Students mobilize a screening clinic with equity and access in mind
Nursing students at Dalhousie University launch an on-campus project to promote student sexual health by providing education and STI testing
Cases of preventable sexually transmitted infections (STIs) reported to the Canadian Notifiable Disease Surveillance System have been rising over the past 20 years (Public Health Agency of Canada [PHAC], 2013). While young people as a group are disproportionately affected by STIs, young women are particularly at risk. In 2010, women age 20 to 24 had the highest rates of chlamydia, at 2005.5 cases per 100,000 population (PHAC, 2013). This is seven times the national average. In the same year, the highest rates of gonorrhea were among women age 15 to 19, at 147 per 100,000, four times the national average.
Findings from a survey of students at eight Atlantic Canadian post-secondary institutions indicated that only 33.9 per cent of respondents had ever been tested for an STI (Cragg, Steenbeek, Asbridge, Andreou, & Langille, 2016). Further, 49 per cent of the students reporting higher-risk sexual behaviour also said they had never been tested for STIs.
At Dalhousie University, with a student body of nearly 20,000, students can at any time seek STI screening at the on-campus health services centre by appointment. During the 2016-2017 school year, while we were in the final year of the BScN program, we developed a mobile STI screening clinic to enhance student uptake of testing services. This project was part of our community health clinical practicum.
Our aim was to offer free, confidential services with a do-it-yourself testing option to maximize ease and access for students. We hoped this approach would increase STI awareness and screening, empower students to be involved in their own sexual health maintenance, provide education and training about diversity and sexual health, and create opportunities for community health practice development among our cohort.
Our preceptor was the nurse lead at the Dalhousie Student Health and Wellness Centre. She encouraged our ideas, obtained funding that allowed us to purchase promotional materials and helped us negotiate with administration, faculty and staff.
Dalhousie is home to three major campuses and its facilities are spread out over 3.5 kilometres. Designing a mobile clinic seemed to be the way to reach out to students. Every Wednesday, for 14 weeks, we operated a pop-up clinic at locations across campus. About a dozen of our peers were involved as staff. Our setup, always in public places, included a desk with a few computers for registering participants, a table with free supplies and pamphlets, promotional posters, and up to six staff at a time.
During these clinics, we offered to do oral swabs for gonorrhea and chlamydia and also provided swabs and urine sample collection kits for clients to self-screen. Self-collection methods have been shown to increase screening uptake, particularly among young women (Fielder, Carey, & Carey, 2013). Only if client screens were positive would one of the centre’s nurses contact them and invite them to schedule an appointment for followup care.
We verbally instructed clients on how to self-screen and referred them to illustrated instructions we posted in the bathrooms near the registration tables. The DIY approach minimized invasiveness and encouraged student participation and ownership. As we expected, clients preferred this approach. Lab requisition forms for blood tests for HIV, hepatitis C and syphilis were also available, which clients could take to a nearby bloodwork clinic.
The centre provided our supplies and equipment, including two laptops, label makers, a large university-branded tablecloth, a cooler to store samples, urine specimen cups and swabs, condoms, lube and dental dams, pamphlets on sexual health and paper forms. We carried everything in large containers to the various clinic sites, often by hand, but made use of tables and chairs in the building in which the clinic was located that week.
Getting the word out about this new service required creative thinking. Because the clinic was mobile, some confusion resulted around the exact location from week to week. Understandably, we were not authorized to manage a social media presence on Facebook and Twitter that was separate from the central university-wide communications office. It was essential to have a URL, so we advertised the dates and locations on a university-managed webpage. The result was that any updates were not always communicated in a timely way.
Not all the spaces our preceptor was able to book for us were in heavily trafficked areas. To overcome this challenge, we developed banners, buttons and paper signage that we distributed across all three campuses. We used whiteboard animation to create a short YouTube Video and obtained permission to present it to students in large undergraduate courses.
The logistical challenges we encountered included sorting out health insurance coverage issues for international and out-of-province students, troubleshooting technical difficulties with laptops and label makers, becoming familiar with university regulations related to promotion (e.g., using sidewalk chalk on campus for this purpose was not allowed) and having to move the equipment and supplies across the campuses.
It was important to us that the clinic be designed to challenge heteronormative practices to increase participation of LGBTQ+ communities. Our aim was to promote respect for transgender and non-binary students. We referred to “people with vaginas” or “people with penises” when explaining how to do the vaginal swabs and collect urine samples. The intake form included questions about gender self-identification and preferred pronouns. When we were asked the purpose of these questions, we had an opportunity to educate clients about trans-inclusive language. For our part, we developed confidence in discussing gender identification and using the right language in therapeutic conversation.
Results and lessons
In total, 487 students were screened; 36 (7.4%) of them received notification of positive screens.
As other client needs surfaced, we incorporated these into the project. For example, we discovered a lack of gender-neutral bathrooms that were clearly indicated as such to facilitate comfort for DIY screening for transgender and non-binary individuals. We embarked on foot to update a university-wide gender-neutral bathroom inventory, later presenting our findings to the university senate and advocating for improved access and signage.
We came to understand that educating and informing students about sexual health matters must include guidance about the importance of consent. We organized several Only Yes Means Yes workshops for nursing students to help them develop their capacity to educate clients about their rights and responsibilities in this area. The workshops were facilitated by the Women’s Legal Education and Action Fund, a national non-profit organization.
All students in health profession programs at Dalhousie must complete interprofessional health education (IPHE) modules during their studies. We designed and facilitated a novel IPHE workshop with a diversity, equity and sexual health theme. This exercise enhanced our competency in teaching and in collaborating with other health professions. Our participatory approach aimed to promote student engagement and discussion and build capacity for STI screening and sexual health promotion. Forty-six students, representing seven programs, registered for this event. The conversations explored the risks for STIs and barriers to screening and treatment, types of protection, our professional roles in sexual health promotion and the needs of diverse populations and how to support them.
We believe that having nursing students create and lead health clinics helps them develop leadership in health promotion in their community and applied skills in caring for patients in an inclusive, compassionate way. We felt deep pride in the approach we had taken and a sense of conviction about the role of nurses in health advocacy.
For students wishing to start projects like ours, we would recommend having tech support on speed dial, knowing the rules in advance of doing promotion, developing materials early on, and buying a dolly or being prepared to take the occasional taxi. Having access to a caring mentor who supports the project team is an invaluable benefit.
We were pleased with the impact the clinic had on student sexual health and the support we received from Dalhousie University faculty, staff, administration and students. In addition, the project allowed us to develop our practice in the provision of inclusive, empowering care to promote sexual health.
We presented on our experience at the Canadian Association of Perinatal and Women’s Health Nurses Annual Clinical, Education, Research Conference in 2017. Attendees responded enthusiastically and suggested we write up this project for Canadian Nurse. Our aim with this article is to encourage students in other post-secondary institutions across North America to consider leading similar projects.
We were excited to learn that the clinic would continue in the 2017-2018 school year with a new cohort of nursing students.
The authors thank their peers who participated in this project, especially Lindsay Rhodes, RN, the video illustrator; and their preceptor, Christina Elgee Davis, for her leadership and vision. She received a Canadian Nursing Students’ Association Award for Preceptors and Mentors for her support of our class of 2017.
Cragg, A., Steenbeek, A., Asbridge, M., Andreou, P., & Langille, D. (2016). Sexually transmitted infection testing among heterosexual Maritime Canadian university students engaging in different levels of sexual risk taking. Canadian Journal of Public Health, 107(2), 2016, E149-154. doi:10.17269/cjph.107.5036
Fielder, R. L., Carey, K. B., & Carey, M. P. (2013). Acceptability of STI testing using self-collected vaginal swabs among college women. Journal of American College Health, 61(1), 46-53. doi:10.1080/07448481.2012.750610
Public Health Agency of Canada. (2013). The chief public health officer’s report on the state of public health in Canada, 2013: Infectious disease — The never-ending threat.