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Your next patient has an abnormal vaginal discharge. Upon further inspection, a positive finding for gonorrhea is made. When you share this news with her, she says, "I can’t have a sexually transmitted disease; I’m on the Pill." Sound familiar?
Many patients may have misguided notions about prevention of sexually transmitted diseases (STDs), but counseling might help, according to the results of a study of some 3,500 STD clinic visitors.1
The study’s findings come from a secondary analysis of a large-scale randomized controlled trial for Project RESPECT, sponsored by the Atlanta-based Centers for Disease Control and Prevention (CDC). Project RESPECT demonstrated that interactive, client-centered HIV/STD counseling resulted in an overall reduction in STD incidence of about 30% after six months
and 20% after 12 months of follow-up.2
"Misconceptions about STD-protective behaviors are common, and the event of an STD or STD counseling or both generally reduces these misconceptions," state the scientists involved in the Project RESPECT analysis group. "Although these misconceptions may not directly translate into risky behavior, they may preclude movement toward safer sex."
Patients enrolled in the Project RESPECT study completed an interview upon study enrollment and every three months following enrollment for a one-year period. A portion of the routine interview assessed participants’ misconceptions about STD-protective behaviors.
At baseline, about 16% believed that washing the genitals after sex protected from STDs. Other common inaccurate STD prevention beliefs included urinating after sex (38.7%), douching (45.7%), and use of oral contraceptives (19.9%). Prevalence of misconceptions was significantly diminished at a three-month follow-up.
Of those study participants who still held misconceptions even after their clinic visit, several demographic characteristics emerged. For example, those age 24 and older with less than a high school education were especially likely to continue to believe that douching prevents STDs.
Routine douching for hygienic purposes has been associated with an increased risk for pelvic inflammatory disease (PID), states Mary Kamb, MD, MPH, a medical epidemiologist at CDC and co-author of the original and secondary Project RESPECT analyses.
"[Douching] is associated with PID, but everyone’s mother tells them to do it," says Kamb. "That [misconception] would be a good one to clarify for young women."
The didactic approach to counseling used in several STD clinics may need to be replaced with the client-centered, interactive approach demonstrated in the Project RESPECT model, suggests Kamb. (Clinic managers and counselors can get counseling protocols, quality assurance protocols, and further information about Project RESPECT at the following CDC web page: www.cdc.gov/hiv/projects/respect/default.htm.)
"This large randomized controlled trial evaluating interactive risk reduction counseling among STD clinic patients is the first to report that counseling leads to reduction in sexually transmitted infections," note the scientists participating in the original analysis. "In addition to concerns about efficacy, concerns that interactive counseling is not feasible for busy, publicly funded clinics, or cannot be conducted by the personnel currently employed by health departments, should now be put to rest."
Although long recommended and supported by counselors, client-centered HIV prevention counseling is seldom done in STD clinics, perhaps because program managers might not believe that a two-session intervention can work, state the scientists. However, the brief counseling model was designed for implementation, at low cost and with existing personnel, in the context of routine health care services.
"The intervention adherence we found suggests that two-session counseling would have at least the same retention as the didactic approach that is currently used and would have greater retention than longer therapies," state the scientists.
Although barriers to effective patient education do exist, clinics can take steps to keep messages prevention-focused, says William DeJong, PhD, professor at the Department of Social and Behavioral Sciences at Boston University’s School of Public Health. Clinics should review quality assurance procedures and guidelines to see that they pose no obstacles to educational innovation. Examine guidelines to encourage experimentation with such strategies as group counseling and see that staff members receive training in prevention-focused communication.3
DeJong is developing an interactive patient education video with Boston City Hospital and the Boston University School of Public Health for use in inner-city STD clinics. While the study to evaluate it is still under way, DeJong says it will examine how to motivate people with STDs to practice safer sex to avoid reinfection.
"The computer-assisted video allows STD patients to select from a series of dramatic vignettes about various prevention-related topics, especially condom use," he explains. "Our expectation is that making their choices will help patients be more engaged with the materials, which should enhance their power to motivate behavior change."
It is crucial for health care providers to concentrate their counseling efforts on people at risk for repeat infections, DeJong observes.
"Beyond that, we need to find ways to engage people in thinking about how to protect their reproductive health," he notes. "This requires time, money, and imagination, but I think the investment is worth it."
1. Crosby RA, Newman D, Kamb ML, et al. Misconcep-tions about STD-protective behavior. Am J Prev Med 2000; 19:167-173.
2. Kamb ML, Fishbein M, Douglas JM, et al. Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: A randomized controlled trial. Project RESPECT Study Group. JAMA 1998; 280:1,161-1,167.
3. DeJong W, O’Donnell L, San Doval AD, et al. The status of clinic-based STD patient education: The need for a commitment to innovation in health communication. J Health Commun 1996; 1:51-63.