Leanne M. Mauriello

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.

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.

Acceptability of a School-Based Intervention for the Prevention of Adolescent Obesity:

This article describes the development and pilot testing of a computer-based, multiple-behavior obesity prevention program for adolescents. Using the Transtheoretical Model as a framework, this intervention offers individualized feedback based on readiness to engage in physical activity, to consume fruits and vegetables, and to limit television viewing. Focus groups and interviews with students, teachers, school administrators, and experts guided the development. Forty-five students participated in a baseline intervention session and completed a 16-item acceptability measure. Ratings were positive, with item means ranging from 3.60–4.75 on a 5-point scale. Student responses to open-ended questions aided in the enhancement of the intervention, for which an effectiveness trial begins in September 2006. This formative work demonstrated the acceptability of this school-based intervention approach, which can be promoted and prescribed by school nurses. Further, if found effective, it can be disseminated as an efficient, low-cost, population-based approach designed to address the epidemic of obesity.

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.

Assessment of the Pros and Cons of Stress Management Among Adolescents: Development and Validation of a Decisional Balance Measure

Purpose. This article reports on the development of a decisional balance measure based on the transtheoretical model (TTM) for stress management among adolescents. Design. Measurement development was conducted with participants of a pilot survey. Setting. Surveys were completed in health and physical education classes. Subjects. Ninth and tenth graders (N = 317) completed an assessment of TTM constructs. Measures. The focus of this paper is the development of a decisional balance measure. Analysis. A split-half cross-validation procedure was implemented. Results. A brief, reliable eight-item instrument was developed measuring the pros and cons of practicing stress management. A theoretically consistent pattern of pros and cons across the stages of change was obtained and indicated construct validity. Girls were more likely to practice and acknowledge benefits of stress management. Conclusion. This instrument will aid future work on promoting stress management practices among adolescents, particularly when using the TTM to develop interventions.

Acceptability and feasibility of a multiple-behavior, computer-tailored intervention for underserved pregnant women.

INTRODUCTION A pilot test of a computer-tailored intervention designed to promote positive health behaviors during pregnancy among a low-income population across multiple ethnic groups was conducted. METHODS Intervention content, based on the transtheoretical model, offered pregnant women assistance with smoking cessation, stress management, and increasing fruit and vegetable consumption. Pregnant women (N = 87) were recruited from federally qualified health centers. After completing the intervention, women answered a 16-item evaluation. RESULTS Participants rated the program very positively, with 89.7% to 95.5% of participants agreeing or strongly agreeing with all evaluation items. For example, 95.4% of respondents reported that the program could help them be healthier, that they learned new information, and that the program was designed for pregnant women like themselves. Additionally, the majority of participants (92%) reported that they would recommend the program to a friend. There were no significant differences in the ratings based on demographic characteristics of the participants. Qualitative responses support acceptability for the program. Further, assessments before and after completion of the program indicated an increase in intention to make behavioral changes. DISCUSSION With acceptability and feasibility confirmed, the next steps are to test efficacy and consequently to distribute the program to populations of underserved pregnant women.

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.

Using mHealth to Deliver Behavior Change Interventions Within Prenatal Care at Community Health Centers

Purpose. To test an iPad-delivered multiple behavior tailored intervention (Healthy Pregnancy: Step by Step) for pregnant women that addresses smoking cessation, stress management, and fruit and vegetable consumption. Design. A randomized 2 × 5 factorial repeated measures design was employed with randomization on the individual level stratified on behavior risk. Women completed three sessions during pregnancy and two postpartum at postdelivery months 1 and 4. Setting. Women were recruited from six locations of federally funded health centers across three states. Subjects. Participants (N = 335) were English- and Spanish-speaking women at up to 18 weeks gestation. Intervention. The treatment group received three interactive sessions focused on two priority health behavior risks. The sessions offered individually tailored and stage-matched change strategies based on the transtheoretical model of behavior change. The usual care group received March of Dimes brochures. Measures. The primary outcome was the number of behavior risks. Stage of change and continuous measures for all behaviors also were assessed. Analysis. Data were analyzed across all time points using generalized estimating equations examining repeated measures effects. Results. Women in the treatment group reported significantly fewer risks than those in usual care at 1 month (.85 vs. 1.20, odds ratio [OR] = .70) and 4 months postpartum (.72 vs. .91, OR = .81). Conclusion. Healthy Pregnancy is an evidence-based and personalized program that assists pregnant women with reducing behavior risks and sustaining healthy lifestyle behaviors.

An Internet-Based Computer-Tailored Intervention to Promote Responsible Drinking: Findings from a Pilot Test with Employed Adults

This article describes pilot test findings of an Internet-based, Transtheoretical Model-based, computer-tailored intervention for adults who exceed national guidelines for low-risk drinking. In a pilot test, 166 adults recruited from worksites completed one session and evaluated the program. Pre- and post-assessments indicate intention to make behavioral changes. Importantly, 94.3% of participants indicated that they would recommend the program. Ratings were positive with the majority of participants agreeing or strongly agreeing with all 14 evaluation items. Feasibility was demonstrated by recruiting and engaging employed adults. This program is a cost-effective prevention program promoting responsible drinking to adults.

Meeting Patients Where They Are At: Using a Stage Approach to Facilitate Engagement

In this chapter, authored by the leading authorities in the stage approach, readers learn how to engage entire populations in the change process, including those who are uninformed, discouraged, or resistant. A sophisticated understanding of how the characteristics of individuals across the stages of readiness impact engagement is delivered. Next, the application of the Transtheoretical Model of Behavior Change and specific tools for implementation is provided. Readers will gain or expand their understanding of applying the stage model to engaging patients in their health journey.