Women who received skills-oriented counseling at an Alabama STD clinic used condoms and microbicides more frequently during the next six months than did women who received only information about the use and effectiveness of these methods, according to findings from a study comparing the interventions.1 However, STD rates did not differ between the two groups. Regardless of which intervention women received, those reporting perfect condom use and those who used a vaginal microbicide at least half of the time had reduced STD rates during the follow-up period (relative risks, 0.3 and 0.5, respectively).
Study participants were recruited between 1992 and 1995; women were eligible if they were 18–35 years old, had not had a hysterectomy, were not pregnant and did not wish to conceive within the next six months. At enrollment, participants were randomly assigned to one of two intervention groups (basic or enhanced); completed a baseline interview that covered their background, medical, behavioral and psychosocial characteristics; received a pelvic examination; and were taught to record information about their sexual behavior and barrier method use in a daily diary. They also were asked to return for six monthly follow-up visits; at each visit, they were reinterviewed, received a pelvic examination, had their sexual diaries reviewed and returned unused method supplies.
For the basic intervention, a clinician spent 5–10 minutes with each woman, explaining the importance of using condoms and microbicides to prevent STDs; the women were given free supplies of the methods and two brochures on how to use them. For the enhanced intervention, women watched a 19-minute video that promoted safer sex and received 30 minutes of skills-oriented counseling, which covered the effectiveness of condoms and microbicides (used individually or jointly), how to use them and how to negotiate condom use with a partner. Participants in the enhanced intervention were given free supplies of the method of their choice and a variety of informational and promotional materials, including product samples to share with a friend. They received a supportive letter from the counselor shortly after the intervention, and viewed a video about condom use and negotiation skills at the first follow-up visit.
The researchers analyzed data on 213 women who received the enhanced intervention and 214 in the basic intervention group. The two groups had similar profiles: On average, the women were 25 years old and had had 12 years of education. The majority were black and single, and nearly half received food stamps. Sexual experience began early for these women, and half had been pregnant by age 17; most were using a contraceptive at the time of their initial visit. At enrollment, nearly three-quarters of women in each group reported having had an STD; laboratory tests of specimens taken during the first pelvic examination detected infection in about half of the women. In the 30 days before the baseline interview, one-quarter of women in each group had had more than one sexual partner. Twenty-six percent of women receiving the enhanced intervention and 19% of those in the basic intervention group had used condoms for every act of intercourse in the past 30 days; 42% and 45%, respectively, had not used them at all.
During follow-up, significantly higher proportions of women in the enhanced than of those in the basic intervention group reported keeping condoms at home (97% vs. 94%), carrying condoms with them (79% vs. 61%), asking a male partner to use a condom (63% vs. 57%) and putting a condom on a partner (43% vs. 25%). The frequency of these behaviors was higher after the intervention than at baseline in both groups, but the change was greater for women who had received skills-oriented counseling than for those in the information intervention.
Differences between groups in the use of condoms and microbicides during follow-up were highly significant: Condoms were used 69% of the time by women in the enhanced intervention group and 49% of the time by those in the basic group; microbicides were used 44% and 29% of the time, respectively. Twenty-one percent of episodes of intercourse among women who received the enhanced intervention and 35% among the basic group were not protected by either method. Joint use of the two methods increased more among women who had received skills-oriented counseling than among those who had received only basic information, and use of microbicides alone increased more among the latter.
Despite the behavioral differences between groups during the follow-up period, their rates of various STDs were statistically indistinguishable. To explore this finding, the researchers further analyzed the data according to consistency of method use and reliability of the diary data (as indicated by information collected during interviews and by interviewers’ comparisons of supplies dispensed and unused). The findings suggest that women reporting perfect condom use—i.e., those with reliable diary data who used condoms consistently and reported no problems with the method—were significantly less likely than inconsistent users to acquire an STD (relative risk, 0.3). However, levels of perfect use were too low to have a measurable impact on the overall STD rate. Women who used microbicides 50% or more of the time had a lower STD risk than those who used these preparations less frequently (0.5).
The researchers observe that the enhanced intervention was substantially shorter than others that have had comparable results in increasing use of barrier methods. On the one hand, they infer that “it may be possible to teach critical skills in less time than is typically expended.” On the other hand, they acknowledge that even 30 minutes may be more time than some clinicians can spend with individual patients. Although interventions excluding some of the components used in the Alabama clinic may yield similar results, the data do not permit an assessment of which elements could be omitted.
1. Artz L et al., A randomized trial of clinician-delivered interventions promoting barrier contraception for sexually transmitted disease prevention, Sexually Transmitted Diseases, 2005, 32(11):672–679.