The U.S. Preventive Services Task Force recommends moderate- to high-intensity behavioral counseling in the clinic setting to prevent sexually transmitted infections (STIs) for all sexually active persons.¹One example of such a counseling approach would be to schedule two separate 20-minute clinical sessions 1 week apart. During the first clinical session, you should assess your patient’s personal risk, barriers to risk reduction, and identify a small risk-reduction step within the next week that he can realistically make. During the second clinical session, you should review the prior week’s behavioral change successes and barriers, provide support for changes made, identify barriers and facilitators to change, and develop a long-term plan for risk-reduction. A study of this method found that participants in intervention clinics receiving structured behavioral counseling reported significantly higher condom use rates and fewer new STIs than participants at control sites.²Males and females in this study benefited equally from counseling interventions, and brief interventions were more effective among adolescents than older participants.

When counseling for behavior change, determine your patient’s readiness for change. For example, in your situation you can determine how well your patient uses condoms, his barriers when not using condoms and how ready he is improve his condom use behaviors. Example possible counseling strategies are listed below depending on his response to you regarding his stage of change.

A number of verbal and written tools are available that can assist health care providers to take a sexual health assessment³and other components of the adolescent’s psychosocial history⁴, includingthe HEADSS assessment.^{5, 6}When counseling for behavior change, one helpful acronym is FRAMES⁷which stands for:

• Provide Feedback on risk/impairment (e.g. it sounds like you are afraid that bringing up condom use at this point in your relationship may make your partner concerned about cheating)
• Emphasize personal Responsibility for change (e.g. I am here to help you, but it’s very important that you take responsibility for changing things. What steps can you take to help yourself?)
• Offer clear Advice to change (e.g. I believe the best thing for you would be to…)
• Give a Menu of options for behavior change and treatment (e.g. You could try X or Y or Z…)
• Counsel with Empathy (e.g. I know that these things can be very difficult...)
• Express your faith in the adolescent’s Self-Efficacy (e.g. “I believe in you, and I know that you can do this, when you decide the time is right”; “I want to congratulate you on all the things that you accomplished since our last visit. These things are not easy and you should be very proud of yourself”)

References

1. Behavioral Counseling to Prevent Sexually Transmitted Infections, Topic Page. U.S. Preventive Services Task Force. Agency for Healthcare Research and Quality, Rockville, MD. U.S. Preventive Services Task Force. 2008; www.ahrq.gov/clinic/uspstf/uspsstds.htm.
2. Kamb ML, Fishbein M, Douglas JM, Jr., et al. Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: a randomized controlled trial. Project RESPECT Study Group. JAMA. 1998;280(13):1161-1167.
3. Monasterio E CN, Warner L, Larsen-Fleming M, St. Andrews A,  Schalet A, Marcell AV, et al. Sexual Health: An adolescent Provider Toolkit. San Francisco, CA: Adolescent Health Working Group, San Francisco. www.ahwg.net; 2010.
4. Knight JR, Shrier LA, Bravender TD, Farrell M, Vander Bilt J, Shaffer HJ. A new brief screen for adolescent substance abuse. Arch Pediatr Adolesc Med. 1999;153(6):591-596.
5. Goldenring JM, Cohen E. Getting into adolescents heads. Contemporary Pediatrics. July 1988;5(7):75-90.
6. Marcell AV, Bell DL. Making the most of the adolescent male health visit Part 1: History and anticipatory guidance. Contemp Peds. 2006;23(5):50-63. contemporarypediatrics.modernmedicine.com
7. Fleming MF, Barry KL, Manwell LB, Johnson K, London R. Brief physician advice for problem alcohol drinkers. A randomized controlled trial in community-based primary care practices. JAMA. Apr 2 1997;277(13):1039-1045.