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

Baseline Predictors of Singular Action Among Participants With Multiple Health Behavior Risks

PURPOSE

Previous studies found that treatment effects can change two behaviors, but not one. This study examined baseline transtheoretical model constructs as three alternative predictors (stage of change, effort, and severity) of singular action among participants with co-occurring health behavior risks.

DESIGN

The study examined participants at risk for three pairs of behaviors (sun and smoking; smoking and diet; and diet and sun). Analyses were conducted with participants who changed only one behavior in a pair (singular action).

SETTING

School and home-based behavior change programs recruited participants via schools, worksites, and physician practices. School, worksite, medical, and home-based prevention programs were the study setting.

SUBJECTS

The sample (N = 3213) was age 44.6 years (SD, 11.1 years), 94.6% white, and 63.7% female.

MEASURES

Stages of change, effort, and severity variables were measured.

ANALYSIS

Pooled data were analyzed using logistic regressions from three randomized controlled trials.

RESULTS

Across all three behaviors, stage of change, effort, and severity effects were consistently related to behavior change at 24 months. Change efforts on one behavior were related to change on another behavior. Baseline sun severity (odds ratio, .97 [.94, 1.00]; p = .046) and smoking severity (odds ratio, .89 [.80, .98]; p = .019) were significant predictors of change on diet at final follow-up.

CONCLUSION

Stage of change was the biggest predictor. Problem severity was the smallest predictor of change at 2-year follow-up. Four of six predictors were within behaviors, whereas two were between.

Treatment Outcome in Male Gambling Disorder Patients Associated with Alcohol Use

Aims: The primary objective of this study was to analyze the association between alcohol consumption and short-term response to treatment (post intervention) in male patients with gambling disorder enrolled in a group cognitive behavioral therapy (CBT) program.

Methods: The sample consisted of 111 male individuals with a diagnosis of Gambling Disorder, with a mean age of 45 years (SD = 12.2). All participants were evaluated by a comprehensive assessment battery and assigned to CBT groups of 10–14 patients attending 16 weekly outpatient sessions lasting 90 min each.

Results: The highest mean pre- and post-therapy differences were recorded for the alcohol risk/dependence group on the obsessive/compulsive and anxiety dimensions of the SCL-90-R. As regards the presence of relapses and dropouts over the course of the CBT sessions, the results show a significant association with moderate effect size: patients with risk consumption or alcohol dependence were more likely to present poor treatment outcomes.

Conclusions: Alcohol abuse was frequent in GD, especially in patients with low family income and high accumulated debts. High levels of somatization and high overall psychopathology (measured by the SCL-90-R) were associated with increased risk of alcohol abuse. Alcohol abuse was also associated with poor response to treatment.

Self-efficacy, pros, and cons as variables associated with adjacent stages of change for regular exercise in Japanese college students

This study examined self-efficacy (confidence to exercise), pros (exercise's advantages), and cons (exercise's disadvantages) as variables associated across the transtheoretical model's six stages of change in 403 Japanese college students. A series of logistic regression analyses were conducted. Results showed that higher pros and lower cons were associated with being in contemplation compared to precontemplation. Lower cons were associated with being in preparation compared to contemplation. Higher self-efficacy was associated with being in action compared to preparation as well as being in maintenance compared to action. Lower cons were associated with being in termination compared to maintenance.

Motivation for HPV Vaccination among Young Adult Men: Validation of TTM Decisional Balance and Self-Efficacy Constructs

Purpose.

In the United States, 36% of human papillomavirus (HPV)–related cancers occur among men. HPV vaccination can substantially reduce the risk of HPV infection; however, the vast majority of men are unvaccinated. This study developed and validated transtheoretical model–based measures for HPV vaccination in young adult men.

Design.

Cross-sectional measurement development.

Setting.

Online survey of young adult men.

Subjects.

Three hundred twenty-nine mostly college-attending men, ages 18 to 26.

Measures.

Stage of change, decisional balance (pros/cons), and self-efficacy.

Analysis.

The sample was randomly split into halves for exploratory principal components analysis (PCA), followed by confirmatory factor analyses (CFA) to test measurement models. Multivariate analyses examined relationships between scales.

Results.

For decisional balance, PCA revealed two uncorrelated five-item factors (pros α = .78; cons α = .83). For the self-efficacy scale, PCA revealed a single-factor solution (α = .83). CFA confirmed that the two-factor uncorrelated model for decisional balance and a single-factor model for self-efficacy. Follow-up analyses of variance supported the theoretically predicted relationships between stage of change, pros, and self-efficacy.

Conclusion.

This study resulted in reliable and valid measures of pros and self-efficacy for HPV vaccination that can be used in future clinical research.

Extending Theory-Based Quantitative Predictions to New Health Behaviors

BACKGROUND

Traditional null hypothesis significance testing suffers many limitations and is poorly adapted to theory testing.

PURPOSE

A proposed alternative approach, called Testing Theory-based Quantitative Predictions, uses effect size estimates and confidence intervals to directly test predictions based on theory.

METHOD

This paper replicates findings from previous smoking studies and extends the approach to diet and sun protection behaviors using baseline data from a Transtheoretical Model behavioral intervention (N = 5407). Effect size predictions were developed using two methods: (1) applying refined effect size estimates from previous smoking research or (2) using predictions developed by an expert panel.

RESULTS

Thirteen of 15 predictions were confirmed for smoking. For diet, 7 of 14 predictions were confirmed using smoking predictions and 6 of 16 using expert panel predictions. For sun protection, 3 of 11 predictions were confirmed using smoking predictions and 5 of 19 using expert panel predictions.

CONCLUSION

Expert panel predictions and smoking-based predictions poorly predicted effect sizes for diet and sun protection constructs. Future studies should aim to use previous empirical data to generate predictions whenever possible. The best results occur when there have been several iterations of predictions for a behavior, such as with smoking, demonstrating that expected values begin to converge on the population effect size. Overall, the study supports necessity in strengthening and revising theory with empirical data.

Understanding self-reported staging of dietary behavior in low-income women

This study examined self-reported staging for the goal of eating a low-fat diet and several specific dietary consumption behaviors to understand better readiness for dieting. Self-assessed motivation, food frequency measures, and psychosocial variables were obtained from 2057 low-income women enrolled in the Maryland Food for Life Program. Results indicated that staging of specific dietary consumption behaviors was significantly related to staging for the global goal of eating a low-fat diet. Women evaluate their motivation about eating low-fat diets based on perceived efforts and specific activities related to dietary consumption with important implications for dietary behavior change measurement and interventions.

Exposure to Theory-Driven Text Messages is Associated with HIV Risk Reduction Among Methamphetamine-Using Men Who have Sex with Men

Fifty-two non-treatment-seeking methamphetamine-using men who have sex with men were enrolled in Project Tech Support, an open-label pilot study to evaluate whether exposure to theory-based [social support theory (SST), social cognitive theory (SCT), and health belief model (HBM)] text messages could promote reductions in HIV sexual risk behaviors and/or methamphetamine use. Multivariable analyses revealed that increased relative exposure to HBM or SCT (vs. SST) text messages was associated with significant reductions in the number of HIV serodiscordant unprotected (i.e., without a condom) anal sex partners, engagement in sex for money and/or drugs, and frequency of recent methamphetamine use; additionally, increased relative exposure to HBM (vs. SCT or SST) messages was uniquely associated with reductions in the overall number of non-primary anal sex partners (all p ≤ 0.05, two-tailed). Pilot data demonstrated that text messages based on the principles of HBM and SCT reduced sentinel HIV risk and drug use behaviors in active methamphetamine users.

Estimating development cost of an interactive website based cancer screening promotion program

OBJECTIVES

The aim of this study was to estimate the initial development costs for an innovative talk show format tailored intervention delivered via the interactive web, for increasing cancer screening in women 50-75 who were non-adherent to screening guidelines for colorectal cancer and/or breast cancer.

METHODS

The cost of the intervention development was estimated from a societal perspective. Micro costing methods plus vendor contract costs were used to estimate cost. Staff logs were used to track personnel time. Non-personnel costs include all additional resources used to produce the intervention.

RESULTS

Development cost of the interactive web based intervention was $.39 million, of which 77% was direct cost. About 98% of the cost was incurred in personnel time cost, contract cost and overhead cost.

CONCLUSIONS

The new web-based disease prevention medium required substantial investment in health promotion and media specialist time. The development cost was primarily driven by the high level of human capital required. The cost of intervention development is important information for assessing and planning future public and private investments in web-based health promotion interventions.

Are Behavioural Interventions Doomed to Fail? Challenges to Self-Management Support in Chronic Diseases

Self-management and self-management support are concepts very familiar to those of us in diabetes care. These concepts require openness to understanding the behaviours of persons with diabetes broadly, not only behaviours restricted to the biomedical perspective. Understanding the importance of health behaviour change and working within the Expanded Chronic Care Model define the context within which self-management support should occur. The purpose of this perspective is to identify a potential limitation in existing self-management support initiatives. This potential limitation reflects provider issues, not patient issues; that is, true self-management support might require changes by healthcare providers. Specifically, although behavioural interventions within the context of academic research studies are evidence based, behaviour change interventions implemented in general practice settings might prove less effective unless healthcare providers are able to shift from a practice based on the biomedical model to a practice based on the self-management support model. The purpose of this article is to facilitate effective self-management support by encouraging providers to switch from a model of care based on the expert clinician encountering the uninformed help seeker (the biomedical model) to one guided by collaboration grounded in the principles of description, prediction and choice. Key to understanding the value of making this shift are patient-centered communication principles and the tenets of complexity theory.

Predictors of Change in Physical Activity and Fruit and Vegetable Intake in a Multiethnic Population in Hawaii at 6 and 12 Months Follow-up

Health-promoting behaviors have been shown to co-exist, but it is unknown if decisional balance with regards to one health behavior may predict change in another behavior. The objective of this study was to examine the relationship between benefits (pros) and costs (cons) of fruit and vegetable (FV) intake and physical activity (PA) and behavior over time, both within behaviors and transbehaviorally. This longitudinal study was conducted in multiethnic adults in Hawaii (n = 700; 63% female; mean age = 47 years; mean BMI = 25.9; mean education = 14.5 years, average household income = $45,000/year). Questionnaires assessed PA and FV pros/cons on a 5-point Likert Scale, PA (MET-min/wk), and FV intake (servings/day). Multiple regression was used to examine the relationship between pros/cons for PA and FV intake and behavior at 6- and 12-month follow-up. At baseline, average FV pros were 4.08 (.91), and average FV cons were 1.88 (.90). Average baseline PA pros were 4.07 (.89), and average PA cons were 1.71 (.77). Multiple regressions revealed that baseline FV pros and cons predicted FV intake, FV cons also predicted PA, and PA pros and cons were not predictive of PA or of FV intake. Study findings provide some support for decisional balance as a useful core construct used in leading theories of behavior change. Improving decisional balance for FV intake may have a beneficial effect on FV intake and potentially PA, indicating a potential gateway effect of decisional balance for FV intake on other behaviors.

Validity and stability of the decisional balance for sun protection inventory

The 8-item Decisional Balance for sun protection inventory (SunDB) assesses the relative importance of the perceived advantages (Pros) and disadvantages (Cons) of sun protective behaviors. This study examined the psychometric properties of the SunDB measure, including invariance of the measurement model, in a population-based sample of N = 1336 adults. Confirmatory factor analyses supported the theoretically based 2-factor (Pros, Cons) model, with high internal consistencies for each subscale (α ≥ .70). Multiple-sample CFA established that this factor pattern was invariant across multiple population subgroups, including gender, racial identity, age, education level, and stage of change subgroups. Multivariate analysis by stage of change replicated expected patterns for SunDB (Pros η² = .15, Cons η² = .02). These results demonstrate the internal and external validity and measurement stability of the SunDB instrument in adults, supporting its use in research and intervention.

Development and validation of green eating behaviors, stage of change, decisional balance, and self-efficacy scales in college students

OBJECTIVE

To develop and validate an instrument to assess environmentally conscious eating (Green Eating [GE]) behavior (BEH) and GE Transtheoretical Model constructs including Stage of Change (SOC), Decisional Balance (DB), and Self-efficacy (SE).

DESIGN

Cross-sectional instrument development survey.

SETTING/PARTICIPANTS

Convenience sample (n = 954) of 18- to 24-year-old college students from a northeastern university.

ANALYSIS

The sample was randomly split: (N1) and (N2). N1 was used for exploratory factor analyses using principal components analyses; N2 was used for confirmatory analyses (structural modeling) and reliability analyses (coefficient α). The full sample was used for measurement invariance (multi-group confirmatory analyses) and convergent validity (BEH) and known group validation (DB and SE) by SOC using analysis of variance.

RESULTS

Reliable (α > .7), psychometrically sound, and stable measures included 2 correlated 5-item DB subscales (Pros and Cons), 2 correlated SE subscales (school [5 items] and home [3 items]), and a single 6-item BEH scale. Most students (66%) were in Precontemplation and Contemplation SOC. Behavior, DB, and SE scales differed significantly by SOC (P < .001) with moderate to large effect sizes, as predicted by the Transtheoretical Model, which supported the validity of these measures.

CONCLUSIONS AND IMPLICATIONS

Successful development and preliminary validation of this 25-item GE instrument provides a basis for assessment as well as development of tailored interventions for college students.

Testing demographic differences for alcohol use initiation among adolescents for the decisional balance and situational temptation prevention inventories

Alcohol use by middle school-aged students is a public health concern because of the numerous adverse social, health and psychological outcomes. Prevention programs attempt to intervene before alcohol use begins. A tailored, computer-delivered program for the prevention of alcohol use and a series of new transtheoretical model measures were developed, including decisional balance (Pros and Cons) of alcohol use and Situational Temptations to Try Alcohol. This study investigated if there were any demographic differences on these measures in a sample of 6th grade middle school students from 20 schools (N=4151) at baseline. Three factorial analysis of variance tests were conducted to explore the impact of race (whites vs. non-whites), ethnicity (Hispanics vs. Non-Hispanics) and gender (males vs. females). A significant two-way interaction effect was found between gender and ethnicity for Pros of Alcohol Use. A significant three-way interaction effect was found between gender, race and ethnicity for Cons of Alcohol Use. Main effects were found for the three demographic factors for Situational Temptations to Try Alcohol. However, the effect sizes for the interaction effects and main effects were very small (all below η(2)=.01), suggesting that race/ethnicity and gender alone may not be highly influential factors in the Decisional Balance for the Prevention of Alcohol and Situational Temptations to Try Alcohol in adolescence. The implications for these results and alcohol use prevention among this group are discussed.

Sustainable transportation stage of change, decisional balance, and self-efficacy scale development and validation in two university samples

Single occupancy vehicle (SOV) transportation is a key contributor to climate change and air pollution. Sustainable transportation (ST), commuting by any means other than SOV, could both slow climate change and enhance public health. The transtheoretical model (TTM) provides a useful framework for examining how people progress towards adopting ST. Short valid and reliable measures for ST decisional balance, self-efficacy, and climate change doubt were developed and their relationship with stages of change was examined. Two large university-based volunteer samples participated in measurement studies. Using multiple procedures, three brief internally consistent measures were developed: decisional balance, self-efficacy, and climate change doubt. The stages of change correctly discriminated both decisional balance and self-efficacy, as well as replicated hypothesized relationships. Climate change doubt did not vary by stages; however, it may prove useful in future studies. Results support the validation of these measures and the application of the TTM to ST.

Cervical cancer screening and psychosocial barriers perceived by patients. A systematic review

Aim of the study

This study aimed at integrating research discussing the role of perceived psychosocial barriers in cervical cancer screening (CCS) uptake. In particular, we analyzed the evidence for the associations between CCS uptake and perceived psychosocial barriers and frequency of psychosocial barriers identified by women.

Material and methods

A systematic search of peer-reviewed papers published until 2011 in 8 databases yielded 48 original studies, analyzing data obtained from 155 954 women. The majority of studies (k = 43) applied correlational design, while 5 had experimental design.

Results

Experimental research indicated a positive effect of 75% of psychosocial interventions targeting barriers. The interventions resulted in a significant increase of CCS uptake. Overall 100% of correlational studies indicated that perceiving lower levels of barriers significantly predicted higher CCS uptake. 53 psychosocial barriers were listed in at least 2 original correlational studies: 9.5% of barriers were related to CCS facilities/environment, 67.9% dealt with personal characteristics of the patient, and 22.6% addressed social factors. As many as 35.9% of perceived barriers referred to negative emotions related to CCS examination procedures and collecting CCS results, whereas 25.7% of barriers referred to prior contacts with health professionals.

Conclusions

Leaflets or discussion on psychosocial barriers between patients and health professionals involved in CCS might increase CCS uptake and thus reduce cervical cancer mortality rates. Communication skills training for health professionals conducting CCS might focus on the most frequently reported barriers, referring to emotions related to CCS examination and collecting CCS results.

Acceptability and Feasibility of a Culturally Tailored Internet-Delivered Intervention to Promote Blood Donation in Blacks

Introduction. A pilot test of a computer-tailored intervention designed to promote blood donation among Blacks was conducted. Method. Intervention content, based on the transtheoretical model, offered participants individually and culturally tailored information on blood donation with emphasis on need specific to race (e.g., sickle-cell disease). Black adults ( N = 150) with a diversity of blood donation experience were recruited from a blood center and a survey recruitment website. Posttest assessment included a 14-item evaluation and transtheoretical model questions. Results. Participants rated the program positively (81.3% to 98.7% of participants agreeing or strongly agreeing with evaluation items). For example, 98.7% of respondents reported that the program gave sound advice and that personal feedback was easily understood, and 87.3% felt the program was designed for people like themselves. Ninety-five percent of participants reported that they would recommend the program to others. There were no significant differences in ratings based on demographics. Qualitative responses support program acceptability. Furthermore, pre- and postprogram assessments indicated an increase in intention to donate, t(149) = 3.56, p = .001, d = .29. Discussion. With acceptability and feasibility confirmed, the next steps are to test efficacy and cost-effectiveness for use to increase blood donation, particularly in priority populations.

Early dropout predictive factors in obesity treatment

Diet attrition and failure of long term treatment are very frequent in obese patients. This study aimed to identify pre-treatment variables determining dropout and to customise the characteristics of those most likely to abandon the program before treatment, thus making it possible to modify the therapy to increase compliance. A total of 146 outpatients were consecutively enrolled; 73 patients followed a prescriptive diet while 73 followed a novel brief group Cognitive Behavioural Treatment (CBT) in addition to prescriptive diet. The two interventions lasted for six months. Anthropometric, demographic, psychological parameters and feeding behaviour were assessed, the last two with the Italian instrument VCAO Ansisa; than, a semi-structured interview was performed on motivation to lose weight. To identify the baseline dropout risk factors among these parameters, univariate and multivariate logistic models were used. Comparison of the results in the two different treatments showed a higher attrition rate in CBT group, despite no statistically significant difference between the two treatment arms (P = 0.127). Dropout patients did not differ significantly from those who did not dropout with regards to sex, age, Body Mass Index (BMI), history of cycling, education, work and marriage. Regardless of weight loss, the most important factor that determines the dropout appears to be a high level of stress revealed by General Health Questionnaire-28 items (GHQ-28) score within VCAO test. The identification of hindering factors during the assessment is fundamental to reduce the dropout risk. For subjects at risk, it would be useful to dedicate a stress management program before beginning a dietary restriction.

Evaluation of the acceptability and feasibility of a computer-tailored intervention to increase human papillomavirus vaccination among young adult women

OBJECTIVE

To examine acceptability and feasibility of a Transtheoretical Model (TTM)-based computer-tailored intervention (CTI) for increasing human papillomavirus (HPV) vaccination in college-aged women.

PARTICIPANTS

Two hundred forty-three women aged 18-26 were recruited between February and May of 2011.

METHODS

Participants completed the intervention and a 14-item evaluation of intervention content and delivery.

RESULTS

Most participants had heard of HPV (91%), but the majority (57%) of participants were in Precontemplation for getting vaccinated. Eighty-nine percent of participants rated the CTI positively across all acceptability items, and 91% endorsed intention to get vaccinated after intervention. Although average ratings in each demographic subgroup were positive, Hispanic women and participants in more advanced stages of change rated the program more favorably than non-Hispanic and earlier-stage participants. Additionally, HPV knowledge was higher among white/non-Hispanic participants.

CONCLUSIONS

Initial acceptability and feasibility data for this intervention are promising. Its computer-based, individually tailored format is state of the art and ideal for inexpensive dissemination.

Protecting adolescents from self-harm: a critical review of intervention studies

OBJECTIVE

To review the studies that test treatments targeting adolescent suicidal ideation, suicide attempts, or self-harm, and to make recommendations for future intervention development.

METHOD

The extant randomized clinical trials that aim to reduce the intensity of suicidal ideation or the recurrence of suicide attempts or self-harm were reviewed with respect to treatment components, comparison treatments, sample composition, and outcomes.

RESULTS

The majority of studies that showed any effect on suicidal ideation, attempts, or self-harm had some focus on family interactions or nonfamilial sources of support. Two of the most efficacious interventions also provided the greatest number of sessions. Some other treatment elements associated with positive effects include addressing motivation for treatment and having explicit plans for integrating the experimental treatment with treatment as usual. In many studies, suicidal events tend to occur very early in the course of treatment prior to when an effective "dose" of treatment could be delivered. Important factors that might mitigate suicidal risk, such as sobriety, healthy sleep, and promotion of positive affect, were not addressed in most studies.

CONCLUSION

Interventions that can front-load treatment shortly after the suicidal crisis, for example, while adolescent suicide attempters are hospitalized, may avert early suicidal events. Treatments that focus on the augmentation of protective factors, such as parent support and positive affect, as well as the promotion of sobriety and healthy sleep, may be beneficial with regard to the prevention of recurrent suicidal ideation, attempts, or self-harm in adolescents.

Coaction in multiple behavior change interventions: consistency across multiple studies on weight management and obesity prevention

OBJECTIVE

Coaction refers to the extent to which taking action on one behavior increases the odds of taking action on a second behavior. This integrative study examines the generalization of coaction in three studies on weight-related behaviors.

METHOD

Data from three randomized trials of tailored interventions (n = 1,277, n = 1,800, and n = 6,000) were examined to determine if coaction of behavior change occurred differentially in treatment and control groups. In each analysis, the likelihood of progressing to the Action or Maintenance stages for the target behaviors was evaluated using logistic regression.

RESULTS

Despite differences in populations, targeted behaviors, levels of tailoring in interventions, and timing of follow-up assessments, 17 out of 24 (70.8%) logistic regressions revealed significant coaction in the treatment group as opposed to only three out of 24 (12.5%) in the control condition. In 23/24 analyses, coaction of behavior change was larger on an absolute basis in the treatment group. Individuals in the treatment group progressing to Action/Maintenance for one behavior were 1.4-5 times more likely to make progress on another behavior compared to those in the treatment group who did not make such progress on the first behavior.

CONCLUSIONS

This study demonstrates that despite considerable variability in study design, coaction reliably occurs more in the presence of Transtheoretical-Model based multiple behavior change interventions. Additional studies are needed to replicate these results in other behavioral areas and to examine the predictors of differential coaction. The ability to consistently create coaction within multiple behavior interventions can increase the efficacy and cost-effectiveness of multiple behavior change interventions.

Measuring kidney patients' motivation to pursue living donor kidney transplant: development of stage of change, decisional balance and self-efficacy measures

While educational interventions to increase patient motivation to pursue living donor kidney transplant have shown success in increasing living donor kidney transplant rates, there are no validated, theoretically consistent measures of Stage of Change, a measure of readiness to pursue living donor kidney transplant; Decisional Balance, a weighted assessment of living donor kidney transplant's advantages/disadvantages; and Self-Efficacy, a measure of belief that patients can pursue living donor kidney transplant in difficult circumstances. This study developed and validated measures of these three constructs. In two independent samples of kidney patients (N 1 = 279 and N 2 = 204), results showed good psychometric properties and support for their use in the assessment of living donor kidney transplant interventions.

Measuring the processes of change for increasing blood donation in black adults

BACKGROUND

Blacks have significantly lower blood donation rates than whites. Many views, experiences, and behaviors associated with blood donation are unique to black culture. Evidence suggests that culturally tailored health promotion programs help with increasing black blood donation. To be effective, tailored interventions should be based on valid and reliable measures. The Transtheoretical Model's (TTM) Processes of Change (POC) construct provides an assessment of participants' covert and overt activities and experiences in blood donation. This study describes development and validation of POC for increasing blood donation tailored to blacks.

STUDY DESIGN AND METHODS

Cross-sectional measure development with online survey dissemination was used in 566 blacks in the Northeastern United States. Factor analytic structural modeling procedures were used to examine validity of the POC measure. Blood donation POC were examined in participants representing a range of blood donation history and intentions (nondonors, sometimes donors, regular donors) based on an established algorithm.

RESULTS

Confirmatory analyses replicated the theoretically expected structure of POC scales which is a 10-factor, fully correlated best-fit model. Expected POC patterns by Stages of Change based on theoretical and empirical predictions were confirmed. The range of effect sizes for 10 POC were η(2) = 0.04 to 0.25, indicating that TTM POC are strong strategies in blood donation decision making for blacks and can be applied to interventions to increase blood donation for a minority population.

CONCLUSION

POC measure was internally and externally valid in a sample of blacks. Interventions can utilize the POC measure to guide stage-matched interventions to encourage use of relevant experiential and behavioral strategies to increase blood donation.

Building a tobacco cessation telehealth care management program for veterans with posttraumatic stress disorder

BACKGROUND

Veterans with posttraumatic stress disorder (PTSD) have high rates of smoking. Motivational interviewing (MI) enhances readiness for change.

OBJECTIVE

To test the feasibility and fidelity of home telehealth care management strategy to improve quit rates.

DESIGN

A telehealth device delivered a cessation curriculum while a nurse supported veterans through weekly MI telephone calls. Treatment fidelity was evaluated. Outcomes measures included changes in smoking behaviors, stage of change, dose effect, and participant satisfaction with intervention.

RESULTS

There was a correlation (r = -.677; p = .03) at the end of treatment between readiness to change and number of cigarettes smoked per day. As 11 participants progressed along stages of change, they smoked fewer cigarettes per day. Two (20%) quit smoking. The nurse adhered to MI principles. Participants were highly satisfied and 100% felt curriculum delivered new information and respected choices.

CONCLUSIONS

It was feasible to deliver the home telehealth care management intervention with high treatment fidelity. Participants were motivated to change smoking behaviors.

Validation of decisional balance and self-efficacy measures for HPV vaccination in college women

PURPOSE

Women younger than 25 years are at greatest risk for human papillomavirus (HPV) infection, including high-risk strains associated with 70% of cervical cancers. Effective model-based measures that can lead to intervention development to increase HPV vaccination rates are necessary. This study validated Transtheoretical Model measures of Decisional Balance and Self-Efficacy for seeking the HPV vaccine in a sample of female college students.

DESIGN

Cross-sectional measurement development. Setting. Online survey of undergraduate college students.

SUBJECTS

A total of 340 female students ages 18 to 26 years.

MEASURES

Stage of Change, Decisional Balance, and Self-Efficacy.

ANALYSIS

The sample was randomly split into halves for exploratory principal components analyses (PCAs), followed by confirmatory factor analyses (CFAs) to test measurement models. Multivariate analyses examined relationships between constructs.

RESULTS

For Decisional Balance, PCA indicated two 4-item factors (Pros -α = .90; and Cons -α = .66). CFA supported a two-factor correlated model, χ(2)(19) = 39.33; p < .01; comparative fit index (CFI) = .97; and average absolute standardized residual statistic (AASR) = .03; with Pros α = .90 and Cons α = .67. For Self-Efficacy, PCA indicated one 6-item factor (α = .84). CFA supported this structure, χ(2)(9) = 50.87; p < .05; CFI = .94; AASR = .03; and α = .90. Multivariate analyses indicated significant cross-stage differences on Pros, Cons, and Self-Efficacy in expected directions.

CONCLUSION

Findings support the internal and external validity of these measures and their use in Transtheoretical Model-tailored interventions. Stage-construct relationships suggest that reducing the Cons of vaccination may be more important for HPV than for behaviors with a true Maintenance stage.

Internists' views of maintenance of certification: a stages-of-change perspective

INTRODUCTION

Board certification has evolved from a "point-in-time" event to a process of periodic learning and reevaluation of medical competence through maintenance of certification (MOC). To better understand MOC participation, the transtheoretical model (TTM) was used to describe physicians' perceptions of MOC as a sequence of attitudinal changes.

METHOD

Data were from a survey of internal medicine (IM) physicians' attitudes toward periodic reevaluation through MOC. An overall importance or decisional balance score was computed for each physician by summing his or her ratings across the 10 quality measures. The decisional balance score was used to classify physicians according to their acceptance of MOC, aligned with the 3 early TTM stages-of-change groups-precontemplation (PC), contemplation (C), and preparation (P)-where PC was least accepting and P was most accepting. Effect sizes assessed whether differences in attitudes toward reevaluation via MOC were of sufficient magnitude to support the TTM principles.

RESULTS

The difference in degree of acceptance of MOC between the P group and the PC and C groups was significant (p < 0.001), but the effect size was lower than predicted by the "strong" principle. Resistance to MOC for the PC and C groups was significantly greater than the P group (p < 0.001) and supported the "weak" principle. Physicians' beliefs about how often they should demonstrate performance on quality measures aligned well with the American Board of Internal Medicine's MOC requirements, with the P group believing in more frequent assessments than the PC and C groups (p < 0.001).

CONCLUSIONS

Results show that physicians in the Preparation stage had overcome resistance to MOC as predicted by the "weak" principle of the TTM, but their attitude scores about the benefits of MOC were below what was expected by theory. This suggests that the structure of MOC may have made it easier for physicians to overcome barriers to MOC participation but may have lacked adequate resources to promote the benefits of participating in the process. More effort is needed to understand the specific benefits of MOC for reevaluating competencies, how to engage physicians and other stakeholders in the design of MOC, and how to communicate the rationale and evidence to those who are less accepting of MOC.

Factor structure of decisional balance and temptations scales for smoking: cross-validation in urban female African-American adolescents

BACKGROUND

The transtheoretical model is an influential theoretical model in health psychology, particularly in its application to smoking cessation research. Decisional Balance (DB) and Temptations are key constructs within this framework.

PURPOSE

This study examines the psychometric properties of the DB and Temptations scales for smoking in a predominantly African-American sample of urban adolescent girls.

METHODS

We used confirmatory factor analysis to compare the fit of previously published factor structures in smokers (n = 233) and nonsmokers (n = 598). External validity was tested by examining stages of change differences in the retained subscales.

RESULTS

Results supported the internal and external validity of the DB scale for smokers and nonsmokers. Notably, previously published three-factor (Social Pros, Coping Pros, Cons) and four-factor (Cons split into "Aesthetic Cons" and "Health Cons") models fit equally well, with Cons subscales correlating highly. For Temptations, a previously published three-factor (Negative Affect, Social, Weight Control) hierarchical model fit well in nonsmokers. In smokers, previously published subscales were reliably measured, but their structural relationship remained unclear. Stage difference tests showed medium to large effect sizes of DB and Temptation subscales in smokers and nonsmokers.

CONCLUSIONS

The use of DB was validated for both smokers and nonsmokers in this sample of primarily African-American adolescent females, where Cons can be combined or separated into "Aesthetic Cons" and "Health Cons" based on practical utility and preference. For Temptations, more research is needed but large stage differences in Temptations subscales underscore the importance of this concept in smoking acquisition and cessation.

Motivating Factors and Psychosocial Barriers to Condom Use among out-of-School Youths in Dar es Salaam, Tanzania: A Cross Sectional Survey Using the Health Belief Model

Condoms remain a cost-effective and relatively simple intervention to prevent HIV infection. However, condom use is still very low, particularly among youths aged 15 to 24. 348 individuals (186 males and 162 females) completed a pre-tested questionnaire. Logistic regression analysis was used to identify factors associated with condom use. Out of 348 respondents, 296 (85.0%) were sexually experienced, and 260 (87.8%) reported noncondom use in the past 3 months prior to the study. Among men, noncondom use was independently associated with feeling shy to buy condoms (AOR = 1.16; 95% CI 1.12–1.34), condoms reducing sexual pleasure (AOR = 8.19; 95% CI 3.98–17.01), and HIV is a serious and deadly disease (AOR = 0.36; 95% CI 0.28–0.46). Among women, experiencing forced sex (AOR = 1.16; 95% CI 1.10–2.78), condoms reduce sexual pleasure (AOR = 8.29; 95% CI 3.36–20.73), and inability to convince a partner to use condoms (AOR = 1.14; 95% CI 1.04–1.28) were predictors of noncondom use. In conclusion, sexually active youths in this population practice risky sexual behaviours, with low condom use practices. Strategies to improve condom use should address these psychosocial barriers associated with noncondom use.

Disruptive innovations for designing and diffusing evidence-based interventions

Evidence-based therapeutic and preventive intervention programs (EBIs) have been growing exponentially. Yet EBIs have not been broadly adopted in the United States. In order for our EBI science to significantly reduce disease burden, we need to critically reexamine our scientific conventions and norms. Innovation may be spurred by reexamining the traditional biomedical model for validating, implementing, and diffusing EBI products and science. The model of disruptive innovations suggests that we reengineer EBIs on the basis of their most robust features in order to serve more people in less time and at lower cost. A disruptive innovation provides a simpler and less expensive alternative that meets the essential needs for the majority of consumers and is more accessible, scalable, replicable, and sustainable. Examples of disruptive innovations from other fields include minute clinics embedded in retail chain drug stores, $2 generic eyeglasses, automated teller machines, and telemedicine. Four new research approaches will be required to support disruptive innovations in EBI science: synthesize common elements across EBIs; experiment with new delivery formats (e.g., consumer controlled, self-directed, brief, paraprofessional, coaching, and technology and media strategies); adopt market strategies to promote and diffuse EBI science, knowledge, and products; and adopt continuous quality improvement as a research paradigm for systematically improving EBIs, based on ongoing monitoring data and feedback. EBI science can have more impact if it can better leverage what we know from existing EBIs in order to inspire, engage, inform, and support families and children to adopt and sustain healthy daily routines and lifestyles.

Validation of the measures of the transtheoretical model for exercise in an adult African-American sample

PURPOSE

African-Americans have high rates of physical inactivity-related morbidity and mortality, thus effective interventions to increase exercise are necessary. Tailored interventions show promise, but measures need validation in this population. This study validated transtheoretical model measures for exercise in an African-American sample.

DESIGN

Cross-sectional measure development.

SETTING

Telephone survey of individuals in North Carolina.

SUBJECTS

521 African-American adults.

MEASURES

Stages of change, decisional balance (pros and cons), self-efficacy and processes of change (POC) for regular exercise.

ANALYSIS

Confirmatory factor analyses tested measurement models. Multivariate analyses examined relationships between each construct and stages of change.

RESULTS

For decisional balance, the two-factor uncorrelated model was the most parsimonious good-fitting model (χ(235) = 158.76; comparative fit index [CFI], .92; average absolute standardized residual [AASR], .04), and alphas were good (pros α = .85 and cons α = .74). The one-factor model for self-efficacy (α = .80) revealed an excellent fit (χ(29) = 45.51; CFI, .96; AASR, .03). For the POC subscales with good alphas (α = .62-.91), a 10-factor fully correlated model fit best (χ(2)[360] = 786.75; CFI, .91; AASR, .04). Multivariate analyses by stage of change replicated expected patterns for the pros, self-efficacy, and POC measures with medium-sized effects (η(2)  =  .05-.13). Results by stage of change did not replicate for the cons scale.

CONCLUSIONS

The structures of these measures replicated with good internal and external validity, except for the cons scale, which requires additional development. Results support the use of these measures in tailored interventions to increase exercise among African-Americans.

Concepts of healthful food among low-income African American women

OBJECTIVE

Describe beliefs about what makes foods healthful among low-income African American women.

METHODS

In one-on-one interviews, 28 low-income African American mothers viewed 30 pairs of familiar foods and explained which food in the pair was more healthful and why. Responses were grouped into codes describing concepts of food healthfulness.

RESULTS

Nutrient content, physical effects of food, and food categories were used to judge the healthfulness of foods. Fruits, vegetables, and dairy foods were considered the most healthful and starchy foods the least healthful because they were believed to cause weight gain. Beliefs about which foods contain which nutrients and which foods have particular physical effects varied widely across participants.

CONCLUSIONS AND IMPLICATIONS

Participants demonstrated awareness of which foods are healthful but lacked understanding of why those foods are more healthful than others. Knowledge about the health effects of foods may be necessary to motivate individuals to choose healthful foods.

Psychosocial correlates of alcohol use and reduction for individuals with hepatitis C

OBJECTIVE

Patients with hepatitis C virus (HCV) are advised to refrain from alcohol consumption. A questionnaire was developed to measure concepts associated with alcohol use for individuals with HCV.

METHOD

Subjects with HCV (N = 527) completed a telephone survey. Eligible respondents had screened negative for current abuse/dependence disorders (Alcohol Use Disorders Identification Test [AUDIT] ≤ 10). Measures of personality, self-efficacy, knowledge, readiness, coping styles, stigma, and symptoms were examined for associations with alcohol use.

RESULTS

Factor analysis supported a measurement structure of 105 items in 35 subdomains. A total of 26 subdomains had significant bivariate associations with alcohol use. Higher self-efficacy for resisting drinking in social situations was associated with lower alcohol use (r = -.68, p < .001), as was knowledge of alcohol and HCV (r = -.27, p < .001). Although agreeableness and marital status are typically associated with lower current drinking in samples of those with alcohol use problems, in our study agreeableness (β = .13, p < .01) and marital status (β = .08, p < .05) were modestly associated with higher current drinking. The final multivariate R² was .55.

CONCLUSIONS

The pattern of associations suggests the importance of the social aspects of drinking for drinking decisions. Existing brief interventions will need to be tailored to a contextualized psychosocial model for medical patients with HCV and AUDIT scores ≤ 10 to optimize effectiveness. Such future interventions should emphasize the potential medical hazards of drinking for persons with HCV, the maintenance of social relationships in the absence of alcohol use, and strategies for building confidence for resisting drinking in specific situations.

Promoting advance care planning as health behavior change: development of scales to assess Decisional Balance, Medical and Religious Beliefs, and Processes of Change

OBJECTIVE

To develop measures representing key constructs of the Transtheoretical Model (TTM) of behavior change as applied to advance care planning (ACP) and to examine whether associations between these measures replicate the relationships posited by the TTM.

METHODS

Sequential scale development techniques were used to develop measures for Decisional Balance (Pros and Cons of behavior change), ACP Values/Beliefs (religious beliefs and medical misconceptions serving as barriers to participation), Processes of Change (behavioral and cognitive processes used to foster participation) based on responses of 304 persons age≥65 years.

RESULTS

Items for each scale/subscale demonstrated high factor loading (>.5) and good to excellent internal consistency (Cronbach α .76-.93). Results of MANOVA examining scores on the Pros, Cons, ACP Values/Beliefs, and POC subscales by stage of change for each of the six behaviors were significant, Wilks'λ=.555-.809, η(2)=.068-.178, p≤.001 for all models.

CONCLUSION

Core constructs of the TTM as applied to ACP can be measured with high reliability and validity.

PRACTICE IMPLICATIONS

Cross-sectional relationships between these constructs and stage of behavior change support the use of TTM-tailored interventions to change perceptions of the Pros and Cons of participation in ACP and promote the use of certain Processes of Change in order to promote older persons' engagement in ACP.

Drinking patterns of pathological gamblers before, during, and after gambling treatment

Despite the high co-occurrence of alcohol consumption and gambling, few studies have investigated alcohol use changes during gambling treatment. Using latent growth modeling, we examined weekly alcohol use trajectories of treatment-seeking pathological gamblers across 36 weeks, allowing rates of change to differ across the 12-week pretreatment, during-treatment and posttreatment periods. For these secondary data analyses, we retained drinking gamblers (N = 163) from a combined sample of two randomized clinical trials for the treatment of pathological gambling. Results indicated a decrease in alcohol use corresponding with treatment entry and maintenance of less drinking during treatment and posttreatment. Despite these decreases in alcohol use overall, 31% (50 of 163) of participants exhibited risky drinking during the treatment or posttreatment periods. Gender, age, at-risk drinking (at any point in the 36-week interval), baseline gambling severity, treatment condition, and gambling during treatment predicted latent alcohol use growth factors. Although entry into gambling treatment was temporally associated with reductions in alcohol use in this retrospective analysis, a substantial portion of the sample exhibited at-risk drinking after treatment entry, suggesting that interventions targeting reductions in alcohol use may be useful for this population.

Prevention of alcohol use in middle school students: psychometric assessment of the decisional balance inventory

A measurement model should be equivalent across the different subgroups of a target population. The Decisional Balance Inventory for the Prevention of Alcohol Use is a 2-factor correlated model with 3 items for Pros of alcohol use and 3 items for Cons. The measure is part of a tailored intervention for middle school students. This study evaluated the important psychometric assumptions of factorial invariance and scale reliability with a large sample of sixth grade students (N=3565) from 20 schools. A measure is factorially invariant when the model is the same across subgroups. Three levels of invariance were assessed, from least restrictive to most restrictive: 1) Configural Invariance (unconstrained nonzero factor loadings); 2) Pattern Identity Invariance (equal factor loadings); and 3) Strong Factorial Invariance (equal factor loadings and measurement errors). Structural equation modeling was used to assess invariance over two levels of gender (male and female), race (white and black), ethnicity (Hispanic and non-Hispanic), and school size (large, indicating >200 students per grade, or small). The strongest level of invariance, Strong Factorial Invariance, was a good fit for the model across all of the subgroups: gender (CFI: 0.94), race (CFI: 0.96), ethnicity (CFI: 0.93), and school size (CFI: 0.97). Coefficient alpha was 0.61 for the Pros and 0.67 for Cons. Together, invariance and reliability provide strong empirical support for the validity of the measure.

Stages of change

The transtheoretical model, in general, and the stages of change, in particular, have proven useful in adapting or tailoring treatment to the individual. We define the stages and processes of change and then review previous meta-analyses on their interrelationship. We report an original meta-analysis of 39 studies, encompassing 8,238 psychotherapy patients, to assess the ability of stages of change and related readiness measures to predict psychotherapy outcomes. Clinically significant effect sizes were found for the association between stage of change and psychotherapy outcomes (d = .46); the amount of progress clients make during treatment tends to be a function of their pretreatment stage of change. We examine potential moderators in effect size by study outcome, patient characteristics, treatment features, and diagnosis. We also review the large volume of behavioral health research, but scant psychotherapy research, that demonstrates the efficacy of matching treatment to the patient's stage of change. Limitations of the extant research are noted, and practice recommendations are advanced.

Establishing construct validity of a stages-of-change algorithm for physical activity

PURPOSE

Examine the construct validity of a modified stages-of-change (SOC) scale among adults with physical disabilities by investigating the relations among the transtheoretical model (TTM) constructs, physical activity (PA), and SOC. Additionally, the SOC algorithm was compared with previously recommended SOC scales.

DESIGN/SETTING

Cross-sectional online survey.

SUBJECTS

271 adults with physical disabilities (x(age)  =  49.25; 73.4% females).

MEASURES

Standardized questionnaires for the TTM constructs and PA. ANALYSES/RESULTS: Based on the multivariate analysis of variance, the hypothesized relations between the SOC and the TTM constructs were supported. According to the analysis of variance, PA levels increased almost linearly across the SOC. Precontemplators (x =  8.53 metabolic equivalent [MET]-h/d) had lower PA scores than contemplators (x  =  14.27 MET-h/d) and preparators (x  =  17.64 MET-h/d), who in turn had lower scores than those in action (x  =  23.03 MET-h/d). Based on the direct discriminant function analysis, all TTM constructs were important predictors of the SOC (e.g., r  =  .85 for behavioral processes; r  =  .69 for self-efficacy; and r  =  .58 for cognitive processes). The most accurately predicted SOC were action (76.9%), precontemplation (70.6%), contemplation (44.6%), and preparation (14.9%), with an overall classification accuracy of 56.8%. The study participants were more evenly distributed across the SOC algorithm compared with previous studies.

CONCLUSION

The construct validity of the SOC scale was supported. The scale differentiated almost linearly the levels of PA and most TTM constructs, and participants were well-represented across SOC. Health promoters should feel confident in using the proposed SOC scale and the TTM to implement stage-matched PA motivational programs.

Predicting oral contraceptive continuation using the transtheoretical model of health behavior change

CONTEXT

Improved continuation of oral contraceptive use may decrease the incidence of unintended pregnancy. Therefore, identifying predictors of continuation is important to informing targeted interventions.

METHODS

A survey conducted in 2003-2005 collected data from young women who sought oral contraceptives at three family planning clinics in New York, Dallas and Atlanta. Cluster analysis of data from 1,245 women was used to identify three distinct groups on the basis of baseline responses to items measuring constructs from the transtheoretical model of health behavior change: perceived advantages of pill use, perceived disadvantages and self-confidence in ability to sustain use. Logistic regression was used to assess the likelihood of continuation among the clusters.

RESULTS

Participants who were confident in their ability to use the pill and who considered both its advantages and its disadvantages important were more likely to continue use for six months than were those who gave low scores to the method's advantages and their ability to use it (odds ratio, 1.4). The same appeared to be true for those who gave high scores to the pill's advantages and their ability to use it, but a low score to the method's disadvantages (1.3); however, this finding was only marginally significant. Demographic variables were not significant after adjustment for cluster membership.

CONCLUSIONS

Cluster membership based on transtheoretical model constructs helps predict oral contraceptive continuation. Women who undervalue the advantages of pill use and have low confidence in their ability to use the method represent a target for interventions and future research.