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Outreach work in sexual health- with a capital O!

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I am the Service Manager and Lead nurse for the Terrence Higgins trust sexual health service, working within the bSHaW service in Buckinghamshire. My speciality and passion has always been in outreach work, taking sexual health to those most vulnerable and at risk, who are unable to access main stream services.

On visiting Cambodia on a holiday I felt inspired to try to impart my passion and skills for outreach work to the local people to help improve their sexual health and choices for contraception. My aim was to find an organization which would be able to use my skills to teach local people. I came across Global Medical who put me in touch with Build Your Future Today (BFT) in Siem Reap. Their vision is built upon two beliefs: Knowledge is Hope – Peace is Development. At BFT Centre, they believe that education is key to developing economic stability and personal well-being along with peace for the individual family, and hence the whole of Cambodian society. BFT work in various villages around Siem Reap province and empower the people living below poverty line to attain a better standard of living, while strengthening their growth for ongoing development.

The Cambodian health care system was destroyed during the Khmer Rouge regime 1975-79, the conflict wiped out an estimated 2 million Cambodian citizens including the majority of health care staff, resulting in the worst health in South East Asia. The royal government of Cambodia’s ministry of health have been working since 1994 in reforming the health care system. Health care workers face many challenges, low salaries, inadequate facilities and equipment, drug shortages. The destruction of the health infrastructure rendered the family planning programmes inoperable for over 20 years. In 1994 family planning campaigns were re-instated but efforts were affected by the country’s poor infrastructure. Over the last decade government and NGOs have made significant improvements to reproductive health.

The volunteer work I did in Cambodia was outreach, but with a capital O! Outreach in poor countries like Cambodia takes on a different meaning. The villages that the health clinic serve are spread out in rural areas anything from 5-30km away. Their only mode of transport is motorbike or bicycle. Some of the health clinics send the nurses out by motorbike to do immunizations, but more often the families have to travel to the clinic to receive health care. This was very powerfully illustrated on my first day when we arrived to hear a woman in late stages of labour, by the time we left the clinic at the end of our first day she left on a motorbike, sitting side saddle with her husband and toddler, grandma was on another carrying the new born driven by grandad!

The conditions of the health centre are very different from those in clinics in England and even within town clinics in Siem Reap. There was no running water; there were sinks but currently not enough water to run these. Water is drawn from a well and they have one outside tap that is still working. Medical supplies are extremely scarce, primarily due to the disjointed health care system with some government support and funding, but reliant on the support from NGOs. There is a pharmacy but again with sporadic supplies of medication. In particular, reliant on the NGO for extra supplies of contraception.

The staff were very dedicated at the rural health centre. Our purpose was to teach them practical skills of long acting contraception, primarily implants as they were confident and competent in IUD fitting. There has been an active government programme promoting LAMs (long acting methods or LARC as we term it). however, the supply of implants and practical training did not reach as far as the rural areas.

Malnutrition is a serious problem in rural Cambodia with multiple pregnancies of 4 + worsening the situation as the mothers health deteriorates and also poverty increases. Education is hard as once the children are no longer being breast fed the parents often travel across to Thailand to try to get work. Thus, leaving ageing grandparents to care for multiple children. Trying to educate on nutrition and introducing new ideas on how to avoid malnutrition is even harder as older generations find it harder to take on new ideas.

Working in the outreach clinics was challenging. The level of hygiene was considerably different to the conditions we were used to working with. There was no running water inside the clinic; water was provided by a well with a single outside tap. The clinic rooms were also the home to much wildlife – chickens, lizards and spiders had no respect for infection control! It was a huge learning experience how to respect the differences in accepted levels of hygiene between our western training and the outreach in Cambodia. Subtly suggesting, via our interpreter, how to improve techniques to raise the standards of hygiene without causing offence, resisting the temptation to get a brush and mop and clean the floor and beds.

We completed the project this year by returning just before the 3 years to retrain any additional staff and also consolidate their training specifically on implant removals. The staff were fully competent and confident at both insertions and removals by the time we left. We were able to re stock their shelves with extra supplies of contraception and implants from the generosity of donations from our friends and family. The experience of doing outreach work in another country was very humbling. Empowering women to have choices over their contraception and enable safe birth spacing to improve the health of the whole family.