Condom use adoption and continuation: a transtheoretical approach

HEALTH EDUCATION RESEARCH Theory & Practice Vol.12 no.l 1997 Pages 61-75 Condom use adoption and continuation: a transtheoretical approach Diane M. Grimley 1, Gabrielle E. Prochaska and James O. Prochaska Abstract The use of latex condoms can reduce the risks of sexually transmitted diseases (STDs), including the human immunodeficiency virus (HIV) that can lead to the acquired immunodeficiency syndrome (AIDS). Yet, most intervention programs have demonstrated little effect on overall condom use. The major limitation of many traditional behavioral change programs is that they are based on an action paradigm which implicitly or explicitly views behavior change as a dramatic and discrete movement (e.g. going from 'never' using condoms to 'always' using condoms). The Transtheoretical Model of Change (TMC) offers an alternative conceptualization of the structure of change, a stage paradigm, that defines behavior change as an incremental process through a series of stages. This paper offers a summary of how measures and models of condom use based on the TMC have been developed and continue to be refined, offers some preliminary findings with diverse populations, and describes intervention applications of a stage paradigm approach to condom use adoption and continuation. Introduction An estimated 12 million cases of sexually transmitted diseases (STDs) occur each year in the United Cancer Prevention Research Center, University of Rhode Island, Kingston, RI 02881-0808 and School of Public Health, Department of Health Behavior, University of Alabama at Birmingham, Birmingham, AL 35294-0022, USA States with serious health consequences for thousands of children and adults (Roper et al., 1993). Specifically, 86% of all STDs occur among individuals between the ages of 15 and 29 (Centers for Disease Control and Prevention, 1991). Some individuals are infected repeatedly with many having more than one infection simultaneously (Aral and Holmes, 1990). Moreover, sexually active individuals today have to deal with the real threat of infection from the human immunodeficiency virus (HIV) that can lead to the acquired immunodeficiency syndrome (AIDS). The consistent use of latex condoms can reduce the risks of infection or transmission of STDs/HTV (Centers for Disease Control and Prevention, 1988; Coates, 1990; Roper et al., 1993); yet, most intervention programs have demonstrated little effect on overall condom use (Catania et al., 1994). It would appear that traditional behavior change technology is being put to the scientific test and the limits of this approach are acutely evident (Chesney, 1993). The major limitation of traditional behavior change technology is that it is implicitly or explicitly based on an action paradigm. Action-oriented approaches to behavior change view condom use adoption as a dramatic and discrete movement from 'never' using condoms to 'always' using condoms. Most intervention programs are developed for small groups of individuals motivated enough to seek help (Chesney, 1993; Kelly et al., 1993). The problem is, a number of studies using different populations (see Table II) point out that only about one-third of individuals at risk for STDs/HI V are prepared to take action for consistent and correct condom use (Prochaska et al., 1990; Fishbein et al., 1993; Bowen and Trotter, 1995; Oxford University Press 61

D. M. Grimley et al. Galavotti et al, 1995; Grimley et al, 1993a, 1995b). Action-oriented programs are missing twothirds of the population at greatest risk because these individuals are less likely to respond to public health messages or to sign up for our intervention programs. Many researchers and practitioners in the area of STD/HIV prevention are beginning to recognize that a single intervention approach may not be appropriate for all individuals who are engaging in unprotected sex. As with other health-related problems, change agents are shifting the focus of their efforts toward identifying the 'best fit' between an individual's characteristics and intervention strategies. The Transtheoretical Model of Change (TMC; Prochaska and DiClemente, 1983, 1984) offers promise for this endeavor by providing a framework or paradigm for understanding condom use behavior (Centers for Disease Control and Prevention, 1992; Galavotti et al, 1995; Grimley and Lee, 1996; Grimley et al, 1993a,b, 1995a-c, 1996; Prochaska et al, 1990). This paper offers a summary of how measures and models of condom use behavior based on the TMC were developed and continue to be refined. The paper also provides some preliminary findings with diverse populations and describes some intervention applications of the stage paradigm approach to condom use adoption and continuation. The TMC The TMC has been postulated as an integrative and comprehensive model of behavior change. Research has provided strong support for the reliability and validity of core constructs from the model such as the stages of change (McConnaughy et al, 1983, 1989), the processes of change (Prochaska et al, 1988), decisional balance (Prochaska et al, 1994; Velicer et al, 1985) and self-efficacy (Velicer et al, 1990). Numerous studies have demonstrated the predictive validity of the TMC's dynamic variables as compared with demographic variables such as age, gender or ethnicity which are imposed on us for the most part rather than determined by us (Lam et al.. 1988; Marcus et al, 1992; Wilcox et al, 1985). At a minimum, these static factors are not under the potential control of professionals trying to facilitate change nor are they under the immediate control of individuals who need to change (Prochaska, 1989). Since the TMC is a 'template' of sorts that is translated or redefined across different healthrelated behaviors (Grimley et al, 1994), the general constructs of the model (i.e. stages of change, processes of change, decisional balance and selfefficacy) have been adapted to the measurement of condom use by making their content specific to condom use in order to operationalize the constructs. In the initial measurement study conducted in collaboration with the Centers for Disease Control and Prevention's Division of STD/HTV (Prochaska et al, 1990), one of the goals was to investigate the dimensional complexity of condom use. Specifically, is it necessary to distinguish between type of sexual partner (primary versus non-primary) and type of sexual intercourse (vaginal versus anal) when examining condom use? Individuals from a community sample at risk for HTV (e.g. IV drug users, prostitutes, at-risk street youth, gay or bisexual men, etc.) were assessed separately on each of the model's key constructs with both types of partners and types of sexual activities. Conceptual model testing results demonstrated that it is necessary to model condom use behavior separately based on partner type as well as specific intercourse activities. Assessing an individual's condom use separately with primary versus non-primary partners results in more explained variance with this behavior as compared with more global measures. The distinction between partner type is a pervasive finding that has been replicated with a number of different populations such as STD clinic patients (Fishbein et al, 1993), women at high risk for HIV infection and unintended pregnancy (Galavotti etal, 1995; Grimley et al, 1992), college students (Grimley et al, 1995b) and a random state-wide sample of women (Grimley et al, 1995c). According to Aggleton et al (1994), as the TMC is further refined for application to HIV/AIDS, 'its use to 62

Condom use adoption and continuation guide intervention development and evaluation of intervention effects is becoming better appreciated' (p. 343). Stages of change A comprehensive model needs to cover the full course of change, from the time an individual becomes aware that engaging in unprotected sex is a problem to the point at which consistent condom use is maintained. There are many steps that precede and follow a person taking action for consistent condom use. In contrast to actionoriented approaches to behavior change, the TMC offers an alternative conceptualization of the structure of change by defining behavior change as an incremental and dynamic process. Thus, acquisition of condom use behavior is the endpoint of a process that involves motivational and decisionmaking interventions as individuals progress through a sequence of discrete stages. Similar to cessation behaviors (e.g. smoking), acquisition of health-enhancing behaviors such as condom use involves the progression through five stages of change of which 'action' is only one. These stages include: (1) precontemplation, (2) contemplation, (3) preparation, (4) action and (5) maintenance. Sample items employed to assess condom use with a primary (main) partner are given in Table I. The following classification scheme results from the assessment of condom use for individuals engaging in vaginal intercourse with a main partner: (1) Precontemplation includes individuals who are not currently using condoms 'every time' for vagina] sex with their main partner and have no intention to start doing so in the foreseeable future (i.e. in the next 6 months). (2) Contemplation includes persons who are not currently using condoms 'every time' for vaginal sex with their main partner, but intend to start doing so sometime in the next 6 months. (3) Preparation consists of individuals who intend to start using condoms 'every time' within the next month and are currently using Itoble L Algorithm of condom use for vaginal intercourse with a main partner Ql. Do you have a main partner of the opposite sex? 1) No (Skip to OTHER Partner) 2) Yes Q2. When you have vaginal sex with your main partner, how often do you use a condom? 1) Every time (Go on to Q3) 2) Almost every time (Skip to Q4) 3) Sometimes (Skip to Q4) 4) Almost never (Skip to Q4) 5) Never (Skip to Q4) Q3. How long have you been using condoms every time you have vaginal sex with your main partner? 1) Less than 6 months 2) More than 6 months (Skip to OTHER partner section) Q4. Axe you seriously thinking about using condoms every time you have vaginal sex with your main partner in the next 6 months'! 1) No (Skip to OTHER partner section) 2) Yes Q5. Are you seriously thinking about using condoms every time you have vaginal sex with your main partner in the next 30 days? l)no 2) Yes (Go on to OTHER partner section) condoms 'sometimes' or 'almost always' with their main partner. The preparation stage, therefore, consists of both intention plus some behavioral 'steps' toward consistent condom use. (4) Action includes individuals who are using condoms 'every time' for vaginal sex, but have been doing so for less than 6 months. (5) Maintenance includes individuals who are using condoms with their main partner 'every time' for vaginal sex for more than 6 months. Progression through the stages is often not linear because many individuals regress or recycle back through earlier stages. Individuals may cycle through the stages several times before they reach the action criterion of using condoms 'every time' they engage in intercourse. Within the framework of the TMC, relapse is viewed as a normal part of the change process as opposed to a failure. It 63

D. M. Grimley et al. simply reinforces the notion that change is difficult and it is unrealistic to expect people to modify unhealthy behaviors without having any 'slips.' The stages of change represent a temporal dimension that provides information regarding when a particular shift in condom use attitudes, intention and behaviors may occur. The notion that behavior change occurs in stages is not unique to the TMC; similar concepts have been postulated by others (e.g. Horn, 1976; Weinstein, 1993). The utility of the stages of change for classifying individuals on their condom use intentions and behaviors has been examined with a number of populations (Prochaska et al., 1990; O'Reilly and Higgins, 1991; Grimley et al, 1992, 1993a,b, 1995b,c; Fishbein et al, 1993; Galavotti et al, 1995; Grimley and Lee, 1997), supporting the validity of the construct with this behavior. Table II shows stage distributions from five independent samples that classify individuals into the stages of change for condom use for vaginal intercourse with the two types of partners. With the exception of male STD patients, individuals were more likely to be using condoms with non-primary (other) as compared with primary (main) partners. In all four studies, individuals were more resistant to using condoms with a main partner (i.e. more likely to be in the precontemplation stage), as compared with other partners. These observations are consistent with previous research reporting condom use frequencies (e.g. Rosenberg and Weiner, 1988; Armstrong et al, 1991; Soskolne et al, 1991; Dorfman et al, 1992, 1993). Table II also shows that about half of the college students, as well as the community high-risk sample, were using condoms with non-primary partners. All other stage distributions indicate that 63-92% of the individuals were not using condoms consistently, with the majority of non-users being in the two earlier stages of readiness precontemplation and contemplation. These observations point out that interventions which are based on the assumption that people are prepared to change (i.e. actionoriented) may not be sensitive to the specific needs of many people who are not protecting themselves from diseases they can contract from having intercourse with an infected partner. To date, men and women have been shown to be evenly distributed across the stages of readiness for using condoms in a college population (Grimley et al, 1995b), with a community sample (Prochaska et al, 1990), and with not-in-treatment IV drug users and crack cocaine smokers (Bowen and Trotter, 1995). Sex differences across the stages of change for using condoms have been reported in only one study with STD clinic patients. Fishbein et al (1993) found that men were more likely than women to be in the precontemplation stage for using condoms within primary relationships. Male STD clients remain an understudied population in urgent need of further intervention research designed to reduce the adverse health consequences of sexual risk behaviors. Ethnicity of individuals as a function of stage has also been reported in one study. Bowen and Trotter (1995) found that with main partners, White participants were more likely to be in the action stage and less likely to be in the contemplation stage as compared with African-Americans, whereas those who were Hispanic were more likely to be in the contemplation stage than African- Americans. These preliminary findings for ethnic difference across the stages of change support the contention that in order to increase adoption and continuation of condom use, assessments and interventions of specific attitudes sensitive to condom use across cultural groups are important considerations when targeting condom use (e.g. Amaro, 1995). Age differences as a significant predictor of stage is beginning to emerge as a more stable finding, with younger individuals being in the later stages of action and maintenance and older persons being in the earlier stages of precontemplation and contemplation for consistent condom use (Bowen and Trotter, 1995; Grimley et al, 1995c). These observations may reflect the fact that younger individuals are becoming better educated regarding their need for safety, may have more positive attitudes regarding condom use, or perhaps possess 64

Condom use adoption and continuation Table II. Percentages of individuals across the stages of change for using condoms with primary versus non-primary partners Sample N Partner type PC (9b) C (%) />(%) A (9b) M (%) Community sample 1-1 ' (Prochaska et al., 1990) STD clinic patients 0 (Fishbein et al., 1993) men women men 218 193 268 233 200 primary non-primary primary 1 primary non-primary 55 21 43 32 15 19 26 18 37 55 25 24 35 9 9 8 8 2 17 44 6 4 7 IV drug users and crack cocaine smoker* (Bowen and Trotter, 1995) 166 99 primary non-primary f 49 22 8 4 31 38 4 9 8 26 Women at high risk 8 (Galavotti et al., 1995) 233 122 primary non-primary 46 26 11 12 15 25 7 9 21 27 University students*-* (Grimley et al., 1995) 134 78 primary^ non-primary 23 6 16 19 33 24 13 21 16 30 Sex differences across stages were not reported. 'This study was conducted before the consistent emergence of the preparatjon stage; therefore, only four stages were assessed. c Percentages were estimated from a graph in Fishbein et al. (1993). d Data from women with non-primary partners were too few for meaningful analysis. e No significant sex differences were found for stage of change with either primary or non-primary partners. f May not equal 100% due to rounding errors. g The preparation stage included both intention and a behavioral component (i.e. currently using condoms 'sometimes' or 'almost always'). Other studies assessed future intention only, without taking any behavioral steps toward consistent condom use into account. awareness that they are having more sexual partners (Bowen and Trotter, 1995). Processes of change The second dimension of the model, the processes of change, provides information on how people change. The processes represent both covert and overt activities individuals use to alter their experiences and/or environments in order to affect behavior, cognitions or relationships. The processes of change have been found to integrate empirically within the stage dimension of change (Prochaska and DiClemente, 1983) showing that these processes are emphasized differentially by individuals in specific stages of change (Prochaska et al., 1985; DiClemente et al., 1991). The processes of change as applied to condom use acquisition and maintenance have received little attention by researchers as compared with other constructs from the model. To date, only two cross-sectional studies have been conducted (Grimley et al., 1992, 1994a). Yet, due to the urgency of assisting individuals at risk for HIV to adopt condom use, behavior scientists at the Centers for Disease Control and Prevention have moved forward and are currently conducting an ongoing intervention study based on general assumptions of the model regarding process use 65

D. M. Grimley et al. (Cabral et al., 1996). Although tentative, some conclusions can be made based on findings from these preliminary efforts. Although 10 processes of change have been found with smoking cessation, 11 processes thus far have emerged with condom use. Assertiveness for condom use is the additional process of change individuals utilize in order to adopt and maintain consistent condom use (Grimley et al., 1993b; Bowen and Trotter, 1995). This additional process of change reflects the interpersonal aspect of sexual behavior compared with more individual behaviors like smoking, exercise, etc. When integrated with the stages, condom use assertiveness increases almost linearly across the stages with assertiveness being the lowest in the precontemplation stage and the highest in the action or maintenance stage. Consistent with model-based research (Prochaska et al., 1988), the 11 processes of change represent two hierarchical factors labeled 'experiential' and 'behavioral'. These two latent factors include consciousness raising, self-reevaluation, dramatic relief, environmental reevaluation and social liberation (experiential processes); selfliberation, counter conditioning, stimulus control, reinforcement management, helping relationships and assertiveness (behavioral processes). Definitions and sample items for the processes of change for condom use are shown in Table III. Some external validity for the measure representing the processes of change has been established by examining standardized process mean scores' across the stages of change for using condoms with main and other partners (Grimley et al., 1992, 1994a). Precontemplators were found to use fewer processes than those further along in the stages of change, as the model predicts. The relationships between the processes and the stage of change for condom use appear to be similar to other problem behaviors with process use increasing after the precontemplation stage. However, preliminary findings indicate that, contrary to cessation behaviors where the behavioral processes tend to level off in the maintenance stage, the behavioral processes for condom use continue to climb well into the maintenance stage. Similar findings have emerged with exercise, another acquisition behavior. These findings suggest that although individuals in the maintenance stage for condom use may feel more confident using condoms and less tempted to engage in unprotected sex, they still have to work at strengthening their commitment to using condoms and have to continue to have condoms with them, so as to maintain behavior change. Also, women have been found to rely heavily on the process of helping relationships with both types of partners, perhaps because women depend on their partner to 'have' condoms available for intercourse. Sacco et al. (1993) note that despite women's more favorable opinions regarding condom use, they rely on their partners to buy condoms and make them available during sex. These observations are supported by the fact that the only process of change men have been found to utilize more than women is stimulus control (e.g. having condoms with them). Utilization of the experiential processes of change as applied to condom use acquisition has also been shown to differ from that found with cessation behavior. In a process evaluation of an ongoing intervention study in which stage of change counseling is provided to high-risk women (Cabral et al., 1996) more emotional and cognitive factors were being addressed with women in the action and maintenance stages for condom use with primary partners than would be expected based on the TMC. These preliminary findings have some support with college women. Grimley et al. (1994a) found that not only were women using consciousness raising and dramatic relief (experiential processes) more than men, they continued to do so in the action and maintenance stages. Overall, these findings suggest that, in general, maintaining condom use within important sexual relationships may require more continued cognitive/emotional effort than may be required with non-primary partners or for the maintenance of other behaviors examined with the model. The fact that men have the final say regarding whether or not a condom is used makes consistent condom use more difficult for women. One implication for 66

Condom use adoption and continuation Table III. Titles, definitions and sample items of the processes of change for condom use Process Consciousness raising Self-reevaluation Self-liberation Counter conditioning Stimulus control Reinforcement management Helping relationships Dramatic relief Environmental reevaluation Social liberation Assertiveness Definitions: sample items Increasing information about condom use and awareness regarding one's risk for STDs/HIV (e.g. 'You remember what people have told you about how condoms can help keep you from getting STDs/HIV). Assessing how one feels and thinks about oneself with respect to his/her lack of condom use (e.g. 'You feel more responsible when you use condoms'). Choosing and committing to act or belief in one's ability to use condoms (e.g. 'You tell yourself you can choose to have sex with a condom'). Substituting low risk sexual behaviors for high-risk sexual behaviors (e.g. 'When you want to have sex but don't have a condom, you find other sexual ways to satisfy yourself and your partner'). Avoiding people, places, or situations that could result in unprotected sex (e.g. 'You carry condoms when you go out'). Rewarding one's self or being rewarded by others for engaging in safer sex (e.g. 'You reward yourself when you use condoms for sex'). Having someone to talk with, share feelings with, and get feedback from regarding one's experiences with using condoms (e.g. 'You have someone you can count on when you're having a hard time using condoms'). Experiencing and expressing feelings associated with not protecting oneselfs from STDs/HIV (e.g. 'You get scared when you hear about people getting STDs/HIV because they didn't use condoms'). Assessing how one's not using condoms could affect the health and lives of others ('You stop to think that using a condom protects your partner, as well as yourself). Changing social norms ('You notice it's getting easier to find partners who don't mind using condoms'). Perception of one's ability to assert the use of condoms in a variety of sexual situations ('If a partner doesn't want to use a condom, you refuse to have sex'). future research is to consider targeting couples as a unit in order to modify high-risk sexual behaviors. With smoking cessation, for instance, if one spouse quits and the other does not, the chances of success are slim. Although these examinations of the processes of change in conjunction with condom use behavior represent important preparatory efforts, future studies will offer stronger evidence of the measure's predictive ability. Further measurement development and model testing of the processes of change for condom use could potentially offer interventionists the ability to conduct much needed process to outcome evaluations. Such evaluations as Cabral et fl/.'s (1996), when completed, will help to determine the extent to which a particular process needs to be emphasized at a particular stage in order to predict advancement to the next stage and to predict relapse. Decisional balance and self-efficacy In addition to the stages and the processes of change, the TMC incorporates two other core constructs: decisional balance (Velicer et ai, 1985; Prochaska et al., 1994) based on the decision making theory of Janis and Mann (1977), and self-efficacy, which Bandura (1977, 1982, 1986) considers as the most important construct in social learning theory. Decisional balance, simply stated, involves weighing the advantages (pros) against the disadvantages (cons) of using condoms, e.g. the potential benefits of using condoms for protection from 67

D. M. Grimley et al. STDs/HTV infection or transmission must be balanced against the perceived costs. Item content of the positive aspects of using condoms within the TMC includes protection from pregnancy and/or diseases, availability, personal responsibility, low cost, and protection for a partner, as well as oneself. An example of a positive item is, 'I would be safer from disease'. The content covered for the negative aspects of using condoms within the TMC includes hassles, decreased sexual enjoyment, the anticipation of a partner's disapproval, as well as having to rely on a partner's cooperation. A sample item of a negative item is, 'My partner would be angry'. Individuals are asked to rate 'how important' each statement is to his or her decision whether or not to use condoms. Figure 1 displays the pros and cons of condom use with main and other partners across their corresponding stage dimensions for college men and women (Grimley et al., 1995b). Comparing individuals across the stages of change on their pros and cons for using condoms has resulted in some highly predictable patterns. For example, the cons of using condoms always outweigh the pros for individuals in the precontemplation stage. The opposite is true for those in the maintenance stage. From precontemplation to contemplation the pros of using condoms always increase, but there are no consistent pattern in the cons. The cross-over of the pros and cons occurs before action takes place. To date, the functional relationship between the pros and cons and the stages has been replicated for condom use adoption and continuation with a high-risk community sample (Prochaska et al., 1990), women at risk for HIV infection or transmission (Grimley et al., 1992; Galavotti et al., 1995), and two independent college samples. (Grimley et al., 1993a, 1995b). Although the characteristic cross-over pattern of the pros and cons of condom use for vaginal intercourse is similar to that found with at least 12 other health-related behaviors (Prochaska et al., 1994), the cons of condom use do not decrease significantly with further movement through the stages. A less pronounced decrease in the cons 50 Pros and Cons of Condom Use-Main Partner 1 PC 1 1 C P Stages of Change j A, - Pros and Cons of Condom Use-Other Partner i C P A M Stages of Change M Pros Con* -Pro* -Cons Fig. 1. Standardized mean scores (M = 50, SD = 10) for the pros and cons of condom use with MAIN and OTHER partners across the five stages of change: precontemplation (PC), contemplation (Q, preparation (P), action (A) and maintenance (M). across the stages of change tends to be more characteristic of acquisition behaviors (e.g. exercise adoption), rather than cessation behaviors, because continual effort is required to maintain the behavior change (Marcus et al., 1992). The results found with condom use are more consistent with the behavioral adoption pattern than with the pattern of cessation behaviors (Galavotti et al., 1995). Thus, even if individuals adopt the use of condoms, the potential for discontinuing condom use remains high, unless the perceived negative aspects are diminished. This circumstance may pose a significant challenge to intervention efforts (Galavotti et al., 1995). Moreover, the cons of condom use are relatively stable across the stages, particularly with non-primary partners (Bowen and Trotter, 1995; Galavotti etal., 1995; Grimley etal., 1995b). 68

Condom use adoption and continuation Bowen and Trotter (1995) speculate that the stability of the cons with non-primary partners may reflect an increased likelihood of relapse as compared with primary partners because of the overall smaller change in decisional balance. Another alternative is that an increase in the pros of condom use with non-primary partners may be all that is necessary. The basic pattern found for the pros and cons of condom use adoption has implications for applied interventions. In order to assist individuals in precontemplation to move to the contemplation stage, programs must increase people's perceptions of the benefits of using condoms. These observations point out that the expensive media campaigns that focus on the negative consequences of unplanned pregnancies and infection from STDs might be more effective if public policy permitted them to stress the advantages and safety of contraceptives as well (Zabin et al., 1993). Information channels such as sex education courses and public health messages may also need to be revised (Bryne et al., 1993). Modification techniques should deal directly with making the pros of condom use more salient for individuals (e.g. 'Using condoms tells your partners that you care about them'). Once a person has progressed from precontemplation to the contemplation stage, and is at least thinking about change, interventions need to focus on decreasing the cons of condom use which should lead to further progress from contemplation to action. Males have been found to evaluate the disadvantages of using condoms as higher than the advantages of their use with primary partners (Grimley et al., 1995b). To date, no sex differences on the pros and cons for using condoms with non-primary partners have been found, suggesting that males and females may share similar attitudes regarding condom use in less psychologically intimate sexual situations. Alternatively, the pros and cons can be integrated with the stages of readiness for sexual acquisition behavior among adolescents. In a random sample of 235 heterosexual female adolescents between the ages of 15 and 19 years, 18% of the sexually inactive teens reported that they were 'seriously thinking about having intercourse' for the first time within the next six months (Grimley and Lee, 1997). Helping teens weigh the subjective advantages and disadvantages of becoming sexually active could assist them in the decision-making process of whether or not becoming sexually active is right for them. Such action could potentially result in the identification of ways in which continued abstinence may be more advantageous and compatible with an adolescent's personal values and long-term goals. Individuals who make an informed decision to engage in intercourse could be provided with information regarding the importance of using condoms in order to protect oneself from STDs, as well as unintended pregnancy. Self-efficacy is defined as the conviction that one can successfully execute the behavior required to produce desired outcomes (Bandura, 1982, 1986). Perceived self-efficacy has been shown to affect whether individuals consider changing their behavior, the degree of effort they invest in changing, and long-term maintenance of behavioral change (Velicer et al., 1990; Bandura, 1982, 1986; O'Leary, 1985). The potential usefulness of individual self-efficacy ratings in predicting health behavior change has been well documented in such areas as smoking, weight control, contraception, alcohol abuse, pain management, recovery from myocardial infarction and adherence to exercise programs (Strecher et al., 1986; Marcus et al., 1992; Velicer et al, 1990). Within the TMC framework, the construct of self-efficacy represents an integration of the model of self-efficacy proposed by Bandura (1982) and the coping models of relapse and maintenance described by Shiffman (1986). When examining condom use adoption, the measure of self-efficacy assesses the degree of situational pull that might exist that could induce an individual to choose to have intercourse without the use of condoms. Some example items include: 'How confident are you that you would use a condom... When you have been using alcohol or other drugs? When you're already using another method for birth control?' The content domain of self-efficacy within the 69

D. M. Grimley et al. TMC also includes biological and partner-related issues. Similar to physical urges to smoke experienced with quitting smoking, self-efficacy for using condoms can be effected by fundamental biological circumstances such as states of high sexual arousal. What is unique to condom use, as compared to other behaviors examined by the model, is the interpersonal or relational aspect inherent to condom use. Despite the fact that the male condom was endorsed as the most acceptable method of contraception by over 2000 women at high risk of HTV infection (Galavotti etal., 1994), lowest levels of confidence for using condoms were reported in situations where the partner might become angry or upset. Yet, in another study with college-age men and women (Grimley et al., 1995c), females reported higher levels of self-efficacy for using condoms with someone other than a main partner, whereas no sex differences in efficacy ratings were found for condom use within primary relationships. In fact, both college-age men and women and women at risk for HTV and unintended pregnancy reported lower levels of confidence for using condoms when engaging in vaginal intercourse with primary, as compared with non-primary partners (Galavotti et al., 1995; Grimley et al., 1995b, 1996). These observations suggest that such interpersonal factors as fidelity, commitment and conflict may inhibit the use of condoms within important intimate relationships, not just for women (e.g. Morrill, 1994; Amaro, 1995), but for some men as well. Figure 2 shows self-efficacy for using condoms with main and other partners across the five stages of change. Efficacy scores are the lowest for individuals in the precontemplation stage and increase almost linearly for those further along in the stages of change for condom use (Prochaska et al., 1990; Galavotti et al, 1995; Grimley et al., 1995c). Ratings of self-efficacy are not strong predictors of outcome before an individual reaches action, but have been shown to be related to utilization of the processes of change (Prochaska and DiClemente, 1992). These findings based on the stages of readiness and self-efficacy for using condoms are consistent Confidence of Condom Use-Main Partner PC C P A M Confidence of Condom Use-Other Partners) C P Stages of Change -Confidence -Confidence Fig. 2. Standardized mean scores (M = 50, SD = 10) for selfefficacy for condom use with MAIN and OTHER partners across the five stages of change: precontemplation (PC), contemplation (C), preparation (P), action (A) and maintenance (M). with the basic premise of the Information-Motivation-Behavioral Skills (1MB) model of AIDSpreventive behaviors postulated by Fisher and Fisher (1992) and Fisher et al. (1994). The 1MB model assumes that different levels of information and motivation may characterize individuals at different stages of the change process. Fisher et al. (1994) contend that individuals in the precontemplation stage may be informed about STDs/HIV, but are not yet motivated to change their unsafe sexual practices; those contemplating change may be informed and somewhat motivated but may still not possess the requisite behavioral skills necessary to engage in consistent condom use; yet, individuals actually enacting change must generally possess the requisite information, motivation and behavioral skills associated with condom use. 70

Condom use adoption and continuation Putting theory into practice Nearly 15 years of research on how people change on their own and in intervention studies has lead to the development of a TMC expert system intervention (Prochaska et al., 1993; Velicer et al., 1993). Expert systems are computerized interventions that are based on a person's own responses to questionnaires that are scored and then interpreted by expert computer technology which then generates a unique report. The reports include feedback on: the individual's stage of change, decisional balance regarding the pros and cons, the processes of change that the individual may be underutilizing, overutilizing or is utilizing appropriately, and self-efficacy across a variety of situations, and points out potentially problematic situations that need to be targeted to prevent relapse. At baseline, each person's scores on all TMC variables are compared to a normative data base (data from individuals from the same population; same age group, etc., who have successfully progressed through the stages for a specific behavior). At follow-up, ipsative feedback (compared to self over time) is also provided on TMC variables that are most important for progressing from one particular stage to the next. Expert systems are theory driven and lead to more scientific and accurate diagnoses of specific problem behaviors. It is important to emphasize that each report generated by the system is truly matched to the individual based on his or her responses to the TMC assessment instrument. Two systems are currently being developed in the area of high-risk sexual behavior change. The first is a multi-media expert system that targets condom use with inner city females 14-17 years old. The overall focus of the study is to prevent cervical cancer and will be provided in several family planning clinics in the Philadelphia area. Females will be randomly assigned to the TMC condition or the usual care condition. Participants in the TMC intervention will sit at a computer and answer questions by clicking on a 'mouse' in regards to condom use intention and behaviors. Each assessment is separated into distinct sections based on the model's constructs. After each section, participants will receive immediate, personalized feedback based on their individual responses regarding their current stage of change for using condoms; the change processes which they may not be using, or perhaps using too much; where they stand in the decision-making process for using condoms based on their pros and cons scores; what ideas they need to think more about in order to motivate them to move to the next stage of change; and alerts them to specific sexual situations they will need to avoid to maintain consistent condom use. This feedback will appear 'on screen' and win also be vocalized through the use of a headset. At the end of each session, each participant and her assigned counselor will be provided with a computer generated printed report reflecting the key issues that need to be addressed in order to promote advancement tiirough the stages. Counselors will then reinforce the computerized feedback with each individual. Teens in the usual care condition will receive generic feedback plus counselor support. The second system is home-based as opposed to the above clinic-based intervention. This expert system is being designed to increase compliance with oral contraceptive use and to promote condom use with women whose sexual behavior, or their partner's behavior, may place them at risk for STDs. This expert system will involve a pencil-andpaper survey that is filled out by women when a prescription for oral contraceptives is given, or completed at home and returned in a postage-paid envelope. Proactive phone calls will be made to women who do not return the completed questionnaire with 2 weeks in order to have each study participant's data. Survey's will then be scanned into a database and a unique report generated, which will then be mailed out to each participant as quickly as possible. In addition to giving feedback based on all constructs of the model regarding adherence to pill-taking directions, women who are having intercourse with more than one partner, 71

D. M. Grimley et al. or with a high-risk partner, will receive feedback on the importance of using condoms along with the pill for disease protection. Such stage-matched interventions have the ability to reach the vast majority of populations at risk by providing interventions which are sensitive to the specific needs of individuals in the earlier stages and not just those who are motivated to change. When used in combination with proactive recruitment methods, stage-matched computer-based expert systems can provide effective standardized, individualized, and interactive interventions while impacting large percentages of the population (Velicer and DiClemente, 1993). A stage-based intervention 2 is currently being employed with women at high-risk for both unintended pregnancy and HTV infection or transmission (Cabral et al., 1996) funded by the Division of Reproductive Health at the Centers for Disease Control and Prevention. This comprehensive AIDS and reproductive health education study (Project CARES) has generated a guide based on the TMC for advocates to utilize when counseling women (Project CARES: Advocates' Guide to Stage of Change Counseling, January 1994). The intervention study focuses on women who are less likely to come into family planning centers and have been recruited through drug treatment centers, homeless shelters, an HTV clinic, and street outreach in high-risk neighborhoods. Participants are assessed on their readiness to change by paraprofessional peer advocates who assist women to engage in stage-based strategies in order to facilitate progress toward action for the consistent use of condoms and other contraceptives. This type of stage-based guide has recently been developed for utilization with heterosexual men who are STD patients in order to increase condom use (Grimley and Prochaska, 1996). Another potential application of the TMC when modifying STD/HIV risk behaviors could be to utilize community outreach workers or street educators who have already developed credibility and rapport with community members. Outreach workers familiar with the TMC can have a much greater impact on the overall community by enabling them to reach and assist large numbers of individuals who are in the earlier stages of change to progress more quickly through the stages. In addition, they possess knowledge of the cultural barriers that may exist in their particular community and can make referrals to other community organizations when needed. Conclusion Many existing behavior change programs offer the best action-oriented strategies available, but seem to be failing. This is due, in part, to providing 'one-size-fits-air interventions without considering a person's readiness to follow such advice (e.g. Prochaska, 1994b). Interventions targeting condom use adoption and continuation based on the TMC have the potential of combining not only the individualization and intensity of the clinical intervention, but also the high participation rates of the public health approach, resulting in high-impact interventions. When we integrate individual and public health approaches, the treatment goal must be to accelerate stage movement to action prior to providing action-oriented treatments (Abrams, 1993). In other words, we need to move away from the old action-oriented paradigm of behavior change to a stage-matched approach if we are to meet the needs of all individuals at risk for STDs/ HIV and not just the relatively small percentage of individuals prepared to take action. Acknowledgements This paper was supported in part by grants CA27821 and CA50087 from the National Cancer Institute and CSA-92-109 from the Centers for Disease Control and Prevention, and funding provided from Ortho Pharmaceutical, Inc. Notes 1. In order to provide a standard metric, data on all TMC constructs are converted from raw scores to 7"-scores (M = 50, SD = 10) when integrated with the stages of change. 2. Stage-based interventions are designed based on a person's current stage of change only. 72

Condom use adoption and continuation References Abrams, D. B. (1993) Treatment issues: towards a steppedcare model. Tobacco Control, 2 (suppl.), S17-S37. Aggleton, P., O'Reilly, K., Slutkin, G. and Davies, P. (1994) Risking everything? Risk behavior, behavior change, and AIDS. Science, 265, 341-345. Amaro, H. (1995) Love, sex, and power considering women's realities in HIV prevention. American Psychologist, SO, 437^(47. Aral, S. O. and Holmes, K. K. (1990) Epidemiology of sexual behavior and sexually transmitted diseases. In Holmes, K. K., et al. (eds), Sexually Transmitted Diseases, 2nd edn. McGraw-Hill, New York. Armstrong, K. A., Kenen, R. and Samost, L. (1991) Barriers to family planning services among patients in drug treatment programs. Family Planning Perspectives, 23, 264-271. Bandura, A. (1977) Self-efficacy: toward a unifying theory of behavior change. Psychological Review, 84, 191-215. Bandura, A. (1982) Self-efficacy mechanism in human agency. American Psychologist, 37, 122-147. Bandura, A. (1986) Social Foundations of Thought and Action: A Social Cognitive Theory. Prentice-Hall, Englewood Cliffs, NJ. Bowen, A. M. and Trotter, R., II (1995) HIV risk in intravenous drug users and crack cocaine smokers: predicting stage of change for condom use. Journal of Consulting and Clinical Psychology, 63, 238-248. Bryne, D., Kelley, K. and Fisher, W. A. (1993) Unwanted pregnancies: incidence, interpretation, and intervention. Applied and Preventive Psychology, 2, 101-113. Cabral, R. J., Galavotti, C, Gargiullo, P. M., Armstrong, K., Cohen, A., Gielen, A. C. and Watkinson, L. (1996) Paraprofessional delivery of a theory-based HIV prevention counseling intervention for women. Public Health Reports, 3, 75-82. Catania, J. A., Coates, T. J., Golden, E., Dolcini, M. M., Peterson, J., Kegeles, S., Siegel, D. and Fullilove, M. T. (1994) Correlates of condom use among black, hispanic, and white heterosexuals in San Francisco: the AMEN longitudinal survey. AIDS Education and Prevention, 6, 12-26. Centers for Disease Control and Prevention (1988) Condoms for the prevention of sexually transmitted diseases. Morbidity and Mortality Weekly Report, 37, 133-137. Centers for Disease Control and Prevention (1991) Division of STD/HIV Prevention Annual Report. US Department of Health and Human Services, Atlanta, GA. Centers for Disease Control and Prevention (1992) A conceptual framework for evaluating behavior change. HIV/AIDS Prevention Newsletter, 3, 2-3. Chesney, M. A. (1993) Health psychology in the 21st century: acquired immunodeficiency syndrome as a harbinger of things to come. Health Psychology, 12, 259-268. Coates, T. J. (1990) Strategies for modifying sexual behavior for primary and secondary prevention of HIV disease. Journal of Consulting and Clinical Psychology, 58, 57-69. DiClemente, C. C, Prochaska, J. O., Fairhurst, S., Velicer, W. F., Velasquez, M. M. and Rossi J. S. (1991) The processes of smoking cessation: an analysis of precontemplation, contemplation, and preparation stages of change. Journal of Consulting and Clinical Psychology, 59, 295-304. Dorfman, L. E., Derish, P. A. and Cohen, J. B. (1992) Hey girlfriend: an evaluation of AIDS prevention among women in the sex industry. Health Education Quarterly, 19, 25-40. Hshbein, M., Douglas, J. M., Rhodes, F., Hananel, L. D. and Napolitano, E. (1993) Distribution of STD clinic patients along a stages-of-change continuum: selected sites, 1993. Mortality and Morbidity Weekly Report, 42, 880-883. Fisher, J. D. and Fisher, W. A. (1992) Changing AIDSrelated risk behavior. Psychological Bulletin, 111, 455-474. Fisher, J. D., Fisher, W. A., Williams, S. S. and Malloy, T. E. (1994) Empirical tests of an information motivationbehavioral skills model of ATDS-preventive behavior with gay men and heterosexual university students. Health Psychology, 13, 238-250. Galavotti, C, Grimley, D. M., Cabral, R., the CDC Perinatal HTV Prevention and Education Demonstration Activities (PHREDDA), and the CDC Prevention of HTV in Women and Infants Demonstration Projects (1994) Condom acceptability among women at high risk of HIV infection. Paper presented at the Society of Behavioral Medicine, Boston, MA. Galavotti, C, Cabral, R., Lansky, A., Grimley, D. M., Riley, G. E. and Prochaska, J. O. (1995) Validation of measures of condom and other contraceptive use among women at high risk for HIV infection and unintended pregnancy. Health Psychology, 14, 570-578. Grimley, D. M. and Lee, P. A. (1997) Condom and other contraceptive use among a random sample of female adolescents: A snap-shot in time. Adolescence, in press. Grimley, D. M., Prochaska, G. E. and Prochaska, J. O. (1993a) Condom use assertiveness and the stages of change with main and other partners. Journal of Applied Biobehavioral Research, 1, 152-173. Grimley, D. M., Riley, G. E., Bellis, J. M. and Prochaska, J. O. (1993b) Assessing the stages of change and decisionmaking for contraceptive use for the prevention of pregnancies, STDs, and AIDS. Health Education Quarterly, 20, 455-470. Grimley, D. M., Riley, G. E., Prochaska, J. O., Redding, C. A., Ruggiero, L., Velicer, W. F. and Rossi, J. S. (1992) The application of the transtheoretical model to contraceptive and condom use in high-risk women. Technical Report to the Centers for Disease Control and Prevention (contract grant CSA-92-109). Grimley, D. M., Prochaska, G. E. and Prochaska, J. O. (1994a) The stages and the processes of change for condom use with main and other partners. Unpublished manuscript. Cancer Prevention Research Center, University of Rhode Island, Kingston. Grimley, D. M., Prochaska, J. O., Velicer, W. F, Blais, L. M. and DiClemente, C. C. (1994b) The transtheoretical model of change. In Brinthaupt, T. M. and Lipka, R. P. (eds). Changing the Self: Philosophies, Techniques, and Experiences. State University of New York Press. Albany, NY, pp. 201-227. 73

D. M. Grimley et al. Grimley, D. M., DiClemente, R. J., Prochaska, J. O. and Prochaska, G. E. (1995a) Preventing adolescent pregnancy, STDs, and HIV: a promising new approach. Family Life Educator. 13, 7-15. Grimley, D. M., Prochaska, J. 0., Velicer, W. F. and Prochaska, G. E. (1995b) Contraceptive and condom use adoption and maintenance: a stage paradigm approach. Health Education Quarterly, 22, 20-35. Grimley, D. M., Willey, C, Johnson, S., Lee, P., Prochaska, J. O. and Redding, C. A. (1995c) Stages of change for contraceptive and condom use: A random state-wide sample. Paper presented at the Annual Meeting of the Society of Behavioral Medicine, San Diego, CA Grimley, D. M, Prochaska, G. E., Prochaska, J. O., Velicer, W. E, Galavotti, C, Cabral, R. J. and Lansky, A. (1996) Cross-validation of measures assessing decisions] balance and self-efficacy for condom use. American Journal of Health Behavior, 20, 406-416. Horn, D. (1976) A model for the study of personal choice health behavior. International Journal of Addiction, 19, 179-185. Janis, I. L. and Mann, L. (1977) Decision Making: A Psychological Analysis of Conflict, Choice, And Commitment. Cassel and Collier Macmillan, London: Kelly, J. A., Murphy, D. A., Sikkema, K. J. and Kalichman, S. C. (1993) Psychological interventions to prevent HIV infection are urgently needed: new priorities for behavioral research in the second decade of AIDS. American Psychologist, 10, 1023-1034. Lam, C. S., McMahon, B. T., Priddy, D. A. and Gehred- Schultz, A. (1988) Deficit awareness and treatment performance among traumatic head injury adults. Brain Injury, 2, 235-242. Marcus, B. H., Rakowski, W. and Rossi, J. S. (1992) Assessing motivational readiness and decision making for exercise. Health Psychology, 11, 257-261. Marcus, B. H., Rossi, J. S., Selby, V. C, Niaura, R. S. and Abrams, D. B. (1992) The stages and processes of exercise adoption and maintenance in a worksite sample. Health Psychology, 11, 257-261. McConnaughy, E. A., DiClemente, C. C, Prochaska, J. O. and Velicer. W. F. (1989) Stages of change in psychotherapy: a follow-up report. Psychotherapy: Theory, Research, and Practice, 4, 494-503. McConnaughy, E. A., Prochaska, J. O. and Velicer. W. F. (1983) Stages of change in psychotherapy: measurement and sample profiles. Psychotherapy: Theory, Research, and Practice, 20, 368-375. Morrill, A. C. (1994) An interpersonal model of HIV risk for heterosexual women. Paper presented at the American Psychological Association Conference: Psychological and Behavioral Factors in Women, Washington, DC. O'Leary, A. (1985) Self-efficacy and health. Behavioral Research and Therapy, 23, 437-451. O'Reilly, K. R. and Higgins, D. L. (1991) AIDS community demonstration projects for HTV prevention among hardto-reach groups. Public Health Reports, 106, 714-720. Prochaska, J. O. (1989) What causes people to change from unhealthy to health enhancing behavior? In Cummings, C. C. and Floyd, J. D. (eds), Human Behavior and Cancer Risk Reduction: Overview and Report of a Conference on Unmet Needs. American Cancer Society, Atlanta, GA, pp. 30-34. Prochaska, J. O. (1994) Helping patients at every stage of change. Behavioral Approaches to Addiction, 3, 2-7. Prochaska, J. O. and DiClemente, C. C. (1983) Stages and processes of self-change in smoking: toward an integrative model of change. Journal of Consulting and Clinical Psychology, 5, 390-395. Prochaska, J. O. and DiClemente, C. C. (1984) The translheorelical approach: Crossing the traditional boundaries of therapy. Dow Jones/Irwin, Homewood, IL. Prochaska, J. O. and DiClemente, C. C. (1992) Stages of change in the modification of problem behaviors. In Herson, M., Eisler, R. M.and Miller, P. M. (eds), Progress in Behavior Modification. Sycamore Publishing, Sycamore, IL. Prochaska, J. O., DiClemente, C. C, Velicer, W. E, Ginpil, S. E. and Norcross, J. C. (1985) Predicting change in smoking status for self-changers. Addictive behaviors, 10, 395-406. Prochaska, J. O., Velicer, W. E, DiClemente, C. C. and Fava, J. (1988) Measuring processes of change: Applications to the cessation of smoking. Journal of Consulting and Clinical Psychology, 56, 520-528. Prochaska, J. O., DiClemente, C. C, Velicer, W. F. and Rossi, J. S. (1993) Standardized, individualized, interactive, and personalized self-help programs for smoking cessation. Health Psychology, 12, 399-405. Prochaska, J. O., Harlow, L. L., Redding, C. A., Snow, M. G., Rossi, J. S. and Velicer, W. E (1990) Stages of change, selfefficacy, and decisional balance for condom use with a highrisk sample. Centers for Disease Control and Prevention, Atlanta, GA (contract grant 0-415-002). Prochaska, J. O., Rossi, J. S. and Wilcox, N. S. (1991) Change processes and psychotherapy outcome in integrative case research. Journal of Psychotherapy Integration, 1, 103-120. Prochaska, J. O., Velicer, W. E, Rossi, J. S., Goldstein, M. G., Marcus, B. H., Rakowski, W., Fiore, C, Harlow, L. L., Redding, C, Rosenbloom, D. and Rossi, S. R. (1994) Stages of change and decisional balance for twelve problem behaviors. Health Psychology, 13, 39-46. Project CARES Working Group. (1994, Revised) Project CARES: Advocates' Guide to Stage of Change Counseling (Draft manual). Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention. Roper, W. L., Peterson, H. B. and Curran, J. W. (1993) Condoms and HIV/STD prevention: clarifying the message. American Journal of Public Health, 83, 501-503. Rosenberg, M. J. and Weiner, J. M. (1988) Prostitutes and AIDS: a health department priority? American Journal of Public Health, 78, 418-423. Sacco, W. P., Rickman, R. L., Thompson, K., Levine, B. and Reed, D. L. (1993) Gender differences in AIDS-relevant condom attitudes and condom use. AIDS Education and Prevention, 5, 311-326. Shiftman, S. (1986) A cluster analytic classification of smoking relapse episodes. Addictive Behaviors, 11, 295-307. Soskolne, V, Aral, S. O., Magder, L. S., Reed, D. S. and Bowen, G. S. (1991) Condom use with regular and casual partners among women attending family planning clinics. Family Planning Perspectives, 23, 222-225. 74