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Despite a specific need for transfused blood among African Americans due to higher rates of sickle cell disease, African Americans donate blood significantly less frequently than their White counterparts. This study describes the development and validation of culturally adapted measures of the transtheoretical model (TTM) constructs of Stage of Change, Decisional Balance, and Self-efficacy applied to blood donation in an African American sample. Exploratory and confirmatory analyses produced one pros and two cons scales for the Decisional Balance Inventory, and one scale for the Situational Self-efficacy Measure. Expected patterns for the Decisional Balance and Self-efficacy Scales by Stage of Change were found, but only the pros and one cons scale varied significantly. Results provide support for use of the TTM applied to blood donation and have important implications for development of effective assessment and intervention tools to increase blood donation among the African American population. [ABSTRACT FROM AUTHOR]

This study evaluated how well predictions from the transtheoretical model (TTM) generalized from smoking to diet. Longitudinal data were used from a randomized control trial on reducing dietary fat consumption in adults (n =1207) recruited from primary care practices. Predictive power was evaluated by making a priori predictions of the magnitude of change expected in the TTM constructs of temptation, pros and cons, and 10 processes of change when an individual transitions between the stages of change. Generalizability was evaluated by testing predictions based on smoking data. Three sets of predictions were made for each stage: Precontemplation (PC), Contemplation (C) and Preparation (PR) based on stage transition categories of no progress, progress and regression determined by stage at baseline versus stage at the 12-month follow-up. Univariate analysis of variance between stage transition groups was used to calculate the effect size [omega squared (omega(2))]. For diet predictions based on diet data, there was a high degree of confirmation: 92%, 95% and 92% for PC, C and PR, respectively. For diet predictions based on smoking data, 77%, 79% and 85% were confirmed, respectively, suggesting a moderate degree of generalizability. This study revised effect size estimates for future theory testing on the TTM applied to dietary fat. [ABSTRACT FROM AUTHOR]

Batterers' resistance to traditional intervention programs has been well documented. Within a Transtheoretical Model of Change (stage of change) framework, a measure of processes of resistance was developed and administered to 346 adult male domestic violence offenders in treatment. The study yielded a 38-item measure that assesses eight dimensions of resistance: (a) System Blaming, (b) Problems with Partner, (c) Problems with Alliance, (d) Social Justification, (e) Hopelessness, (f) Isolation, (g) Psychological Reactance, and (h) Passive Reactance. The relationship between resistance and stage of change, time in treatment, and partner aggression are reported. Results suggest that we look beyond the most common forms of resistance (e.g., denial and victim-blaming) to identify and address other forms of resistance that may be more internally based and difficult to detect. The processes of resistance measure provides a tool for measuring those types of resistance. [ABSTRACT FROM AUTHOR]

It has been suggested that individuals with autism are more vulnerable to, and less able to cope with, the effects of stressors than the general population. However, very little work has been done to develop tools such as surveys or questionnaires that assess reactions to stressors in individuals with developmental disabilities. In the present investigation, the Stress Survey Schedule for Persons with Autism and Other Developmental Disabilities (SSS; Groden et al., 2001) was completed for 180 individuals with autism, varying in gender, verbal ability, and age. The results demonstrate that the SSS is a valid tool for identifying which dimensions of stress are perceived to be the most and least stressful for subgroups of persons with autism. [ABSTRACT FROM AUTHOR]

Missing data are a common practical problem for longitudinal designs. Time-series analysis is a longitudinal method that involves a large number of observations on a single unit. Four different missing-data methods (deletion, mean substitution, mean of adjacent observations, and maximum likelihood estimation) were evaluated. Computer-generated time-series data of length 100 were generated for 50 different conditions representing five levels of autocorrelation, two levels of slope, and five levels of proportion of missing data. Methods were compared with respect to the accuracy of estimation for four parameters (level, error variance, degree of autocorrelation, and slope). The choice of method had a major impact on the analysis. The maximum likelihood very accurately estimated all four parameters under all conditions tested. The mean of the series was the least accurate approach. Statistical methods such as the maximum likelihood procedure represent a superior approach to missing data. [ABSTRACT FROM AUTHOR]

The Transtheoretical Model of Change (TMC) postulates two sensitive mediating variables, decisional balance and self-efficacy. Four measures of condom use developed with 296 women at high risk for HIV infection or transmission representing these two constructs were cross-validated with 248 heterosexually active college men and women. Confirmatory factor analysis (CFA) procedures were conducted with structural equation modeling (SEM). Factor structures for all condom-use measures were replicated using the second independent sample and a different method of analysis, demonstrating the robustness of the scales. Model fit indices were excellent (e.g., decisional balance = .94 and .95; self-efficacy = .97 and .99), suggesting that more standardized measures can be used when assessing attitudes and behaviors toward condom use among heterosexual populations at various risk for HIV or sexually transmitted disease infection. [ABSTRACT FROM AUTHOR]

Objective: Rates of preventive counseling remain below national guidelines. We explored physician and patient predictors of preventive counseling across multiple cancer risk behaviors in at-risk primary care patients.Methods: We surveyed 3557 patients, with at least one of four cancer risk behaviors: smoking, diet, sun exposure, and/or mammography screening, at baseline and 24 months. Patients reported receipt of 4A's (Ask, Advise, Assist, Arrange follow-up); responses were weighted and combined to reflect more thorough counseling (Ask=1, Advise=2, Assist=3, Arrange=4, score range 0-10) for each target behavior. A series of linear-regression models, controlling for office clustering, examined patient, physician and other situational predictors at 24 months.Results: Risk behavior topics were brought up more often for mammography (90%) and smoking (79%) than diet (56%) and sun protection (30%). Assisting and Arranging follow-up were reported at low frequencies across all behaviors. More thorough counseling for all behaviors was associated with multiple visits and higher satisfaction with care. Prior counseling predicted further counseling on all behaviors except smoking, which was already at high levels. Other predictors varied by risk behavior.Conclusions: More thorough risk behavior counseling can be delivered opportunistically across multiple visits; doing so is associated with more satisfaction with care. [ABSTRACT FROM AUTHOR]

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., (©Marie A Sillice, Patricia J Morokoff, Ginette Ferszt, Timothy Bickmore, Beth C Bock, Ryan Lantini, Wayne F Velicer. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 07.02.2018.)

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.

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, ((c) 2017 APA, all rights reserved).)

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.

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., Competing Interests: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported., (© 2017 Sillice M. A.)

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., (© The Author(s) 2016.)

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.

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.

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., (© 2015 Society for Public Health Education.)

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.

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., (© The Author 2014. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

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.

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., (Copyright © 2014. Published by Elsevier Ltd.)

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.

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.

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.

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.

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., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

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., (PsycINFO Database Record (c) 2014 APA, all rights reserved.)

Objective: Worldwide, alcohol is the most commonly used psychoactive substance. However, heterogeneity among alcohol users has been widely recognized. This paper presents a typology of alcohol users based on an implementation of idiographic methodology to examine longitudinal daily and cyclic (weekly) patterns of alcohol use at the individual level., Method: A secondary data analysis was performed on the pre-intervention data from a large randomized control trial. A time series analysis was performed at the individual level, and a dynamic cluster analysis was employed to identify homogenous longitudinal patterns of drinking behavior at the group level. The analysis employed 180 daily observations of alcohol use in a sample of 177 alcohol users., Results: The first order autocorrelations ranged from -.76 to .72, and seventh order autocorrelations ranged from -.27 to .79. Eight distinct profiles of alcohol users were identified, each characterized by a unique configuration of first and seventh autoregressive terms and longitudinal trajectories of alcohol use. External validity of the profiles confirmed the theoretical relevance of different patterns of alcohol use. Significant differences among the eight subtypes were found on gender, marital status, frequency of drug use, lifetime alcohol dependence, family history of alcohol use and the Short Index of Problems., Conclusions: Our findings demonstrate that individuals can have very different temporal patterns of drinking behavior. The daily and cyclic patterns of alcohol use may be important for designing tailored interventions for problem drinkers., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

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.

Longitudinal predictors of dietary behavior change are important and in need of study. This secondary data analysis combined primary data across three randomized trials to examine transtheoretical model (TTM) and specific dietary predictors of successful dietary change at 12 and 24 months separately in treatment and control groups (N = 4178). The treatment group received three TTM-tailored print interventions over 12 months between 1995 and 2000. Chi-square and MANOVA analyses were used to examine baseline predictors of dietary outcome at 12 and 24 months. Last, a multivariable logistic regression was conducted with all baseline variables included. Across all analyses in both treatment and control groups, the most robust predictors of successful change were for TTM-tailored treatment group, preparation stage of change, and increased use of dietary behavior variables such as moderating fat intake, substitution of lower fat foods, and increasing intake of healthful foods. These results provide strong evidence for treatment, stage and behavioral dietary severity effects predicting dietary behavior change over time, and for targeting these variables with the strongest relationships to outcome in interventions, such as TTM-tailored dietary interventions., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Testing Theory-based Quantitative Predictions (TTQP) represents an alternative to traditional Null Hypothesis Significance Testing (NHST) procedures and is more appropriate for theory testing. The theory generates explicit effect size predictions and these effect size estimates, with related confidence intervals, are used to test the predictions. The focus of a study is shifted to a quantitative approach in contrast to the NHST dyadic decision centered on testing a prediction not based on the theory. This article describes the TTQP as an alternative approach by replicating and extending a test of 40 a priori predictions based on the Transtheoretical Model (TTM). Specific quantitative predictions were made about the magnitude of the effect size (ω(2)). The predictions involved movement from 1 of 3 initial stages (Precontemplation, Contemplation, and Preparation) to stage membership 12 months later. In the initial study, 36 of the 40 predictions were confirmed. The same 40 predictions are evaluated on a sample (N = 3,923) of smokers recruited from a large New England HMO for a smoking cessation study. The predictions were recalibrated based on the first study and 99% confidence intervals were employed to test the predictions. Thirty-two of the 40 predictions were confirmed. Of the 8 failures, 4 were judged to reflect a need for further recalibration, 1 was attributed to sampling fluctuation, and 3 suggested revisions of the theory are needed. The results provide overall support for the TTM. The study also illustrates some of the challenges of testing quantitative predictions.

This study examined the effectiveness of two transtheoretical model-tailored, computer-delivered interventions designed to impact multiple substance use or energy balance behaviors in a middle school population recruited in schools. Twenty middle schools in Rhode Island including sixth grade students ( N =4,158) were stratified and randomly assigned by school to either a substance use prevention (decreasing smoking and alcohol) or an energy balance (increasing physical activity, fruit and vegetable consumption, and limiting TV time) intervention group in 2007. Each intervention involved five in-class contacts over a 3-year period with assessments at 12, 24, and 36 months. Main outcomes were analyzed using random effects modeling. In the full energy balance group and in subsamples at risk and not at risk at baseline, strong effects were found for physical activity, healthy diet, and reducing TV time, for both categorical and continuous outcomes. Despite no direct treatment, the energy balance group also showed significantly lower smoking and alcohol use over time than the substance use prevention group. The energy balance intervention demonstrated strong effects across all behaviors over 3 years among middle school students. The substance use prevention intervention was less effective than the energy balance intervention in preventing both smoking and alcohol use over 3 years in middle school students. The lack of a true control group and unrepresented secular trends suggest the need for further study.

The dominant paradigm of changing multiple health behaviors (MHBs) is based on treating, assessing, and studying each behavior separately. This study focused on individuals with co-occurring baseline health-risk behavior pairs and described whether they changed over time on both or only one of the behaviors within each pair. Data from five randomized trials of computer-tailored interventions (CTIs) that simultaneously treated MHBs were analyzed. The differences between treatment and control proportions that achieved paired action and singular action at 24 months follow-up, and the proportional contribution of paired action to overall change on each behavior, were assessed across 12 behavior pairs (including energy balance, addictive, and appearance-related behaviors). CTIs consistently produced more paired action across behavior pairs. Paired action contributed substantially more to the treatment-related outcomes than singular action. Studying concurrent changes on MHBs as demonstrated allows the effect of simultaneously treating MHBs to be assessed.

Objective: Predictive and external validity was studied among cluster profiles for sun protection behavior within stages from Transtheoretical Model of behavior change using follow-up data., Methods: Data from participants in a home-based expert system were analyzed. Longitudinal patterns of clusters on the precontemplation, contemplation, and preparation stages of change were assessed. Differences between clusters on membership in action/maintenance stages and scores on the Sun Protection Behavior Scale (SPBS) were measured at 12 and 24 months after intervention., Results: Differences between clusters on stage progression and on scores from the SPBS were found at 12 and 24 months after intervention at all stages., Discussion: Predictive and external validity of sun protection subtypes was established using sun protection variables after a stage-matched intervention. Results provide information to improve interventions for sun protection.

Background: The transtheoretical model is an influential theoretical model in health psychology, particularly in its application to smoking cessation research. Decisional Balance (DB) and Temptations are key constructs within this framework., Purpose: This study examines the psychometric properties of the DB and Temptations scales for smoking in a predominantly African-American sample of urban adolescent girls., Methods: We used confirmatory factor analysis to compare the fit of previously published factor structures in smokers (n = 233) and nonsmokers (n = 598). External validity was tested by examining stages of change differences in the retained subscales., Results: Results supported the internal and external validity of the DB scale for smokers and nonsmokers. Notably, previously published three-factor (Social Pros, Coping Pros, Cons) and four-factor (Cons split into "Aesthetic Cons" and "Health Cons") models fit equally well, with Cons subscales correlating highly. For Temptations, a previously published three-factor (Negative Affect, Social, Weight Control) hierarchical model fit well in nonsmokers. In smokers, previously published subscales were reliably measured, but their structural relationship remained unclear. Stage difference tests showed medium to large effect sizes of DB and Temptation subscales in smokers and nonsmokers., Conclusions: The use of DB was validated for both smokers and nonsmokers in this sample of primarily African-American adolescent females, where Cons can be combined or separated into "Aesthetic Cons" and "Health Cons" based on practical utility and preference. For Temptations, more research is needed but large stage differences in Temptations subscales underscore the importance of this concept in smoking acquisition and cessation.

Objective: This study compared, in treatment and control groups, the phenomena of coaction, which is the probability that taking effective action on one behavior is related to taking effective action on a second behavior., Methods: Pooled data from three randomized trials of Transtheoretical Model (TTM) tailored interventions (n=9461), completed in the U.S. in 1999, were analyzed to assess coaction in three behavior pairs (diet and sun protection, diet and smoking, and sun protection and smoking). Odds ratios (ORs) compared the likelihood of taking action on a second behavior compared to taking action on only one behavior., Results: Across behavior pairs, at 12 and 24 months, the ORs for the treatment group were greater on an absolute basis than for the control group, with two being significant. The combined ORs at 12 and 24 months, respectively, were 1.63 and 1.85 for treatment and 1.20 and 1.10 for control., Conclusions: The results of this study with addictive, energy balance and appearance-related behaviors were consistent with results found in three studies applying TTM tailoring to energy balance behaviors. Across studies, there was more coaction within the treatment group. Future research should identify predictors of coaction in more multiple behavior change interventions., (Published by Elsevier Inc.)

Establishment of psychometrically sound measures is critical to the development of effective interventions. The current study examined the psychometric properties, including factorial invariance, of a six item Temptations to Try Smoking Scale on a sample of middle school students. The sample of 6th grade students (N=3527) was from 20 Rhode Island middle schools and was 52% male and 84% white. The Temptations to Try Smoking Scale consisted of two correlated subscales: Positive Social and Curiosity/Stress. Structural equation modeling was implemented to evaluate the factorial invariance across four different subgroups defined by gender (male/female), race (white/black), ethnicity (Hispanic/Non-Hispanic), and school size (<200/ >200 6th graders). A model is factorially invariant when the measurement model is the same in each of the subgroups. Three levels of invariance were examined in sequential order: 1) Configural Invariance (unconstrained nonzero factor loadings); 2) Pattern Identity Invariance (equal factor loadings); and 3) Strong Factorial Invariance (equal factor loadings and measurement errors). Strong Factorial Invariance provided a good fit to the model across gender (CFI=.96), race (CFI=.96), ethnicity (CFI=.94), and school size (CFI=.97). Coefficient Alphas for the two subscales, Positive Social and Curiosity/Stress, were .87 and .86, respectively. These findings provide empirical support for the construct validity of the Temptations to Try Smoking Scale in middle school students., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Objective: While the majority of women quit smoking either before or during pregnancy, 60 to 80% relapse in the postpartum period. The objective of this research was to examine postpartum women who quit smoking during their pregnancies and to determine the predictive factors for relapse in the postpartum period by identifying different subgroups that predict risk of relapse., Method: One hundred forty four postpartum women who were abstinent at the time of delivery were recruited. Data regarding the Acquisition Stage of Change, Decisional Balance and Situational Temptations to Smoke were assessed in the immediate postpartum period. Based on their intention to remain abstinent, 121 women identified in the acquisition-Precontemplation (aPC) group comprised the study sample. Smoking status was assessed again at 2 months postpartum., Results: A cluster analysis was performed to identify subgroups of the acquisition-Precontemplation (aPC) group. Four subgroups were identified and were labeled Most Protected, Ambivalent, Risk Denial, and High Risk. Logistic regression was performed to establish external validity of the clusters. The clusters and exclusive breastfeeding were the only statistically significant variables associated with relapse at 2 months postpartum., Conclusions: The results confirmed the clusters identified in previous prevention research with both adolescents and postpartum women, The cluster profiles can serve to guide the development of a tailored intervention program., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

The aim of this study is to identify replicable cluster subtypes within the precontemplation stage of change for sun protection. Secondary data analysis of baseline data from a sample of participants in a home-based expert system intervention was performed. Three random samples were selected from participants in the precontemplation stage (N = 570). Cluster analyses were performed using the scales of pros, cons, and self-efficacy. Interpretability of pattern, pseudo F-test, and dendograms were used to determine the number of clusters. A four-cluster solution replicated across subsamples. Significant differences between clusters on the nine processes of change and on behavioral measures were found. Cluster solutions were robust, interpretable and with good initial external validity. They replicated patterns found for other behaviors, demonstrating long-term predictability and providing basis for tailored interventions.

Increasing adherence to medical recommendations is crucial for improving health outcomes and reducing costs of health care. To improve adherence, we have to better understand behavior change over time. The focus of this study was adherence to treatment for obstructive sleep apnea (OSA). Adherence to positive airway pressure (PAP), the most common treatment for OSA, is poor. This study involved an international sample of 161 participants, each with approximately 180 nights of data, and had three phases. First, a separate time series analysis was performed for each individual. Time series parameters included the mean (average hours of use per night), level (the intercept), slope (the rate of change over time), variance (variability in use), and autocorrelation (a measure of dependency). 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 (see Figure 1 ): Great Users (17.2%; high mean and level, no slope), Good Users (32.8%; moderate mean and level, no slope), Poor 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 on a number of variables that were not involved in the clustering to establish external validity. Some notable findings at later time points include the following: Great Users reported the most self-efficacy (confidence to use PAP), Poor Users reported the most sleepiness, and Great Users reported the highest quality of sleep. Combining time series analysis and dynamic cluster analysis is a useful way to evaluate adherence patterns at both the individual level and subgroup level. Psychological variables relevant to adherence patterns, such as self-efficacy, could be the focus of interventions to increase PAP usage.

To overcome problems with traditional methods for measuring stereotypical motor movements in persons with Autism Spectrum Disorders (ASD), we evaluated the use of wireless three-axis accelerometers and pattern recognition algorithms to automatically detect body rocking and hand flapping in children with ASD. Findings revealed that, on average, pattern recognition algorithms correctly identified approximately 90% of stereotypical motor movements repeatedly observed in both laboratory and classroom settings. Precise and efficient recording of stereotypical motor movements could enable researchers and clinicians to systematically study what functional relations exist between these behaviors and specific antecedents and consequences. These measures could also facilitate efficacy studies of behavioral and pharmacologic interventions intended to replace or decrease the incidence or severity of stereotypical motor movements.

A measurement model should be equivalent across the different subgroups of a target population. The Decisional Balance Inventory for the Prevention of Alcohol Use is a 2-factor correlated model with 3 items for Pros of alcohol use and 3 items for Cons. The measure is part of a tailored intervention for middle school students. This study evaluated the important psychometric assumptions of factorial invariance and scale reliability with a large sample of sixth grade students (N=3565) from 20 schools. A measure is factorially invariant when the model is the same across subgroups. Three levels of invariance were assessed, from least restrictive to most restrictive: 1) Configural Invariance (unconstrained nonzero factor loadings); 2) Pattern Identity Invariance (equal factor loadings); and 3) Strong Factorial Invariance (equal factor loadings and measurement errors). Structural equation modeling was used to assess invariance over two levels of gender (male and female), race (white and black), ethnicity (Hispanic and non-Hispanic), and school size (large, indicating >200 students per grade, or small). The strongest level of invariance, Strong Factorial Invariance, was a good fit for the model across all of the subgroups: gender (CFI: 0.94), race (CFI: 0.96), ethnicity (CFI: 0.93), and school size (CFI: 0.97). Coefficient alpha was 0.61 for the Pros and 0.67 for Cons. Together, invariance and reliability provide strong empirical support for the validity of the measure., (Copyright © 2011. Published by Elsevier Ltd.)

This study was designed to assess if there are consistent treatment, stage, severity, effort and demographic effects which predict long-term changes across the multiple behaviors of smoking, diet and sun exposure. A secondary data analysis integrated data from four studies on smoking cessation (N = 3927), three studies on diet (N = 4824) and four studies on sun exposure (N = 6465). Across all three behaviors, behavior change at 24 months was related to treatment, stage of change, problem severity and effort effects measured at baseline. There were no consistent demographic effects. Across multiple behaviors, long-term behavior changes are consistently related to four effects that are dynamic and open to change. Behavior changes were not consistently related to static demographic variables. Future intervention research can target the four effects to determine if breakthroughs can be produced in changing single and multiple behaviors.

Objective: The major chronic diseases are caused by multiple risks, yet the science of multiple health behavior change (MHBC) is at an early stage, and factors that facilitate or impede scientists' involvement in MHBC research are unknown. Benefits and challenges of MHBC interventions were investigated to strengthen researchers' commitment and prepare them for challenges., Method: An online anonymous survey was e-mailed to listservs of the Society of Behavioral Medicine between May 2006 and 2007. Respondents (N=69) were 83% female; 94% held a doctoral degree; 64% were psychologists, 24% were in public health; and 83% targeted MHBC in their work., Results: A sample majority rated 23 of the 24 benefits, but only 1 of 31 challenge items, as very to extremely important. Those engaged in MHBC rated the total benefits significantly higher than respondents focused on single behaviors, F(1,69)=4.21, p<.05, and rated the benefits significantly higher than the challenges: paired t(57)=7.50, p<.001. The two groups did not differ in ratings of challenges., Conclusion: It appears that individuals focused solely on single behaviors do not fully appreciate the benefits that impress MHBC researchers; it is not that substantial barriers are holding them back. Benefits of MHBC interventions need emphasizing more broadly to advance this research area., (Copyright 2009 Elsevier Inc. All rights reserved.)

Objective: Stage assessments are examined to develop and test refined measurements that can be used for classifying individuals., Design: Stages were assessed in 1,850 persons in terms of their physical activity and dietary behaviors., Main Outcome Measures: Stages for both behaviors were compared to behavior and other test variables. Misclassification, sensitivity, specificity, receiver-operation-curves, and discontinuity patterns were computed. Discontinuity patterns were tested with trends across stages and planned contrasts between adjacent stages., Results: In comparison to previous studies, sensitivity (70% to 80%) and specificity (80% to 87%) were high. When using lower level criteria (such as less intensive activity), sensitivity was lower, whereas specificity was higher. When behavioral maintenance was assessed, results suggested that the temporal cut-off point between action and maintenance was equally optimal at different cut-off points. Applying contrast analyses, nonlinear trends across the stages and a match of 87% of predictions of stage differences resulted., Conclusion: Stage assumptions are supported in general, and refined stage assessment in particular. Levels of psychological variables (e.g., easiness, habit) may discriminate stages as well as or even better than temporal stage definitions., ((c) 2009 APA, all rights reserved)