Crisis & Change

Brittany Mott is a public health nurse and the Sexual Health Team Lead at the Leeds, Grenville, & Lanark District Health Unit. Mott’s story sheds light on how services were stressed through the pandemic, and how it also provided opportunities for changing some aspects of service delivery. Mott notes that while many sexual health services are available for people residing in rural areas, there are barriers for some people, including the isolated physical locations of people in need of particular services, the lack of diverse services (e.g., for individuals who identify in the LGBTQ2S+ community or who require trauma-informed care), and the need for services that are beyond a nurse’s scope of practice. In the context of the Covid-19 pandemic, many of these barriers and challenges to rural sexual health services have been further strained; however, she explains that there have also been some valuable lessons learned for rural sexual health services during this crisis.

At the beginning of the Pandemic in March 2020, sexual health clinics in the Leeds, Grenville & Lanark District Health Unit were shut down, but the need for rural sexual health services did not stop. The clinics continued to operate on an emergency basis only, but what was considered an emergency was determined on a “case by case assessment.” The clinics were slowly re-opened with an adjusted service delivery model. But this reopening has come with challenges for public health nurses like Mott, as there has been an increase in demand for sexual health services in rural areas at the same time that there has been a decrease in staffing as health care workers were being pulled to help on the frontlines of the pandemic.

Mott explained that “right now we’re currently operating with less than half the number of nurses than we normally would, [as] we had a significant number of nurses get redeployed to just strictly COVID work.”

At the Leeds, Grenville & Lanark District Health Unit, the sexual health clinics are run by public health nurses. Mott notes that not having a fulltime physician in clinic can be a barrier in the rural context because “there are certain things that are just beyond a registered nurse’s scope of practice.” Before the pandemic, there was a physician who attended the rural sexual health clinics on a regular basis, which was very useful, as they could quickly diagnose sexual health issues and to prescribe treatment or to perform minor procedures. However, during the pandemic, some tasks, such as exploring the opportunity for a replacement physician, have been delayed, and Leeds, Grenville & Lanark, has been without an associated physician to make these kinds of diagnoses and prescriptions. The impact is that without a physician present “we have to refer to external practitioners a lot more than we did before,” thus adding further burdens of time, travel, and finances to patients seeking care.

The challenges of running a rural sexual health clinic during the pandemic did not just relate to decreased staffing, as Mott attributes an increased demand for sexual health services in her health unit to primary healthcare providers decreasing their services during the lockdowns and stay-at-home orders: “we were having a lot more people accessing our services that may have been doing that through their family doctor [before].”

Mott further notes that the needs of patients have become more complex through the pandemic. For example, some sexually transmitted infections (STIs), such as herpes and genital warts “are exacerbated by stress, and so when you have people living in high stress situations, which everybody was and is [through the pandemic], we noticed a lot more people needing to come in for treatment [and] having more significant outbreaks.” This increase in need for sexual health services in rural areas “indicated that our services were important and needed to continue to be available to people.”

The increase in demand combined with the decrease in staff has made it difficult for public health nurses like Mott to “keep up with the STI case load and contact management that we’re mandated to do, because we were so heavily involved with Covid management. It was really hard to balance all of [those precautions] and making sure that we were still meeting all the mandates of the STI case management work that we are required to do.”

Additionally, “a lot of efforts of things that we were in the middle of trying to achieve have been completely stopped and now that we are trying to recover, we’re basically starting from scratch again.” For example, increasing social media presence and trying to explore the opportunity to offer Pre-exposure Prophylaxis (PREP), a pill that can be taken to reduce the risk of contracting HIV. “It’s going to be a while before we fully recover, and then get back to those efforts that we were trying to push forward.” This means that those in the LGBTQ2S+ community will continue to have to be referred to other areas for particular services.

Running a rural sexual health program during a pandemic is difficult for the nurses’ who are doing more with less and means that patients in rural areas have additional barriers to getting the sexual health services they need.

How Covid Could Change Rural Sexual Health Services for the Better

In addition to the increased demand for services, the service delivery model for the rural sexual health clinics had to be adjusted to pandemic public health regulations. Before the pandemic, rural sexual health services were delivered on a walk-in basis but were shifted to an appointment model in order to screen people and manage the number of people inside the clinic. Nurses were also engaged in providing as many services as possible over the phone, like new client paperwork, and providing services for existing clinic clients (e.g., renewing birth control prescriptions).

But having to adjust to the pandemic and the challenges afforded to the day-to-day operation of the sexual health clinic/clinics has resulted in some improvisations and ideas associated with this new model which might help to make sexual health services more accessible to rural populations:

“As horrible as this all has been, […some services that increase accessibility] are going to stick around that we might not have even entertained before, [as the pandemic] made us realize that we are able to deliver our services in a variety of different ways.” For example, having appointments and self-serve testing.

There are considerations for the future of having a blended approach in which there is both walk-in and appointment options, as well as phone services for certain evaluations and services like birth control refills, which not only make the services more accessible to clients in rural areas, but also facilitate the everyday work of the nurses who previously would be “running non-stop [but now] don’t have the physical bodies in the waiting room,getting frustrated with sometimes long wait times .”

Mott noted that it’s nice to be able to “go through who’s booked to come in” in the morning and do what they can over the phone. This has made accessing birth control more accessible as illustrated by Mott’s statement that “I know a lot of clients have expressed their appreciation” for not having to wait an undetermined amount of time just to pick up their birth control .

Additionally, changes have been made to STI testing. A self-serve testing model was implemented during the pandemic, which is likely to continue. For people who need to be tested for STIs, they can just drop off their urine sample, instead of seeing a nurse. Self-serve testing is “a good option for some people.” This new way to do STI testing makes sexual health services more accessible to those in rural areas and helps to increase testing. Before the pandemic, the nurses in rural sexual health clinics did all the STI case management and follow up. During the pandemic that was no longer possible given the increase in needs for service and decrease in staff. One way to mitigate this was to develop an STI case reporting form for Chlamydia infections, that community health care providers are being asked to complete and submit to the health unit. This shift is also likely to continue. This gives nurses more time to focus on the preventative/promotional efforts and making sexual health services more accessible.

While the pandemic has meant a lot of difficulty and changes for everyone, there is a silver lining for sexual health services in the Leeds, Grenville & Lanark District Health Unit. The pandemic “forced us to revaluate the delivery of our services and become more efficient. And then really shine the light on the gaps that we already knew existed, but it just became even more evident during the pandemic.” For nurses this has “strengthened our desire to advocate for positive change both internally and externally when it comes to accessibility of sexual health services and competent care providers.”

Mott hopes that the changes to the delivery and experience of sexual health services that occurred as a result of the Covid pandemic will help in making long-term changes to the system that increase the accessibility and diversity of sexual health services available to people in rural areas.

If you have questions or are in need of accessing sexual health services, visit online (https://healthunit.org/) or contact Leeds, Grenville and Lanark District Health Unit by phone at: 1-800-660-5853 for more information.