Transcript Slide 1

Terry Lee, MS, RN, BC
Nurse Educator
Denver STD/HIV Prevention Training Center
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I have NO actual or potential conflict of interest
in relation to this educational activity or
presentation.
Terry Lee, MS, RN, BC

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.
1.
2.
3.
4.
5.
6.
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
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> 19 million STDs in US annually
Health consequences of untreated STDs
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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.
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Infant mortality/morbidity
 Neonatal HIV, herpes simplex virus (HSV) and
congenital syphilis
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HIV transmission
Health care cost
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$16.4 billion (2009)†
†Estimates incorporate minor corrections noted in Persp Sex Rep Hlth, Dec 2009.
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Youth
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Racial/ethnic minorities
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Nearly 50% of STDs estimated to occur in 15-24 year
olds
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
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Account for 62% of syphilis cases in 2009
High rates of HIV co-infection
Men
750
Rate (per 100,000 population)
600
450
300
150
0
5.0
150
Age 0
10–14
25.3
Women
300
15–19
250.0
555.3
25–29
238.9
229.4
30–34
145.0
35–39
85.6
60.8
40–44
33.6
11.4
2.7
92.2
106.2
47.6
22.9
45–54
8.7
55–64
2.1
65+
0.5
Total
600
568.8
20–24
407.5
450
105.7
750
Men
3,800
Rate (per 100,000 population)
3,040
2,280
1,520
760
0
13.8
760
Age 0
10–14
127.9
Women
1,520
15–19
735.5
1,234.0
30–34
286.0
511.7
141.3
35–39
81.9
40–44
36.0
45–54
32.0
11.0
55–64
9.1
2.9
219.8
65+
Total
3,800
3,273.9
25–29
573.3
3,040
3,329.3
20–24
1,120.6
2,280
205.8
88.4
2.1
593.4
Men
Rate (per 100,000 population)
25
20
15
10
5
0
0.0
Age 0
10–14
0.2
5
15–19
6.0
5.6
25–29
18.5
3.6
30–34
15.8
3.0
35–39
13.3
13.7
40–44
45–54
8.3
2.9
55–64
0.5
7.8
65+
Total
10
3.3
20–24
20.7
Women
1.9
1.6
1.0
0.2
0.0
1.4
15
20
25
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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
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Infections are commonly asymptomatic, so
relying on report of symptoms is not adequate
Discussions about risk behaviors are necessary.
100
90
% of Providers Who
Assessed STD Risk
80
70
N=208
providers
60
50
N= 12.7
million visits
40
N= 317
physicians
30
20
N= 317
physicians
N= 417
providers
10
0
Primary Care
Providers
Bull 1999
Private
Physicians
Tao 2003
Non-ID
trained
Physicians
Duffus 2003
ID trained
Physicians
Duffus 2003
HIV Care
Providers
Metsch 2004
Ongoing care
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Structural barriers (time/reimbursement concerns)
Patient barriers (privacy/confidentiality concerns)
Provider barriers
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Low priority given to STD prevention
 Acute versus preventive role perception
 Low priority given to sexual health issues
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Provider discomfort discussing sexual issues
Unfamiliarity with content or language
 Perceived complexity of the sexual history
 Inadequate training
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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
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A directive, client-centered counseling style for
helping clients explore and resolve
ambivalence about behavior change (Rollnick,
1991).
Advantages
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Builds rapport
Reduces client
resistance
Increases motivation
Recognizes that change
is a process not an
event
Recognizes expertise of
both pt and clinician
Disadvantages
 More challenging
 May be more time
consuming.
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OARS technique
Building confidence
Ambivalence
Change Talk
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Open Ended Questions
Affirmations
Reflections
Summary
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Allows patient to discuss concerns
Solicits more information from patient
Reinforces that patient has existing skills,
knowledge
Elicits more information quickly
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Directly affirming and supporting the
patient
Compliments
 Statements of appreciation and or
understanding
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Assures the patient that you have heard
and understood what he/she is saying
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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
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Reflecting Emotion
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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.
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Clinician: You’re feeling really frustrated right
now.
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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.
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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.
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Collect the main themes of the
conversation that the patient has offered
and pull them together in a summary.
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Increase a patient’s belief or faith in
his/her ability.
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Techniques:
 Hypotheticals
 Confidence Ruler
 Brainstorming
 Providing information, advice, or suggestions
 Evocative questions
 Discussion of past successes
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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.
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Remember a common response to prochange arguments made by clinicians will
usually cause patients to defend the
current behavior, which makes them talk
themselves out of changing.
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Helps patients make the argument for
change.
Five Kinds of Change Talk (DARN)
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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)
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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.
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Evocative Questions
Advantages of Change
Importance Rulers
Exploring Decisional Balance
Elaboration
Querying Extremes
Looking Forward or Backward
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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.
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Clinician responses:
A. Having partners helps you not feel lonely. What are
some pros and cons to continuing this behavior?
(Exploring Decisional Balance).
B. What is the worst thing that could happen to you if
you keep having sex with multiple partners?
(Querying Extremes)
C. On a scale of 1-10 how important is it for you to
change your sexual activity? (Importance Ruler)
Five stages represent ordered
categories along a continuum of
motivational readiness to change a
problem behavior.
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Precontemplation
Contemplation
Preparation
Action
Maintenance
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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.
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.
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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
 the process of
forming an opinion or
evaluation by
discerning and
comparing.
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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.
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being open-minded
enough to understand
that other people have
different points of
view, and that in their
worldview, they may
be correct.
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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.
1_______________________________4
Low
High
Risks/costs of behavior change
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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.
1______________________________4
Low
Risks/costs of behavior change
High
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Based on the information provided by Tom
which stage of the transtheoretical model of
behavior change is he displaying?
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Precontemplation
Contemplation
Preparation
Action
Maintenance
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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.
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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
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Make no assumptions
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Ask all patient about gender and number of partners
Ask about specific sexual practices
 Vaginal, anal and oral sex
Be clear
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Avoid medical jargon
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Restate and expand
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Clarify stories when necessary
Be tactful and respectful
Be non-judgmental
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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:
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Who, What, How:
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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?
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Chief complaint
General health history
Allergies
Recent medication
Past STDs
Women: brief Gyn
history
HIV risk factors
(IVDU, partner’s
status)
HIV testing history
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Past and current sexual
practices
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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
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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?
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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?
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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.
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So what brings you in today?
What symptoms you are having?
Can you tell me what has you worried about
STIs?
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Remember to use reflections regarding the
statements Henry makes.
Always clarify any information that is not
clear, never assume.
Who, What, How:
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Who do you have sex with?
What types of sex do you engage in?
How do you protect yourself from STIs/HIV
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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.
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What are important next steps:
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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.
The Internet and STD Center for Excellence
presents:
www.STDPreventionOnline.org
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Free for individuals and organizations
Provides resources, discussions, jobs, STD
information, and upcoming events
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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/in
dex.htm
Creegan, L. MS, FNP. An Introduction to Taking a
Sexual History. California STD/HIV Prevention
Training Center