WHO guideline for brief sexuality-related communication: implications for STI/HIV policy and practice

Abstract

Brief sexuality-related communication (BSC) aims to identify current and potential sexual concerns and motivate those at risk to change their sexual behaviour or maintain safe sexual behaviour. BSC in primary health care can range from 5 to 60 minutes and takes into account biological, psychological and social dimensions of sexual health and wellbeing. It focuses on opportunistic rather than systematic or continuous communication and can be used in conjunction with already established prevention programs. The informational and motivational techniques of BSC enable health care providers to communicate more effectively with their patients, encouraging them to take steps to avoid HIV and sexually transmitted infections. The WHO Department of Reproductive Health and Research, following a review and assessment of existing evidence with regards to BSC, has recently published the guideline on Brief Sexuality-Related Communication: Recommendations for a Public Health Approach.

Résumé

La communication brève liée à la sexualité (CBS) vise à identifier les préoccupations sexuelles présentes et potentielles et inciter les personnes à risque à changer leur comportement sexuel ou maintenir un comportement sexuel sûr. Dans les soins de santé primaires, la CBS peut prendre de 5 à 60 minutes et tient compte des dimensions biologiques, psychologiques et sociales de la santé et du bien-être sexuels. Elle se centre sur la communication opportuniste plutôt que systématique ou continue et peut être utilisée en association avec des programmes de prévention déjà établis. Les techniques informatives et motivationnelles de la CBS permettent aux prestataires de soins de santé de communiquer plus efficacement avec leurs patients et de les encourager à prendre des mesures pour éviter le VIH et des infections sexuellement transmissibles. Après un examen et une évaluation des données disponibles concernant la CBS, le Département de santé et recherche génésiques de l’OMS a récemment publié un Guide sur la communication brève liée à la sexualité : recommandations pour une approche de santé publique.

Resumen

La comunicación concisa sobre sexualidad (BSC, por sus siglas en inglés) procura identificar actuales y posibles inquietudes sexuales y motivar a las personas en riesgo a cambiar su comportamiento sexual o mantener un comportamiento sexual seguro. La BSC en el primer nivel de atención puede durar de 5 a 60 minutos y toma en cuenta las dimensiones biológicas, psicológicas y sociales de la salud y el bienestar sexuales. Se enfoca en comunicación oportunista, y no sistemática o continua, y puede utilizarse en combinación con programas de prevención ya establecidos. Las técnicas de BSC informativas y motivadoras les permiten a profesionales de la salud comunicarse de manera más eficaz con sus pacientes y aconsejarles que tomen medidas para evitar el VIH y las infecciones de transmisión sexual. El Departamento de Salud Reproductiva e Investigación de la OMS, después de revisar y evaluar la evidencia relacionada con la BSC, recientemente publicó la guía Brief Sexuality-Related Communication: Recommendations for a Public Health Approach (Comunicación concisa sobre sexualidad: recomendaciones para un enfoque en salud pública).

Key words:

• behaviour change communication
• health promotion
• HIV
• sexually transmitted infection
• prevention
• health policy
• training

Introduction

Behaviour-change interventions have been consistently considered an essential part of comprehensive prevention of HIV and other sexually transmitted infections (STI).¹ Throughout the last decades, substantial research has informed the development of evidence-based behavioural interventions, such as delaying sexual debut, consistent condom use, and partner reduction strategies. Some of those interventions also aim to promote sexual wellbeing by increasing self-esteem, self-regulation and positive attitudes towards one’s own and others’ sexuality.^2–17 Brief sexuality-related communication (BSC) has been identified as a promising intervention to strengthen STI/HIV prevention, particularly in primary health care.¹⁸

A number of effective behaviour change interventions that have used BSC are based on the Information, Motivation and Behavioural (IMB) skills model of behaviour change.^5,16 Using motivational interviewing principles, they have targeted a variety of negative health outcomes associated with behaviour such as harmful alcohol use,¹⁹ poor adherence to antiretroviral therapy¹⁴ and reduction in unprotected sex among people living with HIV,⁵ and drug use and sexual risk behaviours.⁹ Recognizing the capacity of this technique, the World Health Organization (WHO) recently published Brief Sexuality-Related Communication: Recommendations for a Public Health Approach. ²⁰ This guideline advises policy and decision-makers in health professional training institutions on the utility of BSC.

BSC is defined as an opportunistic, dynamic communication process between a patient and a trained health care provider (bound by a code of ethics and practice) that ranges from 5 up to 60 minutes.²⁰ It includes both the management of problems and difficulties related to sexuality and the promotion of sexual wellbeing, taking into account biological, psychological and social dimensions.²¹ BSC enables the participants to address complex themes and taboos of individual, intimate sexuality in the context of a health care consultation.^22,23 Questions may include “Is your intimate life going as you wish?”; “Do you have any question or concern about sexual matters?”; “How do you feel in your sexual relationships with others?”; “Many of my patients with your condition note problems in their sex life/function. Are you noticing anything different?”

BSC is always patient-centred, by adopting the patient's perspective and respecting the patient’s ideas, feelings, expectations and values; it supports them in expressing their emotions, thinking, understanding, and subsequently their behaviour.^24,25 It involves a two-way conversation rather than the ‘disease-centred’ model where the provider makes decisions on behalf of the patient.²⁶ BSC offers the patients ownership of the situation and makes them aware of various options, empowering them to make appropriate decisions. By developing their capacity for self-regulation and autonomy, patients are more able to have a satisfying and safe sexual life.^27–29 BSC also helps to close the gap between intention and behaviour, encouraging patients to establish and achieve clear health goals.²⁷ When problems are too difficult to address within a primary care visit, BSC relies upon referrals to other resources and services.^20,22,28

Creating a safe and confidential environment, BSC is beneficial for both patients (adults and adolescents) as well as health care providers.^20,22,28,30 The use of BSC can be especially attractive in working with adolescents. Sexual activity mostly begins during adolescence, but young people are often ill-informed about their bodies and health, and unprepared for the changes and challenges they will be experiencing, be it within or outside the context of marriage.³¹ Adolescents might become sexually active without knowledge of STIs or family planning, which can have adverse consequences for their future.³² Improving adolescent knowledge and understanding of sexual and reproductive health, along with building life-skills to take charge of their health, is a crucial step in meeting their health needs and fulfilling their rights.³³ BSC provides health providers with the necessary training and knowledge to feel comfortable addressing these issues with adolescents.^34–37

Development of the guideline for brief sexuality-related communication

In 2012, the WHO department of Reproductive Health and Research (RHR) commissioned a systematic review of relevant literature to inform the BSC guideline. The first part of the review explored the use of BSC in preventing and addressing sexual difficulties, STIs/HIV, unwanted pregnancy and abortion, sexual violence, harmful practices, and patient knowledge. It also looked at BSC as a tool for promoting sexual wellbeing. The second part of the review focused on training programs to increase provider knowledge and skills on sexuality communication and counselling.

In the first part of the review, nearly 17 of the 31 included studies, randomized control trials (RCTs) or observational studies with a control group, focused on the impact of BSC on HIV and other STIs. This included: incidence, prevalence, STI/HIV knowledge, behavioural interventions, safer sex behaviour, transition to primary care providers, STI reinfection, asking a partner about the last HIV test, limiting the number of partners, discussing safer sex and the number of previous partners with a new partner. The review found evidence that BSC has some effect in the reduction and prevention of STIs/HIV infection.⁴⁰

There is, however, a lack of strong evidence to answer questions about the impact of BSC on improving sexual wellbeing other than the reduction and prevention of STIs/HIV. The review found only one paper designed to address the question of whether BSC improves sexual wellbeing.⁴⁰ This may reflect a lack of conceptual and methodological clarity in defining and measuring such an outcome. One study among adolescents found BSC to be helpful in increasing conversations around self-esteem and self-regulation, but the long-term sexual health outcomes of these conversations have not been documented.¹²

The second part of the review (14 of the 31 articles) showed that high quality BSC training for health care providers can help to achieve health service goals, particularly when they recognize and effectively address the sexual health concerns of their patients.²⁰ Trainings on BSC must sensitize health care providers to recognize their own values and responses on diverse dimensions of sexuality and sexual health, and then build their knowledge of and skills in conducting BSC.

Although almost all included studies were presented as RCTs by the original authors, a third of the studies were downgraded to observational. Additionally, there were few studies from low- and middle-income countries (4 out of 31) and paucity of studies assessing BSC as an intervention to promote sexual wellbeing.

The systematic review did not find evidence on what types of pre-service training are most successful to enable health care providers to offer effective BSC. However, the Guidelines Development Group (GDG), responsible for the development of the guideline recommendations, indicated that pre-service training provides an opportunity for more systematic knowledge and skills building. The benefits clearly outweigh the harms and providers who feel inadequate or uncomfortable in addressing sexual health issues are likely to avoid providing such essential services.

WHO utilizes the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to assess evidential quality and develop recommendations.⁴¹ Two independent reviewers used the GRADE system to rate the evidence as high, moderate, low, or very low. The GRADE score is based on the analysis of study limitations, confounding factors, directness, consistency of the results, precision, publication bias, magnitude of the effect.^41–46 The quality of the evidence informing the recommendations was rated between very low and moderate quality. The strength of the recommendation is based on the quality of the evidence, the balance of benefits and harms, values and preferences, resource use, and feasibility of the intervention.

Recommendations

First of all, the GDG proclaimed a Good Practice Recommendation to ensure that BSC occurs within a human rights framework (Box 1).

Box 1. Summary of Recommendations

Good Practice Recommendation:

Health policy-makers and decision-makers in health care professional training institutions need to ensure that, where BSC is introduced, it respects, protects and fulfils their clients’ human rights.

Policy Recommendations:

1. BSC is recommended for the prevention of sexually transmitted infections among adults and adolescents in primary health services. Quality of evidence: low–moderate Strength of recommendation: strong

2. Training of health care providers in sexual health knowledge and in the skills of brief sexuality-related communication is recommended. Quality of evidence: low–very low Strength of recommendation: strong

“Good practice recommendations” are overarching principles derived from the pooling of common sense, expert opinion, professional standards of practice, and established international agreements on ethics and human rights; they may or may not be informed by scientific evidence.

Good practice recommendations are considered essential for clarifying or contextualizing specific technical recommendations. They are particularly important when interventions are to be implemented in environments that can be hostile or negative towards them. BSC involves sexuality, sexual health and well-being, requiring an environment and provider commitment that ensures confidentiality. Given the taboo and stigma associated with sexual norms and practices in many parts of the world, as well as the existence of legal and social barriers to access to health services for some populations, the GDG found it necessary to include an explicit recommendation in this guideline about the need for a rights-based approach to BSC.

The evidence in the systematic review informing the first policy recommendation showed that BSC improves sexual health knowledge, attitudes towards and intentions to engage in safer sex and STI prevention skills, through increased consistent condom use, resulting in a decrease of STI incidence (see Policy Recommendation 1, Box 1). These improvements were sustained for six months on average. Studies described the effects of these improvements in various ways and in different populations, particularly in vulnerable groups and key populations (sex workers, men who have sex with men, STI clinic attendees).⁴⁰

Box 2. Research Priorities

Developing and testing a clinical tool

Develop a simple and standardized brief sexuality-related communication guideline. Pilot and adapt it for diverse country, cultural, health service, income and target client audiences.

In-service training of health care providers

Test the provision of in-service training to health care providers in diverse health care settings (including those providing general care rather than sexual health care) in the use of the above clinical tool, with the goal of integrating the tool into existing procedures.

Addressing health systems and operational barriers to BSC implementation

Test the implementation of the BSC by trained providers in diverse health care settings, particularly in resource-poor settings and settings offering general health care rather than sexual health care.

The benefits of the intervention outweigh the harms. While promoting the right to sexual health services that help clients to prevent and deal with STIs, BSC might also endanger them, if they become more assertive towards their sexual partners, for example about condom use.⁴ Well-trained providers should be aware of this risk, broach the subject with their clients and suggest ways to address it. While in the short term, breaking the silence about sexual concerns may cause stress in clients, the process is essential for ultimately improving their sexual health. In addition, supporting clients in protecting and promoting their sexual health decreases costs to the health system.^47,48

Assuming that a health care provider has received appropriate training, BSC has a greater likelihood of overcoming cultural sensitivities around sexuality-related information dissemination and support for adolescents. Nevertheless, parents of young adolescents may need reassurance regarding the BSC.¹² BSC is but one of the interventions necessary to support adolescents in addressing their sexual health concerns and to reduce STIs. Therefore, it should not be chosen in preference to over other effective interventions such as comprehensive sexuality education, but run concurrently. Moreover, since the evidence shows that not all BSC outcomes are sustained in the long term, there is a need for continued intervention.

The second policy recommendation for the provision of BSC requires that health care providers have been given appropriate training (see Policy Recommendation 2, Box 1).

When providers have appropriate training, sexual issues raised by clients can be dealt with in a brief visit, with only the more complex issues requiring referral. However, sometimes people’s physical or psychological sexual health issues 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.

Lack of adequate training undermines the health care providers’ competence and confidence in providing sexual health care, including BSC. Providers who feel inadequate or uncomfortable in addressing sexual health issues are likely to avoid providing essential services. Discomfort with discussing sexual practices, perceived inadequacy of 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.^26,34 This makes clients vulnerable not only to poor quality care, but also to bullying or abuse from health care providers, incapable of distinguishing their personal feelings from their professional role. When balancing the time and resources for BSC training against other priorities, the preventive effects of BSC should be borne in mind.

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.

In addition, some studies suggest using a risk-screening tool as a prompt to ensure that BSC focuses on the specific concerns and contexts of the patient. These studies focus exclusively on STI prevention and consequently the tool did not necessarily address broader sexual health concerns. Still, the utility of a tool to guide assessment is a key finding, but further research is needed on how it can include more aspects of sexual health and wellbeing.

There is a clear need to promote sexual health within the context of other negative outcomes of sexual risk-taking. Due to the lack of evidence of the effect of BSC on preventing unintended pregnancy, sexual violence, female genital mutilation and other sexual concerns, the GDG did not make recommendations in these areas.

Implementation and further research

The guideline has wide ranging implications for policy and human rights. The implementation of the BSC recommendations will require advocacy and communication at national, regional, and global level; implementation research on BSC techniques; the development of a clinical tool on BSC techniques; support for the introduction of BSC into primary health services; and monitoring and evaluation.

Globally, technical assistance and training will target medical and nursing professional associations as well as lecturers responsible for public health, psychology, and STIs in medical and nursing schools. It will be crucial to develop a monitoring and evaluation framework to assess the trainings and to ensure the incorporation of BSC into standardized training curricula. There is a range of models that can inform the health care provider’s approach to BSC, mainly along the theoretical dimensions of the IMB-model.¹⁹ For a full summary of the findings on approaches to BSC, see the complete WHO publication.²⁰

The BSC modes of operation can be divided into three main groups: a) face-to-face communication between trained counsellor and patient^2–10; b) multimedia based communication such as videos, internet, and mobile phone applications, in and out of health facilities;¹¹ and c) a mixed approach where face-to-face communication is supported by multimedia based communication.^12–17 All these approaches have demonstrated their effectiveness in terms of changing behaviour among targeted populations as well as decreasing the incidence of STIs.

BSC is recommended to be an integral component of an STI/HIV combination prevention strategy in conjunction with sex/sexuality education; community-based behaviour interventions; social marketing of condoms; multipurpose prevention technologies; HIV Pre-Exposure Prophylaxis (PrEP) and Treatment as Prevention (TasP); and vaccines and circumcision programmes.

Brief Sexuality-Related Communication: Recommendations for a Public Health Approach is the first WHO guideline addressing human sexuality that summarizes the existing evidence on BSC in primary health care services.

BSC has the potential to improve sexual health outcomes and sexual wellbeing, and WHO has taken a first step to encourage its integration in primary health care. However, the current guideline focuses only on some aspects of sexual health, and it is primarily based on experiences limited to high-income countries. There is little evidence regarding the role of BSC in addressing the drivers of poor sexual health such as low self-esteem (particularly as a result of discrimination, coercion or violence), low self-efficacy and a low sense of sexual wellbeing. Additional research is required to evaluate what tools and techniques can be integrated in primary health care services to address human sexuality as a pivotal component of overall health, and to generate evidence that can inform BSC techniques and step-by-step guidance on their use in different populations. Implementation research can further support the introduction of BSC into primary health care services through adequate trainings and optimal implementation models in low- and middle-income settings (Box 2). Furthermore, larger cost-effectiveness studies are needed to promote appropriate training modalities, particularly in low- and middle-income countries.

Acknowledgements

The authors would like to thank Mr Karel Blondeel, consultant to the Department of Reproductive Health and Research, for the support provided in editing the final version of the article.

Authors’ contribution

Igor Toskin did the scoping of the article; Igor Toskin, Bergen Cooper, Thierry Troussier drafted the manuscript. Barbara Klugman contributed to the writing of the Guidelines and Regina Kulier contributed to the systematic review and GRADE process. The final version was read and approved by all the authors.