Cognitive-behavioral mediators of changing multiple behaviors: smoking and a sedentary lifestyle

Smoking, exercise and dietary behaviors among mothers of elementary school-aged children in a rural North Carolina county

Tobacco use, poor diet, and physical inactivity are risk behaviors established during childhood and influenced by parents. Improving health habits of rural families poses particular challenges because resources may be limited in number and reach. To characterize the kinds of prevention programs needed by rural families, 501 surveys were mailed to caregivers of elementary school children living in a rural North Carolina county. Health behaviors, related attitudes, and demographic characteristics were assessed. Risk behaviors were defined as eating less than 5 fruits and vegetables a day, exercising less than 20 minutes 3 times a week, and being a smoker. Two hundred and sixty-one adults (55%) completed the surveys. Two hundred and forty-four (93%) were female, with a mean age of 37 years, 55% had a high school or less education, 89% reported at least one risk behavior, and 57% reported 2 or more risk behaviors. Female caregivers with multiple risk behaviors had lower educational levels (p < 0.007) and placed less importance on children's health behaviors (p < 0.009) than other caregivers. Female caregivers with multiple risk behaviors were no less confident they could change their behavior than those with only one risk behavior. The majority of female caregivers of elementary school children in this rural population engaged in and modeled multiple health risk behaviors for their children. Health promotion activities that address multiple risk factors and involve children are needed by young families in rural communities.

The transtheoretical model of behavior change: a meta-analysis of applications to physical activity and exercise

The purpose of this study was to summarize findings from empirical applications of the transtheoretical model (TTM) (Prochaska & DiClemente, 1983) in the physical activity domain by using the quantitative method of meta-analysis. Ninety-one independent samples from 71 published reports were located that present empirical data on at least one core construct of the TTM applied to exercise and physical activity. In general, results support the application because core constructs differ across stages and most changes are in the direction predicted by the theory. Three general conclusions are offered. First, existing data are unable to confirm whether physical activity behavior change occurs in a series ofstages that are qualitatively different or along adjacent segments of an underlying continuum. Second, the growing number of studies that incorporate TTM concepts means that there is an increasing need to standardize and improve the reliability of measurement. Finally, the role ofprocesses of change needs reexamining because the higher order constructs are not apparent in the physical activity domain and stage-by-process interactions are not evident. There now are sufficient data to confirm that stage membership is associated with different levels of physical activity, self-efficacy, pros and cons, and processes of change. Further studies that simply stage participants or examine cross-sectional differences between core constructs of the TTM are of limited use. Future research should examine the moderators and mediators of stage transition.

Theoretical applications of smoking cessation interventions to individuals with medical conditions: women's initiative for nonsmoking (WINS)-part III

This paper reviews the Theory of Self-Efficacy, Transtheoretical Model of Readiness for Change, and Theory of Addictions to provide a basis for smoking cessation, and explores how these theories have been used to guide clinical research and clinical interventions. Selected randomized controlled trials of the past ten years are reviewed for demonstrated efficacy, integration of theory into the design of the interventions, and how theories guide analysis. Results show that surprisingly little effort has been put forth to examine and develop these theories within the context of clinical interventions, despite the claims of importance. For example, the relationship between stages of readiness of change and smoking cessation outcome has not been examined. Despite the complexity of smoking behaviors (quitting, relapsing, maintaining, occasional smoking and so on), the concept of self-efficacy was mostly measured on single occasions over the course of most studies reviewed; multiple measurements of concepts were not utilized in the randomized controlled trials. Taking into account the gaps between theory and application, theory driven nursing strategies are offered.

Behavioral risk factors among members of a health maintenance organization

BACKGROUND

Co-occurrence of risk behaviors (RBs) substantially increases the risk of disease. This study examines the co-occurrence of four health risk behaviors (i.e., smoking, high-fat diet, sedentariness, and high-risk drinking) and demographic and psychosocial variables associated with number of RBs in a sample of members of a health maintenance organization who participated in the Seasonal Variation in Cholesterol (Seasons) study.

METHODS

Seasons study baseline data were used. Subjects completed a self-administered questionnaire packet containing questions on demographics, smoking history, and leisure-time physical activity, a 7-day dietary recall instrument, and various psychosocial measures. Results presented here are based on 496 subjects with complete data on all RBs.

RESULTS

Forty-three percent of participants had > or = two RBs. The most prevalent RB combination was high-fat diet/sedentariness, with 30% of subjects reporting both RBs. Associations between RBs were observed. A greater number of RBs were observed among younger and less-educated subjects, those with higher depression scores, and subjects who perceived their health as poor.

CONCLUSIONS

Findings highlight the importance of designing and evaluating primary care-based screening programs and interventions for multiple RBs.

Predictors of older primary care patients' participation in a submaximal exercise test and a supervised, low-impact exercise class

OBJECTIVES

This study is an investigation of physical activity promotion among a nonvolunteer sample of community-dwelling, older, urban primary care patients. Our primary interest was in the rates of exercise test and class participation. Of secondary interest were the medical record and baseline survey predictors of test and class participation.

METHODS

The first 500 nonterminally ill women ages 50 years or more with a visit at one of two predominantly African-American, inner-city primary care clinics received a physician screen, a referral to a submaximal exercise test, and, subsequently, a free, supervised exercise program located in a nearby community center.

RESULTS

Eighty-one percent were eligible for the exercise test per provider screen. Of these, 29% completed the exercise test and 28% attended at least one exercise class. After 1 year, 9.2% were attending the exercise classes. Higher exercise outcome expectations, not smoking, and clinic site were associated with exercise test and class participation.

CONCLUSIONS

Providing free, traditional exercise classes and a primary care referral to the classes resulted in limited physical activity participation among older, urban primary care patients. More development and testing of physical activity promotion programs are needed in this population.

Exercise and the transtheoretical model: a longitudinal test of a population sample

BACKGROUND

The purpose of this study was to test the ability of the Transtheoretical Model (TTM) to predict exercise stage transition of individuals in a large, untreated-population-based, random sample of Canadian adults (18-65 years of age) over two consecutive time periods.

METHODS

Assessments of TTM's stage of exercise behavior change, self-efficacy, pros, cons, experiential processes, and behavioral processes were made at baseline (time 1), 6 months (time 2), and 1 year (time 3). Six hundred eighty-three men and women, identified through random-digit telephone dialing, completed all measures across the three time points. Within each time period (time 1-2; time 2-3) participants were categorized as having regressed (moved back at least on stage), remained (no stage change), or progressed (moved forward at least one stage). Baseline TTM constructs were analyzed for their ability to predict change transition across the two time periods.

RESULTS

Of 40 possible predictions (20 for each time period) 18 (45%) were supported.

CONCLUSIONS

Overall, the findings demonstrate partial support for the internal validation of TTM in the exercise domain. Implications of the findings are discussed and future directions for researchers, practitioners, and program planners are provided.

Mediators of lifestyle behavior change in Native Hawaiians: initial findings from the Native Hawaiian Diabetes Intervention Program

OBJECTIVE

To examine the association of stage of change with diet and exercise behaviors in response to a lifestyle intervention for Native Hawaiians (NHs).

RESEARCH DESIGN AND METHODS

A family ('ohana) support lifestyle intervention was compared with a standard intervention in NHs with or at risk for diabetes in two rural communities in Hawaii (n = 147). Stage of change, as a hypothesized mediator of behavior change, and dietary and exercise behaviors were measured at baseline and at 1 year postintervention.

RESULTS

Stage of change was significantly associated with positive dietary and exercise behaviors. NHs receiving the 'ohana support (OS) intervention were more likely to advance from pre-action to action/maintenance for fat intake and physical activity than the group who received the standard intervention. Participants in the OS group who advanced from pre-action to action/maintenance showed more improvement in fat intake and physical activity than those in the standard group.

CONCLUSIONS

These initial findings suggest that stage of change is an important factor in mediating lifestyle behavior changes in persons with or at risk for diabetes and merits further study among minority populations at high risk for diabetes.

Smokers with multiple behavioral risk factors: how are they different?

OBJECTIVE

The first aim of the present investigation was to examine cross-sectional differences between smokers who engage in additional health risk behaviors (i.e., high-fat diets and low physical activity levels) and those who do not that could affect readiness for smoking cessation treatment and treatment prognosis. The second aim was to examine prospective associations between risk factor status and smoking outcomes (i.e., cessation and quit attempts).

DESIGN

Data were derived from baseline and 1-year follow-up surveys for the SUCCESS project, a randomized trial of worksite smoking interventions conducted in 24 worksites in Minneapolis/St. Paul, Minnesota. Included in the analyses were 2,149 study participants who reported smoking at baseline.

METHODS

Current smokers were categorized into one of three "risk groups": the "1 additional risk factor" group (i.e., either low physical activity level or high dietary fat intake), the "2 additional risk factor" group (i.e., both low physical activity and high dietary fat intake), and the "smoker only" group (i.e., neither low physical activity nor high dietary fat intake). Mixed model regression analyses examined cross-sectional associations between risk group status and baseline demographic variables, smoking dependency, social environments for smoking, and health problems. Prospective associations between baseline risk group status and 1-year follow-up cessation attempts and quits were also examined.

RESULTS

At baseline, risk factor status was associated with smoking dependency for both men and women. Women smokers with at least one additional risk factor reported a greater number of cigarettes smoked per day, higher Fagerstrom Nicotine Dependence scores, and lower self-efficacy for refraining from smoking in a variety of situations compared with smokers with no additional risk factors. Men smokers with at least one additional risk factor reported higher Fagerstrom Nicotine Dependence scores compared with smokers with no additional risk factors. Women smokers with at least one additional risk factor were more likely to report being encouraged to quit by co-workers compared with smokers with no other risk factors. No relationship between risk factor status and social pressure to quit was observed among men. Prospective analyses indicated that baseline risk factor status was marginally related to smoking outcome at 1-year follow-up; however, these relationships were attenuated considerably when controlling for smoking dependence. Relationships between risk factor status and smoking outcomes were stronger for men.

CONCLUSION

Results indicated that the presence of multiple health risk behaviors was related to more serious problems with smoking. However, the presence of additional risk factors did not strongly affect prognosis for smoking cessation.

A social cognitive-based model for condom use among college students

BACKGROUND

Social cognitive theory has been used extensively to explain health behaviors. Although the influence of one construct in this model-self-efficacy-has been well established, the role of other social cognitive constructs has not received as much attention in human immunodeficiency virus (HIV) prevention research. More complete understanding of how social cognitive constructs operate together to explain condom use behaviors would be useful in developing HIV and sexually transmitted disease (STD) prevention programs for college students.

OBJECTIVE

The primary aim of this study was to test a social cognitive-based model of condom use behaviors among college students.

METHODS

Data were collected from a sample of college students attending six different colleges and universities. Participants were 18 to 25 years of age, single, and sexually active. For the sample of 1,380 participants, the mean age was 20.6 years (SD = 1.76). Most participants reported having had vaginal intercourse (95.8%) and oral sex (86.5%); 16% reported anal sex.

FINDINGS

Self-efficacy was related directly to condom use behaviors and indirectly through its effect on outcome expectancies. As predicted, self-efficacy was related to anxiety, but anxiety was not related to condom use. Substance use during sexual encounters was related to outcome expectancies but not to condom use as predicted.

CONCLUSIONS

Overall, the findings lend support to a condom use model based on social cognitive theory and provide implications for HIV interventions. Interventions that focus on self-efficacy are more likely to reduce anxiety related to condom use, increase positive perceptions about condoms, and increase the likelihood of adopting condom use behaviors.

Body image evaluations in women smokers

While body image has been found to be an important predictor for several health behaviors (abnormal dieting. weight regain, exercise), only one study to date has examined body image attitudes in women smokers (Australian sample) with results suggesting that women smokers feel less attractive than nonsmokers. The purpose of the present study was to compare body image in women smokers to normative samples of women. Subjects were 136 women (89.0% White, M age = 39.85, 74% employed. 52% married, body mass index [BMI] = 25.54) entering a randomized clinical smoking cessation trial. Subjects completed the Appearance Evaluation and Fitness Orientation subscales of the Multidimensional Body-Self Relations Questionnaire and the Silhouette Choosing Task. Pooled t-tests showed that subjects scored significantly lower on Appearance Evaluation (t = -6.58, p < .01) and Fitness Orientation (t = -5.55, p < .01) than the normative sample. For the silhouette choosing task, the present sample reported a significantly higher current silhouette (t = 2.29, p < .05) and dissatisfaction score (t = 4.04, p < .01) than the comparative sample. There were no significant differences on the ideal or attraction scores. Results suggest that women smokers may be more dissatisfied with their bodies than women in general. Possible implications include that smoking may adversely affect body image and/or body image concerns may negatively impact cessation attempts.

Patterns and correlates of physical activity among US women 40 years and older

OBJECTIVES

This study describes the patterns of physical activity among minority women by using a variety of definitions and determines sociodemographic and behavioral correlates of physical activity in this population.

METHODS

A cross-sectional study was conducted in 1996 and 1997 among US women 40 years and older (n = 2912) of the following racial/ethnic groups: African American, American Indian/Alaskan Native, Hispanic, and White.

RESULTS

Physical activity was lowest among African Americans and American Indians/Alaskan Natives (adjusted odds ratios [ORs] for no leisure-time activity were 1.35 [95% confidence interval (CI) = 1.08, 1.68] and 1.65 [95% CI = 1.33, 2.06], respectively). A much higher proportion of women were classified as being physically active when occupational activity rather than more traditional assessments of leisure activity were used to determine level of physical activity. On the basis of a composite definition of physical activity, 72% of respondents reported being physically active. Women living in rural regions (OR = 1.33; 95% CI = 1.12, 1.58) were more likely than urban inhabitants to be completely inactive during leisure time.

CONCLUSIONS

Minority women are among the least active subgroups in American society, although not all groups are less active than White women when all domains of physical activity are taken into account.

The relationship between the stages of exercise adoption and other health behaviors

PURPOSE

To examine the relationship between stage of exercise adoption and the practice of other health behaviors.

DESIGN

Demographic, socioeconomic, and health behavior data were collected using a cross-sectional mail survey. Data were collected as part of a larger employee benefits research study.

SETTING

Montana State University-Bozeman, Bozeman, Montana.

SUBJECTS

University employees (n = 1269) comprised of 46% men with a mean age of 44 years.

MEASURES

Demographic and socioeconomic data included age, sex, marital status, level of income and education, dependent status, and job classification. Stage of exercise adoption classifications were based on self-reported responses to four exercise statements. The health behaviors included in this study were cigarette and smokeless tobacco use, seat belt use, alcohol use, and use of stress management practices. Logistic regression analysis was used to determine if stage of exercise predicted the presence of each of the health behaviors while controlling for demographic, socioeconomic, and other health behavior variables.

RESULTS

The survey response rate was 68%. Respondents in action exercise stage (p = .0367) were less likely to smoke cigarettes than respondents in precontemplation stage of exercise. Respondents in contemplation (p = .0419), preparation (p = .0060), action (p = .0432), and maintenance (p = .0006) were more likely to use seat belts than respondents in precontemplation. Respondents in maintenance (p = .0059) were more likely to use regular stress reduction techniques than respondents in precontemplation.

CONCLUSIONS

Although longitudinal research is needed to determine any causal relationships, this research suggests that encouraging individuals to become more involved in exercise could indirectly influence other health behaviors. Hence, exercise could be a possible "gateway" behavior toward healthier lifestyle practices.

Associations between the stages of change and the pros and cons of smoking in a longitudinal study of Swiss smokers

To develop effective smoking prevention interventions, we need to identify modifiable variables, such as the "pros and cons" of smoking, that predict self-initiated smoking cessation. Our objective was to assess associations between the pros and cons of smoking and the stages of change, both cross-sectionally and longitudinally, in a cohort of smokers. In cross-sectional comparisons, the pros of smoking were 0.19-0.31 standard deviation (SD) higher and the cons 0.79-0.87 SD lower in the precontemplation than in the preparation stage. In follow-up data, progressing from precontemplation to contemplation and from contemplation to preparation was associated with substantial and significant increases in the cons (+0.71 SD and +0.50 SD, respectively). No longitudinal associations were found between changes in pros of smoking and progress through stages. Thus this study added evidence from longitudinal data to published evidence from cross-sectional data about the association between the cons of smoking and the stages of change. Intervention studies are necessary to establish whether this association is causal.