Seven counselors recorded a total of four sessions each, two sessions using the P-CIF and two sessions following the E-CIF, resulting in a data set of 28 rapid test sessions. All participating counselors and clients self-identified as gay men. Counselors ranged in experience from less than one to twenty years of test counseling. Of the 28 clients, 23 (82%) identified as white, 3 (11%) Latino, 1 (3.5%) African American, and 1 (3.5%) Asian/Pacific Islander.
3.1. The four distinct tasks of HIV test counselors
We segmented and coded the test sessions using Transana software into four distinct tasks: counseling, information delivery, data collection, and sample collection [25
included only segments in which the client is the primary speaker and the counselor listens. If the provider’s open-ended question only elicits a short, one-turn response from the client, we did not classify this as “counseling.” To qualify as “counseling,” client utterances had to consist of more than one turn at talk. In other words, clients had to offer more than the minimum responses that were typical of information delivery and data collection activities. To help disambiguate “counseling” utterances from other types of utterances, we used conversation analysis (CA), a method of studying naturally occurring social interaction by investigating systematic patterns in the structural organization of talk [5
]. While sequence maps display large patterns across the entire data corpus, CA uses detailed transcription conventions () to focus on turn-taking patterns in question and answer sequences. Using CA, we compared recurrent patterns in the design of questions and responses about condom usage
during the completion of the P-CIF in Phase 1 and in sessions following the E-CIF in Phase 2. By combining sequence maps and conversation analysis in this way, we are able to move away from tautological, category-bound definitions of “counseling” – e.g. any behavior done by the person who is certified or designated as a “counselor” – to a broader and more empirical definition of “counseling” as any activity that elicits more than one utterance during the client’s turn.
combines two kinds of counselor-initiated talk: risk assessment and health education. Risk assessment questions are used by the counselor to construct the facts of the client’s risk profile by asking what, where, when and with whom [18
]. In health education, the counselor talks at length about the test and safer sex. Unlike counseling, in both health education and risk assessment the speaker is primarily the counselor, while the client provides only minimal, one-turn responses [5
]. As expected with rapid test sessions, information delivery predominated at the beginning of the sessions.
Data collection includes those activities oriented to completing the P-CIF questions about past risk. While similar to risk assessment, data collection is typically structured like a standardized survey and oriented to the sequence of questions on the CIF. In this task, the counselor rapidly asks a series of questions about past risk to which the client provides short, unelaborated responses, often choosing from a set of standard responses provided by the counselor. The goal of the structural intervention was to remove data collection tasks from the session.
Sample Collection includes the counselors’ description and use of the HIV oral fluid swab, and the period of time during which the counselor leaves the counseling room to process the rapid test kit and retrieve the results. This category was expanded in Phase 2 to include sample collection for STI tests, such as rectal gonorrhea.
3.2. The Sequential Structure of the Sessions
Each session in Figures and is labeled by a counselor number (1-7) and the session letter A through D (A and B during Phase 1 and C and D during Phase 2). The sessions with the P-CIF (Phase 1) lasted an average of 41 minutes with a range 29 to 61 minutes. The task of completing the CIF accounted for an average of 6.5 minutes (16%) of the session, but remarkably, less than one minute in sessions 7A and 3B. We found two patterns in the clustering of P-CIF questions in . In half of the sessions (1A, 2A, 2B, 3A, 3B, 5A, 5B) counselors completed the CIF questions in larger clusters like a formal questionnaire. In the rest of the sessions (1B, 4A, 4B, 6A, 6B, 7A, 7B) counselors dispersed the CIF questions thereby embedding them in the flow of the session conversation.
Sequence Maps of Phase 1 Sessions with P-CIF
Sequence Maps of Phase 2 Sessions following E-CIF
The length of the sessions recorded for Phase 2 was similar, averaging 37 minutes with a range from 28-62 minutes (see ). Although eliminating the CIF created more time for the other activities, counselors mostly used this time to provide additional STI testing rather than more counseling. In , change in activities is shown as a proportion of the total session. Despite considerable variation by counselor, the overall quantity and proportion of counseling and information delivery changed remarkably little after the intervention. Despite counselor concerns expressed during the pre-intervention focus groups that they would find little to discuss without the help of the P-CIF, and conversational approach in example 2 below suggest that this concern was misplaced. In the next section we describe how the intervention changed the quality of the counseling.
Change in Distribution of Communication Formats from Phase 1 to Phase 2
3.3. Design of Questions and Responses: Questionnaire vs. Conversation
Using conversation analysis, we identified two patterns of question design that we call “questionnaire” and “conversation.” In questionnaire segments from Phase 1, the activity of completing the form was explicitly oriented to as an activity that was discrete from the rest of the session. The P-CIF was introduced by the counselor as “something we have to complete with all clients for the State.” It is important to note that unlike a research survey, the P-CIF questions are not scripted and counselors are free to phrase, combine and sequence questions as they see fit. Despite this, counselors typically delivered the CIF questions rapidly as if completing a standardized survey to elicit fixed choice answers (signified by the −>), as in example (1).
1 C: −> Okay. •hh And did you engage in oral sex with a− (.)
2 any of them,
3 P: Mm hm?
5 C: −> •hh And when you engaged in oral sex did you never
6 sometimes or [always wear a condom,
7 P: [Never
9 C: −> An:d (0.2) did you engage in anal top sex with any of them,
11 P: Mm hm?
13 C: −> And when you topped did you never sometimes or always
14 use a condom.
16 P: I’ll say that I sometimes use a condom.
18 C: −> U:m a:nd did you ever b- bottom for any of your twenty four
21 P: U::m (0.4) I would say:: two.
22 C: −> Okay. •hh And when you did did you never sometimes or
23 always use a condom.
24 P: Always.
25 C: Okay.
The repetitive format of the questions and the use of formal language (e.g. “engage in”) marks the questions as coming from the form and not as part of a conversational inquiry by the counselor. By beginning each question with “and”, the counselor marks his questions as a part of a string of items from the form that are not designed to elicit any elaboration of the previous response [30
]. In addition, the counselor incorporates the particular response options provided in the form (lines 5, 13-4, 22-3), thus orienting to the questioning as a form-filling activity. The client’s use of the response options provided by the counselor’s question also orients to the form as a survey questionnaire.
In contrast to the questionnaire pattern, in seven of the Phase 1 sessions and all of the Phase 2 sessions counselors and clients approached the condom use questions using a more conversational, open-ended format. Counselors often used short silences to provide space for clients to elaborate on their initial responses, thus enabling clients to refer to specific situations and partners while elaborating on their previous turn. For instance, the same counselor from Example (1) used a more open-ended question in example (2), which was recorded during Phase 2.
1 C: −> •hhh How u::m how do you feel about condom:s=and like
2 your:- your history of using them,
4 P: => You know (0.2) I:- (0.2) would say ninety nine: (0.5)
5 percent of the time, I use them.
6 C: Okay,
8 P: +> So: that’s where I- (1.4) I guess par:t of it is just
9 looking back at that- (0.2) situation that I ha:d back in:
10 (0.5) February, (0.5) u:m (0.5) w- why: did I le:t (0.6)
11 that point (1.4) happen?
Although the client begins his response with a frequency of condom use (=>), after the counselor’s Okay (line 6), the client describes a specific risk incident he had introduced earlier in the session (+>).
Similarly in other Phase 2 sessions, counselors used more open-ended questions that referred back to the client’s particular circumstances discussed earlier in the session, when compared to Phase 1. Clients in Phase 2 did not simply respond with the frequency of condom use, but went on to situate their response within the context of their decision making, risk incidents, and relationships. These elaborated responses, unlike short responses in Phase 1, often invited further discussion by displaying concern about their behavior as in Example 2 lines 10-11. Such “motivational statements” as they are called in Motivational Interviewing literature, can serve as a useful platform for a discussion of future risk reduction plans [31
As expected, removing the P-CIF from the Phase 2 sessions eliminated the questionnaire format seen in half the Phase 1 sessions. Furthermore, as the sequence maps illustrate, elimination of the P-CIF reduced the frequent shifting from one task to another evident in Phase 1, resulting in a more focused and uniform flow of sessions in Phase 2. In lieu of the focus on past risks, counselors and clients in Phase 2 discussed a broader range of life and relationship issues related to HIV risks, such as living and working in San Francisco, negotiating open relationships, dating and meeting partners, and specific partner situations. The broader range of topics flowed directly from the client’s concerns brought up during the session. In this way, counselors and clients can co-construct a more nuanced, self-reflexive and contextually situated discussion of condom use and sexual risk.
3.4. Effect of the E-CIF on Client Risk Disclosure and Data Validity
Client participants in this study frequently mentioned that they were more forthcoming when answering the E-CIF and during the ensuing discussion with the counselor. This is exemplified by
one client’s comments recorded during a Phase 2 session.
I would definitely point out the reason why I liked doing the [E-CIF] is that, in the past when I’ve had to do these questions it’s like, I know I have to answer them, I know what the statistics are being used for, but I don’t have enough relationship with the person in front of me to be answering these questions in front of them. …Whereas the [E-CIF] really makes it easier to …reflect, and actually, I think, be more honest… I would not be tempted to fudge anything to look good in front of you, right? …
This same client reported that the P-CIF was a deterrent to regular testing.
I’m sufficiently sexually active that I should really do a regimen of [testing] at least every six months. But it would fill me with a little just annoying – dread’s the wrong word, so anxiety. I have to go in, I have to answer those questions, and I’m going to feel bad if I don’t know the answers. And I think that that’s one of the barriers of testing you know (Client from session 3D).
The invasiveness of the counselor administered P-CIF can serve
as a barrier to data validity and routine testing. By contrast, the E-CIF encouraged greater disclosure during the session, thereby facilitating a more focused and wide-ranging counseling interaction.
3.4. Counselor Reactions to the Intervention
Counselors were initially apprehensive about the E-CIF, fearing that they would be hard pressed find something to discuss for 20 minutes without the aid of the P-CIF. Counselors found it especially difficult to engage experienced and knowledgeable clients into a discussion of risk behavior. “Sometimes [the CIF] does allow you to fill time…if you’ve got somebody who’s very knowledgeable.” Counselors had come to view the form as a tool to “engage the person.” One counselor described, “I use the CIF to do my counseling. [If] I see some red flags…would you like to talk about this?”
During the second focus group, convened three months after the implementation of the E-CIF, the concerns expressed during the first focus group were not apparent. Counselors reported that the elimination of the P-CIF from the session required
them to listen more closely and use greater skill in querying the client about his situation. During a counselor focus group including both participants and non-participants two months after the introduction of the E-CIF, one counselor reported,
In the past, when I was still new at this, the form helped guide me. It’s like training wheels. But I think it’s a lot better without it.
Unlike previous enhanced HIV test counseling interventions such as the RED study and RESPECT and RESPECT2, this study did not implement a particular counseling approach or script [16
]. The improvements in counseling practice were achieved without the need to retrain counselors in a new counseling model. Once the P-CIF was removed from the session, counselors were better able to deploy the active listening skills they had learned during their counselor training. As one counselor described during the focus group,
I guess I’d say I’ve honed my skills more…I can no longer rely on the form to be there.
Counselors were still somewhat ambivalent about the elimination of the form.
Sometimes I feel like I don’t have as complete of a picture of this client’s life. And it’s more up to me, that if I feel I need a complete picture, I have to figure out what questions to ask. But overall, it gives me space to just shape the session however I see appropriate.
Despite this ambivalence, the counselors were generally pleased with the E-CIF.
I like [the E-CIF] a lot. In the counseling session, what’s going on is a conversation. Establishing the rapport and finding out what’s going on with him … Does it really make a difference whether the guy had 3 or 30 partners? No – it matters what he does.
Counselors reported that the new format was more challenging, but ultimately more satisfying [32
]. Satisfaction with their work is a crucial concern for rapid test counselors who frequently complain of burnout due to the stress and repetitiveness of the work.