Transcript Teaching Condom Use Skills: Hands on Practice is Superior to Observation

Teaching Condom Use Skills:
Hands on Practice is Superior to
Observation
Donald Calsyn, Ph.D.1,2, Mary Hatch-Maillette, Ph.D.1, Suzanne
R. Doyle, Ph.D. 1, Sarah Cousins, M.A.3, TeChieh Chen, B.A.4
1Alcohol & Drug Abuse Institute and
2Department of Psychiatry & Behavioral Sciences, University of
Washington, Seattle, WA
3Matrix Institute, Rancho Cucamonga, CA
4University of California San Francisco
Abstract
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Objectives: HIV/STI prevention efforts with substance abusers usually include a condom use
skills component. We hypothesized that participants exposed to a “hands on” practice exercise
would perform better on condom use skills measures than those exposed only to a demonstration
of correct condom use. We predicted that both groups would perform better than participants
exposed to neither intervention.
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Methods: Men in substance abuse treatment who enrolled in a randomized comparison of a five
session (over 3 weeks), gender-specific HIV prevention intervention with a single-session HIV
education intervention, were administered male and female condom use skills measures (MCUS,
14 items, FCUS, 11 items). Measures were given at pre-intervention and at two weeks postintervention. This report focuses on men exposed to the demonstration only (DO, n=141), men
exposed to the demonstration plus a “hands on” exercises (HO, n=104), and enrolled men who
attended no sessions (NS, n=109). Outcome variables were post-intervention MCUS and FCUS
total scores, with baseline MCUS and FCUS scores as covariates.
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Results: Analyses of covariance on the post-intervention scores (baseline scores served as
covariates) comparing DO, HO, and NS groups on the MCUS (F=68.05, p<.0001) and the FCUS
(F=60.24, p<.0001) were significant. Post hoc analyses (Bonferonni corrected) indicated that at
post intervention, the HO group scored significantly higher on the MCUS (M=10.88, SD=2.14)
than the DO (M=8.94, SD=2.33) and NS (M=7.72, SD=2.29) groups. Post hoc analyses also
indicated that at post intervention, the HO group scored significantly higher on the FCUS
(M=8.68, SD=2.05) than the DO (M=6.84, SD=2.07) and NS (M=5.38, SD=2.02) groups. The
DO group scored significantly higher than the NS group on both the MCUS and FCUS.
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Conclusion: A “hands on” practice of condom use was superior in teaching condom use skills
than a condom use demonstration, which in turn was superior to no intervention.
Background
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HIV/STI prevention programs with substances abusers routinely emphasize the importance of
using condoms.
To achieve maximum protection condoms need to be used correctly. Incorrect application and
use can lead to condom failure.
Some HIV/STI prevention programs emphasize the importance of using condoms without
demonstrating their correct usage. Some programs demonstrate correct condom use by having a
facilitator demonstrate the correct way to apply a condom to a model. Some programs have
participants practice applying the condoms to models.
Lindemann et al. (2005) demonstrated that with college students condom use skills improved
after watching a demonstration on correct condom use compared to no intervention. Condom
use skills improved more if the demonstration was accompanied by practice sessions.
In the NIDA Clinical Trials Network Protocol 0018, “HIV/STD safer sex skills groups for men
in methadone maintenance or drug free outpatient treatment programs” we were able to assess
whether similar results could be found for men attending substance abuse treatment.
Hypothesis 1. Men attending a single session HIV prevention intervention during which the
correct use of condoms is demonstrated (demonstration only) will perform better on a condom
use skills measure than men attending no intervention sessions.
Hypothesis 2. Men attending the two sessions (of a five session HIV prevention intervention),
during which the correct use of condoms is demonstrated and the correct use of condoms is
practiced (hands on) will perform better on a condom use skills measure than men attending the
one session intervention with the demonstration only.
References.
Lindemann, D.F., et al. (2005). Towards errorless condom use: A comparison of two courses to
improve condom use skills. AIDS and Behavior, 9, 451,457.
Methods
Subjects. Men enrolled in one of 14 substance abuse treatment programs
across the US were recruited to take part in an HIV/STI prevention project
specifically tailored for men (NIDA Clinical Trials Network Protocol 0018).
Inclusion criteria included age of 18 or more, engagement in unprotected
vaginal or anal intercourse in the prior 6 months, willingness to attend
HIV/STI prevention groups and complete assessments at baseline and at 2 wk.,
3 mo., 6 mo. post intervention. Exclusion criteria included having a primary
partner planning to get pregnant or a Mini Mental Status Exam Score< 25.
This report focuses on men who completed the baseline assessment and the 2
wk. post intervention assessment and who: 1) attended the single session HIVEd (demonstration only) group (n=141), 2) attended sessions 1 and 2 of the
Real Men are Safe (hands on) group (n=104) and men who were randomized
to one of the two interventions, but attended no sessions (n=109).
Demographics for the sample are provided in Table 1.
Table 1
Methods (cont.)
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Procedures. The study schema is presented in Figure 1. This report focuses on
data regarding condom use skills measured at the baseline assessment and at the
2 wk. post-intervention assessment. Presented in Table 2 are the items for the
male condom use skills measure (MCUS, 14 items) and the female condom use
skills measure (FCUS, 11 items.) For the MCUS five types of condoms and four
types of lubricant are placed on a table in front of the participant along with a
penile model like the one in Figure 2. Participants are asked to apply and remove
the condom from the model, verbalizing what they are doing as they do it.
Participants receive a point for each step they demonstrate correctly. For the
FCUS a female condom and a pelvic model like the one in Figure 2 are placed on
the table. The application/removal instructions are repeated. Scoring proceeds
as above. A limitation to the scoring method was using an equal weight for each
item. Some items such as “getting all the air out,” maybe more salient for
preventing condom failure than others such as “check date.”
Data Analysis. The three attendance groups are compared on the 2 wk. postintervention MCUS and FCUS scores by means of separate analyses of
covariance with baseline MCUS and FCUS serving as covariates, respectively.
Post hoc analyses, consisting of pair-wise comparison of adjusted group means
with Bonferonni correction, were conducted to address the limitation of using
equal weights in scoring the MCUS and FCUS.
Figure 1: Study Schema
Advertise Study Availability
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Consent to Screen for Inclusion/Exclusion & Screening Assessment
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Obtain Informed Consent from Eligible Participants
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Conduct Baseline Assessment → Place in Waiting Cohort
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Randomly Assign Cohort to Intervention
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Standard HIV Education
Gender Specific Intervention
(one session)
(five sessions)
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Conduct Post Intervention Assessment
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Conduct Three Month Follow Up Assessment
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Conduct Six Month Follow Up Assessment
Figure 2: Condom Demonstration
and Practice Materials
Table 2: Condom Skills Measures
Female condom skill list
Male condom skill list
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Chose a latex condom
Chose a water-based lubricant
Expiration date on package is
checked
Package is opened carefully
Condom checked for damage
Determined direction in which
condom rolls
Condom rolled correctly downward
Condom rolled to base of penis
Air removed from condom
Space left at tip of condom
Lubricant added to inside tip of
condom or penis
Turned to the side and withdrew
condom
Took care to avoid spilling
Tied off condom and disposed of in
trash
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Expiration date on package is
checked
Package is opened carefully
Condom checked for damage
Condom unrolled and the two rings
separated
Condom rubbed gently to evenly
spread the lubricant
Inner ring squeezed between fingers
Inner ring pushed into vaginal canal
while squeezed
Inner ring placed against cervix so
that it is completely covered
Outer ring covers outside of vagina
End of condom is twisted and
removed by pulling, with care taken
not to spill its contents
Condom disposed of in a trash can
Table 3: Outline of the HIV/STI Prevention
Interventions
HIV Education (one session)
I. Group Introductions. Goals and Guidelines
II. HIV/AIDS Update
III. HIV Risky Behaviors, injection practices
IV. HIV Risky Behaviors, sexual practices
V. Healthy Options
VI. Condom demonstrations
VII. Overcoming Barriers to Condom Use
5 Min
10 Min
5 Min
10 Min
10 Min
10 Min
10 Min
Real Men are Safe
Session 1. HIV/AIDS Update: Identifying Risks
I. Group Introductions. Goals and Guidelines
II. Getting Started
III. HIV Risky Behaviors Exercise
IV. HIV/AIDS Update
V. HIV Risky Behaviors, injection practices
VI. HIV Risky Behaviors, sexual practices
VII. Condom demonstration
VIII. Revisit Risky Behaviors Exercise
10 Min
10 Min
15 Min
15 Min
10 Min
10 Min
10 Min
10 Min
Real Men are Safe
Session 2. HIV/AIDS Update: Planning Prevention
I. Welcome, redo introductions
II. Healthy Options
III. Barriers to Condom Use
IV. Condom Practice
V. Identifying Triggers
VI. Risk Reduction Problem Solving
5 Min
10 Min
10 Min
20 Min
25 Min
20 Min
Results
1.The three attendance groups differed significantly on the Male Condom Use
Skills (MCUS) measure at post intervention when the baseline MCUS is used
as a covariate (Fmodel=68.05, p<.0001; Fgroups=68.21, p<.0001;
Fcovariate=76.64, p<.0001). In post hoc analyses men attending
demonstration + practice sessions scored higher than men attending a
demonstration only session, who scored higher than men attending no sessions
(for all comparisons, p<.001). Means scores at baseline and post intervention
assessments are presented in Figure 3.
2.The three attendance groups differed significantly on the Female Condom Use
Skills (FCUS) measure at post intervention when the baseline FCUS is used as
a covariate (Fmodel=63.75, p<.0001; Fgroups=78.72, p<.0001;
Fcovariate=47.21, p<.0001). In post hoc analyses men attending
demonstration + practice sessions scored higher than men attending a
demonstration session only, who scored higher than men attending no sessions
(for all comparisons, p<.001). Means scores at baseline and post intervention
assessments are presented in Figure 3.
Condom Skill Score
Figure 3: Condom use skills at post-intervention
as a function of intervention attendance
14
12
10
8
6
4
2
0
♂ condoms*
Demo Only Hands On
* Hands On>Demo Only>None
No
Sessions
♀ condoms*
Demo Only
Attendance Group
Hands On
No
Sessions
Baseline (co-variate)
Post intervention
Results (cont.)
3. Presented in Figure 4 are the percent responding correctly to each MCUS item as a function of attendance
groups.
The demonstration + practice group scored higher than the demonstration only and no attendance groups
on the following items:
Checking date, checking for damage, getting air pockets out
avoiding spills upon removal, disposing in the trash.
The demonstration + practice group scored higher than the no attendance groups on the following items:
Choosing a water-based lube, leaving space in the tip
adding lube, moving away from partner after removal.
4. Presented in Figure 5 are the percent responding correctly to each FCUS item as a function of attendance groups.
The demonstration + practice group scored higher than the demonstration only and no attendance groups
on the following items:
Checking date, checking for damage, spreading the lube
evenly.
The demonstration + practice and the demonstration only groups scored higher than the no attendance
groups on the following items:
Squeezing the inner ring between finger for insertion, pushing
inner ring into vaginal canal while squeezed, getting inner ring
over cervix, twisting outer ring and pulling for removal,
disposing in trash.
The demonstration + practice group scored higher than the no attendance groups on the following items:
Opening package carefully, separating the rings, ensuring
outer ring covered vaginal opening.
Figure 4: Male Condom Use Skill Items
as a Function of Group Attendance
*
Put in Trash
*
Avoid Spilling
Remove & Move Away
Add Lube
!
Leave Space at Tip
!
*
Get All Air Out
Roll to Base
Roll Correctly
Determine Direcetion
#
Check for Damage
Open Carefully
*
♂ Condom Skill Item
No Sessions
Hands On
Demo Only
!
Check Date
!
Water Based Lub
^
Choose Latex
*Hands On>Demo Only>None
#Hands On>Demo Only & None0
^Hands On>Demo Only
!Hands On>None
10
20
30
40
50
60
Pecent Correct
70
80
90
100
110
Figure 5: Female Condom Use Skill Items
as a Function of Group Attendance
Put in Trash
^
Twist End & Pull Out
^
♀ Condom Skill Item
Outer Ring Covers Openning
!
Inner Ring over Cervix
^
Inner Ring into Canal
^
Squeeze Inner Ring
^
Spread Out Lub Evenly
#
Rings Seperated
!
#
Check for Damage
No Sessions
!
Open Carefully
Check Date
*Hands On>Demo Only>None
#Hands On>Demo Only & None
^Hands On&Demo Only>None
! Hands On>None
Hands On
Demo Only
*
0
10
20
30
40
50
60
Pecent Correct
70
80
90
100 110
Conclusions
 Men attending HIV/STI prevention interventions while in substance abuse
treatment can effectively be taught correct condom use skills.
 Teaching skills by demonstration was more effective than no intervention, but less
effective than having participants perform “hands on” practice.
 Differences observed included performance on items critical to preventing male
condom failure such as “getting the air out,” “using water based lubricant,” leaving
space in the tip” and “avoiding spills during withdrawal and removal.” Differences
observed on critical female condom skill items included “spreading the lubricant
evenly,” twisting outer ring and pulling for removal” and “ensuring outer ring
covered vaginal opening.”
Acknowledgements
 Supported by NIDA (1 U10DA13714-01, Dennis Donovan, PI).
 The authors wish to thank the CTN 0018/0019 lead node teams, the 23 RRTC and
site PIs, the 15 site coordinators, the 21 research assistants, the 15 therapy
supervisors, and the 29 therapists who worked on this project.
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