665349 research-article2016 QHRXXX10.1177/1049732316665349Qualitative Health ResearchJohnson Article Asking Numbers to Speak: Verbal Markers and Stages of Change Qualitative Health Research 1­–13 © The Author(s) 2016 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049732316665349 qhr.sagepub.com Malynnda A. Johnson1 Abstract Through routine screenings for sexually transmitted infections (STIs) and HIV, medical providers are able to motivate behavior change. Although established models rely on quantitative measures, doing so requires time and ability to score each. Listening for verbal cues, however, could simplify the process of suggesting HIV screenings. Using mixed methods to identify verbal indicators for readiness to change, this article conducted two phases of study. First using quantitative means of identifying participant’s knowledge of HIV, perceptions of safer sex, and readiness to change safer sex behaviors (N = 487). Interviews were then conducted exploring the possibility of verbal markers for one’s readiness to change (n = 25). Results confirmed the use of verbal markers when discussing perceptions of risk. Identification of verbal markers, at three stages of change, provides new possibilities for medical providers’ such as providing time saving and effective tools when seeking to motivate HIV and STI testing, and other safer sex behaviors. Keywords HIV, prevention, motivational interviewing, stages of change, cues to action, survey and interview, Midwestern United States According to the Centers for Disease Control and Prevention (CDC), more than 1.2 million people in the United States are living with HIV, and almost one in eight is unaware of his or her status (CDC, 2016). Countless interventions have sought to lower the continued spread of HIV for young adults (anyone aged 14–25); however, the rate of infection continues to rise. To ebb the continued advancement of HIV, individuals must, at the very least, know their status. To do so, screening and testing by a medical provider is required. However, to obtain preventive screenings, an individual must either seek out testing or be offered one when receiving medical care. Prevention relies on a complex web of both behavioral and personal understandings of risk. Kaufman, Cornish, Zimmerman, and Johnson (2014) argued that often, HIV prevention stems from, among other things, individuals’ knowledge of who is at risk and what behaviors place someone at risk. The common attitude of young adults is that HIV is not an area of concern (Beltzer et al., 2013; Polacek, Hicks, & Oswalt, 2007; Vermund & Wilson, 2002). Having grown up with HIV in the media their entire lives, with most of the focus on discussion of HIV in the world, young people perceive HIV as an “other” world problem (Zoller, 2005). Replicating previous studies, Beltzer et al. (2013) found that young adults continue to misunderstand sexually transmitted infection (STI), including means of HIV transmission, distrust in condom efficacy, and a general decrease in adopting prevention practices. As a result, a call for methods of adapting and modernizing preventive strategies is clear. Health communication scholars and medical providers have identified two challenges that prevent personal identification with any risky behavior: the ability to determine individuals’ (or a general population’s) readiness to change a behavior and the ability to motivate individuals to dissuade the enactment of risky behaviors. One of the most important challenges for those who work in prevention involves finding the most effective modalities and techniques for helping individuals process information and to translate that information into behavior change (Prochaska, Redding, Harlow, Rossi, & Velicer, 1994). As a means of providing a framework for understanding health behaviors, the transtheoretical model (TTM) has served as a reliable tool for understanding the steps toward behavior change (Hogue, Dauber, & Morgenstern, 2010; LaBrie, Quinlan, Schiffman, & Earleywine, 2005). The present investigation not only extends existing literature on motivating health behaviors, but also provides 1 University of Mount Union, Alliance, Ohio, USA Corresponding Author: Malynnda A. Johnson, Department of Communication, University of Mount Union, Alliance, OH 44601-3993, USA. Email: johnsoma@mountunion.edu Downloaded from qhr.sagepub.com at University of Mount Union on August 24, 2016 2 Qualitative Health Research  the continued exploration of the identification and use of verbal cues to action. Applying mixed-methods research, the current study examined verbal cues as indicators of one’s readiness to change sexual health behaviors. The goal being that the identification of potential verbal cues conversations during routine medical discussions, as well as everyday interactions, could serve as an early stage intervention by counselors, educators, and health practitioners. The following provides a foundation of how TTM, specifically stages of change, function as a framework for prevention. TTM (or Stages of Change) Debuting in 1986, Prochaska and DiClemente’s TTM presented a mechanism for understanding how individuals move from pre-contemplation, or not thinking about a health issue, to the modification of a specific behavior. Used to investigate a variety of addictive and risky behaviors, the model provides a versatile framework for understanding how behavior change occurs. Originally, TTM was used to decrease smoking behaviors; however, given its versatility, research has expanded TTM as an effective theory for decreasing other risk behaviors, including alcohol abuse (DiClemente & Hughes, 1990; Litt, Kadden, & Tennen, 2015; Norcross, Prochaska, & Hambrecht, 1991), cocaine abuse (Prisciandaro, McRaeClark, Myrick, Henderson, & Brady, 2014), weight and diet control (Stubbs et al., 2011), and sun exposure and sunscreen use (Craciun, Schüz, Lippke, & Schwarzer, 2012). Second only to tobacco and alcohol studies, TTM has also been used widely in a variety of areas of HIV prevention (Fisher & Fisher, 2000; Naar-King et al., 2006; Prochaska et al., 1994). However, most of the applications of TTM have not been in the area of testing for HIV. Instead, studies have focused largely on behaviors such as the prevention of needle sharing (Patten, Vollman, & Thurston, 2000), sex between men (Wilton et al., 2009), and medical adherence by those living with HIV (Krueger, Berger, & Felkey, 2005). Regardless of the health area, TTM finds that people move through a series of stages when changing behavior. Tenets of the Stages of Change The central organizing framework of TTM is contained within six stages of change. Prochaska (2013) defined these stages beginning with pre-contemplation (individuals are unaware of need to change behaviors). Once individuals begin to recognize that their behavior is problematic, and they start to look at the pros and cons of their continued actions, they enter into contemplation. This initial shift is the greatest challenge for behavior change and can only occur when awareness of change is raised, emotional arousal is heightened to feel a need to make a change, and finally, when the individual feels he or she is in a place where change can occur (HornefferGinter, 2008). Upon contemplation, the individual can begin working toward preparation. In the preparation stage, intention to take action in the immediate future is planned. Small steps toward change might also begin in the preparation stage. The action stage is reached when specific modifications in their lifestyle and positive change have occurred. As such, changes continue to evolve in the maintenance stage, and the person works toward preventing relapse. This stage is thought to be one of the few stages that can last indefinitely. Ultimately, the final stage is termination, where individuals have zero temptation and 100% self-efficacy. It is only in the final stage that individuals are sure they will not return to their old unhealthy habit as a way of coping. However, this final stage is often debated within psychological circles, many scholars changing termination to relapse with the understanding that many behaviors are rarely permanently terminated (DiClemente & Velasquez, 2002). Regardless of whether an individual can reach 100% efficacy, the stages of change provide a vital measurement for understanding how a person sees his or her behavior as risky and ultimately the readiness to change such behaviors. Measuring Readiness to Change Understanding how individuals progress along the ongoing change continuum is an important component of any successful intervention, even when it does not immediately produce the desired behavioral change (Prochaska & DiClemente, 1992). Numerous researchers have used the TTM to develop “readiness to change,” a measure to assess people’s motivation to change a desired behavior. Researchers have developed several measures, including the Stage of Change Readiness and Treatment Eagerness Scale (SOCRATES; Miller & Tonigan, 1996), the University of Rhode Island Change Assessment (URICA; McConnaughy, Prochaska, & Velicer, 1983), and the Readiness to Change Questionnaire (RTCQ; Rollnick et al., 1992). However, each of these measures contains up to 32 items in attempts to determine the level of motivation of individuals by placing them in the appropriate stage of the change continuum. Seeking to simplify the process, Biener and Abrams (1991) created contemplation ladders allowing a patient to self identify his or her level of readiness to change behaviors by selecting a statement that corresponds with the six stages of change. Although contemplation ladders are consistently found to serve as a quick and effective tool (LaBrie et al., 2005), they still require a medical provider to score the measure Downloaded from qhr.sagepub.com at University of Mount Union on August 24, 2016 3 Johnson and create a plan for the conversation. Given the limited time medical providers have with patients and the number of forms patients is already required to fill out, there is a clear need to provide an even simpler tool. One possibility could be the development of a verbally based framework that could be used to guide a conversation during routine visits or everyday conversation. Yet, to date, research has not explored the possibility of verbalized markers (e.g., words or other utterances that reliably indicate) within various stage of readiness. Motivating Behavior Change When thorough sexual histories are obtained, medical providers are able to assess patients’ behavioral risks, offer HIV testing, and provide risk-reduction (Nusbaum & Hamilton, 2002; Wimberly, Hogben, Moore-Ruffin, Moore, & Fry-Johnson, 2006). While obtaining sexual histories, medical providers have the opportunity for patients to discuss their risk for sexually transmitted illnesses, including HIV. In addition, this conversation can also provide indicators of the level of knowledge one has about HIV and whether one’s HIV status is known. Building from what the patient discloses, the provider then has the opportunity to engage in discussions about modifying any risky behavior, commonly referred to as “change talk.” Through “change talk,” medical providers within clinics have the opportunity to engage in a method of communication that is referred to as “motivational interviewing” (MI; Hettema, Steele, & Miller, 2005). The MI strategy begins by listening closely to their clients and assessing clients’ knowledge and perceptions of risk. By allowing clients to openly discuss perceptions, counselors or health care providers can identify clients’ stage of change by assessing whether they are engaging currently in the behavior or whether they have thought about possible changes to improve their health (Elder, Ayala, & Harris, 1999). Through MI, the provider can elicit and encourage the translation of knowledge to change (Rubak, Sandbæk, Lauritzen, & Christensen, 2005). The potential of MI in HIV counseling has been realized in settings where counselors have worked with patients already living with the virus (Chariyeva et al., 2013; Hill & Kavookjian, 2012; Parsons, Golub, Rosof, & Holder, 2007). However, research has yet to explore the application of TTM and MI for motivating HIV screening. Given that MI is based on open conversation, thus is qualitative in nature, a logical first step toward the application of MI for motivating HIV screening is the identification of verbal cues as means of determining a client’s stage of readiness. To identify potential verbal cues two research questions are presented: Research Question 1: What are common perceptions of HIV as voiced by participants at specific stages of change? Research Question 2: What verbal cues are provided by participants that could be used to guide MI? Method: Phase 1 The research design for this study was developed to identify commonalities among those at similar and different levels of readiness to change their sexual health behaviors. Previous studies have supported the partnership of the stages of change as a framework for MI as means of motivating various behavior changes (such as DiClemente & Velasquez, 2002; Miller & Rollnick, 2004). To identify verbal variances between stages of readiness, this study used a mixed-methods approach. Applying traditional measures for identifying participant’s perceptions, behaviors, and readiness to change the first phase of study employed an online survey. Following the approval of the institutional review board by the University of Wisconsin–Milwaukee, participants were recruited through an online survey to participate in the first phase of study. Informed consent was collected through initially by selecting a box agreeing to participate in the online survey, and before the interview began, interviewees signed an additional waver. Participants primarily consisted of current students enrolled in communication courses. After receiving permission from faculty, recruitment emails with the survey links were sent to 20 course lists. Participants were told the study was seeking to understand perceptions of HIV, knowledge about HIV and STIs, and where their knowledge came from. Students in the researcher’s courses were not excluded from the online survey, however, were excluded from the interview phase of study. Through snowball sampling, students in other disciplines were also asked to complete the 70-item questionnaire. Snowball sampling occurred by asking participants who completed the survey to click a link and pass the survey to roommates, friends, and specifically non-communication majors. To obtain an understanding of participants’ knowledge of HIV, sexual behaviors, and readiness to alter prevention habits, a quantitative online survey was utilized. Measures included knowledge of HIV; perceptions of ability and comfort in using preventive methods, such as condoms; and finally, readiness to change behaviors. Participants were also asked to reflect on topics surrounding their sexual behaviors as well as overall perceptions of sexually risky behaviors. Questions about sexual behaviors, such as whether they were sexually active, number of sexual partners they had in the past year, percentage of time that they used a condom, and STI and/or Downloaded from qhr.sagepub.com at University of Mount Union on August 24, 2016 4 Qualitative Health Research  HIV testing practices were also included. Additional questions were constructed from Albarracin, Ho, and McNatt’s (2000) Condom Efficacy Scale, which asks respondents their level of comfort using a condom, negotiating condoms with a partner, and perceived effectiveness of condoms to prevent HIV. To address participants’ readiness to change, contemplation ladders were included. Developed by Biener and Abrams (1991), contemplation ladders were used initially to test a continuous measure of readiness to quit smoking. The 11-point Likert-type scale is depicted as a ladder with the higher rungs representing greater motivation to change. The instrument has been shown to remain consistently reliable in other risk behavior studies, including adult substance abuse (Hogue et al., 2010) and HIV prevention (LaBrie et al., 2005; Lelutiu-Weinberger et al., 2014). Participants completed two contemplation ladders, each including a scale from 0 to 10 that asked participants to rate their readiness to change their safer sex practices. Ladders included perceptions of using condoms on a regular basis and willingness to test for HIV. These areas of behavior change were selected due to the ability to compare ladder results against previously mentioned survey items. Respondents’ readiness was selected by choosing the position on the ladder that best described them. For instance, Level 0 contained the wording “I never think about using condoms,” whereas Level 10 was “I use condoms every time I have sex.” Each level in between built incrementally toward the final stage, indicating that the individual identified a personal risk progressing toward altering behaviors. Contemplation ladders were scored, following previous studies (see Herzog, Abrams, Emmons, & Linnan, 2000), placing participants into categories by level of contemplation. Upon completing distribution analysis, three larger stages were identified. Participants falling between 0 and 2 were considered to be in the pre-contemplation stage, Levels 3 and 7 in a contemplation/ planning stage, and 8 and 10 as being in the stages of action/maintenance. Given that only subtle differences were found between contemplation and planning, these categories were combined. In a similar manner, the action and maintenance stages showed little variance; thus, the stages were also combined. Results: Quantitative Indicators of Readiness to Change This study sought to not only understand college students’ perceptions of HIV risk but, more importantly, to provide a framework that could be applied when engaging young adult populations about adopting safer sex practices. To achieve this goal, participants’ level of readiness to change their behaviors first was identified. Participants included only those who were sexually active, eliminating 57 for a total of 487. The average age of participants was 20 years old (ranging from 18 to 56). Sixty-three percent of participants were female and 77% were of Caucasian decent. In addition, African Americans represented 7.2%, Asian Americans constituted 6%, and Latinos represented 5% of the sample. Overall, the selfidentified sexual orientation of those who participated was 93% heterosexual, 3% bisexual, 1.6% homosexual, and 1% lesbian. In total, 63% had at least two sexual partners in the past 6 months. Sexual activity was defined as engaging in oral, vaginal, and/or anal activity. Thirty-five percent of participants reported consistent condom use less than 10% of the time. When comparing safe-sex practices of men with women, nearly double the number of women (n = 64) reported never using a condom when engaging in vaginal or anal sex. Only 20% of both men and women stated that they used condoms 100% of the time. Readiness to Change In terms of readiness to alter condom use practices, participants appeared to be maintaining healthy perceptions of the need to engage in safer sex (only 10% stated that they never think about using condom). However, the same could not be said about their perceptions of risk for HIV. While initial distribution across each stage was insignificant, larger categories were found to be significant as a discriminant function (Wilks’s , p < .0000). Using the three larger categories, participants were classified primarily as pre-contemplators (scores of 0–2, representing 42%), characterized by, “I never think about risk for HIV”; contemplators (scores of 3–7, representing 26%), characterized by, “I sometimes think about risk for HIV”; and action takers category (scores of 8–10, representing 33%), characterized by, “I know my risk for HIV because I have been tested.” It should be noted that action takers included anyone who was actively engaged in safer sex practices, including condom use and obtaining testing. Given that no variance could be identified between those in action or maintenance stage, these two stages were collapsed. Percentages, such as those found in this study, are not novel to perceptions of HIV or any health risk. However, what has often remained unknown is what the perception at these stages look/sound like. Method: Phase 2 On completion of the Phase 1, willing participants (as indicated at the end of the Phase 1 survey) were contacted and scheduled for a 30- to 45-minute interview. This interview served as the means for identifying verbal patterns between each of the three stages. Participants were Downloaded from qhr.sagepub.com at University of Mount Union on August 24, 2016 5 Johnson asked questions about how they would define risk for STIs and HIV, their own level of risk based on their original definition, and their perceptions of their peers’ behaviors. Interviewees were selected from the 115 participants who noted their willingness to participate in the questionnaire. Purposive sampling was used to select participants based on the following criteria: First, participants who had not been sexually active with more than one partner in the last 6 months were eliminated; second, 10 participants from each of the three stages of readiness were sent invitations for an interview. A final sample of 25 participants, representing each of the three larger stages, was interviewed. Interview Protocol Interviews followed a semi-structured protocol, eliciting stories about perceptions of STIs and HIV, and origins of the perceptions. In analyzing the data, the researcher highlighted significant statements, sentences, or quotes and developed clusters of meaning from these statements (Creswell, Plano Clark, Gutmann, & Hanson, 2003). Doing so allowed for interviews and data analysis to occur simultaneously, illuminating themes and categories. The constant comparative approach also allowed for additional modification to interview questions. Emerging categories were used to create a textural description of what participants experienced. Data Analysis A total of approximately 11 hours of digitally recorded interviews were transcribed by the researcher and verified by an outside reader. It should be noted that to ensure rigorous analysis, the researcher (and outside researchers) were blind to the stages of readiness for each interviewee during the coding process. Using a structural process, data were organized around specific research questions, thus, creating three large organizational categories: perceptions of HIV, perceptions of behaviors, and motivations for behavior change. Once larger organizational categories were identified, all transcripts were uploaded to NVIVO qualitative data management software, used only to track organizational categories. Given research has done little to examine stages of change from a qualitative perspective, an inductive process similar to Corbin and Strauss’s (2008) notion of “open coding” allowed for categories to emerge from the data. Each of the three categories were coded by identifying repeated patterns in language; for example, the use of personal identifiers such as “I” or “my risk.” Similarly, statements implying judgment, “dirty,” or “those people” were identified. To establish the validity of categories, two outside research colleagues independently assessed the data (Lincoln & Guba, 1985). Upon the completion of analysis, stage of readiness and interview participant were matched and reviewed for possible themes. Quotations that were particularly representative of the categories were selected from the transcripts, and pseudonyms were created. Results: Verbal Markers of Change Utilizing the results of the HIV contemplation ladders, participants representing each of the three larger categories of readiness were interviewed. In total, 25 students were interviewed, 11 participants represented precontemplators, seven represented contemplators, and seven represented action takers. Within each of the categories, 36% of interviewees were male. Ages ranged from 18 to 24, with an average age of 20. Sexual orientation of participants included 95% heterosexual. Evaluating responses about current perceptions of risk, the risk of peers, and motivations for sexual behavior change are as described below. “Them” Not “Me”: Verbal Cues of PreContemplators Utilizing words such as “they” and “not me,” precontemplators generated a noticeable attempt to distance themselves from those who would be affiliated with HIV. In other words, when asked who is at risk for STIs and HIV, these participants centered their definitions around the use of either third-person references or “othering” language. Although none of the participants acknowledged a deliberate disconnection, an explanation was offered explicitly by Kristina: “I’ve just never met anyone with HIV.” In a similar manner, Kayla noted, “I know everyone is at risk for spreading it, and I know I should be worried, but it is never around me.” Of the 11 participants categorized as pre-contemplators, only one had known someone with HIV. However, knowing someone in this case only provided a distinct motivation to maintain distance from anyone with HIV. Ben shared that it was his grandfather who had contracted AIDS (in the early 1980s, before HIV was identified): He got it because he was gay, and he had sex with his legal assistants. We don’t talk about it in our family. . . . It was his fault. It’s not that I don’t care but it’s not like he died of cancer or something out of his control. This point of HIV being something that some people (those who are gay) “control” also appeared as a theme for pre-contemplators. As a result, pre-contemplators appear to be assigning an internal locus of control. Downloaded from qhr.sagepub.com at University of Mount Union on August 24, 2016 6 Qualitative Health Research  The common stereotypes of those living with HIV, as presented in the media, center around those who are gay/ bisexual, intravenous drug users, and those who have engaged in sexual activity with multiple partners (M. A. Johnson, 2013). Thus, it was of no surprise that pre-contemplators largely focused on those stereotypes, and thereby, justified their inability to see a personal level of risk. “I don’t do those things,” explained Susan. In a similar manner, Scott stated that “unless you are someone going out every weekend trying to find someone to sleep with, you’re not at risk.” Along with other pre-contemplators, Susan and Scott spoke about the idea that because they do not do “those types of activities,” they would not need to be concerned about HIV. “I Know, But . . . ”: Verbal Cues of Contemplators At the contemplation stage, individuals are aware minimally of their risk and would be likely, at least, to consider a change in their behavior. For the participants of this study, phrases beginning with “I know,” “I would think,” and “our risk” were more frequent, compared with pre-contemplators. Although personal identification was present, many comments seemed to identify only a minimal level of connection. Instead, most contemplators expressed their perceptions of HIV through the lens of reflection. For example, Sandra commented, “I think the people who are at the most risk just don’t think about; it’s like they can’t see it. I feel I might be at risk, but my friends think it will never happen.” Contemplators also were more likely to assess persons’ level of ability to protect themselves; as Taylor explained, “I see college students who sometimes are promiscuous, as well as low-income people who can’t afford condoms. I know anyone is at risk, but they seem more so.” Such statements, made almost explicitly by contemplators, support the idea that young adults are engaged in observing others’ behaviors and reflecting on what is causing “some groups” be at a high risk. Although contemplators did identify the need to modify behaviors, they were still inhibited by the same perceptual barriers as were pre-contemplators, which included an inability to see themselves at risk and a general lack of talk about HIV. With regard to the first barrier, Austin stated, “I know my reasons for thinking about risk, but I don’t think others really worry. Maybe they just need to see it. You know, someone with it.” For Heather, it was not simply seeing someone with HIV; instead, the concern was seeing “normal people.” As she explained, “I know there are people in this world that are geniuses who are HIV positive, but I think others think it doesn’t happen to normal people.” Unfortunately, “normal people” could not be defined more than “You know, average kid. Doesn’t do drugs, or sleep with strangers from the Internet. They sleep with people they know.” Thus, although perceptions by this group of those at risk for HIV did advance beyond stereotypes, risk groups were categorized mostly as either someone living in another country or someone who was “dirty.” The reliance of comparative evaluation by contemplators not only influences their language but also indicates a level of ambivalence. Participants are able to see that safer sexual practices are needed; however, compared with others, they do not need to worry. Contemplators also were more likely to use the words such as “taboo,” “dirty,” and “unclean” when talking about HIV. Sonya, for instance, described how her family “simply doesn’t talk about sex; it is a taboo topic in our house.” Ryan echoed the “taboo” nature of sex talk and HIV, saying, “It’s like this taboo type of thing. They [college students] don’t want to refer to it. It’s kind of this tainted kinda image.” When asked to explain what he meant by “tainted,” Ryan continued, “Just like, you’re dirty for having it. Normally, you got it in some way that you shouldn’t have.” Ryan was not alone in expressing that young adults did not want to talk about HIV, given the “tainted” perception. Thus, it is this negative lens placed on HIV as a discussion topic that also may be the justification for not seeking HIV testing. “Everyone” and “Anyone”: Verbal Cues for Action Unsurprisingly, participants who reported an eight or higher on the contemplation ladders also reported testing for HIV and/or STI (for many, testing occurred more than once). Action takers also used the most inclusive language for example and open-minded perceptions of who was at risk. As Austin explained, “It’s simple for me: anyone who is having sex without using condoms.” For Anna, the understanding that “everyone” is at risk was so accepted that she carries condoms with her. As she further explained, I have been very persistent that I will not have unprotected sex. Even if the guy complains. If he complains, we just don’t do it. I always make sure I carry a condom with me at all times. You never know. Anna explained later that “people lie all the time about their past, so we all need to be smart and protect ourselves.” For Anna, as well as other participants at this stage, the risk was simple in that everyone and anyone could be carrying HIV or STIs, and therefore, everyone needs to be careful. What proved to be the most unique perception of this group was the ability to recall an example of someone having HIV or STIs. Only two shared personal connections; Downloaded from qhr.sagepub.com at University of Mount Union on August 24, 2016 7 Johnson however, four others recalled seeing vividly an actor playing someone with an STI. Being able to identify with people with HIV provided a level of understanding and efficacy. “I think seeing it has opened me up to more discussion with people about HIV. I don’t think it’s ever been a question I had until I saw it,” explained Beth, as she discussed seeing Samantha from the television show Sex and the City talking about HIV testing with her girlfriends. Although members of this group made multiple comments about HIV still being a taboo topic, the ability to make personal connections appeared to influence their desire to talk to others, including peers, partners, and siblings. Motivations to Change Behaviors Relating to someone who was tested for HIV in a television show or seeing someone carry a condom can provide observational motivation for individuals to change their behaviors. Observation has provided a long-standing method of understanding how people perceive risk (Bandura, 2004). Such observations provide an external cue to action; however, such external cues often spark the internal dialogue that later motivates a desire to change. For each of the three groups of participants, distinct internal and external cues to action were verbalized. Pre-contemplators. One of the biggest issues for young adults is their lack of personal connection to HIV. Unless a person observes from those around him or her, it is easy to feel as if nothing bad ever could happen. As Scott puts it, “Until someone I know has it, it’s hard to see the need to change my sexual habits.” Ginger not only echoed this need for personal connection but also provided an explanation: Honestly, as pathetic as it is, I think it will take someone they know being infected for them to think differently. I just feel like we need to bring it back into the media. It feels like it’s forgotten. I just never hear anyone talking about it. I think people think it was a fad and that it’s disappeared. We need to grab their attention that is it still here. For Ginger, HIV is something that people not only do not talk about. As a result, many young people have also forgotten they are at risk. Both Ashley and Denzel mirrored this sentiment by stating, “HIV is not something we think about, so if you want me to change, you need to grab my attention.” The question, of course, becomes how to change that situation. When asked how health promoters could “grab their attention,” Mark explained, “I feel the more we are able to scare people with advertising, the better. For guys, it is tough to slow down the hormones, but I feel if the right scary message could get across.” Although fear tactics can raise awareness in terms of the severity of STI and HIV, such approaches are rarely found to be effective for sustainable change. Contemplators. In general, contemplators believed that more education and personal stories would be the greatest motivation for behavior change. Heather presented the notion that although STIs are sometimes hinted at in television shows, “We never see the aftermath per se, the consequences. We see the babies, but not the STDs.” However, as Heather further explained, the best means of motivation would be policy: “Not saying it’s a sex and rock ‘n’ roll kind of thing, but, really, look at the sex in reality television.” Heather was not alone as Audrey also spoke about how sex in the United States is shown on television, “In Brazil, we see sex, but it is always shown as safer sex. We see conversations about making sure you have a condom with you before going out. It’s just common conversation, both on television and in person.” Although it is not U.S. policy to prevent safer sex from being discussed in the media, it also is not encouraged. “Media outlets have ability to include message about safer sex, but they don’t,” Sabrina pointed out. However, it was not only media that contemplators thought should be encouraging conversations; Ryan, Heather, Taylor, and Sandra thought that physicians, in particular, need to talk to their patients about HIV. As Taylor stated, “I feel like if my doctor would ask me if I wanted an HIV test, I would think about it more. I’m not sure he has ever asked.” Action takers. For those who already were engaging in safe-sex practices only a reminder, that safer sex behaviors needed to continue, is required. For this population, the motivation is facts and statistics about HIV and STIs. Their awareness was already primed for the messages; consequently, entering into discussion with them was easier than with the other groups. However, as Ali described, “HIV is a difficult thing for people to talk about, so if medical people can set a tone, that might help.” Thus, Sophie encouraged medical professionals to lay a foundation to “give us facts to think about and the education of how we can protect ourselves.” Denzel also agreed that facts and education were important; however, he also raised the issue of testing becoming easier, saying, “I have had to insist sometimes that I get a test; my doctor never asked me about it. I had to bring it up.” Although it is encouraging that Denzel and others in the action stage requested testing and information, they were in the minority. Discussion Before any health intervention can be used to increase HIV testing or safer sexual behaviors, one’s readiness to change must be identified. Previous scholarship on Downloaded from qhr.sagepub.com at University of Mount Union on August 24, 2016 8 Qualitative Health Research  readiness to change has been restricted by quantifiable measures. In attempt to streamline the conversation between medical provider and patient, this study aimed to identify verbal markers that could indicate a general level of readiness to change. Combining contemplation ladders and interviews, this study extends the understanding of stages of change by illuminating how participants spoke about perceptions and motivations to alter their safer sex behaviors. Within traditional “mixed-methods” research, triangulation would be used to merge the two sets of data. The goal of this study, however, was to develop an understanding of what various stages of change sound like; therefore, a sequential mixed-methods approach was used as a means of complementarity and development. In other words, the data from the qualitative data were gathered to seek elaboration and illustration of the quantitative data (R. B. Johnson, Onwuegbuzie, & Turner, 2007). Doing so allowed for the identification of stage-specific verbal cues. Verbal cues are thought to provide health practitioners a starting point to guide conversation with young adults seeking to motivate behavior change. While numerous models and theories are abound in health promotion, at the heart of almost all methods of behavior change, two primary goals exist: the first being the need for individuals to assess their own risk factors. Second, and most common, identifying ways one can aid in shifting from pre-contemplation to contemplation. Elder et al. (1999) found that individuals often verbalize a commitment to change to both themselves and to their partners prior to modifying their behaviors. As expected, individuals within the contemplation and action stages of readiness were found to make verbalized understanding of their own need to engage in safer sex practices. Therefore, counselors and doctors working with these populations can, and should, listen carefully for such cues to action. Being able to identify these markers allows for tailored support and motivation that would be most appropriate for the behaviors engaged by the individual. Motivating Movement Through the Stages of Change One method used to assist in motivating a health-behavior chance process is the use of MI (Miller & Rollnick, 2012). During motivational interviews, the medical provider engages in a conversation about the client’s own point of view. To do so, however, the provider must know where a patient sits in terms of readiness to change. By asking the participants “how do you define risk for HIV or STIs,” verbal markers were identified. For those who were not making personal connections with risk, language included “those people” and “not anyone I know.” As a result, it became apparent that these individuals had not yet begun to think about how their own actions might place them at risk. However, phrases such as “everyone is at risk” and “anyone who has sex” indicate a participant’s ability to place himself or herself as someone who has at least considered risk. Once a client’s viewpoint is established, the medical provider or counselor can engage in an open conversation to guide the individuals toward making their own conclusions about risky behaviors. Yet, according Miller and Rollnick (2012), it should be clear the goal within MI practice is not for the provider to give directive advice. Instead, the goal of the provider is to mediate the client’s intrapersonal conversation. Encouraging self-reflection allows for internal cues to populate, resulting in social cognition, which stimulates new understandings of appropriate behaviors. For example, extensive work by DiClemente and Prochaska (2002) identified five internally mediated processes that evoke movement through the various stages of change. These processes include consciousness raising (gaining new information and understanding about behaviors), dramatic relief (experiencing and expressing one’s feelings about a behavior), environmental reevaluation (assessing how a behavior affects the physical environment), social liberation (identify alternatives to the behavior), and selfreevaluation (redefining how one views themselves in relation to the behavior). Within each of these internal processes, the individual has the ability to grow in his or her understanding; however, that growth was connected to the stage of readiness to change (Shinitzky & Kub, 2001). Through guided introspection, providers have an opportunity to help clients explore and acknowledge various levels of ambivalence toward behavior change. For individuals in the pre-contemplation stage, the provider’s focus should be on raising individuals’ awareness of the consequences of not engaging in health-behavior change (Elder et al., 1999). Therefore, given the tendency for pre-contemplators to engage in distancing or “othering” talk, a provider’s focus should be on providing opportunities for self-reflection. For example, if a client describes certain behaviors as being risky, the provider will want to turn the reflection back to the client, “Have you ever engaged in these behaviors?” Allowing the client to make personal connections of severity, susceptibility, as well as self-efficacy creates a sense of control for the client. No longer are the clients being told that they are at risk and need to change; instead, they are thinking about the risk themselves. Medical providers working with contemplators should then be targeting dramatic relief, environmental reevaluation, or social liberation (Horneffer-Ginter, 2008). Individuals at this stage are already able to see some form of personal risk; however, they still require adaption and motivation to make behavior change occur. As a result, providers should closely monitor individuals’ Downloaded from qhr.sagepub.com at University of Mount Union on August 24, 2016 9 Johnson motivations for engaging in the risky health behaviors. Once one’s readiness to change is detected, providers can guide the conversation through ambivalence and shift into motivation (Miller & Rollnick, 2012). Application of Cues to Action for Medical Providers Although physicians and other medical professionals possess a profound opportunity to encourage the modification of people’s behaviors, many lack the tools to communicate sensitive topics (Burke et al., 2007). In 2006, the CDC recommended that all young adults above the age of 16 be screened for HIV infection; yet, studies have continued to find that physicians remain either unaware of these recommendations (Dorell et al., 2011; Minniear et al., 2009; Wong et al., 2013) or simply do not see their patients at risk and, therefore, do not offer HIV tests (Jain, Wyatt, Burke, Sepkowitz, & Begier, 2009). Another common assumption is that patients who are at risk would disclose this information to their physicians and ask for the test themselves (Qaseem, Snow, Shekelle, Hopkins, & Owens, 2009), but it is less likely that young adults will disclose risk factors to physicians voluntarily without some form of prompting (Branson et al., 2006). Participants in the current study, regardless of stage of readiness, believed that a physician beginning the conversation about HIV or STI testing would serve as a significant motivation for thinking about their safer sex behaviors. By applying the notion of cues to action and MI, physicians could initiate a conversation without fear of judgment, given that the initial prompt simply would be about general perceptions of risky behavior. Physicians would not be implying, or even inquiring, about the clients’ behaviors, only their impressions of risk. Listening for the cues to action, physicians could follow up with appropriate questions to motivate their patients to express their concerns or desires for testing. At a minimum, this technique would encourage patients to take a moment and reflect on their own behaviors. Stages of change have long been understood as a continuum and not as static steps; therefore, the ability for anyone to move multidirectionally through the steps is common. The goal for health promoters, at minimum, is to keep the conversation going about what makes certain behaviors risky. If individuals can maintain a contemplative state of mind, greater opportunity for motivation of change exists (Miller & Rollnick, 2012). Talking about the risks of HIV and STIs is vital to preventing further spread of these illnesses. The current study indicates that greater emphasis is needed to break down the continued stereotypes and “taboo” that surrounds HIV. Embracing the Taboo The biggest challenge for modifying safer sex behaviors is the ability to talk about risk. This study supports previous research, finding that many young adults do not make personal connections to risk when it comes to HIV and STIs. However, this study also identified that one cause for this invulnerability is the lack of observing people who are talking about HIV and STIs. Bandura (2004) explained that “even people who are well informed on safer-sex guidelines often err in their subjective appraisal of the extent to which they are putting themselves at risk of HIV infection” (p. 3). As a result, unless college students see themselves at risk for HIV or STIs, they are less likely to be motivated to alter their sexual risk-taking behaviors. Television shows have the potential to highlight the actual settings and characters with which young adults can identify and, thereby, enhance their self-efficacy. These observations could prove capable of affecting viewers’ beliefs that they can, and should, regulate their sexual risk-taking behavior. Regardless of how realistic a television show is or how similar a viewer is to a television character, talking about HIV and STIs is perceived as being taboo. Scholars agree that sex is a personally and socially sensitive topic, with Ingold (2010) arguing that society has established norms about what is appropriate and moral regarding sex. Although cultural narratives have come a long way in terms of talking about sex, many of the participants from this study pointed out that talking about HIV or condoms remains a taboo topic. As a result, the ability to normalize such discussions serves as the greatest barrier to the prevention of HIV and STIs. Until HIV and other sexually related topics are not seen as difficult, taboo topics to talk about with peers, partners, and physicians, it seems unlikely that any intervention will be as effective as is could be. Limitations and Future Research Although this study offers many insights into the perceptions of young adults and the ability to identify verbal markers for motivational interviews, those findings must be interpreted in light of some limitations. At a fundamental level, the findings of this study are limited by the sample; thus, they are not generalizable. In particular, there was not a sufficient amount of diversity among interviewees with regard to demographics. In many cases, only one or two participants were included from various racial backgrounds and sexual orientations. Future research on perceptions should seek to include a more balanced sample by gender, racial background, and sexual orientation. The current study attempted to include as much variety as possible; however, the population of the Downloaded from qhr.sagepub.com at University of Mount Union on August 24, 2016 10 Qualitative Health Research  campus on which the study was conducted, as well as participants’ willingness and ability to meet with the researcher, became problematic. Another limitation of this study was the number of participants in each stage of readiness. Although verbal markers did reach levels of predictably, more work should be done to further test the reliability of the verbal cues. Specifically, future research should apply deductive coding to a larger sample of perceptions of risk to test and identify more fully verbal cues. Additional examination of individuals at the planning and maintenance stages should also be conducted. Although the current participants did not seem to indicate significant levels of distinction between contemplation and planning, this may not be providing the clearest picture. Future studies also should examine if such cues are limited to HIV and STI perceptions or if similar markers can be identified for other risky health behaviors. Although the qualitative data, within the present study, were found to indicate the stage of readiness a participant was in, extensive testing is required before such cues can be used to predict stages with certainty. It should be noted that during the validity review, the two additional researchers were able to accurately predict stages of readiness based on the verbal cues; without seeing the results of the contemplation ladders collected in Phase 1. Therefore, the potential of verbal cues serving as predictors should be further examined. The greatest limitation, and thus, call for future research, is that for cues to action to be identified by counselors or physicians, clients need to be in the office. Therefore, this work still does not complete the larger issue of how to motivate the shift from pre-contemplation to contemplation. However, anytime medical providers conduct health histories, a simple question of how do you define risk of HIV or STIs could spark an opportunity to test and educate. Identifying the need for better representation of safer sex narratives is a starting point; however, more work is needed to understand the types of interventions that are needed to motivate people to start that conversation. Conclusion The CDC states that almost one in eight is unaware of his or her HIV status. Previous studies have identified insufficient time, lack of knowledge/training, lack of patient acceptance, and competing priorities as common barriers for receiving an HIV test (Burke et al., 2007). Often, the most common explanation for the lack of safer sex practice is that knowledge about HIV and other STIs, is not being translated into accurate estimates of risk (Albert & Steinberg, 2011; Ellen et al., 2002; Foster et al., 2011). However, a clinical provider’s interpersonal skills have been identified as successful motivators for people to obtain HIV testing (Leblanc, Flores, & Barroso, 2016). This study had the unique opportunity to build upon the established use of contemplation ladders, as a means of identifying readiness to change, by identifying the verbal cues participants used in early and middle stages. Initial contemplation ladders allowed participants to identify their own readiness to change. Listening to the language used by participants, specific and repetitive vernacular became apparent. Participants at various stages of readiness shared unique phrasing when prompted to speak in general about risk. Thus, it became evident that initial surveys may not be needed if medical providers can be trained to hear externalized cues to action. However, continued work on the predictably of verbal markers is required. Verbal cues were found to provide predictive capabilities, during secondary validity reviews; however, continued testing is vital. The ability to hear vocal prompts and to identify the potential stage of readiness provides important methodological implications for models of behavior change. Identifying phrases, such as “those people,” providers could be given a clue that the patient is “othering” their perceptions of risk, and is likely in a pre-contemplation state. Clients making personal connections, thus remarking with phrases such as “my risk” or “our risk” indicate, at the very least, a stage of contemplation, as they are verbalizing a personal connection to the risk. When listening for verbal cues, medical providers and counselors are presented with a window into how their patient perceives risk. Identifying this perception allows for the first step in behavior modification; defining the stage of readiness. By applying the notion of cues to action, providers can approximate, if not establish, individuals’ readiness to engage in behavior change. Once this stage is identified, providers have the ability to help guide clients through reflection on their own as a way of motivating behavior change. Applying stages of change and MI, health practitioners are able to adjust communication to meet the level or readiness for each client or patient. In other words, by having medical professionals listen for verbal cues, they will be more equipped to adapt and guide each patient with strategic communication. As a result, their clients will learn to identify their own risk behaviors and hopefully advance, at least, to the next stage of readiness. Declaration of Conflicting Interests The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author received no financial support for the research, authorship, and/or publication of this article. Downloaded from qhr.sagepub.com at University of Mount Union on August 24, 2016 11 Johnson References Albarracin D, Ho R, McNatt P, et al. (2000) Structure of outcome beliefs in condom use. Health Psychol, 19: 458–468. doi.org/10.1037/0278-6133.19.5.458 Albert, D., & Steinberg, L. (2011). Judgment and decision making in adolescence. Journal of Research on Adolescence, 21, 211–224. doi:10.1111/j.1532-7795.2010.00724.x Bandura, A. (2004). Health promotion by social cognitive means. Health Education & Behavior, 31, 143–164. doi:10.1177/1090198104263660 Beltzer, N., Saboni, L., Sauvage, C., Lydié, N., Semaille, C., & Warszawski, J. (2013). 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