Health Education Research, Vol. 16, No. 5, 541-553,
October 2001
© 2001 Oxford University Press
Gender differences in the processes of change for condom use: patterns across stages of change in crack cocaine users
1 Center for Health Promotion Research and Development, University of Texas-Houston School of Public Health, PO Box 20186, Houston, TX 77225,
2 Behavioral Research Group/NOVA Research Company, Houston, TX 77006,
3 Duke Comprehensive Cancer Center, Cancer Prevention, Detection and Control Research Program, Department of Community and Family Medicine, DUMC 2949, Durham, NC 27710,
4 University of Wyoming, Department of Psychology, Laramie, WY 82071 and
5 Comprehensive Drug Research Center, University of Miami School of Medicine, Miami, FL 33136, USA
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionConclusionsReferences |
|---|
Interventions to increase condom use in crack users have had mixed results. For interventions to achieve greater success, the mechanisms of behavior change in this population need to be understood. One mechanism, the processes of change, was examined across stages of change for condom use. Results from the analysis of variance for males and females revealed that stage of change was associated with different levels of three experiential processes: consciousness raising, social liberation and self-re-evaluation. However, these analyses found that male and females seem to have different patterns of behavioral process use. Specifically, females in the preparation stage were different from those in precontemplation, whereas this difference was not pronounced in males. In general, people had high levels of experiential processes in every stage of change. The patterns of behavior process use mimicked patterns found for other behaviors with a linear increase across the stages of change. This may indicate that for maintaining condom use, more emotional and behavioral activities are required throughout the process of acquisition and maintenance than are necessary for other health-related activities. Implications of this research are that interventions for increasing condom use in drug users may target behavioral steps differently for males and females.
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionConclusionsReferences |
|---|
The widespread use of crack cocaine in the American drug culture has become an important public health problem rivaling that of injection drug use. Smoking crack leads to increases in high-risk sexual activities associated with HIV infection, such as high frequency of sex, multiple partners and limited use of condoms. Thus, smoking crack has been associated with the increased spread of STDs and HIV (Edlin et al., 1992
, 1994; McBride et al., 1992; McCoy and Miles, 1992; Weatherby et al., 1992; Brunswick and Flory, 1998; Semaan et al. 1998; Ross et al., 1999). Efforts to encourage safe sexual behaviors, particularly the use of condoms during vaginal sex, have met with mixed results (Booth et al. 1993, 1994; Cheney and Merwin, 1996; Jammer et al., 1997) and one reason may be that the program was not tailored on important characteristics, such as gender.
Several studies indicate that men and women have different attitudes and perceptions about condom use. For instance, Jadack et al. found that men were twice as likely as women to report not using condoms for reasons that were related to sexual sensation, whereas women were more likely to cite reasons regarding pregnancy (Jadack et al., 1997). Siegal et al. polled injection drug users and crack cocaine smokers, and found that for women, but not men, trading sex for drugs was associated with not using condoms, while trading sex for money was associated with using condoms (Siegal et al., 1995). In a study that examined the determinants of condom use by African-American crack users, Williams et al. reported that women felt confident and assertive about negotiating condom use when trading sex for money (Williams et al., 2000). Other researchers have found that although men are more likely to report using condoms than women, especially when cocaine use was involved, men have more negative attitudes about condoms than women (Lollis et al., 1996; Hser et al., 1998; Polacsek et al., 1999).
Another reason some of the current programs have been less successful than planned may be that behaviors that are linked to condom use are not well understood. Even though some of the programs were developed using a theoretical framework [e.g. Health Belief Model and Transtheoretical Model of Behavior Change (TTM)], the investigators may not have intervened on key variables that are essential for helping people make behavior changes because this theoretical work has yet to be conducted with condom use. With a clearer understanding of the mechanisms that are linked to increasing condom use, interventions can emphasize key variables to promote behavior change.
The TTM (Prochaska and DiClemente, 1984) is a widely used theoretical framework for behavior change interventions. This model, based on observational studies of smokers, integrates several constructs from behavioral, psychoanalytic and cognitive theories (Prochaska and DiClemente, 1984Prochaska and DiClemente, 1986; DiClemente, 1993).
One main component of the TTM is the stages of change, which represent a person's level of motivation or readiness for change (Prochaska and DiClemente, 1984; DiClemente, 1993). Individuals in the precontemplation stage are not seriously thinking about making a change. People in the contemplation stage are seriously thinking about making a change, but not in the near future. When people are in the preparation stage, they intend to change in the near future and may have already taken some steps toward changing. Individuals in the action stage have begun engaging in the new behavior. A person reaches the maintenance stage after they have engaged in the new behavior for a continuous period of 6 months.
Another important component of the TTM is the processes of change. Transition through the stages is mediated by the processes of change, which represent strategies and techniques that an individual engages in when modifying a behavior (Prochaska et al., 1992; DiClemente, 1993). Studies have shown that the cognitive and behavioral steps people take when changing their behavior is associated with their current stage of change (Prochaska and DiClemente, 1984; DiClemente, 1993; Prochaska et al., 1994). According to the smoking literature, in the earlier stages of change, people engage in the experiential processing more than behavioral. This pattern has been found across a variety of behaviors besides smoking, including alcohol use and contraceptive use (Grimley, 1994; Snow et al., 1994).
The experiential processes have been identified as consciousness raising, dramatic relief, selfre-evaluation, environmental re-evaluation and social liberation, while the behavioral processes are helping relationships, stimulus control, counter-conditioning, reinforcement management and self-liberation (Prochaska and DiClemente, 1984; Prochaska et al., 1994; DiClemente, 1993).
The processes of change have received adequate exploration in the smoking realm, but only two studies have been published that examine process use for condom use (Grimley et al., 1992; Redding and Rossi, 1993). Both of these studies found a different pattern of process use than had been found for other health-related behaviors (Grimley et al., 1992; Redding and Rossi, 1993). Although results from these studies could inform interventions, neither of these studies tested for gender differences in process use.
Based on these observational studies, researchers have developed interventions to maximize process use during specific stages of change to help people progress to the next level of readiness. Similar work is necessary to understand the complex behavior of condom use adoption.
Observational studies are needed to explore the mechanisms involved in being more or less ready to adopt condom use as a permanent behavior and researchers can develop programs based on those mechanisms to help motivate people to use condoms. For instance, it has been shown that for smokers, consciousness raising, an experiential process, is particularly important for those in the precontemplation stage for smoking cessation (DiClemente et al., 1991), especially to increase motivation (Pollak et al., 1999). Smoking interventions have capitalized on this mechanism when trying to get smokers in the contemplation stage to think about the consequences of their smoking to increase their motivation to stop smoking. This same process may or may not be relevant for condom use adoption in crack users, however.
This area of research is relatively unexplored. In view of the limited number of studies that have examined the processes of change in relation to condom use in general, the purpose of the current study is to improve the understanding of what differentiates someone who uses condoms every time with his/her partner from someone who has no interest in using condoms. Specifically, the aim of this study was to (1) determine whether people in different stages had different levels of experiential and behavioral process use, and (2) if this pattern was the same for male and female crack users.
Understanding the relationship between the processes of change and a person's stage of change can help researchers design interventions aimed at increasing condom use. This can be accomplished by targeting men and women whose stage of change for adopting condom use has been identified, with interventions that maximize the appropriate process use for their gender and that stage of change.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionConclusionsReferences |
|---|
Sample
This was a cross-sectional study. The data were collected from participants who lived in Washington, DC, Immokalee, FL and Miami, FL who were using drugs and at high risk for HIV infection. Both male and female participants were recruited at each study site using targeted sampling (Waters and Biernacki, 1989). Three high-risk neighborhoods were identified in all sites. These areas had a higher incidence of reported arrests for drug sales, and reports of drug overdoses, prostitution, sexually transmitted diseases and HIV infection. In the targeted areas, drug use was confirmed by key informants and by ethnographic observation.
Eligibility criteria were being at least 18 years of age, self-reporting having had vaginal sex in the previous week, willing to sign an informed consent form and self-reporting crack or cocaine use in the past week. Self-reported drug use was verified by urine samples tested for opiate or cocaine metabolites with the ‘ON-TRACK’ drug test. All study forms and procedures were approved by the committees for the protection of human subjects at each study site. Respondents were paid a small gratuity ($20) for their time.
Records for the number of people screened for eligibility were kept for the DC site only, where 54% of those screened were eligible for participation. The major reason for ineligibility was that individuals had engaged in sexual activity less than 3 times in the past 30 days (81%). We assume participation rates were similar for the Florida sites, as the populations were similar in make-up.
Data collection and measures
The Sexual Risk Reduction Questionnaire (SRRQ), a face-to-face interview, was used in the study. Reliability for the questionnaire has been established through a 48-h test/re-test study (Weatherby et al., unpublished). The SRRQ includes sociodemographic variables, drug use history, HIV status, health status, sexual behaviors, attitudes, beliefs and intentions related to condom use, as well as stages of change and processes of change. Sexual behavior and condom use data were collected for main, casual, new and trading partners. Trained research assistants administered the questionnaire using Computer Assisted Personal Interviews (CAPI) technology. The interview took approximately 2 h, with one 5 min break.
Stage of change: condom use for vaginal sex with last three people
Participants answered stage of change questions for their last three vaginal sex partners. Stage of change for each of the three most recent partners was assessed using a six-question algorithm that included the following questions:
- Have you used a condom every time you had sex with this person?
- How long have you been using a condom every time you have vaginal sex with this person?
- Will you have sex with this person again?
- Do you plan to use a condom with (partner) the next time you have vaginal sex?
- Do you plan to use a condom with (partner) every time you have sex during the next 30 days?
- Do you plan to use a condom with (partner) every time in the next 6 months?
This algorithm was adapted from items developed by Prochaska et al. (Prochaska et al., 1994). See Figure 1.
|
Stage of change for condom use has been measured in previous studies by assessing when people plan to start using condoms (Grimley et al., 1995
), where stating that they will start using condoms sometime in the next 6 months is viewed as a weaker intention than vowing to start using condoms in the next 30 days. This study reversed these time frames because the interest was not in when people would start using condoms, but rather when they would plan to use condoms every time with their partner. Thus when a participant stated that he/she planned to use a condom every time for the next 30 days, this was viewed as less committed than someone who stated that he/she planned to use condoms every time for the next 6 months. It is thought that this wording gave a more accurate read of intentions for using condoms consistently. Definitions of the stages of change based on these questions are illustrated in Table I.
|
Processes of change
The processes of change were assessed using a 40-item measure that was adapted from the Process of Change Questionnaire developed by Prochaska et al. (Prochaska et al., 1983). The interviewer introduced the process use questions to the participants as ‘thoughts, feelings and behaviors about things they do to try to remember to use condoms’. Given the number of items in this scale, a more parsimonious strategy was used. Interviewers randomly assigned participants to answer the process items for one of five types of partners (main, casual, new, trade sex for crack or paying). Because the partner types for processes of change and stage of change were slightly different, five new categories were made. For this analysis, ‘spouse’ and ‘like a spouse’ were coded as ‘main partner’, ‘close friend’ and ‘friend’ were coded as ‘casual partner’, ‘acquaintance’ was coded as ‘new partner’, and ‘commercial’ was coded as such. The category ‘other’ was dropped. All respondents who designated their partner as a ‘spouse’ or ‘like a spouse’ were coded as a ‘main’ partner, all other partner categories were coded as ‘casual’ partners.
The experiential processes consisted of 18 items that included the following subscales: consciousness raising (four items, 
= 0.74), environmental re-evaluation (two items, = 0.52), dramatic relief (four items, = 0.71), social liberation (four items, = 0.65) and self-re-evaluation (four items, = 0.76). The behavioral processes measure consisted of 20 items that included helping relationships (three items, = 0.60), stimulus control (three items, = 0.77), counterconditioning (five items, = 0.71), reinforcement management (two items, = 0.72) and self-liberation (five items, = 0.73). Another subscale, interpersonal systems control, was deleted because of an unacceptably low . Sample items from the scales are listed in Table II.
|
Exploratory factor analysis was conducted with varimax rotation and 11 factors specified. For each of the experiential and behavioral subscales the items for each subscale loaded strongly (ß
0.40) on one factor only and not strongly on any other factor (ß 
0.30). To be consistent with other studies that have investigated the processes of change, all subscales were included.
Analyses
All data were analyzed using SAS version 6.12 for Windows (SAS Institute Software) and SPSS (Statistical Package for the Social Sciences) version 8 for Windows, and used < 0.05 criterion as the level of significance. Before any of the main analyses were conducted, two multivariate analyses of variance (MANOVA) were conducted. Because previous studies (Bowen and Trotter, 1995; Anderson et al., 1996; Rhodes and Malotte, 1996; Harlow et al., 2001) have found differences in condom use based on partner type, the association of partner type and stage of change on process use was examined. One set of tests examined whether people who claimed having a main versus a casual partner had statistically different levels of process use by stage of change. Thus the interaction of stage and partner type was tested for the five experiential processes and behavioral processes simultaneously. If the interaction of stage and partner type was significant for either the experiential or the behavioral processes, the analyses were conducted by partner type. This same test (MANOVA) was conducted for the interaction of gender and stage of change.
To examine the relationship between the stage of change and the processes of change for condom use, two separate MANOVA analyses of variance were performed for the subscales of experiential and behavioral processes. If the MANOVA was significant, univariate analyses were examined. Tukey's post-hoc pairwise comparisons were used to determine if individuals in the precontemplation stage had lower levels of experiential and behavioral process use than those in other stages of change as has been shown in previous studies. In addition, it was hypothesized that people in the action and maintenance stages would have higher levels of behavioral process use and lower levels of experiential process use than those in other stages.
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionConclusionsReferences |
|---|
Participant characteristics
Data was collected from 321 participants between January 1997 and December 1997, from participants in Miami, FL, Immokalee, FL and Washington, DC. Mean age of the participants was 37 years of age (range 19–67). Approximately 52% of the sample were male. Overall, 69% of participants were African-American, 11% were hispanic/latino and 18% were white.
Level of education for participants did not vary across the sites. Less than half (45%) reported having attained a high school education, with 36% reporting a high school diploma or a GED and 19% reporting some college. Almost half (48%) reported that they were not working or unemployed and more than half (57%) reported their average monthly income was less than $600. The majority were not married (82%) and the same percent reported having a main partner. All participants reported smoking crack cocaine in the 30 days prior to being interviewed, with 96% testing positive for cocaine on a urine test. Approximately 9% reported knowing that they were HIV-positive.
Stage frequencies
Participants were asked staging questions about their past three sexual contacts. In this analysis, the partner for only the most recent sexual encounter was used. As a result, 339 participants (55%) were randomly assigned to answer the process questions for one of the partner types who participated in that encounter. Sixteen data sets were incomplete and, therefore, were dropped. Because only two participants were in the contemplation stage, that stage was also dropped from the analyses. Other studies also have had few people in the contemplation stage for condom use (Anderson et al., 1996; Stark et al., 1998). Thus, 321 (81%) participants with complete data were included in the final analysis. (We also analyzed the data by collapsing the two participants in the contemplation stage with the preparation stage; however, it did not change the significance of any of the findings and minimally changed the means).
Of the individuals who were assigned to answer the process questions about a main partner (n = 144), 37% were in the precontemplation stage for using condoms, 8% were in preparation, 16% were in action and 40% were in maintenance. Of those who were assigned to answer the process questions about a casual or commercial partner (n = 177), 22% were in the precontemplation stage for using condoms, 7% were in preparation, 27% were in action and 45% were in maintenance. Type of partner was associated significantly with stage of change where those who had a main partner were more likely to be in precontemplation and those with a casual partner were more likely to be in maintenance, 
2 (3, N = 321) = 11.15, P < 0.01.
Of the males, 32% were in precontemplation, 7% were in preparation, 25% were in action and 36% were in maintenance. Of the females, 25% were in precontemplation, 8% were in preparation, 19% were in action, while 49% of them were in maintenance. Males and females did not differ significantly on their stage of change, 2 (3, N = 321) = 5.55, P < 0.14.
Multivariate analyses testing for pattern difference for main and casual partners
MANOVA was used to test whether people who claimed having a main partner had different levels of process use based on their stage of change compared to those who claimed having a casual partner. Results indicate that people who had a main partner had similar patterns of experiential process use, all five subscales analyzed simultaneously, across the stages of change as those who claimed having a casual partner, F(15,826) = 1.28, P < 0.21. Similarly, the interaction of stage of change and partner type was not significant for behavioral process use, F(15,846) = 1.14, P < 0.31. Main effects of partner type also were not significant, but stage of change was (data not shown). Therefore, based on the multivariate analyses, the current analyses were not conducted for main and casual partners separately.
Multivariate analyses testing for pattern difference for males and females
MANOVA was used to test whether males had a different pattern of process use across the stages of change compared to females. Results indicate that males had similar patterns of experiential process use across the stages of change as females, F(15,826) = 0.91, P < 0.55. The interaction of stage of change and gender was significant for behavioral process use, however, F(15,846) = 2.12, P < 0.007. Specifically, males differed from females in their patterns of helping relationships across stages of change, F(7,305) = 2.71, P < 0.05 and in their patterns of counterconditioning across the stages of change, F(7,305) = 7.14, P < 0.0001. In both sets of multivariate analyses, both stage of change and gender had a main effect for explaining the variance in experiential and behavioral process use although main effects should not be interpreted in light of a significant interaction. Therefore, based on the multivariate analyses, the current analyses were conducted for males and females separately.
Stage of change comparisons of process use
Results from the analysis of variance for 165 males and 156 females revealed that stage of change was associated with different levels of three of the five experiential processes, i.e. consciousness raising, social liberation and self-re-evaluation, and that stage of change was associated with different levels of all five of the behavioral processes. Tukey's post-hoc pairwise comparisons were conducted for each group of processes. (See Tables III and IV for means.)
|
|
While there were not statistically significant differences between males and females in their use of experiential processes, their patterns of use varied, particularly in the early stages where motivation is low. Men had a higher use of ‘environmental re-evaluation’ in the precontemplation and preparation stages with all the experiential processes rising and converging in the action and maintenance stages. Women had a higher use of ‘dramatic relief’ in the precontemplation stage, with all experiential process use rising and converging in the preparation stage.
All of the behavioral processes were associated significantly with stage for both males and females, but the patterns of use varied by gender, particularly in the preparation stage. For women, all of the behavioral processes increased and converged in the preparation stage. For men in the preparation stage, ‘helping relationships’ and ‘counterconditioning’ declined, and the remaining three increased only slightly, with the highest use of ‘selfliberation’.
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionConclusionsReferences |
|---|
Results indicate that individuals in this study had significantly different levels of experiential and behavioral processes of use depending on their stage of change. However, patterns of process use for condom use appear to differ from those patterns found in smokers. In the early stages, behavioral process use is lower than experiential process use and increases in the later stages. While experiential process use is higher than behavioral process use in the early stages, it does not ‘peak’ and decline, rather, it continues to increase along with the behavioral processes into the later stages. While this pattern varies from that found in other health-related behaviors, it is similar to the findings in previous studies on condom use (Grimley et al., 1992
; Redding and Rossi, 1993). A recent critique questions the predictive ability of the model for staging across a variety of behaviors (Whitelaw et al., 2000).
Although males and females did not differ statistically on their use of experiential processes, their patterns of use are not exactly the same, particularly in the early stages (see Tables III and IV
). Small sample sizes may account for the lack of statistically significant results. However, an important finding in this study is that male and females appear to have different levels of behavioral process use based on their stage of change. This finding is consistent with other studies about their attitudes, perceptions and beliefs about condoms (Siegal et al., 1995; Lollis et al., 1996; Jadack et al., 1997; Hser et al., 1998; Polacsek et al., 1999; Williams et al., 2000).
All five of the behavioral processes were associated significantly with stage for both males and females. Males and females in the precontemplation stage differ from those in the action and maintenance stages on most of the behavioral processes. The gender differences emerge for males and females in the preparation stage. Women in the preparation stage differ from women in the precontemplation stage, but this finding was not replicated for the males. This may indicate that the process of adopting condom use may be a slower, more complex behavior change for women than it is for men. Further, this may indicate that men and women prepare differently for making a commitment to using condoms consistently.
Because people in the precontemplation and contemplation stages present the most challenges for behavior change interventionists, researchers would want to design studies which incorporated stage-based counseling that emphasized the differential processes that are used by men and women. For example, role model stories or brief videos about contracting HIV/AIDS (dramatic relief) may be more effective in motivating women, while an emphasis on the social acceptability and the impact on others (environmental re-evaluation) may be more effective in motivating men to begin thinking about condom use. For women in the preparation stage, the shift in emphasis may be on the self-re-evaluation processes, whereas with men the emphasis may still be on the environmental re-evaluation processes. For both men and women in the action and maintenance stages, all of the experiential processes appear important, so couples counseling or group sessions incorporating all the of them should be effective in increasing their motivation.
Past research has shown that to help people progress to later stages of readiness, increases in motivation may help increase behavioral process use (Pollak et al., 1999). It appears that a motivational counseling approach should be used particularly with men who do not show the expected rise in behavioral process use in the preparation stage. For instance, interventionists can tailor the advantages of changing condom use behavior for men and women. For men to increase their behavioral process use, a motivational approach could emphasize the importance of finding other ways to satisfy sexual urges besides having sex without a condom (counterconditioning) and of the importance of carrying a condom with them at all times (stimulus control). Again, in the action and maintenance stages, both men and women used higher levels of the same processes (self-liberation and helping relationships) so couples or group sessions could be effective. In a recent large multi-site study, The CDC AIDS Community Demonstration Projects Research Group (CDC AIDS Community Demonstration Projects Research Group, 1999) stage-based role model stories and condoms were distributed, and these investigators reported significant progression to higher stages of condom use for vaginal sex, over time.
Attempting to change sexual behaviors presents a difficult challenge, but changing condom use seems even harder. In spite of the known protective benefits of condom use, people in general have negative attitudes towards condoms, and men and women have different views of condom use. This may explain, in part, why in this study and the two others that examined processes, the experiential (affective/cognitive) processes remain high in the action and maintenance stages. It is possible that more emotional and cognitive (experiential) activities are necessary throughout acquisition and maintenance than are required for smoking cessation and some other health related activities. While many health-related behaviors are under individual control, including the use of most contraceptives, condom use is an overt behavior that involves both individuals. Each of two sexual partners may be in different stages about condom use and changing the attitudes of one person may not be sufficient. In addition, sexual activity is more emotionally charged than other behaviors where a decrease in the affective/cognitive processes in the action and maintenance stages has been seen. This factor may have a strong impact on the difference seen in the patterns of process use for the adoption of consistent condom use and those found for other health related behaviors.
Limitations
The results of this study should be viewed with caution. The data are cross-sectional, and, as such, no causal relationship can be inferred between the processes of change and stage progression. Also, in this study, the staging algorithm contained a subtle wording change that may have affected the way that stage was measured. It is not clear whether this change had an impact on the low number of people in the contemplation stage; however, other researchers have had similar findings (Anderson et al., 1996; Stark et al., 1998). It appears that most people are either not thinking about using them at all or are doing so already; however, that does not preclude interventionists from using the model to measure condom use. Rather, when this is known, it implies that interventions can be designed to target motivation to use condoms for precontemplators and others in the early stages, and reinforcement of condom use for those in the action and maintenance stages.
In addition, the model and these constructs were developed based on individual behavioral processes, and do not account for the dual nature of sexual relationships. This factor also may limit the model. An individual may be in a given stage because of their partner's attitude about condoms, not his/her own. This could be particularly true for people who are trading sex for drugs, money or food and a place to live. Stage of readiness may change, not because a person's attitude changed, but because the relationship changed.
One strength of this paper is that it uses data from a study that was a large, multi-site, multi-ethnic sample that is 65% African-American, which includes hispanics and whites, and both males and females. This study sample is unique because it is the first study examining these constructs whose participants were recruited from their neighborhoods and were current crack users who were not in treatment. A further strength of the study is that individuals were assigned to risk level groups, stages of change, based on a previously tested model.
|
Conclusions |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionConclusionsReferences |
|---|
TTM provides a framework for integrating important constructs associated with behavior change and the application of those factors to interventions (DiClemente and Prochaska, 1982
; Prochaska and DiClemente, 1983). Interventions that are sensitive to an individual's readiness to change and the processes that facilitate movement in readiness may result in a more efficacious program. Using the model to enhance the design, implementation and evaluation of intervention programs could improve the ability to achieve behavior change in populations at high risk for HIV infection. It is important for researchers to carry the model a step further by investigating avenues for applying the processes to achieve behavior change. Future research should use counseling programs which incorporate the processes of change and stages of change into the sessions as is being done in the previously mentioned longitudinal study. Future research should attempt to capitalize on what we know about gender differences in the patterns of process use as they consider either an individual or a ‘couples’ approach. Researchers should examine other constructs as well, such as self-efficacy and outcome expectancies, for example, to gain further insight into this complex behavior.
|
Acknowledgments |
|---|
We are grateful for the helpful advise from Dr Carlo DiClemente regarding the Transtheoretical Model. Support for this research was provided by the National Institute on Drug Abuse. The opinions expressed herein are solely those of the authors. Correspondence related to this manuscript should be sent to Dr Sandra Timpson, Behavioral Research Group/NOVA Research Company
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionConclusionsReferences |
|---|
Anderson, J. E., Cheney, R., Faruque, S., Long, A., Toomey, K. and Wiebe, W. (1996) Stages of change for HIV risk behavior: injection drug users in five cities. Drugs & Society, 9, 1–17.
Booth, R. E., Watters, J. K. and Chitwood, D. D. (1993) HIV risk-related sex behaviors among injection drug users, crack smokers, and injection drug users who smoke crack. American Journal of Public Health, 83, 1144–1148.
Booth, R. E., Watters, J. K. and Chitwood, D. D. (1994) How effective are risk-reduction interventions targeting injection drug users? AIDS, 8, 1515–1525.[Web of Science][Medline]
Bowen, A. and Trotter, R. (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, 238–48.
Brunswick, A. F. and Flory, M. J. (1998) Changing HIV infection rates and risk in an African-American community cohort. AIDS Care, 10, 267–281.[Web of Science][Medline]
Cheney, R. and Merwin, A. (1996) Integrating a theoretical framework with street outreach services: issues for successful training. Public Health Reports, 111 (Suppl. 1), 83–88.[Web of Science][Medline]
CDC AIDS Community Demonstration Projects Research Group. (1999) Community-level HIV intervention in five cities: final outcome data from the CDC AIDS Community Demonstration Projects. American Journal of Public Health, 89, 336–345.
DiClemente, C. C. (1993) Changing addictive behaviors: a process perspective. Current Directions in Psychological Science, 2, 101–106.
DiClemente, C. C. and Prochaska, J. O. (1982) Self-change and therapy change of smoking behavior: a comparison of processes of change in cessation and maintenance. Addictive Behaviors, 7, 133–142.[Web of Science][Medline]
DiClemente, C. C., Prochaska, J. O., Fairhurst, S. K., Velicer, W. F., Velasquez, M. M. and Rossi, J. S. (1991) The process of smoking cessation: an analysis of precontemplation, contemplation, and preparation stages of change. Journal of Consulting and Clinical Psychology, 59, 295–304.[Web of Science][Medline]
Edlin, B. R., Irwin, K. L., Faruque, S., McCoy, C. B., Word, C., Serrano, Y., Inciardi, J. A., Bowser, B. P., Schilling, R. F., Holmberg, S. D. (1994) Intersecting epidemics—crack cocaine and HIV infection among inner-city young adults. New England Journal of Medicine, 331, 1422–1427.
Edlin, B. R., Irwin, K. L., Ludwig, D. D., McCoy, H. V., Serrano, Y., Word, C., Bowser, B. P., Faruque, S., McCoy, C. B., Schilling, R. F., et al. (1992) High-risk sex behavior among young street-recruited crack cocaine smokers in three American cities: an interim report. Journal of Psychoactive Drugs, 24, 363–371.[Web of Science][Medline]
Grimley, D. M. (1994) Contraceptive and condom use for the prevention of pregnancy, STDs and AIDS: a transtheoretical approach. Doctoral dissertation, University of Rhode Island, Kingston, RI.
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. Centers for Disease Control and Prevention, Atlanta, GA.
Grimley, D, Prochaska, J. O., Velicer, W. F. and Prochaska, G. E. (1995) Contraceptive and condom use adoption and maintenance: a stage paradigm approach. Health Education Quarterly, 22, 20–35.[Web of Science][Medline]
Harlow, L. L., Prochaska, J. O., Redding, C. A., Rossi, J. S., Velicer W. F, Snow, M. G., Schnell, D., Galavotti, C., O'Reilly, K. and Rhodes, F. (1999) Stages of change in a high HIV-risk sample. Psychology and Health, 14, 143–157.
Hser, Y., Chou, C., Hoffman, V. and Anglin, M. D. (1998) Cocaine use and high-risk sexual behavior among STD clinic patients. Sexually Transmitted Diseases, 26, 82–86.
Jammer, M. S., Wolitski, R. J. and Corby, N. H. (1997) Impact of a longitudinal community HIV intervention targeting injecting drug users stage of change for condom use and bleach use. American Journal of Health Promotion, 12, 15–24.[Web of Science][Medline]
Jadack, R. A., Fresia, A., Rompalo, A. M. and Zenilman, J. (1997) Reasons for not using condoms of clients at urban sexually transmitted diseases clinics. Sexually Transmitted Diseases, 24, 402–440[Web of Science][Medline]
Logan, T. K., Leukefekd, C. and Farabee, D. (1998) Sexual and drug use behaviors among women crack users: implications for prevention. Aids Education and Prevention, 10, 327–340.[Web of Science][Medline]
Lollis, C. M., Johnson, E. H., Antoni, M. H. and Hinkle, Y. (1996) Characteristics of African-Americans with multiple risk factors associated with HIV/AIDS. Journal of Behavioral Medicine, 19, 55–71.[Medline]
McBride, D. C., Inciardi, J. A., Chitwood, D. D., McCoy, C. B. and The National AIDS Research Consortium (1992) Crack use and correlates of use in a national population of street heroin users. Journal of Psychoactive Drugs, 24, 411–416.[Web of Science][Medline]
McCoy, H. V. and Miles, C. (1992) A gender comparison of health status among users of crack cocaine. Journal of Psychoactive Drugs, 24, 389–397.[Medline]
Polacsek, M., Celentano, D. D., O'Campo, P. and Santelli, J. (1999) Correlates of condom use stage of change: implications for intervention. AIDS Education and Prevention, 11, 38–52.[Web of Science][Medline]
Pollak, K. I., Carbonari, J. P., DiClemente, C. C., Niemann, Y. F. and Mullen, P. D. (1998) Causal relationships of processes of change and decisional balance: stage specific models for smokers. Addictive Behaviors, 23, 437–448.[Web of Science][Medline]
Prochaska, J. O. and DiClemente, C. C. (1983) Stages and processes of self change of 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 Transtheoretical Approach. Dow-Jones-Irwin, Homewood, IL.
Prochaska, J. O. and DiClemente, C. C. (1986) Toward a comprehensive model of change. In Miller, W. and Heather, N. (eds), Treating Addictive Behaviors. Plenum, New York, pp. 3–27
Prochaska, J. O., DiClemente, C. C. and Norcross, J. C. (1992) In search of how people change: applications to addictive behaviors. American Psychologist, 47, 1102–14.[Medline]
Prochaska, J. O., Redding, C., Harlow, L. L., Rossi, J. S. and Velicer, W. F. (1994) The transtheoretical model of change and HIV prevention: a review. Health Education Quarterly, 21, 471–486.[Web of Science][Medline]
Redding, C. A. and Rossi, J. S. (1993) The Processes of Safer Sex Adoption. Society of Behavioral Medicine, Mar, San Francisco, CA.
Rhodes, F. and Malotte, C. K. (1996) Using stages of change to assess intervention readiness and outcome in modifying drug-related and sexual HIV risk behaviors of IDUs and crack users. Drugs & Society, 9, 109–136.
Ross, M. W., Hwang, L., Leonard, L., Teng, M. and Duncan, L. (1999) Sexual behavior, STDs, and crack cocaine use in a crack house population. International Journal of STD and AIDS, 10, 224–230.
Semaan, S., Kotranski, L., Collier, K., Lauby, J., Halbert, J. and Feighn, K. (1998) Temporal trends in HIV risk behaviors of out-of-treatment injection drug users and injection drug users who smoke crack. Journal of Acquired Immune Deficiency Syndromes, 19, 274–281.
Siegal, H. A., Falck, R. S., Wang, J. and Carlson, R. G. (1995) History of sexually transmitted diseases infection, drug-sex behaviors, and the use of condoms among Midwestern users of injection drugs and crack cocaine. Sexually Transmitted Diseases, 23, 277–282.
Snow, M. G., Prochaska, J. O. and Rossi, J. S. (1994) Processes of change in alcoholics anonymous: maintenance factors in long-term sobriety. Journal of Studies on Alcohol, 5, 362–371.
Stark, M. J., Tesselaar, H. M., O'Connell, A. A., Person, B, Galavotti, C., Cohen, A. and Walls, C. (1998) Psychosocial factors associated with the stages of change for condom use among women at risk for HIV and STDs: implications for intervention development. Journal of Counseling and Clinical Psychology, 66, 967–978.[Web of Science][Medline]
Watters, J. and Biernacki, P. 1989. Targeted sampling: options for the study of hidden populations. Social Problems, 36, 416–430.
Weatherby, N. L., Shultz, J. M., Chitwood, D. D., McCoy, H. V., McCoy, C. B., Ludwig, D. D. and Edlin, B. R. (1992) Crack cocaine use and sexual activity in Miami, Florida. Journal of Psychoactive Drugs, 24, 373–380.[Web of Science][Medline]
Whitelaw, S., Baldwin, S., Bunton, R. and Flynn, D. (2000) The status of evidence and outcomes in Stages of Change research. Health Education Research, 15, 707–718.
Williams, M. L., Bowen, A. M., Elwood, W. N., McCoy, C. C., McCoy, H. V., Freeman, R. C., Weatherby, N. L. and Pierce, T. (2000) Determinants of condom use among African Americans who smoke crack cocaine. Culture, Health & Sexuality, 2, 15–32.
Received on June 9, 2000; accepted on February 20, 2001
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  P. J. Draus and R. G. Carlson "The Game Turns on You": Crack, Sex, Gender, and Power in Small-Town Ohio Journal of Contemporary Ethnography, June 1, 2009; 38(3): 384 - 408. [Abstract] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||