Stages of change in obesity and weight management: factorial structure of the Italian version of the University of Rhode Island Change Assessment Scale.

PURPOSE: To examine the factorial structure of the University of Rhode Island Change Assessment Scale (IT-URICA) for weight management in a sample of Italian overweight and obese patients enrolled in a nutritional rehabilitation program. METHODS: 334 inpatients completed the translated and adjusted version of the IT-URICA at admission to the hospital. Psychometric testing included confirmatory factor analysis and internal consistency (Cronbach's α). RESULTS: The IT-URICA for weight management was successfully translated into Italian, and the factorial analysis confirmed the four-factor solution of the commonly accepted version of the measure. CONCLUSION: High levels of RTC are considered critical to the long-term success of weight management, and the IT-URICA may be an appropriate measure of motivational readiness for use among Italian overweight and obese patients. Its use is, therefore, recommended for clinical and research purposes.

Examining relationships between multiple health risk behaviors, well-being, and productivity.

Traditionally, the concept of health promotion has emphasized the reduction of health risk behaviors to reduce disease and impairment. Well-being research expands this focus to include positive constructs such as thriving, productivity, life-evaluation, and emotional and physical health. The objective of the present study was to examine the relationships between health risk behaviors and specific measures of individual well-being. Participants (N = 790) from 49 states completed a one-time online assessment that included the Life-Evaluation Index, Emotional and Physical Health Ladders, the Health Risk Intervention Assessment, and the Work Productivity and Activity Improvement Questionnaire for General Health. Life Evaluation and physical and emotional health were all inversely related to the number of health risk behaviors, with higher well-being scores associated with lower number of risk behaviors. Across the three Life Evaluation categories (Suffering, Struggling, and Thriving) the number of health risk behaviors decreased, productivity loss decreased, and emotional and physical health increased. The results add to previous research on how reducing multiple health risk behaviors can be combined with well-being, i.e., an emphasis on increasing life-evaluation, emotional and physical health, better functioning, and productivity.

Computer-Tailored Intervention for Juvenile Offenders.

Studies assessing the efficacy of juvenile justice interventions show small effects on recidivism and other outcomes. This paper describes the development of a prototype of a multimedia computer-tailored intervention ("Rise Above Your Situation"or RAYS) that relies on an evidence-based model of behavior change, the Transtheoretical Model, and expert system technology to deliver assessments, feedback, printed reports, and counselor reports with intervention ideas. In a feasibility test involving 60 system-involved youths and their counselors, evaluations of the program were favorable: 91.7% of youths agreed that the program could help them make positive changes, and 86.7% agreed that the program could give their counselor helpful information about them.

Designing a health behavior change program for dissemination to underserved pregnant women.

OBJECTIVES: The paper describes the formative research conducted toward developing a health behavior change program for underserved pregnant women. It is provided as an example to guide researchers, academics, and practitioners on how to incorporate dissemination in all aspects of project planning and implementation. DESIGN AND SAMPLE: A series of formative research was conducted, including an advisory council, expert interviews, 6 focus groups and 5 usability interviews with the target population (n=53), key informant interviews, expert reviews of the pilot program, and a pilot test (n=87). A total of 140 underserved pregnant women were recruited from Community Health Center Inc. in Connecticut. RESULTS: The extensive formative research served to lay the foundation for the development of a healthy pregnancy behavior change program. The pilot test exemplified the feasibility and acceptability of the program. CONCLUSION: Successful adoption of interventions depends upon strong formative research, participatory research methods, interdisciplinary collaboration, and a commitment to dissemination from project inception. The development of the intervention discussed serves as a useful and practical example for others working in health care and behavioral medicine to improve the overall health and well-being of the underserved.

Results of a multi-media multiple behavior obesity prevention program for adolescents.

BACKGROUND: This study reports on effectiveness trial outcomes of Health in Motion, a computer tailored multiple behavior intervention for adolescents. METHODS: Using school as level of assignment, students (n=1800) from eight high schools in four states (RI, TN, MA, and NY) were stratified and randomly assigned to no treatment or a multi-media intervention for physical activity, fruit and vegetable consumption, and limited TV viewing between 2006 and 2007. RESULTS: Intervention effects on continuous outcomes, on movement to action and maintenance stages, and on stability within action and maintenance stages were evaluated using random effects modeling. Effects were most pronounced for fruit and vegetable consumption and for total risks across all time points and for each behavior immediately post intervention. Co-variation of behavior change occurred within the treatment group, where individuals progressing to action or maintenance for one behavior were 1.4-4.2 times more likely to make similar progress on another behavior. CONCLUSION: Health in Motion is an innovative, multiple behavior obesity prevention intervention relevant for all adolescents that relies solely on interactive technology to deliver tailored feedback. The outcomes of the effectiveness trial demonstrate both an ability to initiate behavior change across multiple energy balance behaviors simultaneously and feasibility for ease of dissemination.

Proactive health consumerism: an important new tool for worksite health promotion.

Consumerism in health care has taken on the form of a major innovation among employers and health plans. Yet many of our efforts to enhance the skills and attitudes that enable consumerism have met with limited success. Proactive Health Consumerism is proposed as an approach that utilizes many of the hard-won lessons from health promotion research. Along with prerequisites that create the motivation and framework for increased health consumerism, this article provides a theory-driven example of a new tool for health promotion professionals to employ when enhancing the health consumer skills of working populations. Strategies for maximization of effectiveness and integration with supporting resources are also described.

Acceptability of a stage-matched expert system intervention for domestic violence offenders.

Most interventions for men who batter are standardized and "one-size-fits-all," neglecting individual differences in readiness to change. A multimedia expert system intervention based on the transtheoretical model (the "stage model") was developed as an adjunct to traditional court-mandated programs. The expert system assesses stage of change, decisional balance, self-efficacy, and processes of change and provides immediate individualized stage-matched feedback designed to increase readiness to end the violence. Fifty-eight male batterer intervention program clients were invited by agency staff to complete an expert system session and an evaluation of the program; 33 men were recruited at program intake and the remainder from ongoing groups. Responses to the intervention were very positive. For example, 87% of participants reported that they found the program to be easy to use, and 98% said it could probably or definitely help them change their attitudes or behaviors. Findings provide encouraging evidence of the acceptability of this stage-matched approach to intervention for domestic violence offenders.

Efficacy and effectiveness trials: examples from smoking cessation and bullying prevention.

If health psychology is to maximize impacts on health, there will need to be a shift from relying primarily on efficacy trials to increasing reliance on effectiveness trials. Efficacy trials use homogeneous, highly motivated samples with minimal complications from a single setting receiving intensive treatments delivered under highly controlled conditions. Two effectiveness trials on bullying prevention illustrate the use of a heterogeneous population from multiple sites receiving a low intensity tailored treatment delivered under highly variable conditions. In spite of considerable noise the effectiveness trials produced robust results (odds ratios of about four) that bode well for population impacts under real-world dissemination.

Teen Choices, an Online Stage-Based Program for Healthy, Nonviolent Relationships: Development and Feasibility Trial.

This paper describes the theoretical foundation, development, and feasibility testing of an online, evidence-based intervention for teen dating violence prevention designed for dissemination. Teen Choices: A Program for Healthy, Non-Violent Relationships relies on the Transtheoretical Model of Behavior Change and expert system technology to deliver assessments and feedback matched to stage of change for using healthy relationship skills. The program also tailors feedback to dating status, risk level, and other key characteristics. Ninety-nine students from high schools in Tennessee and Rhode Island completed a Teen Choices session and 97 completed an 11-item acceptability evaluation. 100% of participants completed the intervention session as intended. Evaluations of the program were favorable. For example, 88.7% agreed the program feedback was easy to understand, and 86.7% agreed that the program could help people develop healthier relationships. Findings provide encouraging evidence of the acceptability and feasibility of this approach to dating violence prevention.

A randomized clinical trial of a population- and transtheoretical model-based stress-management intervention.

Stress has been associated with a variety of chronic and acute conditions and with higher use of health care services. This research reports on 18-month outcomes of a randomized clinical trial of a stress-management program based on the transtheoretical model (TTM; J. O. Prochaska & C. C. DiClemente, 1986). A national sample of 1,085 individuals participated (age range = 18-91 years, M = 55.33; 68.9% female, 31.1% male; 84.8% Caucasian; 15.2% non-Caucasian). Both the treatment and control groups received assessments at 0, 6, 12, and 18 months. In addition to the assessments, the treatment group received 3 individualized reports (0, 3, 6 months) and a manual. The 18-month assessment was completed by 778 individuals (72%). A random effects model indicated that participants completing the study in the treatment group had significantly more individuals reporting effective stress management at follow-up time points than did completers in the control group. Results also indicate that the intervention had significant effects on stress, depression, and specific stress-management behaviors. Results provide evidence for the effectiveness of this TTM population-based stress-management intervention.

Stage of change for making an informed decision about Medicare health plans.

OBJECTIVE: To assess the applicability of the transtheoretical model of change (TTM) to informed choice in the Medicare population. DATA SOURCES/STUDY SETTING: Two hundred and thirty-nine new Medicare enrollees randomly selected from the Center for Medicare and Medicaid Services' October 2001 Initial Enrollee File, a repository of data for persons who are going to turn 65 and become entitled to enroll in Medicare in the next 3 months. STUDY DESIGN: Study participants completed TTM measures of stage of change, decisional balance, and self-efficacy for informed choice, as well as measures of Medicare knowledge, perceived knowledge, and information seeking. Model testing was conducted to determine whether well-established relationships between stage of change, decisional balance, and self-efficacy replicate for informed choice in the Medicare population, and whether Medicare knowledge and information-seeking increase across the stages. DATA COLLECTION/EXTRACTION METHODS: Survey data were collected using mail surveys with telephone follow-up for nonresponders. PRINCIPAL FINDINGS: Predicted relationships were established between stage of change for informed choice and decisional balance, self-efficacy, Medicare knowledge, and information seeking. The amount of variance accounted for by stage of change for informed choice was larger than that found for smoking cessation, where the TTM has had its greatest successes. CONCLUSIONS: The methods and findings lay the groundwork for development of TTM-based interventions for Medicare beneficiaries, and provide a prototype for the application of the TTM to informed decision making among other types of consumers who are being asked to take more responsibility for their health care.

Randomized trial of stage-based interventions for informed Medicare choices.

A randomized trial involving 1,351 new Medicare enrollees was conducted to assess the efficacy of a transtheoretical model (TTM) based manual and multimedia expert system program that delivered guidance and feedback matched to individual stage of readiness to compare Medicare health plans. At 6 months post-intervention, compared to enrollees in the control group, those receiving the manual plus expert system intervention or the manual alone exhibited greater increases in Medicare knowledge. The TTM-based interventions also increased use of and satisfaction with traditional Medicare education materials among most enrollees. The interventions' impact on stage of change for comparing plans was observed only among treatment group participants who had examined and evaluated the materials. The challenges to increasing informed choice and possible dissemination channels for stage-based materials are discussed.

Prevention profiles: Understanding youth who do not use substances.

This study replicates innovative profiles of prevention among students not using substances but who may be at different risks for acquisition. Using the Transtheoretical Model constructs of Decisional Balance and Temptations, cluster analyses were performed on four independent samples of students (n=1240) in the USA, England and Israel. For each sample, the same four distinct profiles emerged. ANOVAs indicated that the processes of prevention varied significantly across these profiles. The prevention profiles were extended to youth in Elementary, Middle, and High Schools and from a focus on single substances to multiple substances, including alcohol, tobacco, and illicit drugs. Implications for developing prevention programs are also discussed.

Efficacy of a transtheoretical model-based expert system for antihypertensive adherence.

Blood pressure is not controlled in as many as 50%-75% of hypertensive patients, primarily because of inadequate adherence to treatment. This paper examines the efficacy of a Transtheoretical Model (TTM)-based expert system intervention designed to improve adherence with antihypertensives in a sample of 1,227 adults. Participants were proactively recruited and randomly assigned to receive usual care or three individualized expert system reports and a stage-matched manual over 6 months. Participants were surveyed at baseline, and 6, 12, and 18 months. Significantly more of the intervention group participants reported being in Action and Maintenance at follow-up time points (ie, 73.1% of the treatment group versus 57.6% of the control group at 12 months and 69.1% of the treatment group versus 59.2% of the control group at 18 months). Scores on a behavioral measure of nonadherence differed significantly at follow-up time points. TTM-based expert system interventions have the potential for a significant impact on entire populations of individuals who fail to adhere, regardless of their readiness to change.

Transtheoretical model intervention for adherence to lipid-lowering drugs.

An estimated 60% of individuals prescribed lipid-lowering medications are nonadherent. Failure to adhere increases morbidity, mortality, healthcare utilization, and healthcare costs. This study examined the effectiveness of a population-based, individualized Transtheoretical Model (TTM) expert system intervention to improve adherence and increase exercise and diet in a randomized 18-month trial involving 404 adults. Compared to usual care, treatment participants who started in a pre-action stage were significantly more likely to be in the Action and Maintenance (A/M) stages for adherence at end of treatment (55.3% versus 40%, z = 2.11, p < 0.05, h = 0.31) and at 18-months (56% versus 37.8%, z = 2.38, p < 0.01, h = 0.36). The treatment group scored significantly better on two measures of adherence at six and 12 months post-treatment (all p < 0.05, odds ratios [OR] 1.49-3.67). Among those who began in A/M, treatment participants were significantly more likely to remain in A/M at 18 months (85.2% versus 55.6%, z = 2.63, p < 0.01, h = 0.67). Those receiving treatment were significantly more likely to progress to A/M for exercise and dietary fat reduction (43.3% versus 24.7% for exercise, and 24.7% versus 12.5% for diet). TTM expert system interventions can have a significant impact on entire populations for adherence. Results for dietary fat and exercise suggest covariation of treatment effects.

Teen Dating Violence Prevention: Cluster-Randomized Trial of Teen Choices, an Online, Stage-Based Program for Healthy, Nonviolent Relationships.

OBJECTIVE: Teen dating violence is a serious public health problem. A cluster-randomized trial was conducted to assess the efficacy of Teen Choices, a 3-session online program that delivers assessments and individualized guidance matched to dating history, dating violence experiences, and stage of readiness for using healthy relationship skills. For high risk victims of dating violence, the program addresses readiness to keep oneself safe in relationships. METHOD: Twenty high schools were randomly assigned to the Teen Choices condition (n=2,000) or a Comparison condition (n=1,901). Emotional and physical dating violence victimization and perpetration were assessed at 6 and 12 months in the subset of participants (total n=2,605) who reported a past-year history of dating violence at baseline, and/or who dated during the study. RESULTS: The Teen Choices program was associated with significantly reduced odds of all four types of dating violence (adjusted ORs ranging from .45 to .63 at 12 months follow-up). For three of the four violence outcomes, participants with a past-year history of that type of violence benefited significantly more from the intervention than students without a past-year history. CONCLUSIONS: The Teen Choices program provides an effective and practicable strategy for intervention for teen dating violence prevention.

Online health behavior and disease management programs: are we ready for them? Are they ready for us?

Advancing the science and practice of health promotion and disease management on the Internet requires a systematic program of research examining the population impact of such programs. With impact described as the combination of effectiveness and participation, such research needs to include the examination of the quality and effectiveness of programs that are available to the general public, as well as descriptive and predictive knowledge about population readiness to participate in such programs. There have been few studies examining the quality of interactive health behavior change (HBC) programs on the Internet, and even fewer investigations of the effectiveness of such programs. Based on the review of over 300 HBC programs on the Internet using the "5 A's" of Health Behavior Change on the Internet (HBC-I Screener), which represent standard minimum guidelines for evaluation, it appears HBC on the Internet is in the early stages of development. As health behavior change on the Internet matures from the provision of health information to meeting the requirements necessary to produce health behavior change, and as program developers take advantage of the interactive nature of the Internet, the basic screening and expanded evaluation criteria developed in this project will provide templates for both consumers and developers of programs. The second component necessary for evaluating the impact of HBC on the Internet is the extent to which the population is ready to participate in such programs. We need to move beyond a narrow focus on early adopters and produce a population perspective that includes those not ready, those getting ready, and those ready to use such programs, as well as those already participating. By understanding participation levels of such programs, and what drives this participation, the development and dissemination of practical tailored and targeted interventions can help maximize population participation in Internet programs for health behavior change.

The Functional Well-Being Scale: a measure of functioning loss due to well-being-related barriers.

The objective of this study was to develop the Pro-Change Functional Well-Being Scale, a measure that provides an informative evaluation of general functioning loss due to well-being-related barriers. Exploratory and confirmatory analyses on data from 642 individuals supported a one-factor solution with good model fit. A strong positive correlation existed between the Pro-Change Functional Well-Being Scale and Well-Being Assessment for Productivity. Initial construct validity was demonstrated by predictable relationships between functioning loss and other measures of health and well-being. This initial psychometric evidence suggests that the Pro-Change Functional Well-Being Scale is a reliable and valid assessment of functioning loss due to common well-being-related barriers.

Size, consistency, and stability of stage effects for smoking cessation.

In the transtheoretical model (TTM), the stage effect is one of the most important determinants of health behavior change. Randomly assigned to 1 of 11 treatment conditions were 4653 smokers. A total of 66 stage effects were possible with 6 for each of the 11 treatment groups. The results suggest that brief stage-matched interventions that help populations progress one stage could produce 75% more abstinence. Interventions that help populations progress two stages could produce 300% more abstinence. The results also support the importance of replicating the stage effects across treatment conditions and over time.

Development of review criteria to evaluate health behavior change websites.

A growing number of major health care organizations, such as the American Heart Association and the Mayo Clinic, are investing considerable resources in developing and marketing Internet-based programs for health promotion and disease management. These programs have the potential to provide some of the best-tailored interventions in behavior change science at relatively low costs. This report discusses review criteria developed in order to conduct a systematic evaluation of Internet programs for preventive behaviors (alcohol, diet, exercise and smoking) and disease management (pediatric asthma, depression and diabetes.) These criteria can be used to develop and evaluate the quality of health promotion programs on the Internet.