Utilizing motivational interviewing techniques to address sexual risk behavior
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Utilizing Motivational Interviewing Techniques to Address Sexual Risk Behavior. Terry Lee, MS, RN, BC Nurse Educator Denver STD/HIV Prevention Training Center. Disclosures. I have NO actual or potential conflict of interest in relation to this educational activity or presentation.

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Utilizing Motivational Interviewing Techniques to Address Sexual Risk Behavior

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Utilizing motivational interviewing techniques to address sexual risk behavior

Utilizing Motivational Interviewing Techniques to Address Sexual Risk Behavior

Terry Lee, MS, RN, BC

Nurse Educator

Denver STD/HIV Prevention Training Center


Disclosures

Disclosures

  • I have NO actual or potential conflict of interest in relation to this educational activity or presentation.

  • Terry Lee, MS, RN, BC


Denver ptc www denverptc org

Denver PTC: www.denverptc.org


Goals and purpose

Goals and Purpose

The primary goal of this presentation is to introduce participants to motivational interviewing techniques that can be utilized in a STI clinic setting to assist patients in developing risk reductions plans related to sexual behaviors.


Objectives

Objectives

Review current STI trends

Identify the basic tenets of MI

Discuss 5 steps of the Behavior Change Theory

Describe Self Perception Theory

Review the concept of personalizing risk

Discuss key components to conducting a comprehensive sexual history


Why diagnose and treat stds

Why Diagnose and Treat STDs?

  • > 19 million STDs in US annually

  • Health consequences of untreated STDs

    • Women’s reproductive health

      • Untreated Chlamydia (CT) or gonorrhea (GC) may lead to pelvic inflammatory disease (PID)

      • Leading infectious cause of infertility in the U.S.

    • Infant mortality/morbidity

      • Neonatal HIV, herpes simplex virus (HSV) and congenital syphilis

    • HIV transmission

  • Health care cost

    • $16.4 billion (2009)†

†Estimates incorporate minor corrections noted in Persp Sex Rep Hlth, Dec 2009.


Populations at greatest risk for stds

Populations at Greatest Risk for STDs

  • Youth

    • Nearly 50% of STDs estimated to occur in 15-24 year olds

  • Racial/ethnic minorities

    • STDs among highest of all racial/ethnic health disparities

    • African-Americans: 71% of GC, 48% CT, 52% syphilis

    • Over last 5 years syphilis cases increased more than 150% among young African American men

  • MSM

    • Account for 62% of syphilis cases in 2009

    • High rates of HIV co-infection


Gonorrhea rates by age and sex united states 2009

Gonorrhea—Rates by Age and Sex, United States, 2009

Men

Rate (per 100,000 population)

Women

750

600

450

300

150

0

0

150

300

450

600

750

Age

10–14

5.0

25.3

15–19

250.0

568.8

20–24

407.5

555.3

25–29

238.9

229.4

30–34

145.0

106.2

35–39

85.6

47.6

60.8

22.9

40–44

45–54

33.6

8.7

2.1

11.4

55–64

65+

2.7

0.5

Total

92.2

105.7


Chlamydia rates by age and sex united states 2009

Chlamydia—Rates by Age and Sex, United States, 2009

Men

Rate (per 100,000 population)

Women

3,800

3,040

2,280

1,520

760

0

0

760

1,520

2,280

3,040

3,800

Age

10–14

13.8

127.9

15–19

735.5

3,329.3

20–24

1,120.6

3,273.9

25–29

573.3

1,234.0

30–34

286.0

511.7

35–39

141.3

205.8

81.9

88.4

40–44

45–54

36.0

32.0

11.0

9.1

55–64

65+

2.9

2.1

Total

219.8

593.4


Primary and secondary syphilis rates by age and sex united states 2009

Primary and Secondary Syphilis—Rates by Age and Sex, United States, 2009

Men

Rate (per 100,000 population)

Women

25

20

15

10

5

0

0

5

10

15

20

25

Age

10–14

0.0

0.2

15–19

6.0

3.3

20–24

20.7

5.6

25–29

18.5

3.6

30–34

15.8

3.0

35–39

13.3

1.9

13.7

1.6

40–44

45–54

8.3

1.0

0.2

2.9

55–64

65+

0.5

0.0

Total

7.8

1.4


Std prevention clinicians role

STD Prevention: Clinicians’ Role

  • Talk to patients about pre-exposure vaccination

  • Provide or refer for prevention/risk-reduction counseling

  • Talk to patients about testing

  • Assess patients’ risk and test accordingly

  • Diagnose and treat infected patients

  • Provide or refer for partner services

  • Report STD/HIV and AIDS cases in accordance with state and local statutory requirements

  • Keep STD/HIV reports confidential


How do we know if our patients are at risk for stds hiv

How do we know if our patients are at risk for STDs/HIV?

  • Infections are commonly asymptomatic, so relying on report of symptoms is not adequate

  • Discussions about risk behaviors are necessary.


Do providers ask about risk

Do Providers Ask About Risk?

N=208 providers

% of Providers Who Assessed STD Risk

N= 12.7 million visits

N= 317 physicians

N= 317 physicians

N= 417 providers

HIV Care Providers Metsch 2004

Ongoing care

Private Physicians

Tao 2003

Non-ID trained Physicians

Duffus 2003

Primary Care Providers

Bull 1999

ID trained Physicians

Duffus 2003


Barriers to taking a sexual history

Barriers to taking a sexual history

  • Structural barriers (time/reimbursement concerns)

  • Patient barriers (privacy/confidentiality concerns)

  • Provider barriers

    • Low priority given to STD prevention

      • Acute versus preventive role perception

      • Low priority given to sexual health issues

    • Provider discomfort discussing sexual issues

    • Unfamiliarity with content or language

      • Perceived complexity of the sexual history

      • Inadequate training


Client centered approach

Client Centered Approach

  • Client is in charge/control

  • Clients are responsible for their own decisions and behavior changes

  • Options, rather than directives, are offered

  • Counseling is not interviewing or educating

  • Focus on feelings as much as information

  • Behavior change is a process


Motivational interviewing definition

Motivational Interviewing Definition

  • A directive, client-centered counseling style for helping clients explore and resolve ambivalence about behavior change (Rollnick, 1991).


Motivational interviewing

Motivational Interviewing

Advantages

Disadvantages

  • Builds rapport

  • Reduces client resistance

  • Increases motivation

  • Recognizes that change is a process not an event

  • Recognizes expertise of both pt and clinician

More challenging

May be more time consuming.


Basic tenets of motivational interviewing

Basic Tenets of Motivational Interviewing

OARS technique

Building confidence

Ambivalence

Change Talk


Oars technique

OARS Technique

Open Ended Questions

Affirmations

Reflections

Summary


Open ended questions

Open Ended Questions

Allows patient to discuss concerns

Solicits more information from patient

Reinforces that patient has existing skills, knowledge

Elicits more information quickly


Affirmations

Affirmations

  • Directly affirming and supporting the patient

    • Compliments

    • Statements of appreciation and or understanding


Reflections

Reflections

  • Assures the patient that you have heard and understood what he/she is saying

    • To summarize in your own words what the patient tells you

    • Links material learned over the course of the interaction

    • Reinforces what has been discussed


Reflection

Reflection

  • Reflecting Emotion

    • Client: (describing relationship with husband) I try and try but hardly get anywhere. Every time I try to do what he wants, it doesn’t work out. When I try to do things the way I think they should be done he doesn’t like that either. I just don’t know what to do.

    • Clinician: You’re feeling really frustrated right now.


Reflection quiz

Reflection Quiz

  • Client: yes, but my major concern is with my girlfriend. I think she’s been sleeping around, and I’m losing my mind trying to figure out what to do about it.

    • A. Sounds as though you feel desperate about the situation.

    • B. That must be awful.

    • C. You main concern, then is what to do about the situation with your girlfriend.


Summaries

Summaries

Collect the main themes of the conversation that the patient has offered and pull them together in a summary.


The good the bad the ugly

The Good, The Bad, The Ugly…


Building confidence

Building Confidence

  • Increase a patient’s belief or faith in his/her ability.

    • Techniques:

      • Hypotheticals

      • Confidence Ruler

      • Brainstorming

      • Providing information, advice, or suggestions

      • Evocative questions

      • Discussion of past successes


Ambivalence

Ambivalence

  • simultaneous and contradictory attitudes or feelings (as attraction and repulsion) toward an action.

  • Patients usually experience ambivalence towards behavior change (while they understand the benefits of changing, they also enjoy some aspect of the current behavior.


Ambivalence1

Ambivalence

Remember a common response to pro-change arguments made by clinicians will usually cause patients to defend the current behavior, which makes them talk themselves out of changing.


Change talk

Change Talk

  • Helps patients make the argument for change.

  • Five Kinds of Change Talk (DARN)

    • Desire: what a patient wants (like, wish, want)

    • Ability: what a patient perceives within ability (can, could)

    • Reasons: specific reasons for change

    • Need: speak to necessity or need (need, have to, got to, should, ought, must)

    • Commitment: agreement or pledge (will, intend, plan, hope, try)


Change talk1

Change Talk

These five steps make up DARN

By exploring DARN, clinicians touch on the patient’s values and aspirations. It is important to explore these values as they can be a powerful motive to change.


Methods for eliciting change talk

Methods for Eliciting Change Talk

  • Evocative Questions

  • Advantages of Change

  • Importance Rulers

  • Exploring Decisional Balance

  • Elaboration

  • Querying Extremes

  • Looking Forward or Backward


Change talk2

Change Talk

  • Client: This is a new thing for me, I never used to have sex with so many guys, I guess I got wild after my divorce. I’m not even sure I like some of the men I sleep with, but I don’t like feeling alone.


Change talk3

Change Talk

  • Clinician responses:

    • Having partners helps you not feel lonely. What are some pros and cons to continuing this behavior? (Exploring Decisional Balance).

    • What is the worst thing that could happen to you if you keep having sex with multiple partners? (Querying Extremes)

    • On a scale of 1-10 how important is it for you to change your sexual activity? (Importance Ruler)


Stages of change theory

Stages of Change Theory

Five stages represent ordered categories along a continuum of motivational readiness to change a problem behavior. 

  • Precontemplation

  • Contemplation

  • Preparation

  • Action

  • Maintenance


Self perception theory

Self Perception Theory

  • To some extent, what we believe is a by product of what we say, especially in situations of ambiguity.

  • Remember patients recognize the behavior has drawbacks, but also values the behavior in some way, BOTH sides are important.

  • Therefore its important to engage patient in self talk related to change.


Exercise four

Exercise Four

a 17 year old female is complaining of weight gain, breast tenderness and is concerned that she hasn’t had her menses. She has no other symptoms. She does not remember when her last menses was, but doesn’t think she can get pregnant. She has had 2 partners in the past 3 months, does not use condoms, and doesn’t believe in contraception. Her last intercourse took place 3 days ago.


Exercise four cont

Exercise Four cont…

List 3 open ended questions to ask this patient

Identify where you think this patient is related to stages of change?

What are you led to believe based on the self perception theory?


Judgment vs non judgment

Judgment vs. Non Judgment

Judgment

 the process of forming an opinion or evaluation by discerning and comparing.

A discriminating or authoritative appraisal or opinion

Non Judgment

  • Being aware of one’s own values and prejudices in order to avoid imposing them on patients.

  • being open-minded enough to understand that other people have different points of view, and that in their worldview, they may be correct.


Personalizing risk

Personalizing Risk

Understanding how patients feel about discussing risk, can help us to be more empathetic. The next exercise will allow us to put ourselves in the role of our patients.


Personalizing risk1

Personalizing Risk

1_______________________________4

Low High

Risks/costs of behavior change


Case study

Case Study

  • Tom is a 33 yr old MSM (man who has sex with men) who visits the bathhouse regularly. He has had 6 new partners in the past month, and engages in both receptive and insertive anal sex. He does not use condoms, and rarely discusses HIV status with new/potential partners. Tom state he is at very low to no risk for contracting HIV/STIs.

  • Using the information in the previous slides determine Tom’s perception of risk and stage of change. Identify how that coincides or conflicts with your risk assessment.


Case study personalizing risk

Case Study Personalizing Risk

1______________________________4

Low High

Risks/costs of behavior change


Case study1

Case Study

  • Based on the information provided by Tom which stage of the transtheoretical model of behavior change is he displaying?

    • Precontemplation

    • Contemplation

    • Preparation

    • Action

    • Maintenance


Set the stage

Set the Stage:

  • Introductions

  • Private space or setting

  • Build rapport

  • Acknowledge clients feelings and the difficulty in disclosing

  • Be aware of facial expressions, body language, and other non-verbal ques.


Prepare the client

Prepare the Client

  • Assure confidentiality

  • Assure the questions are asked of all patients

  • Use lead in questions for difficult or sensitive information

  • Be sensitive

  • Stress health issues related to sexual behaviors

  • Explain how the information will help you care for the patient


Key points to obtaining a sexual history

Key Points to Obtaining a Sexual History

  • Make no assumptions

    • Ask all patient about gender and number of partners

    • Ask about specific sexual practices

      • Vaginal, anal and oral sex

  • Be clear

    • Avoid medical jargon

    • Restate and expand

    • Clarify stories when necessary

  • Be tactful and respectful

  • Be non-judgmental


Key points to obtaining a sexual history cont

Key Points to Obtaining a Sexual History cont…

  • Risk Perception

    Never assume that the patient understands his/her risk for contracting a STI. Pts will often see their own risk very differently than clinicians:


Key questions to ask

Key Questions to Ask

  • Who, What, How:

    • Who: are you having sex with men, women, or both? How many people have you had sex with in the past 3 months?

    • What: what types of sex do you engage in, vaginal, anal or oral.

    • How: how do you protect yourself against STIs and HIV?


Sexual history content

Sexual History - Content

  • Chief complaint

  • General health history

  • Allergies

  • Recent medication

  • Past STDs

  • Women: brief Gyn history

  • HIV risk factors (IVDU, partner’s status)

  • HIV testing history

  • Past and current sexual practices

    • Gender of partners

    • Number of partners

    • Most recent sexual exposure

  • New sex partners

  • Patterns of condom use

  • Partner’s condition

  • Substance abuse

  • Domestic violence issues


Sample history

Sample History:

  • What brings you to the clinic today?

  • Symptomotalogy

  • Past STDs

  • Sexual History

    • When was the last time you had unprotected sex?

    • How many people have you had sex with in the past 3 months?

    • Female, male or both?

    • What types of sex: vaginal, oral, anal?


Case sample

Case Sample

  • Henry is a 35 yr old male patient who comes to the clinic today to get tested. Henry states that he is worried and just wants to be checked and treated for everything.

  • Where do we start?


Henry case study

Henry Case Study

  • Henry, I understand that you have some concerns and are feeling worried. First, let me reassure you that everything we discuss is confidential. I will need to ask you some rather personal questions, but ask all my patients these questions to help me determine how best to care for them.


Henry cont

Henry cont…

  • So what brings you in today?

  • What symptoms you are having?

  • Can you tell me what has you worried about STIs?


Henry cont1

Henry cont…

  • Remember to use reflections regarding the statements Henry makes.

  • Always clarify any information that is not clear, never assume.

  • Who, What, How:

    • Who do you have sex with?

    • What types of sex do you engage in?

    • How do you protect yourself from STIs/HIV


Henry cont2

Henry cont..

  • Utilizing the Who, What and How technique: you learn that Henry is married. He had a “brief” sexual encounter (he received and gave oral sex) with a old male friend recently and now thinks he may have an infection or HIV. Henry states he never uses condoms with his wife and this is his first encounter with another male. He us usually monogamous.


Henry

Henry…

  • What are important next steps:


Conclusion

Conclusion

  • Obtaining a comprehensive sexual history may seem daunting at first, but with consistency and practice, it can actually make it easier to assess patients for risk, and help them develop a risk reduction plan.

  • Remember your patients are experts regarding their behavior, and you are the expert regarding STIs. Utilizing a client centered approach is an ideal way to address risks.


Online resources

Online Resources

The Internet and STD Center for Excellence presents:

www.STDPreventionOnline.org

Free for individuals and organizations

Provides resources, discussions, jobs, STD information, and upcoming events


References

References

  • Centers for Disease Control. Sexually Transmitted Diseases. http://www.cdc.gov/std/stats07/trends.htm

  • Center for Disease Control. Project Respect. http://www.cdc.gov/hiv/topics/research/respect/index.htm

  • Creegan, L. MS, FNP. An Introduction to Taking a Sexual History. California STD/HIV Prevention Training Center


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