Psychosocial factors associated with the stages of change for condom use among women at risk for HIV and STDs: implications for intervention development

Associations between gender norms and HIV self-efficacy among Latina immigrants in a farmworker community

Latina immigrant farmworkers are a vulnerable and understudied population that face a host of socio-cultural and structural barriers that place them at risk for HIV infection. Cultural factors, including traditional gender roles (egalitarian and marianismo) that frequently inhibit communication between partners and promote rigid roles, may particularly affect self-efficacy for HIV prevention among this population.Objective: This study examines the impact of women's gender norms on HIV knowledge and safe sex negotiation skills, along with the moderating influence of HIV self-efficacy among Latina immigrants in a farmworker community.Design: The current cross-sectional analysis study examines data from a sample (N = 157) of mostly undocumented Latina immigrant farmworkers in South Miami-Dade County, Florida. Analysis was performed on secondary data obtained from baseline collected on an intervention pilot study. Measures of traditional American (egalitarian) and Latina (marianismo) gender norms, HIV self-efficacy, and HIV knowledge, as well as key demographic variables were collected.Results: Findings revealed higher American (egalitarian) gender norms directly and indirectly predict higher HIV prevention factors. Additionally, HIV self-efficacy did not mediate effects of marianismo on HIV risk.Conclusion: Findings conclude that HIV prevention can be especially challenging due to socio-cultural and traditional gender norms faced by Latinas in farm working communities and that such norms should be taken into account when developing and adapting culturally appropriate interventions to reduce HIV related risk behaviors for Latinas residing in urban or farm working communities.

Condom use attitude and self-efficacy, and STIs risk perception among Iranian female sex workers: A psychometric study

In this cross-sectional study, we aimed to investigate psychometric properties of the Persian versions of condom use self-efficacy (CUSES), attitude toward condom use (ATCUS), and sexually transmitted infection risk perception (STIsRP) scales among Iranian female sex workers (FSWs). We translated original versions of the scales into Persian, and through census, recruited and interviewed 140 FSWs. Appropriate validity, reliability, functionality and simplicity were demonstrated for the scales. We found the measurement model with a good fit to the data (χ² [104] = 89.537, p < .01, CFI = 0.978, NFI = 0.931, TLI = 0.981, RMSEA = 0.055 [0.023-0.081]). Our findings supported the applicability of the Persian CUSES, ATCUS, and STIsRP in the Iranian and other Persian-speaking FSW populations.

Sexual Health Behavior and Mental Health Among Older African American Women: The Sistahs, Sexuality, and Mental Health Well-Being Project

BACKGROUND

In Los Angeles County, the rates of sexually transmitted infections and diseases among African Americans represent a significant public health disparity. Older African American women are at particular risk as they are more likely to engage in high-risk sexual behaviors and report social isolation and loneliness than their younger counterparts. However, the literature on the relationship between sexual health and mental health in this group is limited. The purpose of this study was to use a community-based participatory research (CBPR) approach to better understand sexual health behaviors and mental health among African American women over 50 years of age who reside in South Los Angeles.

MATERIALS AND METHODS

This project was divided into two phases. Phase I (January-March 2017) of the project consisted of four dialog/focus groups (N = 45) (ages: 50-80; M_age = 67). The purpose of Phase II (April 2017) was to present study results from Phase I to the community via a community-based conference, as well as gather feedback and generate discussion about the next steps for community prevention/intervention.

RESULTS

Women reported that they did not feel comfortable discussing sexual practices with their physician, partners, and friends. Most women identified depression, loneliness, and self-esteem issues as reasons for engaging in high-risk sexual behaviors. During Phase II, potential intervention avenues emerged to address issues such as lack of physician-patient communication, lack of community support, and dialogs about sex.

CONCLUSIONS

The use of CBPR greatly enhanced our knowledge of the core issues surrounding sexual health and mental health among older African American women.

Predictors of Men’s Acceptance of Modern Contraceptive Practice: Study in Rural Vietnam

Studies have shown family planning adoption is likely to be more effective for women when men are actively involved. The transtheoretical model of behavior change was used to examine men’s involvement in general contraception and intrauterine device (IUD) use by their wives. The study was carried out in rural Vietnam with 651 eligible participants. Cons of IUD use for men in precontemplation and contemplation/preparation were significantly higher than those in the action/maintenance stages, whereas the reverse was true for pros of IUD. The self-efficacy for convincing wife to have IUD in precontemplation was significantly lower than for those in higher stages. Women’s education and ages, spontaneous recall of modern contraceptive method, cons for IUD, and self-efficacy for contraception and for convincing wives to get IUD inserted (or continue use) were significant predictors of men’s readiness to accept IUD. Interventions are targeted to reduce cons and increase self-efficacy for IUD use.

Male involvement in family planning program in Northern Ethiopia: an application of the Transtheoretical model

OBJECTIVE

The objective of this study is to use the Transtheoretical behavioral model to assess male involvement in family planning.

METHODS

A cross-sectional study was conducted in Angolela-Tera District of Amhara Region from February 15 to March 14, 2008 on married men. Multi-stage sampling technique was employed to select the 770 study participants. The relationship of stage of change and decisional balance, self-efficacy and processes of change was assessed by ANOVA tests.

RESULTS

225(30.5%) of the men were in the Precontemplation stage, 235(31.8%) were in the contemplation stage, 81(11.0%) were in preparation, 76(10.3%) were in action stage, and, 121(16.4%), were in the maintenance stage. Confidence increased across the stages while experiential and behavioral processes increased in the early stages and then decreased at a transition from action to maintenance stage. The pros were increased across the stages, the cons decreased and a crossover occurred prior to contemplation stage.

CONCLUSION

The findings suggest that counselors need to understand that behavior change is a process that occurs in a series of stages and therefore can facilitate behavioral changes with various strategies. Health educators need to develop educational components that match stages of change.

PRACTICAL IMPLICATIONS

Based on our results, programs aimed at promoting contraceptive prevalence for contraception should seek ways and means for increasing the pros and for increasing self-efficacy.

The effects of alcohol, relationship power, and partner type on perceived difficulty implementing condom use among African American adults: an experimental study

African American adults are disproportionately affected by HIV in the United States, underscoring the need for additional research on barriers to condom use. Guided by the theory of gender and power, this experimental study used a series of vignettes to test causal hypotheses regarding the influence of event-level alcohol use (present and absent), partner type (serious and casual), and relationship power (low and equal) on perceived difficulty implementing condom use. A total of 299 (151 women and 148 men) heterosexual African American adults indicated how "difficult" it would be to use a condom after reading 8 hypothetical sexual encounters, presented in a random order. A 2 × 2 × 2 × 2 repeated measures analysis of covariance with one between subjects factor (gender) and one covariate (condom use self-efficacy) was used to estimate the effects of these variables on an index of perceived difficulty. The women in the study reported significantly higher ratings of difficulty implementing condom use in vignettes characterized by low relationship power (p < .001) and presence of alcohol use (p < .001); the manipulated independent variables did not produce any main effects for men. Both men and women's ratings of perceived difficulty decreased as condom use self-efficacy increased (p < .001). This is the first study to use an experimental methodology to test hypotheses about barriers to condom use among a community-based sample of African American adults. These data can be used to enhance existing HIV prevention interventions.

Adolescent intimate heterosexual relationships: measurement issues

During adolescence, individuals develop increased ability to have emotionally and physically intimate relationships. The type of intimate relationship will make a difference as to whether the adolescent engages in protective behaviors or avoids risky behaviors. However, in reviewing the literature on the association of relationship type and sexual risk and protective behaviors, four methodological challenges were noted. These challenges limit our understanding of the impact of relationship type. These four challenges are: (a) inconsistent definitional frameworks; (b) lack of adolescent voices; (c) lack of consideration of gender; and (d) poor differentiation between individual and relationship risk. These issues direct the course of future work in this area and are necessary to advance the field of adolescent sexual health, particularly with regard to the development and testing of appropriate interventions designed to reduce untoward outcomes of adolescent sexuality.

The Transtheoretical Model and Study Skills

There is empirical support for the transtheoretical model (TTM) of change within the health and psychopathology-related areas, but relatively little research into its applicability in relation to academic settings. The aim of the study was to investigate whether the TTM is applicable to the adoption of improved study skills. Participants were 148 first-year university students. A 2-factor (pros and cons) study-related decisional balance measure was developed and participants completed questionaries assessing their readiness to change, self-efficacy, study strategies and decisional balance. Decisional balance pros and cons were as predicted by the TTM. Cons were higher than pros in precontemplation and pros were higher than cons in maintenance. Self-efficacy increased from contemplation through to maintenance, and students in action and maintenance showed an increase in the use of deep achieving study strategies and a decrease in the use of surface strategies. The data provides initial support for the applicability of the TTM to academic performance enhancement. The TTM may be a useful psycho-educational tool that can facilitate the adoption of improved study strategies through coaching.

Predictors of self-efficacy to use condoms among seropositive middle-aged African American men

Condom use during sexual encounters continues to be a challenge for seropositive individuals. Hence, the influence of personal characteristics, AIDS knowledge, and religious well-being on perceived self-efficacy to use condoms has been examined in a convenience nonprobabilistic sample of 130 middle-aged seropositive African American men from the Mid-Atlantic region. AIDS knowledge and religious well-being are strongly related to self-efficacy to use condoms. These findings indicate that it is critical to explore further the relationship of AIDS knowledge and religious well-being with self-efficacy to use condoms.

Stages of consistent condom use, partner intimacy, condom use attitude, and self-efficacy in African-American crack cocaine users

This study examined how condom use attitude, self-efficacy, and partner intimacy related to five stages of consistent condom use. Interview data were collected from sexually active, heterosexual, African-American crack cocaine smokers (N = 366). Dependent measures assessed both the participants' own responses and their perceptions about their last sex partner's own personal condom use attitude and participants' condom use self-efficacy expectations. Partner intimacy was assessed both as a continuous attitudinal and as a discrete relationship measure. Less than 10% were classified as consistent condom users. Two thirds of inconsistent users were in the Precontemplation (PC) stage. The contemplation (C) and preparation (P) stages were equal among the remainder of the inconsistent condom users. Higher partner intimacy reduced modestly readiness for consistent condom use. The stage but not the intimacy group was related to the condom use attitudes and self-efficacy measures. Last partners' perceived own negative attitudes were significantly related to the stages of consistent condom use and was especially low in the action (A) and maintenance (M) stages. Participants' own negative attitudes were unrelated to the stages. Of the self-efficacy measures, both participants' performance and situational condom use self-efficacies increased significantly after the PC stage and were highest in the P, A, and M stages. However, situational self-efficacy accounted for most of performance self-efficacy variance. In sum, consistent condom use was rare. A partner's attitudes and the participants' own situational self-efficacy expectations, rather than intimacy, determined the readiness to adopt consistent condom use.

Predicting and explaining transtheoretical model stage transitions in relation to condom-carrying behaviour

OBJECTIVES

The stages of change component of the transtheoretical model have been applied to safe sex behaviours in cross-sectional analyses, but have not yet been subject to prospective analysis. It was predicted that: (a) cross-sectional analyses would demonstrate good discrimination between the stages of change; (b) prospective analyses would allow for the identification of predictors of stage transitions; and (c) implementation intentions would explain progression from the preparation stage.

DESIGN

This study employed an experimental longitudinal design. Participants were randomly assigned to the experimental (implementation intention) or control conditions and completed questionnaires at baseline and at 2-month follow-up.

METHODS

Five hundred and twenty-five adolescents who were broadly representative of the UK population completed questionnaires at baseline and follow-up (N=393) measuring: demographic variables; stage of change; theory of planned behaviour constructs; anticipated regret; and moral norm in relation to condom-carrying behaviour. The experimental condition completed a self-generated implementation intention to carry condoms at the end of the baseline questionnaire.

RESULTS

Discriminant function analyses indicated that the stages of change could be accurately discriminated from one another cross-sectionally and that, longitudinally, the measured variables were able to predict transitions between most stages. Implementation intentions caused people to progress from the preparation stage.

CONCLUSIONS

Transitions between most stages were reliably predicted, thereby providing potential targets for intervention. The brief implementation intention intervention was effective and could easily be utilized and expanded to encompass a broader range of sexual health behaviours.

Adolescent sexual risk: factors predicting condom use across the stages of change

This study examined factors associated with high-risk adolescents' movement toward or away from adopting consistent condom use behavior using the Transtheoretical Model Stages of Change. Participants drawn from the inactive comparison condition of a randomized HIV prevention trial (Project SHIELD) responded to items assessing pros and cons of condom use, peer norms, condom communication, and perceived invulnerability to HIV. Participants were categorized based on their condom use behavior using the Transtheoretical Model. Multiple logistic regressions found that progression to consistent condom use was predicted by continuing to perceive more advantages to condom use, reporting greater condom use communication with partners, and less perceived invulnerability to HIV. Movement away from adopting consistent condom use was predicted by a decrease in perceived advantages to condom use, increased perceived condom disadvantages, and fewer condom discussions. Future interventions may be tailored to enhance these factors that were found to change over time.

Effects of a health behavior change model--based HIV/STI prevention intervention on condom use among heterosexual couples: a randomized trial

This study examines an intervention for heterosexual couples to prevent human immunodeficiency virus/sexually transmitted infections. It also evaluates the effect of the intervention, which is based on current models of health behavior change, on intermediate outcomes (individual and relationship factors) and consistency of condom use. Eligible couples were administered a baseline interview and randomized to either a 3-session theory-based intervention or a 1-session standard of care comparison condition. Men and women completed 3-month interviews; only women completed 6-month interviews. No significant intervention effect on condom use was found among couples at 3 months (n = 212) or among women (n = 178) at 6 months. However, condom use increased significantly between baseline and 3 months and baseline and 6 months for participants in both treatment conditions. Intervention effects on condom use self-efficacy were found at 3 months and 6 months and on health-protective communication at 3 months. These findings provide valuable information for the design of future studies to help disentangle the effects of intervening with couples.

Application of the Transtheoretical Model to Identify Aspects Influencing Condom Use Among Korean College Students

Increasing condom use requires an understanding of the influencing factors. Previous research has used psychosocial theories such as the social cognitive theory and health belief to explain AIDS risk factors and condom use. However, it is still difficult to effectively predict the multidimensional factors associated with condom use. The present study utilizes the transtheoretical model to investigate condom use among college students by examining stages of change for condom use and measuring decisional balance and self-efficacy for each stage. The aim was to identify the variables affecting condom use so as to provide scientific data that would aid the development of effective strategies for increasing condom use.

Meta-analytic examination of the strong and weak principles across 48 health behaviors

OBJECTIVE

The strong and weak principles of change state that progress from the precontemplation to the action stage of change is associated with a one standard deviation increase in the pros and a one-half standard deviation decrease in the cons of change. In this study these relationships, originally developed by Prochaska [Prochaska, J.O., 1994. Strong and weak principles for progressing from precontemplation to action on the basis of 12 problem behaviors. Health Psychology, 13, 47-51] based on an examination of 12 studies of 12 different behaviors, were re-examined using many more datasets and much more rigorous statistical methods.

METHODS

The current study analyzes 120 datasets from studies conducted between 1984 and 2003 across and within 48 health behaviors, including nearly 50,000 participants from 10 countries. The datasets were primarily analyzed utilizing meta-analytic techniques.

RESULTS

Despite the range of behaviors and populations, the results were remarkably consistent with the original results (pros=1.00 standard deviation, cons=0.56 standard deviation). Few potential moderators showed any impact on effect size distributions.

CONCLUSIONS

This updated and enhanced examination of two important principles of behavior change is a significant contribution to the field of multiple health risk behaviors, as it clearly demonstrates the consistency of the theoretical principles across multiple behaviors, which has implications for developing multiple health risk behavior interventions.

Desenvolvimento de um jogo terapêutico para prevenção da recaída e motivação para mudança em jovens usuários de drogas

Apesar da alta prevalência do abuso, e dependência de drogas entre jovens, existe uma falta de intervenções originais desenvolvidas especificamente para o tratamento dessa população. Este estudo objetivou desenvolver uma técnica no formato de um jogo de cartas para ser utilizado no tratamento de jovens usuários de drogas. A técnica foi intitulada "Jogo da Escolha", e a sua elaboração envolveu: adaptação da linguagem, avaliação do conteúdo e elaboração de suas instruções junto aos profissionais de dependência química. Após um estudo-piloto, foram realizadas modificações nas instruções e no formato de aplicação, obtendo-se a versão atual do "Jogo da Escolha". O jogo demonstra ser útil para trabalhar crenças típicas de jovens usuários de drogas e promover estratégias de enfrentamento em situações de risco.

Contraceptive use patterns across teens' sexual relationships: the role of relationships, partners, and sexual histories

By using data from the National Longitudinal Study of Adolescent Health, we examine how adolescent relationship characteristics, partner attributes, and sexual relationship histories are associated with contraceptive use and consistency, incorporating random effects to control for respondent-level unobserved heterogeneity. Analyses show that teens' contraceptive use patterns vary across relationships. Teens with more-homogamous partners, with more-intimate relationships, and who communicate about contraception before sex have greater odds of contraceptive use and/or consistency. Teens in romantic relationships, and who are older when engaging in sex for the first time, have greater odds of ever using contraceptives but reduced odds of always using contraceptives. Teens continue habits from previous relationships: teens with experience practicing contraceptive consistency and females who previously have used hormonal contraceptive methods are better able to maintain consistency in subsequent relationships. Also, relationship and partner characteristics are less important for females who previously used hormonal methods.

Relative efficacy of a multisession sexual risk-reduction intervention for young men released from prisons in 4 states

OBJECTIVES

We compared the effects of an enhanced multisession intervention with a single-session intervention on the sexual risk behavior of young men released from prison.

METHODS

Young men, aged 18 to 29 years, were recruited from US prisons in 4 states and systematically assigned to the prerelease single-session intervention or the pre- and postrelease enhanced intervention. Both interventions addressed HIV, hepatitis, and other sexually transmitted infections; the enhanced intervention also addressed community reentry needs (e.g., housing, employment). Assessment data were collected before intervention, and 1, 12, and 24 weeks after release.

RESULTS

A total of 522 men were included in intent-to-treat analyses. Follow-up rates ranged from 76% to 87%. Unprotected vaginal or anal sex during the 90 days before incarceration was reported by 86% of men in the enhanced intervention and 89% in the single-session intervention (OR=0.78; 95% CI=0.46, 1.32). At 24 weeks, 68% of men assigned to the enhanced intervention reported unprotected vaginal or anal sex compared with 78% of those assigned to the single-session intervention (OR=0.40; 95% CI=0.18, 0.88).

CONCLUSION

Project START demonstrated the efficacy of a sexual risk-reduction intervention that bridges incarceration and community reentry.

Correlates of Sexual Abstinence Among Adolescent Virgins Dating Steady Boyfriends in Taiwan

PURPOSES

(a) To examine the relations among processes of change, decisional balance, self-efficacy, perceptions of personal power, and relationship power to stage of change (SOC) for sexual abstinence behavior, and (b) to identify the important explanatory factors of SOC for sexual abstinence among adolescent virgins who were dating steady boyfriends.

DESIGN

A cross-sectional survey. Female adolescents (N=500) who were dating steady boyfriends and had not had sexual experience in the past were selected.

METHODS

An anonymous, self-administered questionnaire was used with parts concerning: age, processes of change for sexual abstinence, decisional balance for sexual abstinence, self-efficacy for sexual abstinence, perceptions of personal power, perceptions of relationship power, and SOC for sexual abstinence.

FINDINGS

Processes of change, decisional balance, self-efficacy, perceptions of personal power, and relationship power differed across the SOC for sexual abstinence. Stepwise logistic regression showed higher self-efficacy for sexual abstinence, higher decisional balance for sexual abstinence, and lower age increased the probability of being in the definite group (preparation and action stage). In the final regression model 77.3 % of the participants were correctly classified.

CONCLUSIONS

This information about SOC for sexual abstinence can be used by health professionals for intervention strategies for adolescent girls who were dating steady boyfriends.

Evidence that implementation intentions promote transitions between the stages of change

A dietary change intervention based on Gollwitzer's (1993) concept of implementation intentions was used to see whether transitions between transtheoretical model stages could be induced in a field experiment. Participants (N=554) were randomized to receive either questionnaire-only or questionnaire-plus-implementation intention. Results showed that, controlling for variables from the theory of planned behavior, implementation intentions helped a significantly greater number of people to progress through the stages of change than did receiving the questionnaire alone. However, the implementation intention intervention did not prevent regression from the stages of change. The discussion focuses on the importance of targeting implementation intention interventions and on the future use of health professional-led analyses of critical situations and precise identification of appropriate responses to prevent regression.

Increasing male involvement in family planning decision making: trial of a social-cognitive intervention in rural Vietnam

We tested a social-cognitive intervention to influence contraceptive practices among men living in rural communes in Vietnam. It was predicted that participants who received a stage-targeted program based on the Transtheoretical Model (TTM) would report positive movement in their stage of motivational readiness for their wife to use an intrauterine device (IUD) compared to those in a control condition. A quasi-experimental design was used, where the primary unit for allocation was villages. Villages were allocated randomly to a control condition or to two rounds of intervention with stage-targeted letters and interpersonal counseling. There were 651 eligible married men in the 12 villages chosen. A significant positive movement in men's stage of readiness for IUD use by their wife occurred in the intervention group, with a decrease in the proportions in the precontemplation stage from 28.6 to 20.2% and an increase in action/maintenance from 59.8 to 74.4% (P < 0.05). There were no significant changes in the control group. Compared to the control group, the intervention group showed higher pros, lower cons and higher self-efficacy for IUD use by their wife as a contraceptive method (P < 0.05). Interventions based on social-cognitive theory can increase men's involvement in IUD use in rural Vietnam and should assist in reducing future rates of unwanted pregnancy.

Applying a transtheoretical behavioral change model to HIV/STD and pregnancy prevention in adolescent clinics

PURPOSE

To evaluate the application of a transtheoretical model (TTM) of behavioral change to adolescent reproductive health counseling.

METHODS

Family planning counselors in Boston Metro school-based and community health centers used a TTM for pregnancy and human immunodeficiency virus/sexually transmitted disease (HIV/STD) prevention. Data were collected from September 2000 through December 2001. Bivariate analyses using chi-square statistics and multivariate analyses using logistic regression were performed to identify the differences between stage of change (SOC) groups and the predictive variables for SOC movement.

RESULTS

Data on 539 sexually experienced clients were examined. Site, client's gender, race, proximity of sexual activity, sexual partner status, level of partner support, and target behavior were significantly associated with initial SOC for both pregnancy and disease prevention (p < .01). For clients meeting stage movement analysis criteria (n = 86 for pregnancy prevention; 128 for disease prevention), there was suggestive evidence that older ones were more likely to move forward for both pregnancy and disease prevention (p = .08 and p = .07, respectively) between their first and second visits. For disease prevention, those initially in the precontemplation/contemplation stages were more likely than those in the action/maintenance stages to be forward movers (odds ratio = 3.89, p = .06). Counselors/supervisors reported that the TTM helped structure an integrated message and increased client engagement.

CONCLUSIONS

Efforts to prevent teen pregnancy and HIV/STDs should acknowledge the roles of partner support and age in SOC. Adolescents in preparation may need specific skill-building for behavioral change. Overall, TTM represents a promising approach to promoting integrated pregnancy and disease prevention in family planning counseling.

Determinants of condom use stage of change among heterosexually-identified methamphetamine users

There is a paucity of research on the association between methamphetamine use (meth) and sexual risk behavior among heterosexual meth users. This study used a multiple theories approach to identify factors associated with stage of change for condom use in a sample of 181 HIV-negative, heterosexually identified meth users. Background characteristics, drug use variables, and theoretical mechanism of change variables were examined in relation to Prochaska's contemplative and preparation stages of change. Sexual risk behavior was highest among those in the contemplation stage of change. When compared with those in the preparation stage of change, contemplators were more likely to be never married, more likely to have an STD, consumed larger amounts of meth and other illicit drugs, had lower scores on self-efficacy and outcome expectancies for condom use and negotiation of safer sex practices, and had less positive social norms in relation to AIDS preventive behaviors. A multivariate logistic regression revealed that the preparation stage of change was associated with increased self-efficacy for condom use, stronger social norms regarding condom use, and reduced occurrence of sexually transmitted diseases. The findings are discussed in relation to the development of sexual risk reduction interventions for heterosexual meth users.

Predictors of Condom-Related Attitudes among At-Risk Women

BACKGROUND

Negative attitudes toward using male condoms tend to be associated with higher rates of sexual risk. Little has been written about the factors that influence women's attitudes toward condom use, and this has implications for HIV intervention efforts.

METHODS

Two hundred fifty adult women considered to be at risk based on demographic and family characteristics and residing in the Atlanta, Georgia, metropolitan area were interviewed between August 1997 and August 2000. Street outreach efforts were used to identify potential study participants, with further expansion of the sample done via targeted sampling and ethnographic mapping procedures.

RESULTS

Women held ambivalent to weakly positive attitudes toward condoms. Multivariate analysis revealed that five factors were associated with a greater frequency of engaging in seven specific types of sexual activities known to be associated with HIV transmission: condom-related attitudes (negative condom attitudes), marital status (being married vs. other marital status classification), religiosity (lesser), childhood physical abuse (greater), and the amount of illegal drug use (greater). Four significant predictors of condom attitudes were also identified: age (better condom attitudes among younger women), childhood neglect (more conductive condom attitudes among nonneglected women), self-esteem (more self-esteem = more favorable condom attitudes), and the number of drug problems experienced (more drug problems = more negative condom attitudes).

CONCLUSIONS

The more negative at-risk women's attitudes were regarding condom use, the more often they tended to engage in risky sex. Specific backgrounds and characteristics of the women were associated with greater/lesser condom use. To increase condom use, programs should consider targeting specific types of women as well as their specific attitudes toward condom use.

"At risk" women who think that they have no chance of getting HIV: self-assessed perceived risks

During the past two decades, a fair amount of inconclusive research has been conducted to examine the relationship between perceived risk of contracting HIV and actual HIV risk behavior practices. The present study examines HIV risk perceptions among a sample of 250 urban, economically-disadvantaged, primarily minority women. In particular, we focus on differences between those saying that they have no chance whatsoever of contracting HIV and those who indicated at least some possibility of becoming HIV-infected. Three research questions are addressed: (1) Are there differences between these groups attributable to their risk behavior practices? (2) To what extent do women who think that they are not at risk for HIV engage in risky behaviors that could expose them to HIV? (3) What are the most salient predictors of the women's perceived risk classification? Results showed that women perceiving themselves to have at least some HIV risk engaged in higher rates of risky behaviors than their counterparts who perceived themselves to have no possibility of contracting HIV. Despite this finding, more than one-half of the "no perceived risk of HIV" sample had engaged in at least one risky practice during the preceding year and more than one-quarter had engaged in at least two such behaviors. Age, childhood maltreatment experiences, self-esteem, number of HIV risk behaviors practiced, amount of illegal drug use reported, and number of times having sex were significant predictors of women's perception of having some HIV risk versus having no HIV risk.

HIV prevention with jail and prison inmates: Maryland's Prevention Case Management program

Prevalence of HIV infection and AIDS cases is higher among inmates of correctional facilities than among the general population, especially for female inmates. This creates a strong need for effective HIV prevention with this population. Maryland's Prevention Case Management (PCM) program provides individual or group counseling to inmates nearing release to promote changes in risk behavior. Pretest and posttest surveys assess changes in perceived risk, condom attitudes, condom use self-efficacy, self-efficacy to reduce injection drug risk and other substance use risk, and behavioral intentions during participation in the program. Client contact logs, kept by counselors, document the number and duration of sessions, and the specific modules, completed by participants. Over a 4-year period, PCM records identified 2,610 participants in the program. Pre-intervention and postintervention data were available for 745 participants, with client contact log records available for 529 (71%) of these individuals. Significant, positive changes were found in self-reported condom attitudes, self-efficacy for condom use, self-efficacy for injection drug use risk, self-efficacy for other substance use risk, and intentions to practice safer sex post-release. Inmate populations are a crucial audience for HIV/AIDS testing, treatment, and prevention efforts. The Maryland PCM program has documented positive changes in participants' attitudes, self-efficacy, and intentions related to HIV risk, over a 4-year period.

Factors associated with condom use among at-risk women students and nonstudents seen in managed care

OBJECTIVES

Sexually transmitted diseases (STD) research has focused on high-risk populations such as STD clinic patients and college students. This report examines predictors of unprotected sex among nonstudent women seen in primary care.

STUDY DESIGN

Data are taken from the baseline survey of an intervention trial testing tailored print materials to encourage condom use.

POPULATION

Eligible women were identified from automated databases of two managed care organizations and were ages 18-25, unmarried, heterosexually active in the prior 6 months, and not in a long-term monogamous relationship.

OUTCOMES

The frequency of and relative contribution of risk behaviors to occurrences of unprotected vaginal sex were compared among non-full-time students (n=711) and full-time students (n=390).

RESULTS

STD risk behaviors were prevalent and had similar associations with unprotected sex in both subsamples. Older age, using hormonal or no usual contraception, and having a "primary" partner increased unprotected sex; partner approval of condoms and having bought or carried condoms decreased unprotected sex.

CONCLUSION

While sexually active single women seen in primary care perceive themselves at low STD risk, their risk profiles are similar to those of higher risk populations. Clinic-based interventions that include proactive identification of at-risk women and systems for encouraging safer sex practices are needed.

Applying the transtheoretical model to pregnancy and STD prevention: a review of the literature

PURPOSE

To conduct a systematic review of the peer-reviewed literature on the Transtheoretical Model (TTM) and pregnancy and STD prevention.

DATA SOURCES

Computer database search (Applied Social Science Index and Abstracts [ASSIA], Biological Abstracts, Criminal Justice Abstracts, CINAHL-Allied Health, Current Contents, Current Index to Journals in Education, Education Index, ERIC, Excerpta Medica, Family Index, Index Medicus, Medline, Multicultural Education Abstracts, PsychInfo, Psychological Abstracts, Research Alert, Social Science Citation Index, Social Work Abstracts, and Sociological Abstracts), and manual journal search.

STUDY INCLUSION AND EXCLUSION CRITERIA

All English, peer-reviewed, original articles on the TTM as it relates to pregnancy and STD prevention published prior to December 31, 2001, were included. Editorials, commentaries, thesis/dissertations, unpublished studies, technical reports, and books were not included.

DATA EXTRACTION METHODS

Articles were categorized as Intervention, Population (stage distribution), or Validation studies. Within each category, articles were subdivided into groups, summarized, and analyzed.

DATA SYNTHESIS

The 32 articles reviewed included 9 intervention studies, 11 population studies, and 12 validation studies. Studies represented a variety of U.S. populations of a broad demographic range. Evidence both for and against criterion-related and construct validity of the TTM was found.

MAJOR CONCLUSIONS

Age, partner type, gender, reasons for engaging in safer sex behaviors (i.e., pregnancy vs. disease prevention), self-efficacy, sexual assertiveness, and perceived advantages and disadvantages of condom use were related to stage of change. The use of the TTM to reduce risk of pregnancy and STDs is a relatively new, but important, area of research. However, because of the wide-ranging differences in methodologies and samples, no strong conclusions about its effectiveness can yet be made.

HIV sexual risk-reduction interventions for youth: a review and methodological critique of randomized controlled trials

The authors review and provide a methodological critique of randomized controlled studies of HIV risk reduction interventions that measured sexual risk behavior outcomes with adolescents. Studies conducted in school, community, and health care settings were reviewed. Overall, 13 of 23 interventions (57%) were effective in reducing sexual risk behavior. Methodological strengths of extant studies included an emphasis on a theoretical framework, evaluation of both individualized and group-intervention formats, use of multiple assessments of risk behavior (including biological outcomes), and inclusion of efficacy and effectiveness trials. Methodological limitations included limited evaluation of theoretical mediators of risk reduction, failure to report effect sizes, and lack of sustained findings. Inconsistencies were found in data analytic procedures and reporting, including how nested designs, skewed data, and attrition were addressed. Recommendations for designing methodologically rigorous interventions are provided.

Intention to use condoms among three low-income, urban African American subgroups: cocaine users, noncocaine drug users, and non-drug users

Cocaine use, marijuana use, alcohol use, and polysubstance use (e.g., alcohol and cocaine, alcohol and marijuana) are associated with high-risk sexual behavior and higher rates of sexually transmitted diseases (STDs) and human immunodeficiency virus (HIV). The purpose of this study was to examine readiness for using condoms among three groups (cocaine users, noncocaine drug users, and non-drug users) of African Americans living in low-income urban settings. African Americans in this sample differed in sex risk behaviors according to their drug use status. Noncocaine drug users reported higher levels of sex risk behaviors than non-drug users, and cocaine users reported the highest levels of risk. Cocaine users also reported lower levels of condom use with their main and nonmain sexual partners than both other groups. Results of multivariate analyses indicate that, compared to the other two groups, cocaine users are at earlier stages of readiness for condom use with main partners. Cocaine users have accurate perceptions of their HIV risk, but are more likely to factor into their decisions for using condoms cost and the trouble that it takes to get condoms. Different approaches to sexually transmitted disease and human immunodeficiency virus prevention will be necessary to meet the needs of these three different subgroups.

Modeling condom-use stage of change in low-income, single, urban women

This study was undertaken to identify and test a model of the cognitive antecedents to condom use stage of change in low-income, single, urban women. A convenience sample of 537 women (M=30 years old) attending two urban primary health care settings in western New York State anonymously completed questionnaires based primarily on two leading social-cognitive models, the transtheoretical model and the information-motivation-behavioral skills model. We used structural equation modeling to examine the direct and indirect effects of HIV-related knowledge, social norms of discussing HIV risk and prevention, familiarity with HIV-infected persons, general readiness to change sexual behaviors, perceived vulnerability to HIV, and pros and cons of condom use on condom-use stage of change. The results indicated two models that differ by partner type. Condom-use stage of change in women with steady main partners was influenced most by social norms and the pros of condom use. Condom-use stage of change in women with "other" types (multiple, casual, or new) of sexual partners was influenced by HIV-related knowledge, general readiness to change sexual behaviors, and the pros of condom use. These findings suggest implications for developing gender-relevant HIV-prevention interventions.

Crack smokers' intention to use condoms with loved partners: intervention development using the theory of reasoned action, condom beliefs, and processes of change

Prevalence rates of HIV infection acquired through heterosexual contacts have risen steadily since 1982. Crack cocaine smokers are at particular risk of HIV infection due to heterosexual exposure. HIV risk reduction interventions seeking to increase condom use among drug users have met with minimal success, and there is a need for interventions to be strongly grounded in psychosocial models of behaviour change. This study presents the results of an investigation of predictors of intention to use condoms and related therapy processes among heterosexual drug users. Data were analyzed from 586 crack smokers recruited in Washington, DC, Miami, Florida, and Collier County, Florida who reported having both primary and casual sex partners. Participants responded to items derived from the theory of reasoned action, the theory of planned behaviour and the transtheoretical model of change. Condom use beliefs and therapy processes used to initiate and maintain condom use were assessed. Outcome expectancies and normative beliefs were the strongest predictors of intention to use condoms with a primary sexual partner. In turn, beliefs that condoms inhibit sexual romance and decrease sexual pleasure strongly predicted outcome expectancies. Therapy processes found to be associated with these constructs included: self-liberation, counter conditioning and stimulus control/reinforcement. Results suggest that HIV risk reduction interventions using a group format and targeting condom beliefs related to sexual romance and pleasure will decrease negative outcome expectancies about condom use. Also, reinforcing attempts to use condoms with intimate partners should increase positive outcome expectancies and intention to initiate or maintain condoms with a primary sexual partner.

HIV prevention in single, urban women: condom-use readiness

OBJECTIVE

To understand women's readiness to use condoms and their perceived pros and cons for condom use.

DESIGN

Comparative, descriptive design guided by the Transtheoretical Model.

SETTING

Data were collected at two urban primary health care centers in western New York.

PARTICIPANTS

364 single urban women with steady (main) or other (casual, concurrent, multiple, new) sexual partners. Most participants were young (mean age of 27 years), economically disadvantaged women of color.

MAIN OUTCOME MEASURES

Each participant completed an anonymous questionnaire that included items for the stage of change algorithm, decisional balance of the pros and cons of condom use, sexual history, and HIV risk information.

RESULTS

Most women were in the early stages of change (not intending to use condoms), but those with other partners were further along in the stages of change for condom use than those with steady partners. The pros or advantages of condom use differed for these women depending on partner type. The change in the balance between the pros and cons occurred as theoretically predicted for women with steady and other partners.

CONCLUSION

Effectiveness of HIV prevention interventions for women may be enhanced if they are tailored to both readiness to change and partner type.