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Brief Sexuality-Related Communication: Recommendations for a Public Health Approach. Geneva: World Health Organization; 2015.

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Brief Sexuality-Related Communication: Recommendations for a Public Health Approach.

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4EVIDENCE AND RECOMMENDATIONS

4.1. RECOMMENDATION 1: BRIEF SEXUALITY-RELATED COMMUNICATION TO PREVENT STIS

RECOMMENDATION 1

BSC is recommended for prevention of STIs among adults and adolescents in primary health services.

Strong recommendation, low to moderate quality of evidence

4.1.1. Background

Adults and adolescents view health-care providers as a trusted source for health information (49) and often wish to discuss sexuality-related issues with them (10). However, health-care providers tend not to proactively engage their clients about sexual health and well-being (6, 17). Clients often have to raise the issues themselves, even though they may be embarrassed to do so (41, 44).

The focus of most sexual health programmes is prevention of unintended pregnancies and prevention and treatment of STIs, and most of the literature on the use of sexual health counselling skills addresses STIs. It demonstrates that provider support can make the difference in enabling clients to prevent STIs (46).

However men, women and people living with alternate genders and sexualities across diverse cultures have different perceptions and capacities to prevent STIs, and these may be influenced by a wider range of concerns and problems relating to their own (or their partners') sexual health and well-being, for which they also need health service support (140). These may be disease-related problems; for example sexual problems that result from chronic diseases, cancer treatment or diabetes, or STIs (45, 111); or they may be interpersonal, psychological or social problems (12, 69). Yet aside from psychologists, sexologists or sex therapists, health-care providers are often not encouraged or sufficiently trained to feel comfortable in diagnosing these concerns in order to help those who are seeking care (2, 44, 55, 132).

People's own perceptions of sexual concerns or problems are quite diverse, subjective and relational in nature and severity. Key dimensions identified as outcome indicators for individual sexual health concerns include people's concern regarding the shape and size of their penis, vagina or breasts; their sexual performance or satisfaction, or that of their partner; their gender identity; and their sexual orientation and relationships.

Adolescence is a period of personal development and self-construction, and is thus a critical opportunity for ensuring successful transition to adulthood (56). Expression of sexuality and sexual experimentation are an expected and healthy dimension of adolescence (88). Many adolescents grapple with their changing sense of self and body image and their sexual development in the absence of information and psychosocial support to counteract misconceptions, fears and insecurities (5, 143). Adolescence is a time of exploration and defining personal limitations as part of the process of transforming towards adulthood (141). Negative responses to adolescents' disclosure of being gay, lesbian or bisexual have been shown to negatively affect their health, resulting in higher levels of depression, drug use and unprotected sex – with the associated increased vulnerability to STIs (124).

Adolescents have an evolving capacity to take action to fulfil their right to health (30), and this can be enhanced through provision of appropriate services (34, 96). One of the studies that form the evidence base for this guideline document showed that adolescents who talked to their provider about HIV were more likely to use condoms and take other precautions to prevent infection (41). Yet adolescents' access to services, which could provide the support they need in this process, is often hampered by cultural norms (13, 96, 129). There is a wide gap between what adolescents would like health services to address and what is offered (96, 143).

WHO's Framework for Sexual Health Programmes notes: “specific strategies are needed to expand services to hard-to-reach groups, such as adolescents and young people who do not attend school, or who are unemployed, refugees, young sex workers, street children, sexually abused children, lesbian, bisexual and gay young people, and drug users. An important aspect to consider when identifying people who are hard to reach is the complex nature of vulnerability. Services should be available and accessible without parental consent, taking into account the young people's evolving capacity and best interests” (37: 38).

Approaches to adolescent sexual health need to accept sexuality as a normal and positive aspect of a person's life, “enabling young people to explore, experience and express their sexuality in healthy, positive, pleasurable and safe ways. This can only happen when the sexual rights of young people are respected.” (143: 69).

4.1.2. Available evidence

The evidence identified in the systematic review showed that BSC improves sexual health knowledge, attitudes towards and intentions to engage in safer sex, and STI prevention skills; these improvements were sustained over a 12-month period (24, 107).

Studies described the effects of these improvements in different ways and on different populations, including particularly vulnerable groups. Studies found BSC resulted in: fewer sexual risk behaviours; an increased reported consistency of male condom use (32, 85, 107), especially in high risk populations (47, 81, 114); and decreases in STI incidence (32, 47, 79, 85, 107, 147). Four studies found fewer sexual partners and fewer episodes of unprotected sexual events with BSC (24, 81, 85, 114). One article found a significant increase in glove use during digital-vaginal sex post-treatment for bacterial vaginosis (BV) among same-sex female partners (95).

There is no single model of BSC, and not all study reports use the same terminology to describe their methods or outcomes. The BSC studies that were accepted as evidence from the systematic review for this guideline all had similar components of BSC, such as asking sexual health questions, providing information, and supporting clients by building their self-confidence and skills to take steps towards protecting their sexual health and well-being. All of these components used a client-centred approach, including how to use condoms correctly (32, 47, 81, 114) and how to negotiate condom use (32, 47, 81, 107, 114), both of which are key to STI prevention.

A study of female sex workers at clinics in Antananarivo and Tamatave, Madagascar used BSC. Nurses spent 15 minutes in a two-way exchange with the client that included: conducting an individual risk assessment; discussing transmission and verifying the client's basic knowledge about STIs and HIV; dual protection; demonstrating condom use and giving the client the opportunity to practice with models; reinforcing skills for negotiating condom use; and promoting the “no condom equals no sex” policy. The nurses tailored the BSC to individual circumstances (47).

BSC was used in a study with women who have sex with women. At a dedicated women's health research clinic in the United States, health-care providers began with a computer-assisted self-interview to assess behavioural risks, because this method has been shown to yield significantly higher rates of disclosure for same-sex behaviour and undesirable social behaviours when compared directly with self-administered questionnaires (95, 142). The intervention addressed four factors. To address perceived susceptibility to BV, participants were educated about the relatively high prevalence of BV among women reporting sex with other women and the high degree of concordance of BV within monogamous female sexual partnerships. Perceived severity was addressed by educating participants on the symptoms of BV and its consequences. To address perceived benefits, providers “emphasized the benefits of treating and preventing BV, including the possibility of the reduced likelihood of BV transmission to female sex partners. Finally, perceived barriers to implementing the behavioural intervention were explored with participants, including ways to incorporate cleaning of sex toys or using male condoms on sex toys [in] participants' sexual routines.” (95: 3)

In a study with female sex workers in Tijuana and Ciudad Juarez, Mexico, BSC addressed four areas: “(i) motivations for practicing safer sex (e.g. to protect one's own health, to avoid STIs, to feel clean) versus those for practicing unsafe sex (e.g. financial gain); (ii) barriers to condom use (e.g. threats of physical violence); (iii) techniques for negotiating safer sex with clients; and (iv) enhancement of social supports.” (114: 2052)

Two studies found that there is no difference in outcomes between BSC interventions and more intensive interventions, both of which had some behavioural dimension (24, 85), while another showed that individual BSC by a clinician is more effective than peer education (47).

Kamb et al. (85) found that in addition to the value of the interactive dimension of the conversation between provider and client, including the development of a personalized risk reduction plan played a key role in the effectiveness of BSC (e.g. increased condom use and fewer STIs). Other studies elaborated this; for example Patterson et al. (114) described how BSC would identify barriers to implementation and how to overcome them. This included considering potential risks of violence and how to avoid these.

Regarding group interventions, a study in two public STI clinics in New York City that used a 45-minute intervention with groups of 4–8 participants resulted in a 23% reduction in STI incidence over 17 months of follow-up and better attitude, knowledge of condom use and efficacy (138). A study in Los Angeles inner-city STI clinics of a waiting room group intervention that compared different types of input – a social influence approach versus a skills approach – found a decrease in STI reinfections among men, but not among women, with both group approaches (32). This study led the GDG to conclude that, while group interventions can be effective, one-on-one BSC is more likely to reach a broader range of clients. This view is reinforced by the above-mentioned study of female sex workers in Madagascar comparing peer education alone with peer and health-care provider BSC, where health-care provider counselling produced stronger outcomes regarding reduction in STIs (47).

The key study regarding adolescents that supports this recommendation is a study in Washington DC that used the Awareness, Skills, Self-efficacy/Self-esteem, and Social Support (ASSESS) Programme. It advocates “increasing adolescent awareness about sexual risks, skills to avoid risky sexual situations, self-efficacy (such as a feeling that peer pressure can be resisted), and social support (such that adolescents felt encouraged by the physician)” (17: 109). It involved an 11-question risk assessment for young adolescents and an audio recording responding to their concerns, followed by health-care provider STI/HIV-prevention counselling and supported with information pamphlets for the adolescents and their parents. After three months, the clients in the intervention group were making greater use of condoms if they had sexual intercourse, but this impact dissipated by nine months. However, self-reported STI outcomes suggested a positive programme impact at nine months, indicating that “the cumulative effect of the increases in adolescent awareness and condom use was a decrease in sexual risk” (17: 113).

While BSC takes many forms, in this case the sexual health assessment portion of the audio recording that adolescents listened to at the start of the session asked 11 questions (with response options of “yes”, “no” and “does not apply”) about feelings and behaviours that may be associated with STI/HIV transmission (including feelings of sexual attraction; history of holding someone in your arms; history of kissing; ability to say no to sexual intercourse; history of masturbation; history of vaginal, oral or anal intercourse; condom use; and use of street drugs or alcohol). The final educational portion of the recording described the possible relationship of each response option to STI or HIV infection risk (17). The conversation between provider and client took place after the client had listened and responded to the tape. Both parents and adolescents were given reading materials to take home.

It has been suggested that multiple-session interventions are needed for effective change of sexual behaviour, but the evidence challenges this view. Six studies found that a single BSC intervention was as effective as several (17, 24, 81, 107, 114, 147).

Four studies found that brief interventions were as effective as intensive ones, where “brief” refers to one-on-one provider BSC, and “intensive” refers to more thorough skills training, usually in groups with peer support and interactive processes such as role-play (24, 81, 85, 95). This further increases the appropriateness of incorporating BSC into routine services.

Two studies found that client motivation may influence the effectiveness of BSC. For example, people who already have an STI have greater motivation to prevent future sexual health problems (85, 147). Lack of client motivation to attend intensive interventions also reinforces the value of incorporating BSC into routine provider-client visits. Carey et al. noted that the process of completing a baseline assessment in itself may have influenced behaviour (24).

4.1.3. Balance of benefits and harms, feasibility and acceptability

Benefits and harms

The benefits of the intervention outweigh the harms.

Everyone has the right to sexual health services that help them prevent and deal with STIs. At the same time, the process of BSC, if effective, might lead clients to be more assertive with their partners (e.g. about condom use), and this assertiveness could in turn endanger the client (32). Well-trained providers will be aware of this risk and can broach the subject with clients and suggest ways to address it. While in the short term, breaking the silence about sexual concerns may cause clients stress, the process is essential for ultimately improving their sexual health. In addition, failure to support clients in protecting and promoting their health not only undermines their health, it also results in increased costs to the health system (28, 109).

Adolescents have the right to seek and receive information (118). In the absence of the information, support and skills needed to promote and protect their health and well-being, adolescents can suffer harms such as stigma, sadness, shame, guilt and anxiety, as well as STIs and unintended pregnancies (87, 117).

There is no evidence that BSC leads to increased sexual activity in general, including among adolescents (17).

The recommendation for the provision of brief sexuality-related communication (BSC) requires that health-care providers have been given appropriate training (see Recommendation 2).

When providers have appropriate training, sexual issues raised by clients can be dealt with in a brief visit to their primary provider, with only more complex issues requiring referral (88). However, sometimes people's sexual health problems (or physiological health problems that are giving rise to sexual difficulties) are beyond the professional capacities of providers at the first level of care. In this context, providers need to know what other services are available and refer clients as necessary. To offer BSC in a context where providers lack the capacity to address certain issues, either directly or through referral, may be suboptimal.

Feasibility and acceptability

Some studies directly assessed the feasibility of the intervention. A recent study in Russia recruited men and women to receive either a 60-minute motivational/skills building intervention to reduce HIV risk behaviours, or written HIV prevention material alone. With follow-up occurring at three and six months, the intervention group showed a significant decrease in the number of unprotected sexual acts (84). The feasibility of BSC in a single session in health-care settings was evaluated in South Africa (84), Kenya, Tanzania and Trinidad (137), and Mexico (114). Results showed that the intervention is feasible within the STI/HIV prevention programmes in low- and middle-income settings, as well as in different cultural contexts.

A study conducted in the United States compared women randomized to a single-session skills-based sexual risk reduction intervention – i.e. a BSC intervention – with women in an AIDS-only education intervention. In this case, almost every patient from the BSC intervention group returned for follow-up assessment at three months, and this group reported significantly higher condom use. BSC was found to be more feasible than group interventions, the method of intervention thought of as more cost-effective (10).

Although the above studies found implicit acceptability insofar as clients returned for more sessions, few directly assessed the acceptability of BSC. Some studies questioned its acceptability by patients and health-care providers when it is conducted in couples (137), and its acceptability by patients only when it is linked to HIV/STI testing (84). However, other studies confirmed the acceptability of the intervention in some populations. In a mixed-method study on the acceptability of BSC for postpartum and breastfeeding women in the United States, the vast majority of women found the assessment to be both acceptable and important (43). More studies are needed to evaluate acceptability of the intervention, particularly in low and middle-income countries in order to adapt it to the needs of different populations within the various local contexts.

Additional points of discussion

Because BSC is provided by a health worker, it has greater a likelihood of overcoming cultural sensitivities that exist in many contexts around information dissemination and support for adolescents in relation to sexuality, assuming that the provider has received appropriate training, as discussed in section 4.2. Nevertheless, parents of young adolescents may need reassurance regarding the BSC (17).

BSC is but one of the interventions necessary to support adolescents in addressing their sexual health concerns and to reduce STIs and unintended pregnancies. Therefore, BSC should not be chosen in preference over other effective interventions such as comprehensive sexuality education in schools. Moreover, since the evidence shows that not all changes that BSC contributes towards are sustained in the long term, there is a need for continued intervention.

4.2. RECOMMENDATION 2: TRAINING OF HEALTH-CARE PROVIDERS

RECOMMENDATION 2

Training of health-care providers in sexual health knowledge and the skills of brief sexuality-related communication is recommended.

Strong recommendation, low – very low quality of evidence

4.2.1. Background

Few studies were identified that focused on training health-care providers to address sexuality-related topics with their clients (2, 55, 57, 77). Health workers may not recognize signs of sexual health problems; for example, they may focus on the physical symptoms of intimate partner violence while overlooking less obvious ones such as poor mental health (68). Discomfort with discussing sexual practices, perceived inadequacy in their skills, discomfort with sexual language, lack of information about treatment options, fear of offending the client, the provider's embarrassment about sexuality, and time constraints have all been identified as important barriers to taking a sexual history and providing counselling (41, 44, 49, 55, 69, 110, 61, 132). Such discomfort is not necessarily the same for all sexual health issues. For example, one study found that providers found it easier to talk with clients about HIV prevention in general and about the importance of using condoms than about specific sexual risk behaviours or how to talk to a partner about condom use (41). One study of general practitioners and nurses reported that they experienced particular barriers with clients who differed from themselves, for example in sexual orientation or gender or ethnicity (55, 73) or who had intellectual disabilities (1). Religion, politics, family dynamics and other factors shape what health-care providers believe and what they do in practise (66, 86, 98).

Studies on sexuality-related issues as diverse as abortion (65, 91), maternal health (82, 125) and HIV (67, 135) have found some health-care providers' negative attitudes to be barriers to care. Similarly, groups that experience social stigma, marginalization or violence on the basis of disability or sexual orientation sometimes have this same experience repeated with health-care providers, who should be serving them in a supportive and non-judgmental manner (83, 151). In addition, gender stereotypes often shape health-care providers' interactions with clients (115), and providers' response to adolescents seeking sexual health care can be similarly shaped by their own personal views and experiences (38). For all of these reasons, health-care providers' may then promote interventions that are more in keeping with their own beliefs than with the needs and desires of their clients (37).

The quality of the client's relationship with the health-care provider influences the subsequent actions that they take (66, 144). Once providers have the knowledge and skills to deliver those programmes to their clients, they can help them make enduring changes in their health-related behaviours (138).

Increasing clinician's involvement in promoting preventive behaviours can be done with clinician's education and environmental supports (17). Training providers in communication skills improves their level of comfort in dealing with sexual issues (69). Training of service providers in sexuality and sexual health has been demonstrated to be one of the key factors in increasing service use, including adolescents. Interventions such as “values clarification” (103), Health workers for change (72), Stepping stones (148), and Inner spaces outer faces (23) have been shown to make a significant improvement in clients' experience of provider attitudes on socially challenging issues such as sexual and reproductive health and rights (66, 87, 76, 145).

Therefore, the need for effective training and preparation of health-care providers is essential for supporting and sustaining behaviour change among clients (16, 19, 21, 24). Yet a literature review of medical school curricula across countries found that training in recording sexual histories, assessment of medication for sexual issues, and treatment was “variable, non-standardized, or inadequate” (110). A summit of medical school educators and sexual health experts had a similar finding in the United States and Canada (33). Finally, specific training on adolescent health is lacking in health-care curricula throughout the world (133).

Improving sexuality-related communication depends on investment in training that clarifies and positively influences service providers' values, with intensive follow-up supervision and support (36).

GDG experience indicates that training to meet sexual health-related challenges experienced by health-care providers should involve the acquisition of knowledge on those dimensions of sexuality that most frequently arise in a primary health care setting. It also has to build providers' counselling and brief intervention skills. These include active listening with empathy and the ability to ask questions; the capacity for reflexivity, including understanding of their own practice and attitudes towards sexuality; and the ability to conceptualize and optimize their response in ways that are appropriate to the different needs of different clients (27).

4.2.2. Available evidence

Training needs to first sensitize providers to enable them to recognize their own values and responses on diverse dimensions of sexuality and sexual health. It needs to build their knowledge of and skills in BSC (17, 20, 41).

Three studies of in-service BSC training were accepted as evidence for this guideline document:

  1. In a study during which all clinic staff at seven HIV care clinics in different parts of the United States were trained using the Positive Steps curriculum, providers showed significant increases in their comfort level and willingness to counsel clients after the training, and they conducted prevention counselling with clients more frequently (138). Clients reported that their providers and other clinic staff discussed safer sex and disclosure with them more frequently 12 months after the intervention started than before the intervention was initiated (138). The training included a pre-workshop self-study component, a four-hour workshop and a two-hour booster session four to six weeks after the initial training. Training was interactive, using lectures, discussions, modelling of prevention discussions and role-plays. Training covered four domains: enabling providers to acknowledge that their clients engage in unsafe sexual behaviours; to open a conversation about risk with their clients; to jointly develop a risk-reduction plan with their clients; and to recognize the need for ongoing discussions on risk with their clients (138). The study concluded that training all clinic staff in BSC can create an enabling environment for clients to explore their sexual health concerns (138).
  2. A training intervention in two primary care clinics at a health maintenance organization in Washington State found that, after BSC training, the proportion of visits during which the provider asked about the client's sexual activity increased. Similarly, there was an increase in cases where the provider talked to the client about HIV/STIs, with higher levels for high-risk clients. Providers discussed personalized risk-reduction strategies, an element important for behaviour change. The effects on provider effort were sustained during nine months of follow-up (41).
  3. The third study, which was among physicians in the Washington DC metropolitan area, found that providers who used the educational materials on how to address STIs with a client performed significantly better than those who did not use them in eliciting more information, displaying better client interaction skills and meeting more of the educational goals (20).

The training programmes differed, but all included some element of education to improve knowledge, and some element of practising and interactive skills-building. Provision of materials alone, without the interactive dimension, has limitations. A study by Bowman et al. (20) gave health-care providers educational materials (monograph, pamphlet and audio recordings) to help them prepare for a simulated client visit. The simulated client subsequently gave feedback to the provider about the quality of the experience from the client perspective. While those who used the materials performed better than those who did not, outcomes were not ideal. More than 90% of the physicians performed client comfort skills; but only 61% acknowledged client discomfort, and even fewer elicited client concerns (20). This suggests the importance of interactive training that incorporates skills-building through simulated provider–client interaction (20, 44, 138).

These studies all reinforce the value of supporting providers with a risk-screening tool that prompts them to ensure that the BSC focuses on the specific concerns and context of the client. In the GDG's assessment, the limitation of these studies was their focus on sexually transmitted disease prevention; thus, the provider assessments did not necessarily address broader sexual health concerns. The use of a tool to guide assessment is a key finding, but the GDG proposes that the tool should cover all aspects of sexual health and well-being as defined by WHO. Another component of the provider training that was found effective in these studies was their ability to support clients in developing a personal plan for protecting their sexual health (44, 138), and this reinforces evidence outlined in earlier sections of this guideline document.

The systematic search did not identify acceptable evidence on what types of pre-service training most successfully build health-care providers' capacity to offer effective BSC. However, GDG's experience indicates that pre-service training provides an opportunity for more systematic knowledge- and skills-building of health-care providers. In addition, lessons learned from studies of what makes in-service training effective could be applied to the pre-service context.

4.2.3. Balance of benefits and harms, feasibility and acceptability

Balance and harms

The benefits of the intervention outweigh the harms. However, larger cost-effectiveness studies or investment cases are needed to promote appropriate training modalities, particularly in low- and middle-income countries.

Lack of adequate training undermines health-care providers' competence and confidence in providing sexual health care, including brief sexuality-related communication. Providers who feel inadequate or uncomfortable in addressing sexual health issues, as discussed in the background above, are likely to avoid providing essential services. Discomfort with discussing sexual practices, perceived inadequacy in their skills, discomfort with sexual language, lack of information about treatment options, fear of offending the client, providers' own embarrassment about sexuality, and time constraints have all been identified as important barriers to taking a sexual history and providing counselling (41, 44, 49, 55, 69, 78, 110, 132). This makes clients vulnerable not only to poor quality care, but also to personal abuse from health-care providers incapable of distinguishing their personal feelings from their professional role. High-quality training can benefit from both the achievement of health service goals and the clients who need providers to recognize and effectively address their sexual health concerns. When balancing the time and resources for BSC training against other priorities, the preventive effects of BSC should be borne in mind.

Feasibility and acceptability

Several studies evaluated the feasibility of in-service BSC training in health-care providers with no prior counselling skills or minimal training. The duration of the training sessions evaluated in those health-care providers who were not exposed to any prior training ranged from eight hours (81) to two weeks (128); among those who had basic counselling skills, the range was from two hours (84) to three days (35). All studies concluded that in-service training is feasible in primary health care settings.

The Bowman study, as explained in the previous section, paired physicians with simulated patients (20). The physicians reported that this method of training was acceptable, appealing, and an effective educational experience. A randomized controlled trial conducted in Australia studied a three day in-service sexuality training programme for interdisciplinary teams working with patients suffering from spinal cord injuries. The intervention group showed improvements in both comfort and attitude in addressing sexual health with their patients (50).

Additional points of discussion

The lack of more studies on the issue of effective training in BSC, and of any studies in the pre-service context, indicates the need to identify training programmes that approach sexual health in its broadest sense (rather than with a purely disease-oriented focus) and which move beyond imparting information to building skills within a human rights orientation. Such training programmes should be studied in order to build a stronger body of evidence to guide health-care provider curricula development for pre- and in-service training.

Copyright © World Health Organization 2015.

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Bookshelf ID: NBK311022

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