Family Practice Vol. 17, No. 1, 56-59
© Oxford University Press 2000
Condom promotion in women attending inner city general practices for cervical smears: a randomized controlled trial
Department of General Practice and Primary Care and
a Department of Genitourinary Medicine, St George's Hospital Medical School, London, UK.
Oakeshott P, Kerry S, Hay S and Hay P. Condom promotion in women attending inner city general practices for cervical smears: a randomized controlled trial. Family Practice 2000; 17: 56–59.
Received 29 March 1999; Revised 12 August 1999; Accepted 6 September 1999.
Abstract
Background. Although condom promotion schemes have been widely piloted in UK general practices, there have been no rigorous evaluations of their effectiveness.
Objectives. To see if a practice-based sexual health education intervention increases the number of women having smears who are given condoms and advice on avoiding STDs. To see if this low cost intervention affects subsequent condom use.
Method. We conducted a cluster randomized trial of condom promotion in 1382 women aged <35 years attending 28 South London general practices for cervical smear tests.
Results. More women in intervention than control practices reported receiving advice on avoiding sexually transmitted infections (27% versus 10%) and being given condoms (28% versus 1%, P < 0.05). However, there was no difference in subsequent condom use, even in the 22% of women reporting 
2 sexual partners in the previous year.
Conclusions. To provide evidence of effectiveness, future interventions may need to be more intensive or focus on higher risk groups.
Keywords. Condoms, family practice, randomized controlled trial, sexual health promotion..
Introduction
In response to the epidemic of sexually transmitted diseases (STDs) and HIV infection, many condom promotion schemes have been initiated in primary care. However, none have been evaluated rigorously.1 Our first aim was to see if a practice-based sexual health education intervention was effective in encouraging GPs and practice nurses to offer leaflets and advice on avoiding sexually transmitted infections and to provide free condoms to women attending for cervical smears. Our second aim was to determine if such a cheap and simple intervention had any effect on subsequent condom use.
Methods
In spring 1994, we invited 33 general practices who sent pathology specimens to St George's Hospital via the daily courier service to take part in the study. Twenty- eight practices agreed to participate. We visited each practice, obtained practice details and went through the protocol. Practices were put into matched pairs on the basis of number of principals (
2/>2), Jarman underprivileged area rating (25/<25) and cervical smear target reached (<80%/80%). Each practice was asked to recruit 50 consecutive women aged <35 years attending for a cervical smear, test them for chlamydia and ask them to complete a postal questionnaire on sexual health.2 The questionnaire was sent 1–3 months later to the address on the patient's consent form. To obtain comparable data, questions on numbers of partners and condom use were similar to the national survey.3 One practice in each pair was allocated randomly to receive the intervention. (Fig. 1
.)
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Intervention
Practice nurses and GPs in each intervention practice were given 10 minutes practice-based teaching on condom promotion in women. This was backed up with regular supplies of condoms and patient leaflets for the duration of the study. When appropriate, practices were asked to advise women having smears about safer sex and to offer them free condoms and the leaflet "Wise up to condoms". (This describes how to negotiate condom use and where to obtain further supplies of condoms.)
Analysis
We randomized and analysed by practice using matched pairs. For each practice, we calculated the proportion with the outcome variable. A weighted analysis of variance with pair number as a factor was used to compare intervention and control groups. This allowed for pairing and weighting for numbers of patients in each practice.
Results
Characteristics of practices
The 28 practices comprised three single-handed practices, seven double-handed and 18 group practices. Mean Jarman underprivileged area score for the electoral wards covered by the practices was 23 (range 14–40). This compares with a mean score for England and Wales of zero. Nine practices achieved the 80% cervical smear target.
Characteristics of patients
A total of 1382 women aged 16–34 years (mean age 27 years) were recruited between May 1994 and October 1995. Of these, 1056 women (76%) returned postal questionnaires: 80% of responders were white, 8% Afro-Caribbean, 5% Black African, 3% Indian subcontinent and 4% other ethnic groups. This is similar to the local ethnic profile in the 1991 census. Response rates, ages, prior condom use (16% always, 11% usually, 29% sometimes, 44% never) and numbers of sexual partners in the previous year (6% none, 73% one, 14% two, 7% more than two) were similar in intervention and control groups. However, fewer women in intervention than control practices considered themselves to be of Afro-Caribbean or black African ethnic origin: 10% (49/491) versus 15% (85/561) P < 0.01.
Sexual health promotion
More women from intervention than control practices reported being offered advice on avoiding sexually transmitted infections and being given condoms (P < 0.05, Table 1). However, there was no difference in subsequent condom use, even in women with 2 sexual partners. Results were the same when women of black ethnicity, who were over represented in the control group, were excluded from the analysis.
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Discussion
We found that brief practice-based education on sexual health promotion was effective in changing doctors' and nurses' behaviour. Despite the interval of 1–3 months between attending for a cervical smear and completing the postal questionnaire, significantly more women from intervention than control practices remembered being given condoms and advised on safer sex.
Unfortunately, as the first UK general practice-based study to evaluate the effectiveness of sexual health promotion in changing patients' behaviour, it was disappointing. However, out of nearly 300 reports of sexual health interventions2 only three have reliably shown an increase in condom use. These were very intensive, costly and time-consuming interventions in highly selected American populations—runaway teenagers, 18-year-old female psychology students, and high risk genitourinary clinic attenders.4 In the most recent trial,4 a seven-session HIV risk reduction intervention resulted in more consistent condom use (42% versus 30%) over a 12-month follow-up period. However, there was no significant difference between the groups in STD re-infection rates.
By contrast, our intervention was cheap, brief and pragmatic. It was applicable to the wide range of women in inner city populations and covered women of various ages and ethnic groups. Unlike the American interventions, it was possible to include it opportunistically into a routine consultation in ordinary general practices. In addition, many women in our study were relatively low risk. Only a fifth had 2 sexual partners in the previous year and only 4% were teenagers. Sexually active teenagers are known to be at high risk of STDs but tend to be relatively infrequent attenders in primary care and are not included in UK cervical screening targets.
The study has several limitations. As with all self-reported data, there are problems of reliability and recall.3 However, the percentage of women reporting 2 sexual partners in the previous year was similar to a contemporary study in North London general practices.5 In both studies, condom use was higher than in the national survey of sexual attitudes and lifestyles 5 years earlier.3 Other limitations include the small sample size, the lack of qualitative data and the fact that the study only included women attending for cervical smears.
In conclusion, our simple intervention changed doctors' and nurses' behaviour and showed that condom promotion is possible at the time of cervical smear testing. However, there was no detectable effect on condom use. This highlights some of the difficulties of research into the effectiveness of sexual health promotion.1 Future intervention trials in primary care may need to be more intensive and focus on higher risk groups such as teenagers or those with multiple sexual partners. Outcomes ideally should include not only condom use but also incidence of sexually transmitted infections.4 Despite considerable NHS investment in sexual health promotion, there remains an urgent need for reliable evidence of the effectiveness of specific sexual health interventions in general practice.
Acknowledgments
We thank the patients, nurses and doctors from South London general practices based at the following: Acorn Practice, Balham Health Centre, Balham Park Surgery, Battersea Rise Practice, Bridge Lane Health Centre, Brocklebank Health Centre, Earlsfield Practice, Falcon Rd Medical Centre, Garratt Lane Surgery, Greyswood Practice, Lavender Hill Group Practice, Mitcham Medical Centre, Queenstown Rd Practice, Southfields Group Practice, Tod Practice, Tooting Bec Surgery, Triangle Surgery, Trinity Rd and Cavendish Rd Partnership,Waterfall House, Winstanley Group Practice, 4 Ashvale Rd, 7 Farrant House, Winstanley Rd, 13–15 Barmouth Rd, 47 Boundaries Rd, 51 Princes Rd, 119 Northcote Rd and 263 Lavender Hill. We are also grateful to research assistant Diana Mason and to Professor S Hilton and Dr A Majeed. This study was funded by the South Thames Project Grant Scheme with additional support from the South London Faculty of the RCGP.
References
1
Oakley A, Fullerton D, Holland J et al. Sexual health interventions for young people: a methodological review. Br Med J 1995; 310: 158–162.
2
Oakeshott P, Kerry S, Hay S, Hay P. Opportunistic screening for chlamydial infection at time of cervical smear testing in general practice: prevalence study. Br Med J 1998; 316: 351–352.
3 Johnson AM, Wadsworth J, Wellings K. Sexual Attitudes and Lifestyles. London: Blackwell Scientific Publications, 1994.
4
National Institute of Mental Health Multisite HIV Prevention Trial Group. The NIMH multisite HIV prevention trial: reducing HIV sexual risk behavior. Science 1998; 280: 1889–1894.
5
Grun L, Tassano-Smith J, Carder C et al. Comparison of two methods of screening for genital chlamydial infection in women attending in general practice: cross sectional survey. Br Med J 1997; 315: 226–230.
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