Can’t get patients to use condoms?

Try mix of staging and counseling

Your patient, a 24-year-old with multiple partners, has indicated no interest when you discuss condoms. You’ve talked about the risks for sexually transmitted diseases, and you’ve even pointed out the rising number of HIV infections in your community — all to no avail.

You’re likely to have better success if you use a behavior model to "stage" your patient, and couple that staging with brief, appropriate counseling, suggests Karena Sapsis, MPH, CHES, a consultant with the Centers for Disease Control and Prevention in Atlanta.

In Changing For Good by James Prochaska, John Norcross, and Carlos DiClemente (Avon, 1994), the authors promote the use of the transtheoretical model, a five-stage process for effecting positive behavioral change. Robert A. Hatcher, MD, MPH, professor of OB/GYN at Emory University in Atlanta and senior author of Contraceptive Technology (Irvington, 1994), notes that Prochaska’s model is being used throughout the country in influencing human behavior.

By assessing where your patient is in using condoms, you can provide some brief, but effective, counseling and information that will help him or her reach consistent, effective condom use.

This combination of staging and counseling offers benefits for clinician and patient alike, says Sapsis.

"This helps clinicians make good use of their time," she notes. "They’re quickly going to be able to determine what this person’s counseling needs are, just by asking them the few simple questions that are in the staging algorithm." (See algorithm illustration, inserted in this issue.)

By applying the algorithm for assessment and using the transtheoretical model for staging, a clinician quickly can identify what a patient needs, whether it’s information or skills. By identifying and meeting those needs, the clinician has set the patient off toward a more positive outcome.

The transtheoretical model takes into account that people don’t necessarily move through the stages in any particular order, with some even skipping steps. It also acknowledges that people will "recycle," or relapse to a previous stage. That’s an important point in something as emotionally charged as negotiating effective condom use, says Sapsis.

"Failure can be hard for people if they’re not prepared to deal with it, so giving them an intervention that’s appropriate for them, then talking to them about what might tempt them to relapse, is really important," she points out. "That’s something that is very unique to this model: It sees relapse as a normal part of the process. It also sees that people shouldn’t have to relapse from all to nothing."

The five stages defined

According to the transtheoretical model, a patient will move through five stages of change toward regular condom use:

Precontemplation. Patient doesn’t plan to use condoms any time soon.

Contemplation. Patient recognizes the need for condoms and has started thinking about using them in the next six months.

Preparation. Patient has started taking steps toward condom use, such as reading take-home literature or even experimenting with different brands. Use, however, is not consistent.

Action. Patient is committed to regular condom use, and has used condoms for 30 days up to six months.

Maintenance. Patient has used condoms for six months or more. The behavior is now a habit.

How to determine and deal with the stages

A person’s stage is determined by three factors: consistency, duration, and intention. These factors are incorporated in the staging algorithm.

In the precontemplation stage, patients may not even be aware of the importance of condom use. They are often likely to feel nagged if others show concern, says Sapsis.

"People in this stage may say, ‘I don’t need to use condoms because I’m not at risk, I’m in a relationship,’" she notes.

For these patients, assessing their knowledge and reviewing their health risks might be helpful, says Sapsis. Use guided imagery to start them thinking about such issues as how to bring up condom use with a partner. If a patient is receptive, write down some "baby steps" they can try out at home, such as practicing placing a condom on a banana. Getting them comfortable to just the thought of condom use is important.

The contemplation phase of condom use is often the longest, as patients weigh all the pros and cons, says Sapsis. They may be afraid to bring up the subject with their partner or feel that condoms will interfere with sexual pleasure.

Many patients and their partners have negative connotations associated with condoms. That’s why counseling must be combined with distribution, Sapsis says.

"There are too many attitudinal and social barriers, too many issues like, ‘If I carry a condom, I’m perceived as a slut’ or, ‘If I want him to use a condom, he thinks I’m cheating on him,’" she points out. "There are those social issues that go along with condoms that we have to address if we’re ever going to get people to use them effectively."

Counseling doesn’t have to be a long, involved procedure, says Sapsis. Just allow the patient to share her concerns on condom use with you, she notes.

"If you let a woman actually sit there and tell you about her feared outcome, and then also talk about positive outcomes, that’s really helpful to her decision making," she explains.

When patients reach the action phase, they are starting to use condoms on a regular basis. They will share their triumphs with you, so offer them positive feedback, says Sapsis.

Once the maintenance stage is reached, clinicians must help patients to "keep the faith." Develop a condom "sampler" with colored and flavored models so your patients can see the wide range of choices, and advocate the use of water-based lubricant to increase sensation. Help your patient to work with her partner in keeping condom use a consistent habit.

"People who have been using condoms consistently for six months or a year may want to relapse because it gets a little tiring, and they start to feel like, ‘We’ve been together so long, we really are safe. We really could stop this’," counsels Sapsis. "That’s the point where they really need to learn a lot of different, fun ways to make condoms more enjoyable, like putting them on with their mouth or using a lubricant. Reframe condom use as something that can be more erotic that can enhance their relationship."

[Editor’s note: For more information on condoms, lubricants, and related materials, refer to the resource list provided by Sapsis, inserted in this issue. This is a partial listing; the Condom Resource Center also offers similar condom contact information. Contact the Condom Resource Center at P.O. Box 30564, Oakland, CA 94604. Telephone: (510) 891-0455.]