Using Relational Agents to Promote Exercise and Sun Protection: Assessment of Participants' Experiences With Two Interventions.

BACKGROUND: Relational agents (RAs) are electronic computational figures designed to engage participants in the change process. A recent study, Project RAISE, tested the effectiveness of RAs, combined with existing computer-based interventions to increase regular exercise and sun protection behaviors. Results showed these interventions can be effective but need further development. OBJECTIVE: The purpose of this study was to examine participants' experiences using RAs to increase participant engagement and promote behavior change . METHODS: A qualitative approach was primarily utilized. A 25-question interview guide assessed different components of participants' experiences with the intervention, including motivation, engagement, satisfaction or dissatisfaction, quality of their interaction with the RA, and behavior change. Quantitative assessment of satisfaction was based on a scale of 1 to 10, with 1 representing least satisfied and 10 representing most satisfied. A summative analytic approach was used to assess individuals' qualitative responses. A single analysis of variance (ANOVA) examined levels of satisfaction by gender. RESULTS: Of the original 1354 participants enrolled in Project RAISE, 490 of 1354 (36%) were assigned to the RA group. A sample of 216 out of 490 (44%) participants assigned to the RA group completed the interventions, and follow-up assessments were contacted to participate in the semistructured interview. A total of 34 out of 216 (16%) completed the interview. Participants were motivated by, and satisfied with, the intervention. Participants viewed the RA as supportive, informative, caring, and reported positive behavior change in both exercise and sun protection. Some participants (15/34, 44%) noted the RA was less judgmental and less "overbearing" compared with a human counselor; other participants (12/34, 35%) said that the interaction was sometimes repetitive or overly general. The majority of participants (22/34, 65%) viewed the RA as an important contributor to their behavior change for exercise, sun protection, or both. Levels of satisfaction ranged between 7 and 10. There were no gender differences noted in levels of satisfaction (P=.51). CONCLUSIONS: RAs provide an innovative and attractive platform to increase exercise and sun protection behaviors and potentially other health behaviors.

Psychometric assessment of the processes of change scale for sun protection.

The fourteen-factor Processes of Change Scale for Sun Protection assesses behavioral and experiential strategies that underlie the process of sun protection acquisition and maintenance. Variations of this measure have been used effectively in several randomized sun protection trials, both for evaluation and as a basis for intervention. However, there are no published studies, to date, that evaluate the psychometric properties of the scale. The present study evaluated factorial invariance and scale reliability in a national sample (N = 1360) of adults involved in a Transtheoretical model tailored intervention for exercise and sun protection, at baseline. Invariance testing ranged from least to most restrictive: Configural Invariance (constraints only factor structure and zero loadings); Pattern Identity Invariance (equal factor loadings across target groups); and Strong Factorial Invariance (equal factor loadings and measurement errors). Multi-sample structural equation modeling tested the invariance of the measurement model across seven subgroups: age, education, ethnicity, gender, race, skin tone, and Stage of Change for Sun Protection. Strong factorial invariance was found across all subgroups. Internal consistency coefficient Alpha and factor rho reliability, respectively, were .83 and .80 for behavioral processes, .91 and .89 for experiential processes, and .93 and .91 for the global scale. These results provide strong empirical evidence that the scale is consistent, has internal validity and can be used in research interventions with population-based adult samples.

Intervention effects on stage transitions for adolescent smoking and alcohol use acquisition.

The health impacts of smoking and alcohol abuse have been long established with smoking representing one of the most preventable causes of disease and alcohol use the most popular psychoactive substance among adolescents. The current study evaluated stage of change progression in a large (N = 4,158) school-based, computer-delivered, transtheoretical model (TTM)-tailored multiple behavior intervention focused on preventing acquisition of smoking and alcohol use in adolescents. Assessments began in sixth grade and continued yearly until eighth grade, with a follow-up in ninth grade. Markov modeling was used to (a) characterize the best pattern of stage movement (e.g., no stage change, stage-sequential change, stages skipped), (b) test whether the identified pattern was stable over time (e.g., between assessments and after intervention completion), and (c) to determine whether the substance use prevention (SP) intervention effectively kept adolescents in acquisition stages (e.g., prevents stage movement toward substance use), relative to the comparison intervention. Major findings supported positive effects for both the intervention and comparison condition, which focused on energy balance (EB) behaviors and provided no direct intervention on substance use behaviors. Substantial differences in stage membership and transitions across intervention conditions highlighted the process of smoking and alcohol use acquisition in middle school students across each intervention condition. (PsycINFO Database Record

Intervention Effects on Stage of Change Membership and Transitions among Adolescent Energy Balance Behaviors.

The transition from childhood to adolescence is a crucial period for the development of healthy behaviors to be sustained later in life. With obesity a leading public health problem, the promotion of healthy behaviors has the potential to make a huge impact. The current study evaluated Stage of Change progression in a large (N = 4158) computer-delivered, Transtheoretical Model-tailored intervention focusing on physical activity and fruit and vegetable consumption (FV). Markov models were used to explore stage transitions and patterns of discrete change from sixth to ninth grade. Nested model comparisons examined the consistency of these patterns across time and intervention condition. Major findings supported models in which participants were free to transition forward and backward to any of the stages, but higher probabilities were observed for remaining in the same stage or for transitioning one or two stages forward. Participants in the intervention group had higher probabilities of transitioning toward Maintenance, with more change occurring relative to the comparison group during transitions from grades six to eight but not for grades eight to nine.

Assessing demographic differences in decisional balance for smoking prevention and temptations to try smoking among adolescent subgroups.

INTRODUCTION: Cigarette smoking initiation remains prevalent in adolescence. Effective prevention methods are needed to dissuade this behavior. Demographic factors are identified as important risk factors in the developmental nature of smoking in adolescence. The current study investigates potential demographic differences for two new trans-theoretical model measures, the Decisional Balance Inventory (pros and cons) for Smoking Prevention and the Temptations to Try Smoking Scale. METHODS: A sample of 6th grade Rhode Island students from 20 middle schools (N = 4151) who were participating in a longitudinal and computer-delivered intervention for substance abuse prevention was assessed on these measures at baseline. Three MANOVA tests were conducted to assess the impact of race (White vs. Non-White), ethnicity (Hispanic vs. Non-Hispanic) and gender (male vs female). RESULTS: Significant effects for race and ethnicity were found for Decisional Balance and Temptations to Try Smoking. For race, Whites reported lesser pros (p <.0001) and Non-Whites reported higher cons (p <.0001) and temptations to try smoking (p <.0001). Differences for ethnicity showed that Hispanics were higher on pros (p <.0001) and temptations to try smoking (p <.0001) than Non-Hispanics. Non-Hispanics reported higher cons (p <.0001). Gender differences were noted only for temptations to try smoking, and showed females were higher on this construct than males (p <.0001). The effect sizes were .01 or below. CONCLUSIONS: The results did not demonstrate a strong association between these demographics and constructs, suggesting that tailored prevention methods based solely on these factors may not dissuade smoking in this group.

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.

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.

Fat Reduction Efforts: A 24-Month Longitudinal Comparison of a Large Sample of Maintainers, Relapsers, and Non-Changers.

This research examined dynamic transtheoretical model (TTM) constructs for dietary fat reduction. This secondary data analysis pooled three large population-based TTM-tailored school, worksite, medical, and home-based intervention studies and examined use of constructs across three groups organized by longitudinal progress (dynatypes): Maintainers, Relapsers, and Stable Non-Changers. The criteria for successful change, at the time, were that less than 30% of calories came from fat. A total of 2,718 adults met criteria for an unhealthy diet at baseline. The majority of participants were female, White, married, and middle-aged. Demographics, Stage of Change, Processes of Change, Decisional Balance, and Temptations were measured. Dynatype groups were assessed with reliable and valid scales assessing constructs at baseline and 6, 12, and 24 months. Analyses included a multivariate analysis of variance followed by a series of analyses of variance, with Tukey follow-up tests assessing differences in use of TTM constructs across the three groups at each time point. Relapsers and Maintainers were similar in their use of all TTM Processes of Change at baseline, with the exception of Self-Liberation (η(2) = 0.15, p < .001) and Reinforcement Management (η(2) = 0.01, p < .001). Although Relapsers reverted to an unhealthy diet, their overall greater use of Processes of Change suggests that their behaviors and strategy use remain better than that of the Stable Non-Changer group. Results suggest that specific cognitive and behavioral constructs may contribute differentially to intervention outcomes.

Transtheoretical Model Constructs' Longitudinal Prediction of Sun Protection Over 24 Months.

PURPOSE: This research examined dynamic transtheoretical model (TTM) constructs for adopting sun protection practices. This secondary data analysis pooled four large population-based TTM-tailored intervention studies and examined use of constructs across three groups, organized by longitudinal progress: maintainers, relapsers, and stable non-changers. METHODS: A total of 3463 adults, in the USA, who met criteria for unsafe sun exposure at baseline received a TTM-tailored computerized intervention at baseline, 6 months, and 12 months. The final analytic sample consisted of 1894 participants; the majority were female, White, married, and middle-aged. The three groups were assessed with reliable and valid scales assessing use of TTM constructs at baseline, 6 months, 12 months, and 24 months. Analyses included a MANOVA followed by a series of ANOVAs, with Tukey follow-up tests assessing differences in use of TTM constructs across the three groups at each timepoint. RESULTS: Findings demonstrated that relapsers and maintainers were similar in their use of most TTM processes of change at baseline, with the exception of Consciousness Raising, Stimulus Control, Reinforcement Management, and Self-Liberation. CONCLUSIONS: These findings suggest that although relapsers reverted to unsafe sun practices, their overall greater use of processes of change indicates that their change efforts remain better than that of stable non-changers.

Identifying Longitudinal Patterns for Individuals and Subgroups: An Example with Adherence to Treatment for Obstructive Sleep Apnea.

To improve complex behaviors such as adherence to medical recommendations, a better understanding of behavior change over time is needed. The focus of this study was adherence to treatment for obstructive sleep apnea (OSA). Adherence to the most common treatment for OSA is poor. This study involved a sample of 161 participants, each with approximately 180 nights of data. First, a time series analysis was performed for each individual. Time series parameters included the mean (average hours of use per night), level, slope, variance, and autocorrelation. Second, a dynamic cluster analysis was performed to find homogenous subgroups of individuals with similar adherence patterns. A four-cluster solution was found, and the subgroups were labeled: Great Users (17.2%; high mean and level, no slope), Good Users (32.8%; moderate mean and level, no slope), Low Users (22.7%; low mean and level, negative slope), and Slow Decliners (moderate mean and level, negative slope, high variance). Third, participants in the identified subgroups were compared to establish external validity. These steps represent a Typology of Temporal Patterns (TTP) approach. Combining time series analysis and dynamic cluster analysis is a useful way to evaluate longitudinal patterns at both the individual level and subgroup level.

Comparing Visual and Statistical Analysis in Single-Case Studies Using Published Studies.

Little is known about the extent to which interrupted time series analysis (ITSA) can be applied to short, single-case study designs and whether those applications produce results consistent with visual analysis (VA). This article examines the extent to which ITSA can be applied to single-case study designs and compares the results based on two methods: ITSA and VA, using papers published in the Journal of Applied Behavior Analysis in 2010. The study was made possible by the development of software called UnGraph®, which facilitates the recovery of raw data from the graphs. ITSA was successfully applied to 94% of the examined graphs with the number of observations ranging from 8 to 136. Moderate to high lag-1 autocorrelations (>.50) were found for 46% of the data series. Effect sizes similar to group-level Cohen's d were identified based on the tertile distribution. Effects ranging from 0.00 to 0.99 were classified as small, those ranging from 1.00 to 2.49 as medium, and large effect sizes were defined as 2.50 or greater. Comparison of the conclusions from VA and ITSA had a low level of agreement (Kappa =.14, accounting for the agreement expected by chance). The results demonstrate that ITSA can be broadly implemented in applied behavior analysis research. These two methods should be viewed as complementary and used concurrently.

Reducing Sun Exposure for Prevention of Skin Cancers: Factorial Invariance and Reliability of the Self-Efficacy Scale for Sun Protection.

The Self-Efficacy Scale for Sun Protection consists of two correlated factors with three items each for Sunscreen Use and Avoidance. This study evaluated two crucial psychometric assumptions, factorial invariance and scale reliability, with a sample of adults (N = 1356) participating in a computer-tailored, population-based intervention study. A measure has factorial invariance when the model is the same across subgroups. Three levels of invariance were tested, from least to most restrictive: (1) Configural Invariance (nonzero factor loadings unconstrained); (2) Pattern Identity Invariance (equal factor loadings); and (3) Strong Factorial Invariance (equal factor loadings and measurement errors). Strong Factorial Invariance was a good fit for the model across seven grouping variables: age, education, ethnicity, gender, race, skin tone, and Stage of Change for Sun Protection. Internal consistency coefficient Alpha and factor rho scale reliability, respectively, were .84 and .86 for Sunscreen Use, .68 and .70 for Avoidance, and .78 and .78 for the global (total) scale. The psychometric evidence demonstrates strong empirical support that the scale is consistent, has internal validity, and can be used to assess population-based adult samples.

Mediation analysis of decisional balance, sun avoidance and sunscreen use in the precontemplation and preparation stages for sun protection.

OBJECTIVE: Mediation analyses of sun protection were conducted testing structural equation models using longitudinal data with three waves. An effect was said to be mediated if the standardised path between processes of change, decisional balance and sun protection outcomes was significant. DESIGN: Longitudinal models of sun protection using data from individuals in the precontemplation (N = 964) and preparation (N = 463) stages who participated of an expert system intervention. MAIN OUTCOME MEASURES: Nine processes of change for sun protection, decisional balance constructs of sun protection (pros and cons), sun avoidance behaviour and sunscreen use. RESULTS: With the exception of two processes in the preparation stage, processes of change predicted the pros (r = .126-.614), and the pros predicted the outcomes (r = .181-.272). Three models with the cons as mediator in the preparation stage, and none in the precontemplation stage, showed a mediated relationship between processes and outcomes. CONCLUSION: In general, mediation analyses found both the process of change-to-pros and pros-to-behaviour paths significant for both precontemplation and preparation stages, and for both sun avoidance and sunscreen use outcomes. Findings provide support for the importance of assessing the role of underlying risk cognitions in improving sun protection adherence.

Replicating cluster subtypes for the prevention of adolescent smoking and alcohol use.

INTRODUCTION: Substance abuse interventions tailored to the individual level have produced effective outcomes for a wide variety of behaviors. One approach to enhancing tailoring involves using cluster analysis to identify prevention subtypes that represent different attitudes about substance use. This study applied this approach to better understand tailored interventions for smoking and alcohol prevention. METHODS: Analyses were performed on a sample of sixth graders from 20 New England middle schools involved in a 36-month tailored intervention study. Most adolescents reported being in the Acquisition Precontemplation (aPC) stage at baseline: not smoking or not drinking and not planning to start in the next six months. For smoking (N=4059) and alcohol (N=3973), each sample was randomly split into five subsamples. Cluster analysis was performed within each subsample based on three variables: Pros and Cons (from Decisional Balance Scales), and Situational Temptations. RESULTS: Across all subsamples for both smoking and alcohol, the following four clusters were identified: (1) Most Protected (MP; low Pros, high Cons, low Temptations); (2) Ambivalent (AM; high Pros, average Cons and Temptations); (3) Risk Denial (RD; average Pros, low Cons, average Temptations); and (4) High Risk (HR; high Pros, low Cons, and very high Temptations). CONCLUSIONS: Finding the same four clusters within aPC for both smoking and alcohol, replicating the results across the five subsamples, and demonstrating hypothesized relations among the clusters with additional external validity analyses provide strong evidence of the robustness of these results. These clusters demonstrate evidence of validity and can provide a basis for tailoring interventions.

Randomized trial outcomes of a TTM-tailored condom use and smoking intervention in urban adolescent females.

Smoking and sexual risk behaviors in urban adolescent females are prevalent and problematic. Family planning clinics reach those who are at most risk. This randomized effectiveness trial evaluated a transtheoretical model (TTM)-tailored intervention to increase condom use and decrease smoking. At baseline, a total of 828 14- to 17-year-old females were recruited and randomized within four urban family planning clinics. Participants received TTM or standard care (SC) computerized feedback and stage-targeted or SC counseling at baseline, 3, 6 and 9 months. Blinded follow-up telephone surveys were conducted at 12 and 18 months. Analyses revealed significantly more consistent condom use in the TTM compared with the SC group at 6 and 12, but not at 18 months. In baseline consistent condom users (40%), significantly less relapse was found in the TTM compared with the SC group at 6 and 12, but not at 18 months. No significant effects for smoking prevention or cessation were found, although cessation rates matched those found previously. This TTM-tailored intervention demonstrated effectiveness for increasing consistent condom use at 6 and 12 months, but not at 18 months, in urban adolescent females. This intervention, if replicated, could be disseminated to promote consistent condom use and additional health behaviors in youth at risk.

Transtheoretical Principles and Processes for Adopting Physical Activity: A Longitudinal 24-Month Comparison of Maintainers, Relapsers, and Nonchangers.

This study examined longitudinal differences in use of transtheoretical model (TTM) behavior change constructs in maintainers (who reached and maintained exercise guidelines), relapsers (who reached guidelines, then regressed), and nonchangers (who did not reach guidelines). Data from two population-based TTM-tailored randomized trial intervention groups targeting exercise behavior (N = 1050) were pooled, and analyses assessed differences in TTM constructs between the three groups at baseline, 12 months, and 24 months. Findings indicated that relapsers tended to use TTM variables similarly to maintainers with the exception of self-efficacy, consciousness raising, and most behavioral processes of change, at 24 months. Nonchangers, however, used all TTM variables less than maintainers at nearly every time point. Findings suggest that relapsers remain more active than nonchangers in terms of use of change processes. Poor response to interventions (nonchangers) may be predicted by low baseline engagement in change processes. Although relapsers reverted to physical inactivity, their overall greater use of TTM constructs suggests that their efforts to change remain better than those of the stable nonchanger group. Future research can focus on treatment engagement strategies to help the stable nonchangers initiate change and to help relapsers to maintain treatment gains.

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 η (2) = .15, Cons η (2) = .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.

Automated indexing of Internet stories for health behavior change: weight loss attitude pilot study.

BACKGROUND: Automated health behavior change interventions show promise, but suffer from high attrition and disuse. The Internet abounds with thousands of personal narrative accounts of health behavior change that could not only provide useful information and motivation for others who are also trying to change, but an endless source of novel, entertaining stories that may keep participants more engaged than messages authored by interventionists. OBJECTIVE: Given a collection of relevant personal health behavior change stories gathered from the Internet, the aim of this study was to develop and evaluate an automated indexing algorithm that could select the best possible story to provide to a user to have the greatest possible impact on their attitudes toward changing a targeted health behavior, in this case weight loss. METHODS: An indexing algorithm was developed using features informed by theories from behavioral medicine together with text classification and machine learning techniques. The algorithm was trained using a crowdsourced dataset, then evaluated in a 2×2 between-subjects randomized pilot study. One factor compared the effects of participants reading 2 indexed stories vs 2 randomly selected stories, whereas the second factor compared the medium used to tell the stories: text or animated conversational agent. Outcome measures included changes in self-efficacy and decisional balance for weight loss before and after the stories were read. RESULTS: Participants were recruited from a crowdsourcing website (N=103; 53.4%, 55/103 female; mean age 35, SD 10.8 years; 65.0%, 67/103 precontemplation; 19.4%, 20/103 contemplation for weight loss). Participants who read indexed stories exhibited a significantly greater increase in self-efficacy for weight loss compared to the control group (F1,107=5.5, P=.02). There were no significant effects of indexing on change in decisional balance (F1,97=0.05, P=.83) and no significant effects of medium on change in self-efficacy (F1,107=0.04, P=.84) or decisional balance (F1,97=0.78, P=.38). CONCLUSIONS: Personal stories of health behavior change can be harvested from the Internet and used directly and automatically in interventions to affect participant attitudes, such as self-efficacy for changing behavior. Such approaches have the potential to provide highly tailored interventions that maximize engagement and retention with minimal intervention development effort.

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.