Clinic-based service programs for increasing responsible sexual behavior

Journal of Sex Research, Feb, 2002 by J. Dennis Fortenberry

Clinic-based service programs for increasing responsible sexual behaviors offer advantages that complement community-based prevention programs. Clinic clients are often at higher risk than persons in the general population. Clinic staff may be seen as authoritative sources of prevention information. Clinic visits may serve as important cues to action that serve as a basis for behavior change. The purpose of this paper is to review issues relevant to effective, clinic-based programs that address responsible sexual behaviors.

Clinic-based prevention programs encompass a variety of clinical settings, target populations, and desired outcomes. For the purpose of this summary, programs located in any type of U.S. health-care facility are included even if located within a larger organization. For example, school-based clinic interventions are addressed even though they take place within the larger context of schools. Programs are included without regard to target population. Outcomes of interest are both behavioral (e.g., increased condom use or reduction in number of sexual partners) as well as biological (e.g., reduction in rates of sexually transmitted diseases).

The clinic-based programs were separated into three categories for conceptual clarity: (a) clinic-based educational/ counseling programs, (b) school clinic-based condom or contraceptive distribution programs, and (c) clinic-based STD/HIV screening programs. Education/counseling programs and condom/contraceptive distribution programs encourage responsible sexual behavior before any adverse outcome may have occurred, and are examples of primary prevention efforts. STD/HIV screening programs may be seen as attempts to encourage responsible behavior by reducing disease transmission and by prevention of sequella.

CLINIC-BASED EDUCATIONAL/COUNSELING PROGRAMS

Several evaluations of programs show increased responsible sexual behavior, reduced adverse outcomes of sexual behavior, or both. Successful clinical interventions have several elements in common. Similarities include:

1. The successful interventions have a clear theoretical basis and are grounded in the empirical lessons of earlier research. The importance of theory for successful behavioral interventions is the delineation of modifiable factors that are associated with a specific behavior, as well as an understanding of factors required in order to change the behavior.

2. Successful interventions require an investment of effort and time (Kalichman, Carey, & Johnson, 1996). Each program requires specific commitment of staff effort as well as additional time from clients. Such commitments entail costs that may be difficult to reimburse.

3. The most successful interventions are tailored to individuals rather than limited to generic education, recommendations, or advice.

4. Successful interventions include skill-building exercises as well as education and counseling components. Skill building includes behaviors such as negotiation practice with potential partners or practice of correct condom use (Exner, Seal, & Ehrnhardt, 1997).

A variety of approaches to risk-reduction counseling have been used. These approaches include brief (less than 20 minutes) didactic counseling during one visit; brief, personalized counseling over a 7 to 10 day period; and extensive individual or small-group counseling sessions during an interval of several weeks. Populations addressed by studies of risk reduction in clinical settings include interventions targeting adolescents, high-risk women, racial/ethnic minorities (primarily African American and Hispanic), and sexual minorities. Condom use is the most frequently used outcome but incident sexually transmitted infections (including HIV) and behaviors such as number of new sexual partners are also often measured.

Current standards for clinical practice include at least some risk reduction counseling for at-risk persons (U.S. Preventive Services Task Force, 1996). This standard is equivalent to brief, didactic, risk-reduction messages. In clinical samples, preintervention levels of consistent condom use are often less than 20%. Most studies show that brief risk-reduction messages are associated with increases in consistent condom use compared to preintervention levels of use (Cohen, Dent, & MacKinnon, 1992; Cohen, Dent, MacKinnon, & Hahn, 1991; Kamb et al., 1998; Mansfield, Conroy, Emans, & Woods, 1993). This level of condom use may be sustained for up to 12 months following the counseling session although decay of effects over time is almost universal (Kamb et al., 1998). Thus, most authorities believe that additional sessions are required to maintain desired behaviors.

Sexual risk behaviors other than condom use may also be influenced by brief clinic-based interventions. Number of recent sex partners (Cohen et al., 1992; Mansfield et al., 1993) and incident sexually transmitted infections (Cohen et al., 1992; Kamb et al., 1998) are also reduced.

A few studies of single-session counseling--such as that provided during HIV pretest counseling--demonstrate no influence of counseling on subsequent levels of self-reported condom use or sexually transmitted infections (Clark, Brasseux, Richmond, Getson, & D'Angelo, 1998; Wenger et al., 1992) These clinical interventions may typically represent highly didactic prevention messages that may seem inappropriate to many patients. Such differences may explain the relative success of more individualized behavior change approaches.