Healthy People 2010, created by the U. S. Department of Health and Human Services, set goals to improve health behaviors and increase the healthy population by the year 2010. One of those goals is increasing responsible sexual health behavior. Responsible sexual health behaviors include regular condom use, abstinence, and any other methods used to the spread of sexually transmitted infections and prevent unintended pregnancies. Adolescent pregnancies cost the American taxpayers anywhere from $7 billion to $15 billion per year, and sexually transmitted infections cost around $17 billion annually; also, the cost of treating just one person with HIV infection is around $155, 000. It is easy to see why Healthy People 2010 focused on this goal to be one of the many to work toward. The goal is to increase the proportion of adolescents who abstain from sexual intercourse or use condoms while they are sexually active (U. S. Department of Health and Human Services, 2000). While acknowledging that the problem of irresponsible sexual behavior exists and setting a goal is a start, the general population needs to understand what they can do to make healthy behavior changes. The first part in realizing that a change must occur happens when one realizes new facts, ideas, or information that leads them to realize that previous behaviors were unhealthy.
The Transtheoretical Model (TTM) outlines the stages of change that are helpful in transitioning from the unhealthy behavior to the healthy one; these stages of change include precontemplation, contemplation, preparation, action, maintenance, and termination (Prochaska, Redding, & Evers, 2008). This paper will discuss how utilizing the TTM allows the population to make healthy sexual behavior changes. It will look specifically at adolescents that are of high school age. The TTM is particularly in line with the adolescent population because many of the constructs involve social support, which is very important in the teenage population, as well as self-efficacy, which teens are really learning at this stage in their lives.
The TTM states that the first stage of change is precontemplation. In this stage, the individual has no intention to take action within the near future, or what is usually quantified as the next 6 months (Prochaska & Velicer, 1997). At this point, the individual does not realize that their behaviors may be risky and does not believe there is any reason to make a change. With risky sexual health behaviors, this may mean engaging in sexual acts with multiple partners, not using barrier protection to provide against sexually transmitted infections (STIs), or not using preventative measures to prevent unintended pregnancy. In order to make the change from precontemplation, where the individual does not view that there is anything wrong with their current behaviors, to contemplation, where they begin to realize that they need to make a behavior change to improve their health outcomes, can take many steps. There are constructs within the TTM that show how the transitions through these stages are able to occur.
The processes of change are a construct of the TTM that outlines the steps that the individual may go through while working through all of the stages of change. While moving from precontemplation to contemplation, the individual will primarily be using consciousness-raising, dramatic relief, self-reevaluation, environmental reevaluation, and self-liberation in this process. Consciousness-raising involves finding out new facts, ideas, or tips that can help someone make a healthy change. In the case of high school age adolescents, much of this can happen in school sexual health education classes. A prevention program in the school setting would work well for adolescents, as this is the place where they spend the majority of their time. They have peers and friends in this setting, which may make them more comfortable to attend since sexual behaviors are very personal matters. Also, having a prevention program that is easily accessible allows the majority of the population is being reached and higher attendance. Research shows that there has been an increase in both abstinence among teens and an increase in condom use over the last few years among teens who are sexually active; programs in the school settings are most effective if they teach about both abstinence and condom use (U. S. Department of Health and Human Services, 2000). The Centers for Disease Control (CDC) states that in high school age adolescents, these classes would be best taught by a trained health instructor who understands the adolescent stage of development and can use age-appropriate teaching methods. They also state that if a qualified health education teacher is not available, that it should be a faculty member with some similar training to provide effective education to teens (CDC, 2008). Teachers need to understand the adolescent mindset that they do not feel that bad things are likely to happen to them. The teacher needs to break through that mindset and reinforce that risky behaviors can have serious consequences for the rest of their lives. If the adolescent is able to realize that they were engaging in behaviors that were risky based on these facts and ideas, the conscious-raising experience may be enough to get them to move from precontemplation to contemplation.
Often with adolescent populations, they may not realize they are at risk until they have a health scare. For some, this may be a pregnancy scare after having unprotected sexual intercourse. Experiencing these emotions, such as fear or anxiety, and being able to associate these feelings with a risky health behavior may be enough to make the teen realize that a healthy change is necessary. This is the construct of the TTM known as dramatic relief (Prochaska et al., 2008).
As the teen moves from precontemplation to contemplation, where they are realizing the need for a change and have the intention to make a change in the near future, they may be reevaluating themselves; understanding that making this healthier behavior change is an important part of who they are and what they are going to become. This goes along with Erik Erikson’s theory of development that adolescents are working toward building their identity. This stage requires adolescents to figure out who they are, and how they can fit in with the rest of society (Boeree, 2006). Fitting in socially with peers is part of the environmental reevaluation that takes places while moving from precontemplation to contemplation. Peer pressure and the need for acceptance can play a large role in an adolescent’s choices, and they may be more likely to understand the need for a change in health behaviors if they realize that teenage pregnancy or STIs have a negative effect on how their peers will view them and their ability to fit in. They may need to weigh the pros and cons of making a behavior change, but as they see that there is more to gain through making a healthy change, they may be ready to move to the next stage. They may also realize that engaging in risky sexual behaviors is endangering their health and reputation (Prochaska et al., 2008).
As the teen is now fully aware that there is a problem with current behaviors, and they now see that in the near future they will need to make a change, they move to the preparation stage. They are going to begin to take action, and may have even implemented some healthy changes already. Self-liberation is one of the processes of change where the individual is making an unyielding commitment to change. They may seek out helping relationships, where they can use social support for the healthy behavior change (Prochaska et al., 2008). With sexual health behaviors, this may be as simple as the adolescent choosing to be around friends that practice abstinence or safe sex behaviors only. Adolescents are looking for the approval of their peers, so surrounding themselves with people who have similar behaviors to those that they wish to carry out is a way of ensuring they have the support they need and the motivation to stay on track. In peer groups, they may be able to discuss the difficulties and challenges to remaining abstinent or using condoms with every sexual encounter, and give each other advice and support on sticking with healthy behaviors. With the help of these relationships, the adolescent will be able to move through the preparation stage and onto action.
In the action phase, the teen has been able to carry out the healthy sexual behaviors for less than six months (Prochaska et al., 2008). In the action phase, the helping relationships will continue to play a key role in support for the teen to continue the healthy behaviors. By surrounding themselves with people with similar beliefs and values, the adolescent will be to reinforce the behavior change, and may start to see the positive effects of making their change. They may have less fear and anxiety related to STIs and unintended pregnancy, and they may have higher self-esteem related to the ability to make an informed choice that could be improving their life in the long run. They can avoid any of the people or places that caused them to make risky sexual choices in the past, as so not to provoke that behavior again. Once the proper education has been provided, and teens have the proper support systems, the social norms can change from one where risky sexual behaviors were the norm to one where abstinence and protection are popular thought systems (Prochaska et al., 2008).
The maintenance phase is one where the teen is going to continue the behavior change for greater than six months (Prochaska et al., 2008). For sexual health behaviors in adolescents, it may be easy for them to relapse, perhaps out of peer pressure or the desire to impress a new partner. It is very important that there are support systems and prevention programs set up within school systems for adolescents to encourage healthy sexual behaviors as well as somewhere they can go to if they need help after a relapse. Understanding the processes of change is important when initiating a prevention program in the school setting (Prochaska & Velicer, 1997). The environment needs to be nonjudgmental, fact-based, and should have input from adolescents. Adolescents may be able to look past the feeling of invincibility that occurs in the teenage years if they hear from a peer who went through the same decisions and may have had a poor health outcome, such as an untreated STI that lead to pelvic inflammatory disease, an STI that is unable to be cured, or an unintended pregnancy that changed the course of the individual’s life forever.
The CDC states that a good prevention program in the school setting should encourage teens that have not yet engaged in sexual behaviors to continue abstinence until in a mature and monogamous relationship, preferably within the confines of marriage. They also state that education regarding injecting illicit drugs should be included, as this is a major risk factor for the spread of HIV and AIDS. For teens who are engaging in sexual intercourse or are using drugs that are injected, the preventative program should aim to teach them that discontinuing these behaviors would be best for their health, and they should refrain from having sexual intercourse until they are in a mutually exclusive relationship. Always, information and support should be given to teens to stop using illicit drugs, especially injecting drugs (CDC, 2008).
It is not enough to tell adolescents that they should not be engaging in sexual intercourse, and it needs to be understood that there will still be some individuals who believe that they are still not at risk, because their partner would never be dishonest with them, and would never give them a disease. These teens need education as well regarding avoiding sexual intercourse with people who are known to have HIV/AIDS, using a latex condom with every sexual encounter, and seeking health care if they believe they may have a sexually transmitted infection (CDC, 2008). A prevention center in the school setting should be a place where teens are able to come without fear of judgment, where they know they can be open and honest, and will receive open and honest answers in return. The faculty who work within the prevention center should know where to refer adolescents if the issue they are dealing with is out of the scope of the group.
In many situations, people may feel that openly discussing sexual behaviors will make teens feel that it is okay to engage in these behaviors as long as they use condoms, or engage in other sexual behaviors other than intercourse. It is important to be open and honest, and explain that STIs can be transmitted through oral, anal, vaginal, or even just skin to skin contact. While the hope is that adolescents will not engage in sexual acts until they are in a mutually monogamous relationship, research has shown that the best education and preventative programs focus both on abstinence and condom use (U. S. Department of Health and Human Services, 2000). If all of these options are not being taught openly in a preventative setting, adolescents may choose to get their information from friends, siblings, or the internet, which may or may not be including factual information.
Having a preventative program can help with another of the key constructs of the TTM, which is self-efficacy. Self-efficacy, in this case, includes the confidence that allows the adolescent to cope with tempting behaviors and resist a relapse. Confidence is an issue that many high school age teens struggle with, and having a support system in place where people hold similar beliefs is paramount to their success in sticking with a healthy behavior change. If temptations arise, the student has a place they know they can turn to for advice and encouragement. If there is a relapse into risky sexual behavior, the student also knows there is a place where they can go to and get back on track. The TTM acknowledges that relapses occur, and allows for it. The individual can reenter or revert back to any of the stages of change at any time after a relapse. Eventually, if the healthy sexual behavior changes have been implemented and used successfully for some time, the individual may move into the final stage of the TTM – termination. In this phase, there is no longer any temptation to revert back to previous behaviors (Prochaska, et al., 2008). The individual has the healthy mindset, support system, values, and knowledge that they are making the right choices and do not have any trouble resisting temptation. While this stage may not occur for many adolescents, working through the TTM helps them to get to this stage in their young adult years.
The TTM, with the stages of change constructs, is a behavior model that can be used to take an unhealthy behavior and transform it into a long-term, sustainable, healthy behavior. The steps of the TTM occur naturally, and will work in the adolescent population. The TTM can be used to lay the foundation for continuing healthy sexual behaviors in the young adult years. A preventative program should be established within the school system to guide adolescents along their way and teach them the importance of responsible sexual behaviors. A knowledgeable and open staff will encourage adolescent participation and create an environment where abstinence or safe sex is the social norm. If a preventative program can help even a percentage of the population from engaging in risky sexual behaviors while in their high school years, then we will be closer than ever to reaching the Healthy People goals.
