Risk behaviours in HIV-positive men who have sex with men participating in an intervention in a primary care setting.

Men who have sex with men receiving HIV care reported their sexual behaviours and their intentions, classified according to the Transtheoretical Model of Change, to modify the following behaviours: (1) condom use by partner type and activity type; (2) reduction of partner number; and (3) disclosure of HIV serostatus to partners. Most participants were white (68.8%) or black (29.5%) and were more likely to report unprotected sex with HIV-positive than with serodiscordant partners for most activities. Whites reported more partners than black patients (mean 4.1 versus 2; P < 0.0001) and black participants reported fewer HIV-negative (P = 0.0084) and -unknown status partners (P = 0.00095) than whites. Cocaine/crack use was associated with more sexual partners (P = 0.001) and more frequent unprotected sex with HIV-negative or -unknown status partners (P = 0.036). Readiness to change risk behaviour varied by partner status and type of sexual activity. Understanding patients' risks and their readiness to change behaviours may help providers to promote sexual health.

A process evaluation of the implementation of a computer-based, health provider-delivered HIV-prevention intervention for HIV-positive men who have sex with men in the primary care setting.

There is increasing interest in using healthcare providers to deliver HIV-prevention services to their patients. Unfortunately, lack of counselling skills and time constraints within busy clinics serve as barriers to such efforts. The Providers Advocating for Sexual Health Initiative (PASHIN) study used state-of-the-art computer technology to assess each participant's risk behaviours and to determine the patient's readiness for changing each behaviour. The computer synthesized the participant-entered data, determined the targeted risk behaviour and printed a behavioural theory-based provider advice sheet and a 3-point patient prescription for the targeted risk behaviour. Since the intervention does not require providers to spend time performing a detailed sexual-risk assessment and it does not require providers to have received extensive counselling training, it has the potential to minimize some of the barriers associated with provider-delivered interventions. Thus, the purpose of this process evaluation was to assess how the PASHIN intervention was implemented in the field, including issues such as the fidelity of implementation and health providers' views on and experience with implementing the intervention. Overall, the results demonstrated that the computer-based, provider-delivered intervention was successfully delivered by providers within the context of regularly scheduled treatment sessions with HIV-positive men who have sex with men (MSM) patients. The majority of providers (79.4%) and patients (83.5%) reported that the quality of HIV-prevention services delivered during these sessions was 'good'. The majority of the providers also reported that they had received adequate training, felt more confident in communicating HIV-prevention issues with their patients and provided more HIV-prevention counselling to their patients, due to the project. However, the experience of delivering HIV-prevention counselling during an 18-month period did not appear to change providers' attitudes toward a provider-delivered HIV-prevention intervention nor their belief in the effectiveness of HIV prevention in general. Future studies should focus on how to enhance providers' acceptance and commitment to delivering HIV-prevention counselling to their patients during the clinic visit.

Understanding patient perceptions of asthma: results of the Asthma Control and Expectations (ACE) survey.

In spite of support among UK healthcare professionals for asthma guidelines, studies continue to show that many patients fail to reach the suggested management goals. Patient expectations and poor communication may be factors in this failure. This survey assessed patients' asthma control, expectations in respect of asthma and communication with healthcare professionals. A structured questionnaire, designed for self-completion, was developed and distributed to asthma patients at participating pharmacies. A total of 1031 questionnaires were returned. Most of the respondents, even among those feeling well, reported lifestyle restrictions because of asthma. These restrictions were not generally discussed with healthcare professionals. One-third did not perceive the benefits of inhaled corticosteroids. Low expectation may be a major contributor to the poor control seen in this survey. The failure to discuss lifestyle restrictions and symptom levels with healthcare professionals gives little scope for recommendation of appropriate and adequate treatment. Improved communication between healthcare professionals and patients may help such understanding and raise patient expectations.

Relation of health literacy to gonorrhoea related care.

OBJECTIVE: To assess the relation between health literacy and receipt of a screening test for gonorrhoea in the past year. METHODS: Study design was multisite, cross sectional survey of subjects enrolled from clinics, from community based organisations, and by street intercept. Data were obtained using face to face interview. The dependent variable was self reported receipt of a test for gonorrhoea in the past year. Health literacy was measured by the Rapid Estimate of Adult Literacy in Medicine (REALM), recoded to represent 8th grade or lower reading or 9th grade and higher reading level. Statistical analyses were adjusted to account for selection bias in literacy assessment. RESULTS: 54% of the sample reported at least one gonorrhoea test in the previous year. 65% of the sample read at a 9th grade level or higher. REALM score was moderately correlated with the respondent's years of education. After adjustment for missing REALM data, past suspicion of gonorrhoea, self inspection for gonorrhoea, self efficacy for care seeking, REALM score of 9th grade reading level or higher, and younger age were independently associated with gonorrhoea testing in the previous year. For the average respondent, REALM reading grade level of 9th grade or higher is associated with a 10% increase in the probability of having a gonorrhoea test in the past year. CONCLUSIONS: Low literacy appears to pose a barrier to care for sexually transmitted infections such as gonorrhoea.

Smoking cessation counseling practices: a survey of Alabama obstetrician-gynecologists.

BACKGROUND: Minimal interventions delivered by obstetrician-gynecologists (OB-GYNs) to their pregnant patients who smoke could result in a substantial decrease in smoking during pregnancy. We examined performance and motivation levels of Alabama OB-GYNs for engaging in clinical practices based on National Cancer Institute (NCI) guidelines. METHODS: Questionnaires assessing attitudes, intentions, and behaviors specified by the NCI's "4-A" model (ask, advise, assist, and arrange follow-up) were mailed to all OB-GYNs licensed in Alabama. RESULTS: A total of 130 physicians completed the questionnaire. Nearly all reported that they ask (93%) and advise (90%) their patients who smoke to quit; however, significantly fewer reported that they assist (28%) or arrange follow-up (24%) with their pregnant patients. CONCLUSIONS: Interventions are needed to motivate, support, and guide OB-GYN physicians to assist and follow-up with their pregnant patients who smoke.

Pharmacists' readiness to assess consumers' over-the-counter product selections.

OBJECTIVE: To measure and explain pharmacists' readiness to adopt a proposed new standard for assessing consumers' over-the-counter product selections. DESIGN: Cross-sectional, descriptive study based on the theoretical underpinnings of the Transtheoretical Model of Change. A questionnaire was used for data collection. Sections included: (1) pharmacists' readiness to engage in a proposed standard of practice; (2) the positive and negative aspects of doing so; (3) pharmacists' agreement with current legislative status of pharmacist-only products; and (4) demographics. SETTING: Community pharmacy. PARTICIPANTS: Community pharmacists in one Canadian province. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Pharmacists' readiness to adopt a proposed new standard of care. RESULTS: Response rate was 70.6%. Most respondents were staff pharmacists in independent pharmacies. The majority were not ready to adopt the proposed new behavior--57.6% were in the precontemplation stage. Age, sex, year of graduation, workload, and size of town/city had no significant effect on readiness for change. As expected, precontemplators showed less overall support for keeping pharmacist-only agents behind the counter. Positive and negative beliefs about the proposed standard varied across stages. CONCLUSION: Any initiatives to increase pharmacist involvement in assessing consumer nonprescription product selections must acknowledge that pharmacists differ in their degree of readiness for change.

Population-level intervention to promote chlamydia screening. Moving toward implementation of chlamydia hedis 2000 measure

Background: HEDIS 2000 measure includes chlamydia screening in women which is designed to assess the percentage of sexually active women 15 to 25 years who have received at least one screening test for chlamydia during the reporting year. This study is being undertaken to determine feasibility of implementing a population-level intervention within HMOs to promote chlamydia screening. This abstract presents preliminary findings from the Birmingham project of this multicenter study.Methods: In partnerships with two HMOs, series of outreach methods were used in a stepwise fashion to determine potential barriers and enabling factors for the implementation of chlamydia HEDIS measure in a conservative social environment. Mail outreach was sequentially combined with newspaper, TV, radio advertisements and poster displays. Both qualitative and quantitative impact of the outreach efforts were measured across the timeline. The measures included reporting for chlamydia screening (urine LCR) and infection rate, monitoring chlamydia hotline and staffed phoneline use, and assessment of untoward effects and cost-analysis of the chlamydia outreach campaign.Results: The key findings are: the benefit of chlamydia screening is not understood by general public, letters send by Health Plans to their members are not read by many subscribers, and there are wide gaps between adolescents and their parents, in knowledge, attitudes, beliefs in regard to obtaining information and accessing the screening services (teens prefer hotline, brochure in an envelop addressed to teens, incentives for reporting to the clinic for screening, vs. parents prefer staffed phone consults, "exposed" brochure addressed to parents, and no incentives). A month of sustained and repeat multi-media campaign resulted in 330 hotline calls, 83 phone calls and only 17 subjects being tested (3 were positive) though many more intended to come. Cumulative effects and cost of various outreach efforts are being monitored. Informational chlamydia brochures and free test cards mailed to the homes generated no negative response from the subscribers, contrary to the concerns of the HMOs. Conclusion: To be effective, investment in public education campaign and social marketing strategies must be integrated in population-level intervention for the implementation of the chlamydia HEDIS 2000 measure.

The development and structural confirmation of the Rhode Island Stress and Coping Inventory.

A new measure, the Rhode Island Stress and Coping Inventory (RISCI), was developed to examine perceived stress and coping independent of specific stress situations. An adult sample (N = 466) was randomly divided into equal halves for developmental and confirmatory instrument development. Initial instrument development used principal components analysis, item analysis, and a measure of internal consistency (Coefficient alpha). Confirmatory factor analysis (CFA) was employed on the confirmatory sample to examine the structure of the refined item set. Several CFA fit indices indicated excellent fit for a model that represents perceived stress and coping as two moderately correlated dimensions. Validity analyses found strong relationships in the expected directions for both RISCI subscales with the 5-item Mental Health Inventory. Further validity analyses supported the utility of the RISCI in applied research with smokers and confirmed past research findings that successful quitters experience less perceived stress and cope better than relapsers.

Sexual Assertiveness Scale (SAS) for women: development and validation.

Four studies were conducted to develop and validate the Sexual Assertiveness Scale (SAS), a measure of sexual assertiveness in women that consists of factors measuring initiation, refusal, and pregnancy-sexually transmitted disease prevention assertiveness. A total of 1,613 women from both university and community populations were studied. Confirmatory factor analyses demonstrated that the 3 factors remained stable across samples of university and community women. A structural model was tested in 2 samples, indicating that sexual experience, anticipated negative partner response, and self-efficacy are consistent predictors of sexual assertiveness. Sexual assertiveness was found to be somewhat related to relationship satisfaction, power, and length. The community sample was retested after 6 months and 1 year to establish test-retest reliability. The SAS provides a reliable instrument for assessing and understanding women's sexual assertiveness.

PIP: The construct of sexual assertiveness has potential for codifying the strategies women use to achieve sexual autonomy. The Sexual Assertiveness Scale (SAS) was developed to measure initiation of wanted sexual experience, refusal of unwanted sexual experience, and prevention of pregnancy and sexually transmitted diseases (STDs) with a regular partner. Four independent studies were conducted to establish the stability of the factor structure of the SAS, evaluate the set of predictors of sexual assertiveness, further assess construct validity in a population at high risk of STDs, and test reliability through two follow-ups. A total of 1613 US women from university and community populations were included in the studies. Confirmatory factor analyses indicated that Initiation, Refusal, and Pregnancy/STD Prevention remained stable across samples. Consistent predictors of sexual assertiveness were sexual experience, anticipated negative partner response, a history of sexual victimization as an adolescent or adult, and self-efficacy. Relationship satisfaction, power, and length were moderately related to sexual assertiveness. Finally, test-retest reliability was confirmed. Use of the SAS could facilitate the design of programs to help women to become more able to negotiate condom use, for example.

Condom and other contraceptive use among a random sample of female adolescents: a snapshot in time.

This study examined the sexual practices of 235 females aged 15 to 19 years and their readiness to use specific contraceptive methods for birth control and sexually transmitted disease (STD) prevention. The investigation was based on the stages-of-change construct from the Transtheoretical Model (Prochaska & DiClemente, 1983, 1984). Results demonstrated that despite the availability of newer contraceptive methods (e.g., Depo-Provera), most sexually active adolescents were least resistant to using condoms and were further along in the stages of change for condom use as compared with other contraceptive methods. Moreover, the females perceived the male condom as an acceptable method for prevention of both pregnancy and STDs. These findings suggest that interventions designed to target consistent and correct condom use may result in better compliance, reducing the number of unintended pregnancies and STD cases among this populations.

PIP: The Transtheoretical Model's stages-of-change construct was used to investigate the sexual practices of 235 females 15-19 years of age from New York State (US) and their willingness to use specific contraceptive methods for the prevention of pregnancy and sexually transmitted diseases (STDs). 121 adolescents (52%) had experienced vaginal intercourse and 97 (80%) reported vaginal sex in the 3 months preceding the study. 20 sexually inactive teens (18%) were seriously thinking about initiating sexual activity within the next 6 months. Among teens who had been sexually active in the last 6 months, 64 (66%) had used the male condom and 19 (20%) were taking the pill; another 9 (9%) used no method. Most adolescents were less resistant to condom use than use of other methods and further along in the stages of change. Among the 32 teens who were not currently using condoms consistently, 12 had no intention to use this method with their main partner within the next 6 months (precontemplation), 2 intended to start condom use within the next 6 months (contemplation), and 18 intended to start using condoms in the next 30 days (preparation). The male condom was perceived as effective for both pregnancy and STD prevention. Although the male condom may be less effective than some methods for pregnancy prevention (primarily because of user failure), interventions that target consistent, correct condom use may be most suitable for adolescents.

Pharmacists' readiness for rendering pharmaceutical care.

OBJECTIVE: During the 1970s and 1980s, Prochaska and DiClemente developed the Transtheoretical Model (TTM) of Change to explain, predict, and change multiple human behaviors. This study applied the TTM to measure pharmacists' readiness for rendering pharmaceutical care. It also identified and measured factors that facilitate rendering pharmaceutical care and factors that are barriers, as well as the strength of these factors for each stage of readiness. DESIGN: Data were collected using an instrument developed following the work of Prochaska. Pharmacists completed this survey at the 1996 APhA Annual Meeting & Exposition. RESULTS: The results support the theory behind the TTM; that is, with any behavior change, individuals will fall into several stages of readiness for change, and the vast majority will not be ready to take action within the next six months. Also consistent with the theory, the cons of engaging in a behavior tended to be more salient for individuals in the precontemplation/contemplation stages than for those in the action/maintenance stages. Individuals in administrative positions are more likely to engage in behavior that leads to submitting documentation for compensation. CONCLUSION: Continuing education efforts must address the needs identified in each stage of readiness.

Validation of measures of condom and other contraceptive use among women at high risk for HIV infection and unintended pregnancy.

This study assessed the applicability of the transtheoretical model of behavior change (J.O. Prochaska & C.C. DiClemente, 1983, 1984) to the measurement of contraceptive use among 296 women at high risk for HIV infection and transmission. Structural equation modeling suggested that a measure of general contraceptive use could be used to assess use of oral contraceptives and hormonal implants but that measurement of condom use required separate assessments for main and other partners. Self-efficacy (SE) and decisional balance scales were internally consistent for general contraceptive use, for condom use with main partners, and for condom use with other partners. Consistent with research on other health behaviors, SE scores rose significantly across stages, from precontemplation to maintenance, and a shift in decisional balance was observed for 2 of 3 behaviors. This measurement strategy may enhance the ability to evaluate prevention programs for women at risk.

PIP: The authors assessed the applicability of the transtheoretical model of behavior change to the measurement of contraceptive use among 296 women at high risk for HIV infection and transmission. Data were collected in 1992 from the US Centers for Disease Control's multisite Prevention of HIV in Women and Infants Demonstration Project. In the transtheoretical model, which originated from smoking cessation and psychotherapy research, behavior change is a gradual, continuous, dynamic process in which people move through a sequence of five stages. Structural equation modeling suggested that a measure of general contraceptive use could be used to assess the use of oral contraceptives and hormonal implants, but that measurement of condom use requires separate assessments for main and other partners. Self-efficacy (SE) and decisional balance scales were internally consistent for general contraceptive use, for condom use with main partners, and for condom use with other partners. SE scores rose significantly across stages, from recontemplation to maintenance, and a shift in decisional balance was observed for two of three behaviors. This measurement strategy may enhance the ability to evaluate prevention programs for women at risk.

Contraceptive and condom use adoption and maintenance: a stage paradigm approach.

The Transtheoretical Model of Behavior Change was examined for its applicability to contraceptive and condom use adoption and maintenance using N = 248 heterosexually active college-age men and women. The model posits that individuals do not go directly from old behaviors to new behaviors to new behaviors, but progress through a sequence of stages: precontemplation, contemplation, preparation, action, and maintenance. The stages of change offer a temporal dimension that provides information regarding when a particular shift in attitudes, intentions, and behavior may occur. The model also postulates a set of or outcome variables--the pros and cons of change and self-efficacy. The results demonstrated that individuals were furthest along in the stages of change for general contraceptive use, followed closely by condom use with other (e.g., casual) partners, and then condom use with main partners. Although no sex differences were found for the stages for the three separate contraceptive behaviors, males and females differed on the pros and cons and levels of self-efficacy when engaging in intercourse with the two types of partners. MANOVA/ANOVA results indicated that the relationship between stages and other constructs follows predicted patterns suggesting that the transtheoretical model may provide a useful framework or paradigm for understanding contraceptive and condom use behavior.

PIP: The applicability of the Transtheoretical Model of Behavior Change to contraceptive and condom use adoption and maintenance was assessed in a study of 248 sexually active students (mean age, 18.88 years) at a US university. This model posits that individuals progress through a sequences of five stages in moving from old to new behaviors: precontemplation, contemplation, preparation, action, and maintenance. The pros and cons of change and self-efficacy act as intervening or outcome variables. The present investigation attempted to refine the model further by examining the utility of "intention to change in the next 30 days" combined with the behavioral criterion of currently using contraception and/or condoms "almost every time." Condom use was reported by 39.8% of students with main partners and by 75.3% with casual partners. Study subjects were farthest along in the stages of change for general contraceptive use, followed closely by condom use with casual partners, and then condom use with main partners. Those in the precontemplation stage evaluated the cons of contraceptive use as higher than the pros, but a crossover of the pros and cons occurred sometime before the action stage. Similarly, perceived self-efficacy was lowest in the precontemplation stage, but increased with movement along the continuum of change. These findings suggest that programs that seek to reduce high-risk behaviors should be tailored to individuals' particular stage of change.

Assessing the stages of change and decision-making for contraceptive use for the prevention of pregnancy, sexually transmitted diseases, and acquired immunodeficiency syndrome.

A synergistic approach was taken to examine contraceptive use adoption for two related behaviors: pregnancy prevention and the prevention of sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS). One hundred twenty-three young adults responded to questionnaire items based on two constructs from the Trans-theoretical Model of Change, the Stages of Change and Decisional Balance, as well as other pertinent variables. In Phase 1, two Decisional Balance measures were developed: One for the prevention of pregnancy and one for disease prevention. Final versions of both measures consisted of two 10-item scales: one representing the positive aspects (PROS) and one representing the negative aspects (CONS) of contraceptive and condom use. In Phase 2, the same individuals were staged for both pregnancy and disease prevention according to their readiness to change for contraceptive and condom use. MANOVAs and ANOVAs indicated that the PROS and CONS for both measures were related to stage of change for both contraceptive and condom use. Results from this pilot study were consistent with prior applications of the Trans-theoretical Model to the cessation of such problem behaviors as smoking and to the adoption of positive health behaviors such as exercise acquisition.

PIP: The authors adopted a synergistic approach to explore the adoption of contraceptive use for the prevention of pregnancy and the transmission and contraction of sexually transmitted diseases (STD). 123 students from a freshman level psychology course at a northeastern university were sampled via questionnaire in 1992. Questionnaire items were based upon 2 constructs from the Transtheoretical Model of Change, Stages of Change and Decisional Balance, and other pertinent variables. Subjects were of average age 19.87 years in a range of 18-25; 62% were female; 95% were Whites; and 99% reported being heterosexual. 87% had engaged in oral and vaginal intercourse, and 14% had experienced anal intercourse. 39% reported having 5 or more sex partners since becoming sexually active. 17% reported to be currently having vaginal intercourse with someone in addition to their main or steady sex partner; 10% had been diagnosed with an STD at one time; and 14% stated that a pregnancy had occurred in one of their relationships. 2 Decisional Balance measures were developed in phase 1. In phase 2, the subjects were staged for pregnancy and disease prevention according to their readiness to change for contraceptive and condom use. It was found that the pros and cons for both measures were related to stage of change for both contraceptive and condom use.