Intervention to Promote Dual Method Use for Urban Teens
INTERVENTION TO PROMOTEDUAL METHOD USE FOR URBAN TEENS Carol F. Roye, EdD, RN, FAAN Hunter College School of Nursing National Chlamydia Coalition Meeting February 21, 2013
ACKNOWLEDGEMENTS• Beatrice Krauss, PhD• Paula Perlmutter Silverman, MPH• Funders • National Institute of Nursing Research • American Nurses Foundation
BACKGROUND• Young people are at highest risk for chlamydia and other STIs.• Young women who use hormonal contraceptives may be a subgroup of adolescents that is at elevated risk for HIV Some evidence that is true for chlamydia as well.• Biological and psychosocial reasons
BIOLOGICAL FACTORS• Role of cervical ectopy • May increase susceptibility to infection and infectivity • Appears to persist longer in women who use hormonals
PSYCHOSOCIAL FACTORS• Developmentally, adolescents may lack cognitive and communication skills to effectively negotiate for safer sex behaviors• Serial monogamy
CLEARLY:• Effective use of contraception to prevent STIs/HIV and pregnancy requires that a young woman who uses a hormonal method has a male partner(s) who uses condoms consistently.
HOWEVER• Adolescents appear to regard the use of any contraceptive primarily as a measure to prevent pregnancy.
PRELIMINARY STUDIES• 600 adolescent and young adult women at a community clinic in Manhattan• Condom use by three groups of young women was the outcome of primary interest. The three groups were those who use: 1) oral contraceptives, 2) long- acting agents, i.e. Depo-Provera or Norplant, and 3) no hormonal contraceptive
PRELIMINARY STUDIES• Logistic regression was used to assess those factors which influenced condom use.• Independent variables: • oral contraceptive use in the last four weeks, • Depo-Provera or Norplant use • ethnicity • length of relationship
INDEPENDENT VARIABLES (CONTD) • number of lifetime partners • frequency of intercourse • history of an STI • history of pregnancy
PRELIMINARY STUDIES• Variables significantly associated with not using condoms were: • oral contraceptive use (OR 1.6) • Depo-Provera or Norplant use (OR 1.8)
PRELIMINARY STUDIES• Those who used hormonal contraceptives were significantly less likely to use condoms than those who used condoms only, even though they all identified AIDS risk as an important concern in their choice of contraceptive method
CONDOM USE IN GENERAL WAS POOR• Only 34% of the entire sample used condoms “often” or always”• 47% of those who had been sexually active in the last 4 weeks had not used a condom at all
WHO ARE THE DUAL METHOD USERS?• Dual users (N = 60) had significantly: • more previous STIs than hormone only users (N = 99) (p=.000) or condom only users (N = 201) (p=.000). • Significantly more lifetime partners (p=.005)
QUALITATIVE STUDIES• To understand the context of condom use and nonuse• Two studies in New York City
QUALITATIVE STUDIES• Open-ended interviews based on the work of other researchers in the field• Research assistants were trained to interview teens about sexual behaviors
WHAT THE TEENS TOLD US• Analysis suggested gaps in knowledge and motivation to use condoms• Barriers to condom use we had not thought to ask about
“I WANT YOU TO THINK BACK TO THE LAST TIME YOU HAD VAGINALINTERCOURSE AND DID NOT USE A CONDOM. WHAT WERE THE REASONS YOU DID NOT USE A CONDOM?” The NUMBER 1 REASON FOR NOT USING CONDOMS: They were using other protection - - OCs or Depo - -to protect them from pregnancy“Cause I was on the pill and can’t get pregnant.”
“I WANT YOU TO THINK BACK TO THE LAST TIME YOU HAD VAGINALINTERCOURSE AND DID NOT USE A CONDOM. WHAT WERE THE REASONS YOU DID NOT USE A CONDOM?”• Monogamy is another reason that they do not use condoms• Even though many questioned their partners fidelity, and many engage in serial monogamy.• “Because I feel that I can trust my partner, or at least I hope I can,”
“I WANT YOU TO THINK BACK TO THE LAST TIME YOU HAD VAGINAL INTERCOURSE AND DID NOT USE A CONDOM. WHAT WERE THE REASONS YOU DID NOT USE A CONDOM?”• Importance of trust in the young womens decision- making about risk-reduction behaviors. • They use condoms when they have not seen their boyfriend for "a while", but do not need to use condoms if they have been together for days
“I WANT YOU TO THINK BACK TO THE LAST TIME YOU HADVAGINAL INTERCOURSE AND YOU USED A CONDOM. WHAT WERE THE REASONS THAT YOU USED A CONDOM?”• To prevent pregnancy and, secondarily, STIs• “Because I was not on the pill yet and I did not want to get pregnant,”
“I WANT YOU TO THINK BACK TO THE LAST TIME YOU HADVAGINAL INTERCOURSE AND YOU USED A CONDOM. WHAT WERE THE REASONS THAT YOU USED A CONDOM?”• Lack of trust• “’Cause he was not my boyfriend anymore”• “Because I did not know the person that well.”
“CAN YOU THINK OF WAYS THAT WE COULD HELPTEENAGERS LIKE YOU USE CONDOMS MORE REGULARLY WHEN THEY HAVE SEX?”• Improve access to condoms• “. . . Make [condoms] cheaper because they are kind of expensive in the store.”
“CAN YOU THINK OF WAYS THAT WE COULD HELP TEENAGERS LIKE YOU USE CONDOMS MORE REGULARLY WHEN THEY HAVE SEX?”• “Showing [teens] the risk of being pregnant.”• “. . . reading about it, see posters, reading newspapers, seeing it on the television . .”
“CAN YOU THINK OF WAYS THAT WE COULD HELP TEENAGERS LIKE YOU USE CONDOMS MORE REGULARLY WHEN THEY HAVE SEX?”• Personalizing the message.• “I am going to say it but there are a lot of teenagers that have AIDS. And, if they come out on TV and do like little conventions and stuff like that, [teens] can see that it can happen to teenagers also. Suppose it being someone my age, it would scare me. . . . It would make me think and I would use condoms.”
THEREFORE: • A video tailored to this population makes a lot of sense.
AND• We implemented a brief counseling protocol as well.
THE GOALS• To develop and test • Specifically, brief interventions to interventions which promote condom are low- or no-cost, use in this and can be vulnerable implemented in any population. clinical setting.
THE FIRST RCT (FUNDED BY NIH)• RCT of: 1. Brief patient counseling 2. Video 3. Video followed by brief patient counseling 4. Usual care
SITES• Planned Parenthood in the Bronx and Brooklyn
THE COUNSELING• Adaptation of Project RESPECT -- a CDC program for adults. It was amended for one-session use with teens. • Original trial - 4 sessions vs 2 sessions • Our trial - 15-20 minute interactive session • The counselors are Planned Parenthood medical assistants whom we have trained
THE VIDEO• Based on the qualitative responses• Features two young HIV-positive women one who is Black, and the other who is Latina• Both young women speak to school groups about HIV-prevention, so they are comfortable discussing their status.
THE VIDEO• Two young men (one Black and the other Latino) also discuss condom use.• They each had some experience with peer education in high school
THE VIDEO• Focus groups of teens helped in the editing process• Analysis of data from these sessions demonstrated that the video is very powerful
RECRUITMENT• 400 young women aged 15-21 who were sexually active, using or starting use of a hormonal method • Not pregnant
METHODS• Data were collected at baseline and 3 month follow-up • computer-based questionnaire via ACASI
• Trained the counselors who were high school educated Planned Parenthood medical assistants • Working at Planned Parenthood
RESULTS• Ethnicity • 45% Black/African American • 55% Latina
SEXUAL BEHAVIORS• Number of vaginal sex partners: • Range 1-30 • Mode = 3 (20%)• Oral sex: • 90% had engaged in oral sex• Anal sex: • 35% had engaged in anal sex
RESULTS• Main outcome variable: • condom use at last vaginal intercourse with main partner• At 3-month follow-up, young women who received only the video intervention or only the counseling intervention did not differ significantly on this outcome from those in the usual care group
Young women who saw the videoand then received counseling were 2.5 times morelikely to have used a condom at last vaginalintercourse with their main partner at 3-monthfollow-up than teens in the usual care group
PROBLEM• The MAs had little time to do the counseling, and would not have done it if no research assistant was onsite.• Therefore, the intervention, in its current format, was likely not easily replicable in other clinics
SOLUTION• Received funding from ANF to enhance the video by adding a segment showing a nurse counseling a young woman• RCT testing: • the enhanced video • the original video plus in-person counseling• Outcome variable • Condom use at last intercourse with main partner
SUBJECTS• N = 99• Age 14-24• Ethnicity • 63% Hispanic • 37% Black
RESULTS• No difference between the 2 groups in condom use• The enhanced video appeared to be as effective as video plus in-person counseling
CONCLUSIONS• A brief, low-cost intervention, i.e. enhanced video, appears to be effective at improving condom use by teenagers, including those who use hormonal contraception.
THANK YOU• To receive a free copy of the DVD or amended Project RESPECT protocol email Carol Roye:• email@example.com