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Background: Past studies have shown mixed results on how gender and living with a spouse or partner impact advance care planning (ACP). Few if any have tested for the interaction between these two variables., Objective: We examined how gender and couple status interact to impact the use of ACP practices including written instructions, designating a durable power of attorney for healthcare (DPOAHC), and discussing one's decisions with others., Design: We used cross-sectional data taken from the Health and Retirement Study, a longitudinal study of adults over the age of 50 in the United States., Methods: Data are from 632 respondents who died between the 2016 core survey and the 2018 exit survey. Participants had completed the 2016 survey and had a proxy informant complete the 2018 exit survey after their death. Generalized linear mixed models were used to test for main effects and interactions., Results: Women were more likely than men to designate a DPOAHC and to discuss their wishes with others. Women living without a partner were more likely than men living without a partner and coupled households to discuss their wishes with family or others., Conclusion: Both gender and couple status are important variables associated with ACP practices. Healthcare providers may want to reach out to women living within a coupled household and men living without a partner to ensure that they know the benefits of ACP., Competing Interests: The authors declare that there is no conflict of interest., (© The Author(s), 2024.)

Context: Unraveling the intricacies of what factors influence advance care planning (ACP) is an ongoing research challenge. Research shows much ACP is crisis-based and takes place at the end of life. Complicating this late-stage approach may be demographic differences based on race, ethnicity and socioeconomic status. Objective: We examined the relationship between demographic factors, chronic health conditions, and healthcare utilization in predicting who was most likely to engage in ACP activities, including designating a durable power of attorney for healthcare (DPOAHC), having a living will, and discussing wishes with family or others. Methods: We conducted a secondary analysis using 2018 Health and Retirement Study (HRS) exit data provided by a proxy for the deceased participant that matched the 2016 survey participant data (N = 884). Generalized linear mixed models were used for the analysis. Results: The number of chronic health conditions and healthcare utilization were not associated with ACP activities, but several of the demographic variables showed strong associations. Participants who were female, white, older, and from a higher socioeconomic status were more likely to have engaged in ACP. Conclusion: People continue to defer ACP discussions and documentation end of life or when facing medical crises. More needs to be done to reach out to younger adults, racial minorities, and those with lower socioeconomic status to encourage them to engage in ACP.

Nurses and social workers are uniquely positioned to advocate for patients' wishes for do-not-hospitalize (DNH) directives. The purpose of the current study was to explore the impact of DNH education, policy, and advocacy on the use of DNH orders by nurses (RNs and licensed practical nurses [LPNs]) and social workers employed in skilled nursing facilities (SNFs). This multisite secondary analysis used cross-sectional survey data and analyzed responses of RNs, LPNs, and social workers ( N = 354) from 29 urban SNFs. Mixed model regression was used to examine possible predictors of frequency of DNH orders within SNFs while adjusting for random effects. Results showed that having a DNH written policy, education on DNH orders, and having an advanced care planning advocate in the facility were strongly associated with a higher reported frequency of DNH discussions with residents and their families ( p < 0.01 for each variable). [ Journal of Gerontological Nursing, 48 (11), 45-52.].

In cases whereby the continuation of life-sustaining medical therapies is not in the infant's best interest and does not align with the parents' goals, it is ethically and morally advisable to withhold/withdraw life-sustaining medical therapies. Withdrawing/withholding artificial nutrition hydration is not morally or ethically different from other medical treatments. Determination of what and when to withdraw should occur through shared decision-making considering the parents' values and the infant's physiology and comfort. The practice of physician recommendations followed by parental informed nondissent should be considered in these instances., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background and Objectives: We examined the impact of advance care planning (ACP) self-efficacy and beliefs in explaining skilled nursing facility (SNF) provider judgments about resident need and provider responsibility for initiating ACP conversations., Research Design and Methods: This observational multi-site study of 348 registered nurses, licensed practical nurses, and social workers within 29 SNFs used an anonymous survey in which providers judged vignettes with assigned situational features of a typical SNF resident. Mixed modeling was used to analyze the vignette responses., Results: Providers who had more negative beliefs about ACP were less likely to judge residents in need of ACP and less likely to feel responsible for ensuring ACP took place. Self-efficacy did not have a significant impact on judgments of need, but did significantly increase judgments of responsibility for ensuring ACP conversations. Providers with the highest levels of ACP self-efficacy were most likely to feel responsible for ensuring ACP conversations. In an exploratory analysis, these relationships remained the same whether responding to high or low risk residents (i.e., based on risk of hospitalization, type of diagnosis, functional status, and rate of declining health)., Discussion and Implications: Both negative beliefs about ACP and self-efficacy in one's ability to conduct ACP discussions were associated with professional judgments regarding ACP. The findings illustrate the importance of addressing negative beliefs about ACP and increasing provider ACP self-efficacy through education and policies that empower nurses and social workers.

Introduction: Food insecurity is a problem for individuals across Ohio, including those living in Appalachia. Adequate access to resources that help combat food insecurity is important for these populations., Purpose: To examine how rurality relates to food insecurity and need for food resources, as well as availability of those resources including food pantries and soup kitchens, in 15 northern Ohio Appalachian counties., Methods: A cross-sectional study with a geographical analysis was conducted using data from the American Community Survey census data, County Health Rankings data, and regional foodbank websites., Results: Rural counties had a higher ratio of potential clients per service for food insecurity than did non-rural counties. They also had slightly more children eligible for free or reduced-price lunches than non-rural counties. However, the non-rural counties had slightly higher percentages of residents classified as food insecure and with limited access to healthy food., Implications: There are more potential clients per service for food insecurity in rural counties compared to non-rural counties. To promote greater access, additional food pantries should be opened in rural counties., (Copyright © 2021 Cooper T. Johnson, Rebecca Fischbein, and Kristin R. Baughman.)

Background: Previous research shows that pediatricians inconsistently utilize the ethics consultation service (ECS). Methods: Pediatricians in two suburban, Midwestern academic hospitals were asked to reflect on their ethics training and utilization of ECS via an anonymous, electronic survey distributed in 2017 and 2018, and analyzed in 2018. Participants reported their clinical experience, exposure to formal and informal ethics training, use of formal and informal ethics consultations, and potential barriers to formal consultation. Results: Less experienced pediatricians were more likely to utilize formal ethics consultation and more likely to have formal ethics training. The most commonly reported reasons not to pursue formal ECS consultation were inconvenience and self-reported expertise in pediatric ethics. Conclusions: These results inform ongoing discussions about ethics consultation among pediatricians and the role of formal ethics training in both undergraduate and graduate medical education.

Background: Maternal mental health status remains an important area of study due to its influence on maternal health outcomes. Past reviews on anxiety in pregnancy have included multiple mental health diagnoses and pre-existing conditions. A systematic review was performed to understand maternal state anxiety during pregnancies affected by obstetrical complications., Methods: A systematic search of electronic databases was performed including quantitative, primary studies in the English language. The population of interest was women whose pregnancies were affected by maternal and/or fetal obstetric (not pre-existing) complications with state anxiety as the outcome. Twenty-six studies met the inclusion and methodological criteria and were included in the review., Results: The review revealed that 20% to 100% of women experiencing pregnancies affected by obstetric complications had high levels of state anxiety, and these rates are negatively influenced by complication type and severity, demographic characteristics, and maternal perceptions and expectations. Overall, antenatal state anxiety was shown to improve over the course of the pregnancy, though levels remained above clinical thresholds., Limitations: This review was based only on English peer-reviewed articles, many of which used convenience sampling with homogenous samples, limiting generalizability. Additional limitations include how anxiety prevalence was aggregated due to differences in measurement across studies., Conclusions: Anxiety is prevalent among women experiencing pregnancies affected by obstetric complications. Based on this review, we recommend that all women treated for obstetric complications are screened for anxiety; facilitating detection, referral, and treatment, ultimately contributing to optimal maternal outcomes., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Problem: A disconnect exists between caregivers and health care providers, resulting in fragmented communication, which increases caregiver stress and compromises patient care. Although providers have a responsibility to recognize caregiver burden, they receive scant training on issues important to caregivers., Approach: From 2014 to 2017, as part of the Building Caregiver Partnerships Through Interprofessional Education project-a collaborative effort between Northeast Ohio Medical University and Summa Health-the authors developed curricula to foster effective partnerships between health care providers and caregivers by exposing medical students and residents to highly personal caregiving narratives. The curricula center on a short film featuring 4 families representing diverse caregiving experiences. The authors crafted several discussion guides, case-based learning exercises, structured clinical encounters, team-based simulations, and clinical cases as companion educational tools for the film., Outcomes: Medical students reported the educational tools piloted to be valuable in broadening their understanding of caregivers' needs, while residents reported the educational tools piloted to also be valuable in improving their communication and building partnerships with caregivers. Undergraduate and graduate faculty reported finding the pilots valuable., Next Steps: Future goals include conducting an outcome evaluation, based on ACGME milestones, to identify and examine clinical outcomes to determine whether communication increases and quality of care improves as a result of the project. The authors would also like to include caregivers in the evaluation. Finally, because caregiving is best addressed from a team approach, the authors plan to pilot the project at other health professions programs.

Background and Objective: Families are the backbone of our long-term care system, managing complicated illnesses, providing direct care, and assisting with the day-to-day functioning of elderly patients. Medical education, however, provides students with little, if any, exposure to the challenges faced by family caregivers or how best to communicate with them to optimize patient care. We assessed the value of an educational program combining film and discussion as a means of sensitizing third-year medical students to caregiver issues. During their family medicine clerkship, third-year medical students at Northeast Ohio Medical University view the film, No Roadmap: Caregiver Journeys and discuss issues of family caregiving., Methods: A mixed-methods approach was used to evaluate the program, including a qualitative focus group with clerkship preceptors and ongoing quantitative student evaluations., Results: Preceptors reported that students related to the film in highly personal ways, often recounting experiences within their own families, and gained a greater appreciation of caregivers. Three years of student evaluations (n=403) were used to validate preceptor comments. Students agreed that the program helped them establish a comfortable relationship with caregivers, increased their awareness of caregiver challenges and rewards, and provided valuable insights into caregiver experiences., Conclusions: Film depicting compelling narratives of caregiver journeys, coupled with guided discussion, is a valuable strategy for increasing student awareness of the important role of caregivers., (© 2019 by the Society of Teachers of Family Medicine.)

Background and Objectives: Lack of advance care planning (ACP) may increase hospitalizations and impact the quality of life for skilled nursing facility (SNF) residents, especially African American residents who may be less likely to receive ACP discussions. We examined the professional judgments of SNF providers to see if race of SNF residents and providers, and risk for hospitalization for residents influenced professional judgments as to when ACP was needed and feelings of responsibility for ensuring ACP discussions., Research Design and Methods: Nurses and social workers (n = 350) within 29 urban SNFs completed surveys and rated vignettes describing eight typical SNF residents. Linear mixed modeling was used to examine factors that impacted ratings of need for ACP and responsibility for ensuring ACP., Results: Neither the race of the provider, resident, nor the interaction of the two were associated with either outcome variable. In contrast, providers rated (on a 9-point scale) residents at high risk for hospitalization as more in need of ACP (estimate = 0.86, confidence interval [CI] 0.65, 1.07) and felt more responsible for ensuring ACP (estimate = 0.60, CI 0.42, 0.78)., Discussion and Implications: Research on ACP is continuing to evolve and these results show the primacy of disease trajectory variables on providers' judgments about ACP. Differences between providers indicate a need for stronger policies and education. Further, research comparing rural, suburban, and urban SNFs is needed to explore possible forms of structural racism such as residential and SNF segregation., (© The Author(s) 2017. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

: Objective: This study compared the advance care planning (ACP)-related beliefs, sense of self-efficacy, education, and practices of RNs and LPNs., Methods: Data were extrapolated from a larger multisite study that was conducted across seven counties in one midwestern state. The sample consisted of RNs and LPNs working in 29 urban skilled nursing facilities in zip code areas with greater than 10% African American residents. The survey tool, a self-administered written questionnaire, gathered data on participants' demographics and ACP-related beliefs, sense of self-efficacy, education, and practices. The two main outcome variables were the percentage of residents with whom a nurse discussed ACP and the timing of the most recent such discussion., Results: A total of 136 RNs and 178 LPNs completed the survey. Multivariate mixed-model analysis of the two main outcome variables showed that negative beliefs were not significantly associated with the percentage of residents with whom nurses discussed ACP but were significantly associated with the timing of the most recent ACP discussion. Having higher levels of ACP-related self-efficacy and education were significantly and positively associated with both outcome variables. RNs and LPNs did not differ significantly in their ACP-related beliefs, but RNs reported significantly higher levels of self-efficacy and education than LPNs did., Conclusions: There has been a paucity of research comparing RNs and LPNs regarding their ACP practices in skilled nursing facilities. Better education and policies that empower nurses to take a more active role are critical to increasing conversations about ACP. Further research exploring how the complementary roles of RNs and LPNs can be used to improve ACP processes and inform ACP policies is needed.

Aims and Objectives: To examine barriers of advance care planning (ACP) experienced by care managers (CMs) through a mixed methods approach. A concurrent nested design was used to acquire a deeper understanding of ACP and to identify nuances between quantitative and qualitative data., Background: Past quantitative studies on providers have identified barriers related to time, culture, knowledge, responsibility and availability of legal documents. These barriers, and accompanying attitudes and feelings, have been taken at face value without rich qualitative data to identify under what conditions and to what extent a barrier impacts care., Design: A two-part multisite, mixed methods study was conducted using surveys and focus groups., Methods: Surveys were completed by 458 CMs at 10 Area Agencies on Aging and 62 participated in one of eight focus groups. Data were analysed using a concurrent nested design with individual data analysis and a merged data approach., Results: There were three main distinctions between the quantitative and qualitative data. First, while CMs reported on the survey that ACP was not too time consuming, focus group data revealed that time was an issue especially related to competing priorities. Second on the survey 60% of the CMS reported they had enough knowledge, but qualitative data revealed about more nuances. Last, the reported comfort levels in the quantitative data were less overt in the qualitative date where additional feelings and attitudes were revealed, for example, frustration with families, preferences for more physician involvement., Conclusions: Care managers reported their attitudes about ACP, clarified through a rigorous mixed methods analysis. Care managers can successfully lead ACP discussions, but require further education, resources and team-based guidance., Relevance to Clinical Practice: Advance care planning is essential for reducing emotional, social and financial burdens associated with healthcare decision-making, and CMs can positively impact ACP discussions when appropriately supported by the clinical community. The many nuances in the ACP process that we found illustrate the need for ongoing discussions, education and research on this important topic., (© 2018 John Wiley & Sons Ltd.)

Background: Although patients prefer that physicians initiate advance care planning (ACP) conversations, few physicians regularly do so. Physicians may be reluctant to initiate ACP conversations because they lack self-efficacy in their skills. Yet, no validated scale on self-efficacy for ACP exists. Our objective was to develop a scale that measures physicians' ACP self-efficacy (ACP-SE) and to investigate the validity of the tool., Methods: Electronic questionnaires were administered to a random sample of family medicine physicians (n = 188). Exploratory factor analysis was performed to determine whether the scale was multidimensional. An initial assessment of the scale's validity was also conducted., Results: The exploratory factor analysis indicated that a single factor was appropriate using all 17 items. A single, unidimensional scale was created by averaging the 17 items, yielding good internal consistency (Cronbach α = 0.95). The average scale score was 3.94 (standard deviation = 0.71) on a scale from 1 to 5. The scale was moderately correlated with a global single-item measure of self-efficacy for ACP ( r = .79, P < .001), and the scale differentiated between physician groups based on how much ACP they were doing, how recently they had an ACP conversation, formal training on ACP, and knowledge of ACP. In a multivariate analysis, the ACP-SE scale was a strong predictor of the percentage of patients with chronic life-limiting diseases with whom the physician discussed ACP., Conclusion: The final ACP-SE scale included 17 items and demonstrated high internal consistency.

This study examines the prevalence of comorbid physical health conditions within a community sample of individuals with severe mental illness (SMI), compares them to a matched national sample without SMI, and identifies which comorbidities create the greatest disease burden for those with SMI. Self-reported health status, co-morbid medical conditions and perceived disease burden were collected from 203 adults with SMI. Prevalence of chronic health conditions was compared to a propensity-matched sample without SMI from the National Comorbidity Survey-Replication (NCS-R). Compared to NCS-R sample without SMI, our sample with SMI had a higher prevalence of seven out of nine categories of chronic health conditions. Chronic pain and headaches, as well as the number of chronic conditions, were associated with increased disease burden for individuals with SMI. Further investigation of possible interventions, including effective pain management, is needed to improve the health status of this population.

Problems paying medical bills have been reported to be associated with increased stress, bankruptcy, and forgone medical care. Using the Behavioral Model for Vulnerable Populations developed by Gelberg et al as a framework, as well as data from the 2010 Ohio Family Health Survey, this study examined the relationships between difficulty paying medical bills and forgone medical and prescription drug care. Logistic regression was used to examine associations between difficulty paying medical bills and predisposing, enabling, need (health status), and health behaviors (forgoing medical care). Difficulty paying medical bills increased the effect of lack of health insurance in predicting forgone medical care and had a conditional effect on the association between education and forgone prescription drug care. Those who had less than a bachelor's degree were more likely to forgo prescription drug care than those with a bachelor's degree, but only if they had difficulty paying medical bills. Difficulty paying medical bills also accounted for the relationships between several population characteristics (eg, age, income, home ownership, health status) in predicting forgone medical and prescription drug care. Policies to cap out-of-pocket medical expenses may mitigate health disparities by addressing the impact of difficulty paying medical bills on forgone care.

Organizational characteristics may impede the uniform adoption of advance care planning (ACP) best practices. We conducted telephone interviews with site directors of a Midwestern state's Medicaid waiver program administered by the Area Agencies on Aging and surveyed the 433 care managers (registered nurses and social workers) employed within these 9 agencies. Care managers at 2 agencies reported more frequent ACP discussions and higher levels of confidence. Both sites had ACP training programs, follow-up protocols, and informational packets available for consumers that were not consistently available at the other agencies. The findings point to the need for consistent educational programs and policies on ACP and more in depth examination of the values, beliefs, and resources that account for organizational differences in ACP., (© The Author(s) 2014.)

Our objective was to better understand the values and ethical dilemmas surrounding advance care planning through stories told by registered nurses and licensed social workers, who were employed as care managers within Area Agencies on Aging. We conducted eight focus groups in which care managers were invited to tell their stories and answer open-ended questions focusing on their interactions with consumers receiving home-based long-term care. Using narrative analysis to understand how our participants thought through particular experiences and what they valued, we identified seven themes representative of their work with consumers and families: humility, respect, responsibilities, boundaries, empowerment, courage, and veracity.

Background: Initiating advance care planning (ACP) discussions in the home may prevent avoidable hospitalizations by elucidating goals of care. Area agencies on aging care managers (AAACMs) work in the home with high-risk consumers., Purpose: To determine which AAACM characteristics contribute to an increased frequency of ACP discussions., Method: Cross-sectional investigator-generated surveys administered to AAACMs at 3 AAAs in Ohio., Results: Of 289 AAACMs, 182 (63%) responded. The more experience and comfort AAACMs felt with ACP discussions, the more likely they were to initiate ACP discussions., Discussion: It may be necessary to build interactive educational experiences where, for example, AAACMs are asked to fill out their own advance directives and/or facilitate others in ACP discussions to improve experience and comfort with ACP discussions.

Factorial surveys were used to examine community-based long-term care providers' judgments about consumers' need for advance care planning (ACP) and comfort levels in discussing ACP. Providers (448 registered nurses and social workers) judged vignettes based on hypothetical consumers. Hierarchical linear models indicated providers judged consumers who were older, had end-stage diagnoses, multiple emergency department visits, and uninvolved caregivers as most in need of ACP. These variables explained 10% of the variance in judgments. Providers' beliefs about ACP predicted judgments of need for ACP and comfort level in discussing ACP. Provider characteristics explained more variance in comfort levels (44%) than in judgments of need (20%). This study demonstrates the need for tailored educational programs to increase comfort levels and address ACP misconceptions.

To better understand how community-based long-term care providers define advance care planning and their role in the process, we conducted 8 focus groups with 62 care managers (social workers and registered nurses) providing care for Ohio's Medicaid waiver program. Care managers shared that most consumers had little understanding of advance care planning. The care managers defined it broadly, including legal documentation, social aspects, medical considerations, ongoing communication, and consumer education. Care managers saw their roles as information providers, healthcare team members, and educators/coaches. Better education, resources, and coordination are needed to ensure that consumer preferences are realized.

Context: There is limited research on how community-based long-term care (CBLTC) providers' personal characteristics and attitudes affect their decisions to initiate advance care planning (ACP) conversations with consumers., Objectives: To examine judgments by CBLTC providers as to whether a consumer was in need of ACP and to compare the relative influence of situational features of the consumer with the influence of personal characteristics of the CBLTC provider., Methods: Factorial surveys with vignettes with randomly assigned situational features of a hypothetical consumer were obtained from 182 CBLTC providers at three Area Agencies on Aging located in the Midwestern U.S. Measures included the consumer's situational features, such as demographics, diagnosis, pain level, level of functioning, and caregiver involvement. Personal characteristics of the CBLTC provider included demographics, discipline, past experience with ACP, and attitudes toward ACP., Results: Hierarchical linear models indicated that most variability in ACP decisions was the result of differences among CBLTC providers (64%) rather than consumers' situational features. Positive decisions to discuss ACP were associated with consumers who needed assistance with legal issues and had a cancer diagnosis; these variables explained 8% of the vignette level variance. Significant personal characteristics of the CBLTC provider included a nursing background, less direct contact with consumers, past experience with ACP, and positive attitudes toward ACP; these variables explained 41% of the person-level variance., Conclusion: This study shows the lack of normative consensus about ACP and highlights the need for consistent educational programs regarding the role of the CBLTC provider in the ACP process., (Copyright © 2012 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.)

Objectives: We evaluated a fully structured interview for restless legs syndrome (RLS) for potential use in primary care settings and in epidemiological research., Methods: Seventy-four veterans were recruited at Veterans Affairs outpatient clinics. The interview was administered telephonically by trained non-clinicians (time 1) and readministered face to face (time 2). A physician conducted gold standard examinations. We calculated sensitivity, specificity and reproducibility., Results: Reproducibility was low (kappa = 0.34, P < 0.01), but was higher for interviews repeated within 1 year (kappa = 0.55, P < 0.01). Including those reporting > or =3 symptoms as cases, sensitivity ranged from 63% (time 1) to 75% (time 2). Specificity ranged from 88% to 71%., Conclusions: The sensitivity and specificity reported here are lower than previously reported in specialty care. This interview for RLS might be useful for preliminary screening of patients with related complaints if followed by additional diagnostic maneuvers or might be used in observational epidemiological research.

Contradictory results have been reported for the association between antidepressant use and Restless Legs Syndrome (RLS). Our aim was to clarify the relationship and examine possible gender differences. We interviewed 1,693 veterans receiving primary care from the Cleveland VA Medical Center and obtained prescription drug information from their medical records. Overall, use of an antidepressant was associated with RLS for men (RR = 1.77, CI = 1.26, 2.48) but not for women (RR = 0.79, CI = 0.43, 1.47). Analyses of individual antidepressants revealed an association between RLS and fluoxetine for women (RR = 2.47, CI = 1.33, 4.56), and associations between RLS and citalopram, (RR = 2.09, CI = 1.20, 3.64), paroxetine (RR = 1.97, CI = 1.02, 3.79), and amitriptyline (RR = 2.40, CI = 1.45, 4.00) for men. We conclude that RLS may be associated with antidepressant use, but the association varies by gender and type of antidepressant. Antidepressant use is more strongly associated with RLS in men than in women., ((c) 2009 Movement Disorder Society.)

Objective: The objective of this study was to examine the longitudinal relationship between the elapsed time in the action and maintenance stages of change for multiple target behaviors and weight loss or gain., Research Methods and Procedures: The research design was a prospective cohort study of overweight and obese primary care patients randomized to an obesity management intervention based on the Transtheoretical Model and a chronic disease paradigm. The target behaviors included increased planned exercise and usual physical activity, decreased dietary fat, increased fruit and vegetable consumption, and increased dietary portion control. The participants were 329 middle-aged men and women with elevated body mass indices recruited from 15 primary care practices in Northeastern Ohio; 28% of the participants were African Americans. The main outcomes were weight loss (5% or more) or weight gain (5% or more) after 18 or 24 months of follow-up., Results: There were significant (p < 0.05) longitudinal relationships between the number of periods (0 to 4) in action or maintenance for each of the five target behaviors, or a composite score taken across the five target behaviors, and weight loss. In all cases, there was a significant (p < 0.05) stepped (graded) relationship between the time in action or maintenance and weight loss (or gain)., Discussion: The data support the concept of applying the Transtheoretical Model to the problem of managing obesity in primary care settings. The remaining challenge is to identify those factors that reliably move patients into the action and maintenance stages for long periods.