Presented by Carol Roye, EdD, CPNP, RN, Professor of Nursing, Assistant Dean for Research, Hunter College School of Nursing at the 2013 National Chlamydia Coalition Meeting

1. INTERVENTION TO PROMOTE
DUAL METHOD USE FOR URBAN TEENS
Carol F. Roye, EdD, RN, FAAN
Hunter College School of Nursing
National Chlamydia Coalition Meeting
February 21, 2013

2. ACKNOWLEDGEMENTS
• Beatrice Krauss, PhD
• Paula Perlmutter Silverman, MPH
• Funders
• National Institute of Nursing Research
• American Nurses Foundation

3. 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

4. BIOLOGICAL FACTORS
• Role of cervical ectopy
• May increase susceptibility to infection and infectivity
• Appears to persist longer in women who use hormonals

5. PSYCHOSOCIAL FACTORS
• Developmentally, adolescents may lack cognitive
and communication skills to effectively negotiate
for safer sex behaviors
• Serial monogamy

6. 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.

7. HOWEVER
• Adolescents
appear to regard
the use of any
contraceptive
primarily as a
measure to
prevent
pregnancy.

8. 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

9. 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

10. INDEPENDENT VARIABLES (CONTD)
• number of lifetime partners
• frequency of intercourse
• history of an STI
• history of pregnancy

11. PRELIMINARY STUDIES
• Variables significantly associated with not
using condoms were:
• oral contraceptive use (OR 1.6)
• Depo-Provera or Norplant use (OR 1.8)

12. 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

13. 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

14. 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)

15. QUALITATIVE STUDIES
• To understand the context of condom use and
nonuse
• Two studies in New York City

16. 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

17. 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

18. “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?”
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.”

19. “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?”
• 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,”

20. “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 women's 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

21. “I WANT YOU TO THINK BACK TO THE LAST TIME YOU HAD
VAGINAL 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,”

22. “I WANT YOU TO THINK BACK TO THE LAST TIME YOU HAD
VAGINAL 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.”

23. “CAN YOU THINK OF WAYS THAT WE COULD HELP
TEENAGERS 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.”

24. “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 . .”

25. “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.”

26. THEREFORE:
• A video
tailored to this
population
makes a lot of
sense.

27. AND
• We
implemented
a brief
counseling
protocol as
well.

28. 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.

29. THE FIRST RCT (FUNDED BY NIH)
• RCT of:
1. Brief patient counseling
2. Video
3. Video followed by brief patient
counseling
4. Usual care

30. SITES
• Planned
Parenthood in
the Bronx and
Brooklyn

31. 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

32. 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.

33. 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

34. THE VIDEO
• Focus groups of
teens helped in
the editing process
• Analysis of data
from these sessions
demonstrated that
the video is very
powerful

35. RECRUITMENT
• 400 young women aged 15-21
who were sexually active, using or
starting use of a hormonal method
• Not pregnant

36. METHODS
• Data were collected at baseline and 3
month follow-up
• computer-based questionnaire via ACASI

37. • Trained the counselors who were high
school educated Planned Parenthood
medical assistants
• Working at Planned Parenthood

38. RESULTS
• Ethnicity
• 45% Black/African American
• 55% Latina

39. 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

40. 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

41. Young women who saw the video
and then received counseling were 2.5 times more
likely to have used a condom at last vaginal
intercourse with their main partner at 3-month
follow-up than teens in the usual care group

42. 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

43. 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

44. SUBJECTS
• N = 99
• Age 14-24
• Ethnicity
• 63% Hispanic
• 37% Black

45. RESULTS
• No difference between the 2 groups in
condom use
• The enhanced video appeared to be
as effective as video plus in-person
counseling

46. 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.

47. THANK YOU
• To receive a free copy of the DVD or
amended Project RESPECT protocol
email Carol Roye:
• croye@hunter.cuny.edu