Colleen A. Redding

The Transtheoretical Model of Change and HIV Prevention: A Review

The transtheoretical model of health behavior change is described and supporting empirical work is presented that reviews the central constructs of the model: the stages of change, processes of change, decisional balance, confidence, and temptation. Model-based applications to a broad range of problem behaviors are summarized. Applications to human immunodeficiency virus (HIV) prevention behavior changes are highlighted for each variable. Finally, several questions about the area of sexual behavior change to reduce risk of HIV exposure are explored and future research ideas are described within the context of this model.

Multiple risk expert systems interventions: impact of simultaneous stage-matched expert system interventions for smoking, high-fat diet, and sun exposure in a population of parents.

Three stage-based expert system interventions for smoking, high-fat diet, and unsafe sun exposure were evaluated in a sample of 2,460 parents of teenagers. Eighty-four percent of the eligible parents were enrolled in a 2-arm randomized control trial, with the treatment group receiving individualized feedback reports for each of their relevant behaviors at 0, 6, and 12 months as well as a multiple behavior manual. At 24 months, the expert system outperformed the comparison condition across all 3 risk behaviors, resulting in 22% of the participants in action or maintenance for smoking (vs. 16% for the comparison condition), 34% for diet (vs. 26%), and 30% for sun exposure (vs. 22%). Proactive, home-based, and stage-matched expert systems can produce significant multiple behavior changes in at-risk populations where the majority of participants are not prepared to change.

Treatment for cigarette smoking among depressed mental health outpatients : A randomized clinical trial

OBJECTIVES Using a brief contact control, we tested the efficacy of a staged care intervention to reduce cigarette smoking among psychiatric patients in outpatient treatment for depression. METHODS We conducted a randomized clinical trial that included assessments at baseline and at months 3, 6, 12, and 18. Three hundred twenty-two patients in mental health outpatient treatment who were diagnosed with depression and smoked > or =1 cigarette per day participated. The desire to quit smoking was not a prerequisite for participation. Staged care intervention participants received computerized motivational feedback at baseline and at 3, 6, and 12 months and were offered a 6-session psychological counseling and pharmacological cessation treatment program. Brief contact control participants received a self-help guide and referral list of local smoking-treatment providers. RESULTS As we hypothesized, abstinence rates among staged care intervention participants exceeded those of brief contact control participants at months 12 and 18. Significant differences favoring staged care intervention also were found in occurrence of a quit attempt and stringency of abstinence goal. CONCLUSION The data suggest that individuals in psychiatric treatment for depression can be aided in quitting smoking through use of staged care interventions and that smoking cessation interventions used in the general population can be implemented in psychiatric outpatient settings.

Stage of change, decisional balance, and temptations for smoking: Measurement and validation in a large, school-based population of adolescents

Developing interventions for reducing adolescent smoking rates based on the Transtheoretical Model (TTM) requires the development of quality measures of the key constructs of the model. The goal of this investigation was to evaluate the psychometric properties of measures of Stage of Change, Decisional Balance and Situational Temptation for both smokers and nonsmokers and to test if the predicted relationships between these constructs were confirmed in a large (N=2808) sample of adolescents. A correlated three factor model (Social Pros, Coping Pros and Cons) provided an excellent fit to the 12-item Decisional Balance inventory for both smokers (CFI=0.957) and nonsmokers (CFI=0.963). A hierarchical four factor model (negative affect, positive social, habit strength and weight control) provided an excellent fit to the eight-item Situational Temptations inventory for smokers (CFI=0.969). A hierarchical five-factor model (same four as smokers plus Curiosity) provided an excellent fit to the 10-item Situational Temptations inventory for nonsmokers (CFI=0.943). The relationships between both the Decisional Balance and temptation scales and the Stages of Change were verified for both smokers and nonsmokers. The measures for adolescents are similar to but not the same as the measures of these constructs for adults.

Teen Reach: Outcomes From a Randomized, Controlled Trial of a Tobacco Reduction Program for Teens Seen in Primary Medical Care

Objective. To test the long-term efficacy of brief counseling plus a computer-based tobacco intervention for teens being seen for routine medical care. Methods. Both smoking and nonsmoking teens, 14 to 17 years of age, who were being seen for routine visits were eligible for this 2-arm controlled trial. Staff members approached teens in waiting rooms of 7 large pediatric and family practice departments within a group-practice health maintenance organization. Of 3747 teens invited at ≥1 visits, 2526 (67%) consented and were randomized to tobacco intervention or brief dietary advice. The tobacco intervention was individually tailored on the basis of smoking status and stage of change. It included a 30-second clinician advice message, a 10-minute interactive computer program, a 5-minute motivational interview, and up to two 10-minute telephone or in-person booster sessions. The control intervention was a 5-minute motivational intervention to promote increased consumption of fruits and vegetables. Follow-up smoking status was assessed after 1 and 2 years. Results. Abstinence rates after 2 years were significantly higher for the tobacco intervention arm, relative to the control group, in the combined sample of baseline smokers and nonsmokers (odds ratio [OR]: 1.23; 95% confidence interval [CI]: 1.03–1.47). Treatment effects were particularly strong among baseline self-described smokers (OR: 2.42; 95% CI: 1.40–4.16) but were not significant for baseline nonsmokers (OR: 1.25; 95% CI: 0.97–1.61) or for those who had “experimented” in the past month at baseline (OR: 0.95; 95% CI: 0.45–1.98). Conclusions. Brief, computer-assisted, tobacco intervention during routine medical care increased the smoking cessation rate among self-described smokers but was less effective in preventing smoking onset.

Tailored communications for smoking cessation: past successes and future directions*

Tailored communications are one of the most promising approaches to smoking cessation interventions for entire populations. Assessments based on the Transtheoretical Model are processed by computer-based expert systems that generate feedback reports tailored to each individual to accelerate their progress through the stages of change for smoking cessation. Seven studies are reviewed that range from a more traditional clinical trial to trials on entire populations of smokers to population trials designed to change multiple behaviours, including smoking. A series of three tailored communications was found to produce long-term point prevalence abstinence rates within the narrow range of 22-26% abstinence. This same range of abstinence was found even when two or three other behaviours (e.g. diet and sun protection) were treated in the population. These results point to a future in which health behaviour risk interventions will be assessed not solely by their efficacy but by their population impact.

A Network-Individual-Resource Model for HIV Prevention

HIV is transmitted through dyadic exchanges of individuals linked in transitory or permanent networks of varying sizes. A theoretical perspective that bridges key individual level elements with important network elements can be a complementary foundation for developing and implementing HIV interventions with outcomes that are more sustainable over time and have greater dissemination potential. Toward that end, we introduce a Network-Individual-Resource (NIR) model for HIV prevention that recognizes how exchanges of resources between individuals and their networks underlies and sustains HIV-risk behaviors. Individual behavior change for HIV prevention, then, may be dependent on increasing the supportiveness of that individual’s relevant networks for such change. Among other implications, an NIR model predicts that the success of prevention efforts depends on whether the prevention efforts (1) prompt behavior changes that can be sustained by the resources the individual or their networks possess; (2) meet individual and network needs and are consistent with the individual’s current situation/developmental stage; (3) are trusted and valued; and (4) target high HIV-prevalence networks.

Treating Tobacco Dependence in Clinically Depressed Smokers: Effect of Smoking Cessation on Mental Health Functioning

We analyzed data from a randomized trial of 322 actively depressed smokers and examined the effect of smoking cessation on their mental health functioning. Only 1 of 10 measures at 4 follow-up time points was significant: participants who successfully stopped smoking reported less alcohol use than did participants who continued smoking. Depressive symptoms declined significantly over time for participants who stopped smoking and those who continued smoking; there were no group differences. Individuals in treatment for clinical depression can be helped to stop smoking without adversely affecting their mental health functioning.

A Framework for Incorporating Dyads in Models of HIV-Prevention

Although HIV is contracted by individuals, it is typically transmitted in dyads. Most efforts to promote safer sex practices, however, focus exclusively on individuals. The goal of this paper is to provide a theoretical framework that specifies how models of dyadic processes and relationships can inform models of HIV-prevention. At the center of the framework is the proposition that safer sex between two people requires a dyadic capacity for successful coordination. According to this framework, relational, individual, and structural variables that affect the enactment of safer sex do so through their direct and indirect effects on that dyadic capacity. This dyadic perspective does not require an ongoing relationship between two individuals; rather, it offers a way of distinguishing between dyads along a continuum from anonymous strangers (with minimal coordination of behavior) to long-term partners (with much greater coordination). Acknowledging the dyadic context of HIV-prevention offers new targets for interventions and suggests new approaches to tailoring interventions to specific populations.

Sun protection behaviors and stages of change for the primary prevention of skin cancers among beachgoers in Southeastern New England

Sun exposure is the most important avoidable cause of skin cancers. We report characteristics of a representative sample (N=2,324) of beachgoers in Southeastern New England during the summer of 1995. This sample was not employing adequate sun protection behaviors (83% did not often avoid the sun during midday and only 45% often used sunscreen). Important demographic and skin cancer risk factor differences in sun protective behaviors and stages of change for sun protection were found, especially differences based on age, gender, and degree of sun sensitivity. Consistent with previous research, increased age, female gender, and greater sun sensitivity were each independently associated with more sun protective behaviors. These findings underscore the need for interventions targeting high-risk populations, such as those receiving high-intensity sun exposures at the beach.