Behavior change model promotes HIV drug compliance, safe sex practices

Model uses stages of change’ approach to encourage prevention efforts

A model of how people change their behavior may hold the long-sought keys to the two biggest issues facing public health officials and clinicians in their battle to stop the spread of AIDS: The model provides a way to teach at-risk people how to incorporate safe-sex practices into their daily lives, and it helps clinicians encourage HIV-infected people to comply with their medication regimens.

While not a magic wand, the transtheoretical model of health behavior change is a logical and well-studied tool that is being used in trial studies across the country.

"The first applications of the model had to do with psychotherapy and what helps people change, and the first data applications were with smoking cessation," says Colleen A. Redding, PhD, assistant research professor with the Cancer Prevention Research Center in Kingston, RI. Redding has used the model, which was developed at the University of Rhode Island in Kingston, for HIV prevention.

"The developers of the model started by studying people who were changing on their own, and they then developed ideas to apply to the change in a therapy situation or with counselor assistance, as well as self-change efforts," Redding adds.

Educational efforts are geared to specific changes

The model is based on six processes of change, although some projects may use only the first five stages. Before people actively change a certain habit or behavior, they go through each or a portion of these stages. Sometimes people already will have moved through one or more of the stages on their own before clinicians first see them. When clinicians are working with patients and desire to help them make a behavior change, they should gear their education and efforts toward the specific stage the patient is in. (See chart on stages of change for medication adherence, p. 51.)

The six stages are as follows:

1. Precontemplation: At this stage, a person is not thinking about making a change in the near future, which the model describes as the next six months. This is the stage in which patients need more education about the consequences of continuing their behavior.

2. Contemplation: Now the person is beginning to think about changing and is weighing the costs, benefits, and risks involved in the change, explains Christine Galavotti, PhD, research behavioral scientist and chief of behavioral research unit in the Division of Repro duc tive Health at the Centers for Disease Control and Prevention in Atlanta.

3. Preparation: This is when a person becomes ready for action and has a firm intention to change behavior within the immediate future, Galavotti says. The person might have a plan of action at this point.

"Then they’re focused on skills needed to imple ment the change," she says. For example, if the change has to do with smoking cessation, the person might begin to notice people who don’t smoke and become better educated about the hazards of smoking.

HIV-infected patients might begin at this stage to think about their personal resources, such as physician support and family support. They may ask clinicians about side effects of drug therapy and how best to cope with them.

4. Action: This is the most volatile stage of change. The person at this stage begins to carry out the plans devised in stage three. Clinicians would define a person in the action stage as someone who has made overt changes in his or her behavior over the past six months. For instance, a smoker has stopped smoking, at least for a few months.

However, a person in the action stage could easily relapse to an earlier stage unless the person has adequate support. This is the stage where clinicians should most closely monitor a patient who is taking HIV medication, for instance. It’s possible that patients could experience some adverse side effects and decide to stop taking their drugs, and they might not communicate the problem to their physicians.

5. Maintenance: This stage is achieved when a person has maintained the desired behavioral change for a longer period of time, such as six months to five years. The person in this stage is taking actions to prevent relapse. For example, in the case of the smoker, the person might become involved with a social network that includes nonsmokers.

6. Termination: At this stage, the person has finally so incorporated the new behavior into his or her lifestyle that it is automatic and no longer a question of weighing the pros and cons. It’s like when people put on their safety belts every day without thinking about the benefits or inconvenience. This is the stage where clinicians no longer have to monitor the patient’s progress, and they can be confident that the patient is complying with treatment.

Researchers first used this model for smoking cessation, which is a major priority for grant funding from the National Cancer Institute in Washington, DC. They later applied it to sun exposure protection, dietary behavior change, and exercise, among other health behaviors.

CDC studied model for prevention use

In 1989, Rhode Island researchers began collaborating with the CDC to use the model in an HIV prevention program that promoted protected sex among high-risk populations. (See related story, p. 52.)

The next project was aimed at women who were at high risk for HIV infection. The model would apply to pregnancy prevention as well.

The Cancer Prevention Research Center has since developed computer-based expert system interventions that give participants feedback on effective and ineffective strategies for change. The interventions could work for a variety of projects, including HIV medication compliance.

One of Redding’s collaborators, Cynthia Willey Lessne, PhD, an associate professor at the University of Rhode Island, has developed tools that will measure stages of change for adherence to HIV-related medication regimens.

"We studied about 230 HIV-positive patients to develop these measurement tools, and afterward we asked them questions about their readiness to take the medication as directed," she says.

Researchers developed the questionnaire, which will be published later this year, by asking HIV-infected people to describe what they see as the pros and cons of medication adherence.

The patients’ answers were very helpful. "Patients think very differently about medications than clinicians do," Willey Lessne explains. "There are very common misconceptions about what the cons are, and it was an education for me to hold these focus groups and hear the patients’ perspectives."

For example, HIV-infected patients would look at their medicine bottle every day, and it would remind them that they are sick. After a while, they didn’t have the emotional strength to look at that medication bottle.

"So it’s easier for them to push the bottle away and stay in denial," Willey Lessne says.

Another common response was equally surprising to researchers: "A lot of patients would say that they would stop taking their medication because they needed to give their bodies a rest," Willey Lessne says. "This is also something that most clinicians don’t understand, and I didn’t understand it at first until we continued to talk with patients."

The HIV patients apparently had a common misconception that the medication is unnatural and takes a toll on their bodies, so after they had taken the medicine for a while they would need to give their bodies a rest.

"I think part of it is folk knowledge, and we’ve seen this with a lot of other medications too," Willey Lessne says. "I was not sure about putting these items into the questionnaire, but we did include it because over and over again we heard people say, I need to give my body a rest.’"

Clinicians need to address this type of misconception early on by helping patients concentrate on the pros of the medication, such as how it keeps the virus from replicating as long as it is taken faithfully.

After devising the questionnaire, researchers monitored the patients’ medication-taking behavior for 30 days to see if their answers on the stages of change could predict their compliance. The tool consists of a long questionnaire, but the model also can be streamlined.

"We find the best way to predict future compliance with medication and to assess a patient’s temptation to skip medication is with 14 questions," Willey Lessne says. The questions have been submitted for publication in a national peer-reviewed journal.

"And we did find that when we compared the stages of change with other potential predictors of compliance, like severity of illness as measured by CD4 counts and demographic variables, the stages of change was the strongest predictor of compliance," Willey Lessne says. "So that was quite encouraging."

The experiment found two potential benefits of the stages-of-change model:

• The model may be a useful way of helping clinicians communicate differently with patients at different levels of readiness of change.

• It provides a good predictor of who is likely to be successful and who will need more assistance in complying with medication regimens.

When clinicians use the model to improve patients’ medication compliance, they need to pay attention to what Willey Lessne calls the temptation to skip medication.

For example, one question researchers asked patients was: "How likely are you to skip your medication?" Then the questionnaire listed a variety of situations in which a person might skip medication, such as "when you’re upset" or "when your family is not being supportive." Questions measuring temptation to relapse are important because they will help a clinician address the issues that are most important to the patients.

Give patients permission to explore issues

One reason this model works better than some other compliance programs is because the questions are nonjudgmental, Willey Lessne says.

Sometimes, clinicians will count doses to assess compliance or they’ll ask patients how many times they’ve missed their medication in the past week or month. But patients tend to view these methods as judgmental. In contrast, this model gives patients permission to explore the issues that make it harder for them to take their medications.

"We found that patients liked filling out the questionnaire," Willey Lessne says. "And when we held focus groups with these patients, we asked them about their reaction to these scales, and they really felt the issues were relevant to them.

"We think this method has good clinical utility, and so we’re doing a follow-up study now, and clinicians are using it with their patients, and we’re asking them how useful it was in terms of opening discussion with their patients," Willey Lessne explains.

The National Institute of Health in Washington, DC, is involved in a national trial, called Project Treat, using this model to encourage medication adherence among HIV-positive adolescents. "We assisted this group with developing a method for determining the stages of change for adolescents, and they’re going to be examining the effect of interventions that are developed for each stage of change," Willey Lessne says.