help those of us who are trying to Promote Good Sexual Health - proactively.

Don’t dumb down the great importance of ‘old fashioned’ contraception services while promoting integrated sexual health services in their stead. They deliver a heck of a lot more than just pills and condoms and patients deserve dedicated choice where they don’t have to wait 40 mins while the person before them completes their shopping list of ‘wants’, because it’s all free and they ‘might as well’ check everything while there. Our antenna‘teach and twitch’ continuously about a whole host of other issues during consultation which pharmacists and even GU settings are too busy to home in on, especially under pressure.
Don’t just give it all to the empire builders because they are good at form filling. Together – we really can promote good sexual health and make a difference. If we don’t, the financial, physical, emotional and other costs are just too hideous to think about. To show just how far down the list of importance this subject really is, just now, I was to be judging the increasingly popular Sexual Health category of the Nursing Times Awards this year, but they have just had to cancel that category due to lack of support. Sadly, we can’t cancel people’s sexual activity so easily.

FURTHER NOTES: not used yesterday due to lack of time.

But where and by whom is Sexual Health promoted?
• at school ? - many teachers don’t like doing it - indeed, they are not trained to do it - they are only trained to touch the surface, if at all.

But it ticks a box...
• in clinic or general practice - where there is not enough time to teach all that is required, yet ‘in fighting’ for statistics, and number crunching to maintain or grow funding
• at home - but were parents taught? I suspect not - so why should we expect them to be able to teach young people about sexual health. Parents are aliens to many young people!
• youth services - clubs and community organisations - OK for young people but what about older people, too• via the media - TV - health magazines - lads mags - girls mags - problem pages, phone in shows etc etc etc - by whom and who pays and do they explain the topic fully or flippantly?
• via government promotions? - how well do YOU listen to Government promotions, or do you switch off? The Iceberg Campaign was brilliant but we have had nothing really memorable since, to compete.
• via product manufacturers - whose bottom line is ‘sales’ to remain in business
• What good is promoting something without explaining it in a comprehensive way - and who is well enough equipped to do that? The answer - Contraception and Sexual Health Professionals who, on a regular basis, see it, meet it, treat it and because the patient doesn’t appreciate the importance what we say about avoiding re-infection, often have to retreat it.
• The Invincibility of Youth... and The Complacency of Old Age.
• I can’t see it, so I can’t catch it.

THE BIGGEST KILLERS of all are TARGET FATIGUE and STAFF BURNOUT

We also have chlamydia fatigue amongst young people.

Despite spending millions, there is a VAST lack of understanding, despite awareness about HIV, Hepatitis, other STIs and contraceptive methods
We have condom and HIV fatigue in the ‘gay community’ and groups of young people who have never heard of it or if they have, don’t know what it means. We have EC, PEP and PREP promotion, which, although useful, with side effects, reduce people’s vision of the importance of simple, cost effective prevention. Increase nursing and medical budgets and make sure you have more than enough well trained and EXPERIENCED staff in place, first. You can’t just ‘train people up’ - these are two specialist fields that take a long time to be worked well. Contraception staff can learn Sexual Heath topics much more quickly and safely than Sexual Health Service staff can learn contraception subjects safely. Stop paying expensive advertising companies that send people to get screened in clinic before all the dominos are in place properly

Stop trying to integrate two different disciplines, everywhere. Patients do not always like it. GPs are not generally interested enough to take additional time out to develop this well. TIME is required as well as an interest in the actual subject. Patient Choice is being eroded, not improved. Bring back or protect dedicated services where staff are motivated to deal with an area they chose to work in. Don’t assume we are all happy to extend our roles and keep on pushing boundaries, paperwork, computer targets and statistics, statistics, statistics - we are NOT and you are losing highly qualified, experienced practitioners. Morale in this field is rock bottom and mistakes are inevitable.

So...
Awareness is definitely 'there' but sufficient understanding to effect behaviour change does not match this. We have too much fatigue - condom, chlamydia, and HIV fatigue, short attention spans, and an inherent kamikaze'it won't happen to me' attitude amongst people across the age range - not just young people. In conclusion, things may be improving in pockets, but statistics, everywhere, are still rising.

With I million people, globally, contracting a curable STI every single day of every single year, something has to be done in a much more proactive and sustained way than has been done thus far. I think our society has a very long way to go before we will see any real progress in this field but as generations change, younger parents are becoming more open with their children.

My main concern, everywhere, is that if the parents weren't taught, how can we expect them to teach. This subject belongs in the category of lifelong learning, not just in the school curriculum - we need a two pronged approach that includes parents as well as children. In financial terms, the need for promoting good sexual health has never been more important - no Government on earth can afford the amount of money required to address this issue properly but they can all afford to encourage condom use considerably more proactively than they do now. And, with a vested interest in that, the
condom companies SHOULD do considerably more to help those helping them to market their product. Not merely sit back and smile that others are doing their marketing for them. After all, in bottom line terms, the people doing that marketing could promote an opposition brand, or another product !

We used to have more interaction between pharmaceutical and condom companies in clinics where reps could speak with professionals directly. Some of my most memorable learning in my early days in Family Planning was via the reps who could explain their products in a totally different way, which was actually very interesting. They knew I had no say in what was prescribed or stocked, yet they took time to teach me about their product from their perspective and gave me an opportunity to ask as many questions about that, and other methods, as I wanted. Soft sell perhaps but it helped me understand the different methods far more than a lesson in a classroom, which is, after all, another form of soft sell, surely. I can not be alone in missing that contact, now reserved merely for Consultants and conference stands and I would dearly love to see that return. I don't suppose it ever will, for there is so much fear about undue influence, backhanders and bribes to make that likely... which is sad.

It's called TEAM WORK - and TOGETHER, we can make this place a safer world.

Speech component of Preventive Health conference - GovNet - June 25th 2009 - copyright Helen Knox

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