Southern Online Journal of Nursing Research
Issue 4, Vol. 2, 2001

www.snrs.org

 

Examination of the Processes of Change, Decisional Balance, Self-Efficacy for Smoking and the Stages of Change in Mexican American Women

 

Colleen S. Keller, PhD, RN, FNP;
 Nancy McGowan, RN, MSN

 

 

 

 

Colleen S. Keller, PhD, RN, FNP, Professor
School of Nursing

University of Texas Health Science Center at San Antonio; 

Nancy McGowan, RN, MSN,
Associate Professor
University of Texas at Brownsville and Texas Southmost College,
Doctoral Candidate,

School of Nursing

University of Texas Health Science Center at San Antonio 

 

Abstract

The Transtheoretical Model (TTM) provides a structure from which relationships among specific cognitive-behavioral and motivational mechanisms, and health behaviors such as smoking cessation, can be examined. Considerable empirical evidence supports the TTM as a promising model to predict smoking cessation readiness. However, the use of the processes of change have been equivocal; some processes are used more frequently at certain stages than others, and there is no evidence that certain processes move individuals through the stages, or that the processes are exclusive to certain stages. Additionally, other mediating constructs such as Self Efficacy and Decisional Balance were shown to be related to smoking behavior. The TTM has been primarily tested on white, employed populations, and the cultural specificity and cross-economic status applicability of this theory/model has not been established. This study purpose was to determine the relationships among Self-Efficacy, Decisional Balance, and the Processes and Stages of Change in 50 Mexican American women who smoke cigarettes. The variables important to this sample of Mexican American women included those Processes of Change that indicate decision making and commitment, rewarding oneself, expressing feelings, supportive relationships, and concern for others. These findings suggest that strategies useful in enhancing these processes, such as values clarification, social support, decision-making therapy, and empathy training might be beneficial in strengthening the decision and commitment for smoking cessation in Mexican American women.

 

Key words: Mexican-Americans; Minority groups; Health promotion; Women's Health; Smoking; Smoking cessation

 


 

 

 

 

 

 

 

 

 

 

1Crespo, C.J., Loria, C.M., & Burt, V.L. (1996). Hypertension and other cardiovascular disease risk factors among Mexican Americans, Cuban Americans, and Puerto Ricans from the Hispanic Health and Nutrition Examination Survey. Public Health Reports,3,(Suppl 2), 7-10.
2Caraballo, R.S., Giovino, G.A., Pechacek, T.F., Mowery, P.D., Richter, P.A., Strauss, W.J., Sharp, D.J., Eriksen, J.P., Pirkle, J.L. & Maurer, K.R. et al. (1998). Racial and ethnic differences in serum cotinine levels of cigarette smokers: The Third National Health and Nutrition Examination Survey. Journal of the American Medical Association, 280, 135-139.

3Freeman, H., Delgado, J.L., & Doublas, C.E. (1993). Tobacco use: An American crisis. In: Final conference report and recommendations from America's health community. Chicago: American Medical Association.

 

 

Examination of the Processes of Change, Decisional Balance, Self-Efficacy for Smoking and the Stages of Change in Mexican American Women

Introduction

Nearly one-fourth of all Americans smoke, despite evidence that it increases risks for the leading causes of death: cancer and heart disease. Among Hispanic subgroups, the smoking rate of Mexican American women is 23.8%, and rates of smoking among younger Hispanic women have increased over time.1-3

 

 

 

 

 

 

 4Blake, J.M. (1996). Redefining smoking and the self as a nonsmoker. Western Journal of Nursing Research, 18(4), 414-28.

5ibid

6Marin, B.V., Perez-Stable, E.J., Marin, G., Sabogal, F., & Otero-Sabogal, R.(1990). Attitudes and behaviors of Hispanic smokers: Implications for cessation interventions. Health Education Quarterly, 17(3), 287-297.

7ibid

 

Differences among men and women and among ethnic subgroups may contribute to the success or failure of smoking cessation interventions. For example, women may establish more of their self-image in connection to smoking and be less inclined to quit.4 In addition, women have different motivations, such as stress reduction and weight loss, than do men for smoking.5 Hispanics have different smoking patterns than do non-Hispanic whites.6For example, Hispanic women begin smoking later than Hispanic men do, and report smoking fewer cigarettes than non-Hispanic white women.7

 

 

 

 

 

 

 8DiClemente, C.C., Prochaska, J.O. Fairhurst, S.K., Velicer, W.F., Velasquez, M.M. & Rossi, J.S. (1991) The process of smoking cessation: An analysis of precontemplation, contemplation, and preparation stages of change. Journal of Consulting and Clinical Psychology, 59(2), 295-304.

 

 

 

 

9Prochaska, J.O., & DiClemente C.C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51, 390-395.

10 ibid

11Prochaska J.O., DiClemente C.C., Velicer.W.F., & Fava J. (1988). Measuring processes of change: Applications to the cessation of smoking. Journal of Consulting and Clinical Psychology 56, 520-528.

12Velicer, W.F., DiClemente, C.C., Prochaska, J.O., & Brandenburg, N. (1985). Decisional balance measure for assessing and predicting smoking status. Journal of Personality and Social Psychology, 48(5), 1279-1289.

 

 

The Transtheoretical Model (TTM) provides a structure from which relationships among specific cognitive-behavioral and motivational mechanisms and health behaviors, such as smoking cessation, can be examined.  The Transtheoretical Model, or Stages of Change, are identified with a wide variety of problems or target behaviors.8 The stages are used as a classification schema based on attitudes and behaviors regarding the change of a target behavior, such as smoking. The identified stages are Precontemplation, Contemplation, Preparation, Action, and Maintenance. Individuals engaging in a new behavior move through the stages of Precontemplation (not intending to make a change), Contemplation (considering change in the next 6 months), Preparation (making small changes), Action (actively engaging in a new behavior), and Maintenance (sustaining the change over time).9 Among non-Hispanic whites, stage classifications for smoking cessation are consistently related to Self-Efficacy,10 processes of change for smoking cessation,11 and Decisional Balance.12 Considerable empirical evidence supports the TTM as a promising model to predict smoking cessation readiness. However, actual use of experiential and behavioral processes of change has been equivocal in terms of stage specificity. Some processes are used more frequently at certain stages than others, but there is no evidence that certain processes move individuals through the stages, or that the processes are exclusive to certain stages. Additionally, the TTM has been primarily tested on white employed populations. Cultural specificity and cross-economic status applicability of this theory/model has not been established. Therefore, the exploration of the relationships among the variables associated with Stages of Change in an understudied group, Mexican-American women, was the goal of this work.

 

 

The broad objectives of this exploratory study were to examine the Transtheoretical Model for its utility as a framework for studying the smoking behavior of Mexican American women smokers, and to clarify the motivational factors that influence smoking behavior in Mexican American women. The specific aims were to: 1) examine the behavioral change processes that are associated with stages of change in smoking behavior in Mexican American women who smoke cigarettes, and 2) determine the relationships among Self-Efficacy, Decisional Balance and the Processes and Stages of Change in Mexican American women who smoke.

The relationships among the Processes of Change, Self-Efficacy, Decisional Balance, and Stages of Change are depicted in Figure 1. The model depicts the hypothesized direct and indirect relationship of the Processes of Change to Decisional Balance, Self-Efficacy and Stages of Change. Additionally, it was hypothesized that Self-Efficacy and Decisional Balance would have a direct effect on the Stages of Change.

Figure 1. Theoretical Framework

 

 

Relevant Literature

 

 

 

 

  13Prochaska, 1983

 

The Transtheoretical Model

The Transtheoretical Model was developed over 12 years of research that focused on both addictive behaviors, including smoking cessation, and non-addictive behaviors.13 The term transtheoretical means that the Stage of Change is similar across populations dealing with a variety of problems such as smoking, psychological distress, and obesity. The TTM identifies five stages of change representing a temporal dimension allowing us to understand when a change in attitude toward the problem behavior occurs. Using the concepts from the TTM to address smoking cessation, the model is applied in the following way: Precontemplation (not ready to stop smoking), Contemplation (thinking about smoking cessation within the next 6 months), Preparation (planning to stop smoking in the next 30 days), Action (stop smoking), and Maintenance (sustaining smoking cessation). The Transtheoretical Model encompasses three major concepts: Stage of Change, Processes of Change, and Decisional Balance.

 

 

 14 DiClemente, C.C. & Prochaska, J.O. (1982). Self-change and therapy change of smoking behavior: A comparison of processes of change in cessation and maintenance. Addictive Behavior, 7, 133-142.

15Prochaska J.O., & Goldstein, M.G. (1991). Process of smoking cessation: Implications for clinicians. Clinics in Chest Medicine, 12(4), 727-735.

 

 

16Prochaska, J.O., Velicer, W.F., Rossi, J.S., Goldstein, M.G., Marcus, B.H., Rakowski, W., Fiore, C., Harlow, L.L., Redding, C.A., Rosenbloom, D. & Rossi, S.R. (1994) et al.(1994). Stages of change and decisional balance for 12 problem behaviors. Health Psychology, 13(1), 39-46.

17Prochaska, 1983

 

Stages of Change

There is strong evidence for the validity of the use of the stage classification among smokers.14 Prochaska and colleagues15 found that 10-15% of smokers are Prepared for Action, approximately 30-40% are Contemplators, and 50-60% are Precontemplators, indicating that efforts targeted towards individuals in the Contemplation stage would capture the largest number of individuals thinking about smoking cessation. Individuals progress through these stages at varying rates, and may leave and re-enter the continuum of change at varying points.16 The vast majority of individuals who have relapsed, approximately 85 percent of all smokers, will cycle back to the Contemplation or Preparation stage.17

 

 

 

 

 

18ibid

 

Processes of Change

While Stages of Change represent dimensions that allow understanding of when changes occur, the processes of change allow understanding of how changes occur.18 Ten processes of change have been identified and specific processes are associated with particular stages of preparation for change (see Table 1).

 

 

19Prochaska, J.O., DiClemente, C.C., & Norcross, J.C. (1992). In search of how people change: Applications to addictive behaviors. American Psychologist, 47(6), 1102-1114.

 20ibid

 

 

21ibid

 

There is integration between the Processes of Change and the Stages of Change.19 Effective self-change depends on doing the right things (processes) at the right time (stages). With a mismatch in stage and processes, a successful behavioral change is unlikely to occur.20 In a review of 12 problem behaviors and Stages of Change, individuals used eight of the change processes during the Precontemplation stage significantly less than in any of the other stages.21 Precontemplators processed less information about their problems, devoted less time to their problem, and experienced far fewer emotional reactions to the negative components of their problems. Individuals in the Contemplation stage were most open to Consciousness Raising techniques, and used techniques of Dramatic Relief, a process that raised emotions and led to a lowering of the negative effect of the behavior. Movement from Precontemplation to Contemplation involved the use of increased cognitive, affective, and evaluative processes of change. Individuals in the Action stage used self-liberation, believing they had the control to change their lives in important ways. Those in the Action stage also used Counter-conditioning and Stimulus Control. Maintenance was enhanced by the continual application of processes such as Counter-Conditioning and Stimulus Control. These findings emphasize the importance of the assessment of the individual’s stage of change and tailoring interventions to the specific stage, with the correct use of processes.

22Ahijevych, K., & Wewers, M.E. (1992). Processes of change across five stages of smoking cessation. Addictive Behavior, 17(1), 17-25.

 

 

 

 23ibid

 

 

 

24ibid

 

 

Ahijevych and Wewers,22 using a cross-sectional approach with 190 smokers and ex-smokers, determined the processes individuals use to modify behaviors across the five Stages of Change. In general, they found that Precontemplators reported less use of the processes of change than other groups.23 Recent quitters reported very high use of the behavioral process of Self-Liberation; long-term quitters report most frequent use of the behavioral processes of Environmental Re-evaluation and Counter-conditioning.24

25DiClemente, 1991

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

26ibid

 

DiClemente and colleagues25 compared smoking history, Processes of Change, Self-Efficacy and Decisional Balance, and one and six month cessation activity among non-Hispanic white smokers who were in eitherPrecontemplation, Contemplation, or Preparation stages. Subjects included 691 volunteers who completed the Smoking Abstinence/Self Efficacy questionnaire, the Fagerström Tolerance Questionnaire, and the Smoking Decisional Balance scale. Precontemplators were the least active in using the processes of change, and those in the Preparation stage were the most active. The processes of change patterns supported the notion that Preparation stage subjects were actively modifying their smoking habit, Contemplation stage subjects were gathering information and evaluating their smoking habit, and Precontemplation stage subjects were doing the least across all change processes.26 Those subjects considered to be in the Preparation stage had significantly higher levels of confidence (Self Efficacy) to stop smoking, while those in the Precontemplation stage were most likely to be tempted to smoke (lower Self Efficacy). The positive aspects of smoking (Decisional Balance) decreased across stages, with Precontemplative subjects reporting the pros of smoking as more important.

27Fava, J.L, Velicer, W.F., & Prochaska, J.O. (1995). Applying the Transtheoretical Model to a representative sample of smokers. Addictive Behavior, 20(2), 189-203.

 

Fava, Velicer, and Prochaska27 applied the constructs of the Transtheoretical Model (stages of Change, Processes of Change, and Decisional Balance) to a large sample of smokers. One thousand smokers were surveyed by telephone using the Measures of Smoking behavior questionnaire, the Stages of Change questionnaire, the Processes of Change inventory, the Decisional Balance inventory, and the Situational Temptation (Self Efficacy) inventory. Multivariate analysis of variance was used to test for group differences on the key constructs of the Transtheoretical Model. Precontemplators used the Processes of Change the least, while those in the Preparation stage used it the most. Differences among measured stages of change (Precontemplation, Contemplation, and Preparation) showed significant effects of Situational Temptation (from the Self-Efficacy scale) and the Cons of Smoking (from the Decisional Balance scale). Those participants in Preparation had the highest scores on the Cons of Smoking subscale. Additionally, those participants in Preparation were least tempted by Positive/Social situations and most tempted to smoke in Negative/Affective situations.

 

 

 

 

28Janis, I.L. & Mann, L. (1977). in Decision making: A psychological analysis of conflicts, choice and commitment (pp.77-79). NY: Collier Macmillan.

29Velicer, 1985

30Prochaska, 1994

 

Decisional Balance

Decision-making, or the individual’s evaluation of the pros and cons of a particular behavior, has been identified as a critical component in the modification of problem behaviors.28 Decisional Balance is a useful predictor in the movement between stages.29 Prochaska and colleagues30 investigated the Stages of Change and Decisional Balance for 12 different problem behaviors, including smoking cessation, cocaine cessation, weight control, safer sex, and sunscreen use. Approximately 3,800 participants were given the Stages of Change and Decisional Balance questionnaires; the results indicated that there were clear commonalities across the problem behaviors. Relating the pros and cons of decision making to the Stages of Change resulted in highly predictable patterns. For all samples, the cons of changing the behavior outweighed the pros for subjects who were in the Precontemplation stage. The opposite was true for subjects in the Action stage in 11 of the 12 behaviors. This would suggest that to move from Precontemplation to Contemplation, there isan associated increase in the pros of changing the behavior. This idea supports the notion of designing interventions that increase the pros of changing, and decrease the cons of changing, leading to movement from Contemplation to Action.

 

 

 

 

 

31Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Reviews, 84 (2), 191-205.

32ibid

33DiClemente, C.C., Prochaska, J.O., & Gibertini, J. (1983). Self-efficacy and the stages of self-change of smoking. Cognitive Therapy Research, 9(2), 181-200.

 

34ibid

 

 

 

 

 

 

35DiClemente, 1991

 

Self-Efficacy

Self-efficacy is a construct that describes a person’s perceived ability (efficacy expectations) on a given task.These perceptions are believed to influence future attempts to perform that task.31 An efficacy expectation is the notion that a person can successfully perform the behaviors required to produce an expected outcome.32 DiClemente, Prochaska, and Gilbertini33 found that in individuals who smoked and were trying to quit, self-efficacy demonstrated predictive ability to differentiate those individuals who were likely to succeed in quitting, and those who were likely to experience failure.34 The implications of these findings are important. Studies that use a sweeping net to recruit participants in a smoking cessation study will likely find that a large number of the participants are Precontemplators and Contemplators. If the program is intended for those in Preparation and Action, the success rates will likely be low.35

 

 

 

 

 

36Marin, 1990

37Perez-Stable, E.J., Marin, G., & Posner, S.F. (1998). Ethnic comparison of attitudes and beliefs about cigarette smoking. Journal of General Internal Medicine, 13(3), 167-174.

38ibid

 

 

39Marin, 1990

 

Smoking Behavior in Hispanic-Latino Individuals

Initial studies of Hispanic-Latino smokers (including Mexican Americans and Central American Hispanic-Latino individuals) have shown significant differences in smoking attitudes and behaviors.36,37 In comparison with non-Hispanic whites, Latino smokers are significantly more influenced by situational cues for smoking, such as talking on the telephone and drinking alcohol.38 Techniques used by Hispanic smokers to initiate cessation include willpower (voluntad propia) and the negative effects of smoking on the self and others.39 These situational cues and process strategies used to aid smoking cessation result from descriptive work, and are conceptually consistent with process strategies found to be salient in examinations of smoking attitudes and behaviors in non-Hispanic populations. Since much of the work has targeted Caucasian men, little is known about the effectiveness of the model and the mediating processes in other, more vulnerable groups, such as minority women.

 

 

Methods

Subjects

The sample for this study included 50 Mexican American women who reported current smoking and who spoke English. They ranged in age from 17 to 64 years (Mean = 24.1). Twenty-five percent were 19 years old. The age at which they began smoking ranged from 14 to 24 years (Mean = 17). The largest percentage (75%) began smoking between the ages of 14 and 18 years. Fifty-three percent reported that there were currently other smokers living with them, and 26 percent reported that there were children under the age of 14 currently residing with them in the home.

Procedure

Volunteers who were smokers were recruited from two settings: a community health clinic, which serves a largely indigent population, and a clinic that serves a largely working class population. Procedures for the protection of human subjects were followed throughout the study: the data forms were assigned a code number, informed consent was obtained, and participants could withdraw from the study at any time. It was explained that with the completion of the six questionnaires, the participants would receive $10.00 and a lottery ticket. Participants completed the instruments in English, which took approximately 45 minutes.

 

 

Study Variables and Instrumentation

The Stages of Change questionnaire is a forced-choice instrument that determines the category of intent related to smoking. If the participant quit smoking in the last six months, they were in the Action stage. Persons with cessation greater than six months were in the Maintenance stage. Participants who were categorized as “smokers” were asked whether they were seriously thinking about quitting in the next 30 days (Preparation stage), within the next 6 months (Contemplation), or they did not intend to quit smoking (Precontemplation).

 

 

 

 

 40Prochaska, 1988

 

 

 

41ibid

 

 42ibid

 

43ibid

 

 

The Processes of Change Questionnaire is a 40-item Likert-type scale. Four items for each of the 10 processes of change are answered on a scale of 1 (never) to 5 (repeatedly).40 A panel of four experts established content validity. Construct validity through principal components factor analysis resulted in the 10-factor solution across time and geographically distinct samples.41 Internal consistency was established with alpha coefficients ranging from .69 to .92.42 Two scales, Social Liberation and Reinforcement Management, had coefficient alphas less than .80.43 Each of the 10 questions in the subscale are summed and averaged with a possible range of scores for each subscale of 4-20.

 

 

 

 

 

 

 

 

44ibid

 

 

  

45Prochaska, J.O., DiClemente, C.C., Velicer, W.F., Ginpil, S., & Norcross, J.C. (1985). Predicting change in smoking status for self-changers. Addictive Behavior, 10(4), 395-406.

 

 

The Self-Efficacy/Temptation Scale is a 10-item Likert-type scale with scores ranging from 1 (not at all tempted to smoke in a situation) to 5 (extremely tempted in a situation). The items are grouped into three categories: positive affect/social situations; negative affect situations; and habitual craving situations, and rates both temptations (cue strength) and self-efficacy for smoking cessation.44 Internal consistency was established by Cronbach’s alpha. Alpha coefficients were very high for the temptation measures (a=. 97) and the confidence measures (a =.98).45

 

 

 

 

 

46ibid

 

 

 

 

 

47Velicer, 1985

 

The Pros and Cons of Smoking scale was used to determine Decisional Balance. This instrument is a 20-item Likert-type scale describing factors about smoking ranging from 1 (not important) to 5 (extremely important).46 Both subscales have acceptable internal consistency: pro (a=.88) and con (a=.89). This instrument was found to be a useful construct in predicting movement from Precontemplation to Contemplation and has also reliably differentiated smokers in different Stages of Change.47

 

 

Data Analysis

To determine the associations among the Processes of Change related to Stages of Change, logistic regressions with single predictors were computed to determine which Process of Change was associated with movement across the Stages, from Precontemplation to Contemplation to Preparation. The dependent variable in the first regression model was Precontemplation (0), and Contemplation (1), excluding Preparation. The second model included Contemplation (0), and Preparation (1), excluding Precontemplation. These logistic regressions explained which processes of change were associated with movement from a lower stage to a more advanced stage. Three logistic regression models, by Stage of Change, acted on by 10 Processes of Change subscales, were computed. The process required that we first determine which Processes of Change to keep. A backward selection was used for a logistic regression model where each stage equals all ten processes of change subscales. The backward selection was set to drop all processes of change that had probability values greater than p = 0.25.

Next, logistic regression models were computed to fulfill the hierarchical model. The object was to determine the strength (influence) of the Processes of Change subscales in the model with respect to the other predictors: the Self-Efficacy subscales and the Decisional Balance subscales. The determining factor was the Log Likelihood Chi-square value that was compared across three logistic models as follows:

1. Outcome: Stages of Change each level (Precontemplation, Contemplation, and Preparation) = Stage of Change.

2. Predictors: Processes of Change = Process of Change; Self Efficacy Subscales: (positive affect/social situations; negative affect situations; and habitual craving situations) = Self-Efficacy; Decision Balance Subscales (Pros & Cons) = Decisional Balance.

The Likelihood Ratio Chi- Square was compared among the six logistic regression runs (see Table 2). The Likelihood Ratio Chi-Square was the chi-square value for the predictors only, and was the difference between the -2 Log (Likelihood) Chi- Square for Intercept Only, and Intercept and Covariates (predictors).

 

 

Findings

The participants indicated their readiness to engage in a smoking cessation program by identifying the stage in which they currently considered themselves. Seventeen (34%) were in the Preparation stage; i.e., they intended to quit within the next 30 days. Fourteen (28%) were in the Contemplation stage, considering smoking cessation in the next 60 days, and 19 (31.7 %) were in the Precontemplation stage, with no current plans to quit smoking.

The mean scores in this sample for Social Liberation were 16.47, Self-Liberation 14.90, Helping Relationships 14.3, Consciousness Raising 12.9, Counter-Conditioning 11.9, Dramatic Relief 11.3, Self-Re-evaluation 11.08, Reinforcement Management 9.68, and Stimulus Control 8.03. The Self-Efficacy Scale was divided into three scores: positive affect/social situations, negative affect/social situations, and habitual craving situations. In the “positive affect/social situations” the mean score was 20.3, with a minimum of 6.0, and a maximum of 29.0. “Negative affect situations” had a mean score of 20.1, with a minimum of 6.0, and a maximum of 30.0. The “habitual craving situations” exhibited a mean of 10.2, with a minimum of 5.0, and a maximum of 20.0. The Pros and Cons of Smoking exercise (the Decisional Balance scale) was strongly weighted in the cons of smoking. Eight participants had scores in which the “pros” outweighed the cons of smoking. One participant had equal scores. In the cons of smoking the mean score was 34.3, with a minimum score of 20.0 and a maximum score of 47.0. The “pros” of smoking exhibited a mean of 25.1, with a minimum of 10.0 and a maximum of 38.0.

 

 

Data Reduction

 For Specific Aim 1, the examination of the Processes of Change and their relationships among the Stages of Change, logistic regression models were computed among Processes of Change and Precontemplation (model 1), Contemplation (model 2), and Preparation (model 3). There were no Processes of Change associated with the Precontemplation Stage. In the Contemplation stage, Environmental Re-evaluation and Reinforcement Management showed significant associations with the stage. In the Preparation stage, only Consciousness Raising showed a significant association with forward movement across the stage.

 

 

Relationships Among Processes of Change, Self-Efficacy, Decisional Balance and Stages of Change
For Specific Aim 2, to determine the relationships among the Processes of Change, Stages of Change, Decisional Balance and Self-Efficacy, six hierarchical regression models were computed. The first model, (Precontemplation = Process of Change + Decisional Balance + Self-Efficacy) showed no significant hierarchical models associated with the Precontemplation stage. The first hierarchical model in the Contemplation stage (Contemplation = Decisional Balance + Process of Change) showed significant associations with Self-Liberation, Dramatic Relief, Environmental Re-evaluation and Reinforcement Management. Decisional Balance showed no contribution to the model. The second model (Contemplation = Self Efficacy + Decisional Balance + Process of Change) showed significant associations with Self-Liberation, Dramatic Relief, Environmental Re-evaluation, Helping Relationships, and Reinforcement Management. Decisional Balance and Self-Efficacy showed no contribution to the model. The first and second hierarchical model in the Preparation stage (Preparation = Process of Change = Decisional Balance and Preparation = Self-Efficacy + Decisional Balance + Process of Change) showed a significant association of Consciousness Raising, without a significant contribution of Decisional Balance or Self Efficacy. Table 3 displays the six hierarchical models for the Stages of Change.

 

 

 

 

  48ibid

 

 

 

49Prochaska, 1994

 

 

 50Prochaska, 1992

 

 

 

 

 

 

51Marin, 1990

 

 

 

52Perez-Stable, 1998

 

 

 

 

 

53Marin, B.V., Perez-Stable, E.J., Marin, G., Sabogal, F., & Otero-Sabogal, R.(1990). Attitudes and behaviors of Hispanic smokers: Implications for cessation interventions. Health Education Quarterly, 17(3), 287-297.

 

Discussion

Like other investigations where subjects used few Processes of Change in the Precontemplation Stage, these women used none.48 The use of Dramatic Relief in the Contemplation stage is consistent with the use of the process shown by other investigators.49 For other samples, subjects in the Contemplation stage were found to gather information and evaluate their smoking habit.50 In this sample, Environmental Re-Evaluation, Reinforcement Management, and Self-Liberation were additionally associated with the movement from Contemplation to Preparation stage. These processes are most frequently associated with the Preparation and Action stages in other samples studied.51 The processes of choosing, committing to act, and assessing how one’s behavior affects others were important constructs in this group of Mexican American women. The Latino sample studies by Perez-Stable and colleagues52 used strategies for smoking cessation similar to these processes, such as familiaismo (love of family), awareness of the negative effect of smoking on children and others, and setting a good example for children. Work by Marin and colleagues53 showed that Hispanics (Mexican and Central Americans) used the strategy of willpower to initiate smoking cessation. This construct/process is remarkably similar to the Process of Self-Liberation, indicating that the notion of perceived ability to change one’s behavior is a salient construct in this ethnic group.

 

 

 

 

 

 

 

 

54Perez-Stable, E.J., Marin, G. & Posner, S.F. (1998). Ethnic comparison of attitudes and beliefs about cigarette smoking. Journal of General Internal Medicine, 13, 167-174.

55ibid

 

In this study, Decisional Balance (the Pros and Cons of smoking) and Self-Efficacy did not contribute to the results of the hierarchical regressions. These findings do not correspond with other studies that examined smoking among Latinos. The cons of smoking, i.e., the negative effects of smoking behavior on others was a salient theme in motivating smoking cessation among Latino individuals.54 In other samples, those in the Preparation stage had the highest values on the con of the decisional balance scale, and were also found to be the least tempted in Situational Temptation (Self-Efficacy).55 While the cons of smoking was a salient variable in other groups of Latino subjects, this variable did not contribute to the models in this study. The variables important to this sample of Mexican American women included those Processes of Change that indicate decision making and commitment (Self-Liberation), supportive relationships (Helping Relationships), awareness of the problem behavior (Consciousness Raising), and concern for others (Environmental Re-evaluation). These findings suggest that strategies useful in enhancing these processes such as values clarification, social support, decision-making therapy, and empathy training might be beneficial in strengthening the decision and commitment for smoking cessation in Mexican American women.

56Brown, J. M. (1996).Redefining smoking and the self as a nonsmoker. Western Journal of Nursing Research, 18(4), 414-428.

 

 

 

 

 

 

 

 

57Marin, 1990

58Perez-Stable, 1998

 

59Prochaska, 1985

 

Recent work by Brown56 shows that adults who quit smoking demonstrate a distinct psychosocial process during the quitting phase. Using a grounded theory method, Brown described the major theoretical categories used as individuals redefine smoking and the self as nonsmokers: recognizing the need to quit, making the decision, learning to be a nonsmoker, and sustaining the quit. Brown’s substantive theory is conceptually congruent with the findings from this study. The initial step in the process of redefining oneself as a non-smoker is the recognition of the need to quit. The processes of Self-Liberation, Environmental Re-evaluation and Dramatic Relief were important concepts/strategies in this study, and are similar to constructs used in studies by Marin and others57 and Perez-Stable and colleagues.58 Clearly, the processes described by Prochaska and colleagues59of thinking about the negative effects of smoking and coming to some conclusion are salient mediators in decision-making for smoking cessation across study and ethnic groups.

 

 

Three important limitations of our study should be noted. First, the complete model of the TTM was not explored. Information about the full model might be obtained by including women who are actively attempting to quit smoking and women who are maintaining smoking cessation. Second, the sample size precluded a complete path analysis, so while our regression analyses showed no direct effects of Self-Efficacy on Stages of Change, these variables may have mediated the effects of the Processes of Change. Last, we did not assess the acculturation of these Mexican American women. These results indicated that this sample of Mexican American women use different Processes of Change than do other samples of Caucasian subjects; this might be due to cultural assimilation, rather than ethnic differences.

 

 

Clinical Implications

The largest portion of the smokers in this study (31.7%) was in the Precontemplation stage (no intention of initiating a quit attempt in the near future). Most smoking cessation interventions are aimed at those individuals in the Preparation or Action stage, composed of those people who have made the decision to quit. With a large number of smokers in the Precontemplation stage, the majority of interventions designed for individuals in the Action stage will unlikely prove successful. It is important that interventions be designed that target the majority of smokers who are not in the Preparation or Action stage. Because the majority of smokers move to the next adjacent stage, interventions must be designed that would move smokers in the early stages to the adjacent stage. Increasing the use of the Processes of Change among those in Precontemplation may be a useful tool. Increasing the sense of mastery, i.e., the smoker’s self-efficacy, may also prove helpful in encouraging the individual to progress to the next stage. Thus, an important area for research would be the investigation of increasing the self-efficacy and use of the processes of change among smokers in the Precontemplation stage. Movement to the next stage, that of Contemplation, would be consistent with previous research findings and would allow interventions to be tailored to the right stage at the right time.

 

 

In Mexican American participants, such as the sample recruited for this study, the context of smoking behavior may be more complex and different than in other samples. The context of the problem of smoking behavior should be examined for the intrapersonal, interpersonal, organizational, community, public policy, and cultural factors affecting this behavior. Additionally, the individual beliefs and attitudes related to smoking cessation are developed and maintained within social and organizational contexts. Interventions might be more innovative if developed within these contexts. The problem of smoking cessation has been examined extensively using the TTM as a guide for the prediction of individual’s stages of readiness to change. However, the majority of the multiple variations of the model have not been derived from participants who are ethnically and socio-economically diverse.

 

 

 

60Sidani, S., & Braden C. J. Chapter 3: The Theory-Drive Approach to Effectiveness Research, in Evaluating nursing interventions: A theory driven approach (Sage, Thousand Oaks, CA), p. 43.

61Sidani, S. (1996). Methodological issues in outcomes research. Canadian Journal of Nursing Research, 28(3), 87-94.

 

 

Smoking behavior is a significant health problem that presents with variety in the nature, manifestation, causative factors, level of severity, and under different conditions and among different persons.60 The multiple facets of a health behavior has been termed the theory of the problem, whereby theory is used to understand how a specific health problem is socially produced and maintained.61 The results of this study showed that the processes of change for readiness to quit smoking are not inclusive to particular Stages of Change. More work is needed in describing the mediators salient to each stage of change before an intervention can be developed.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

62Chen, H., & Rossi, P.H. (1983). Evaluating with sense: a theory-driven approach. Evaluation Reviews, 7, 283-302.

 

More work needs to be done in determining the application of the TTM to groups with diverse cultural and economic backgrounds. What little has been done has demonstrated that smoking behavior has a wide variety of meanings within cultural and economic groups. Future investigations should include the selection of appropriate theoretical constructs. This would provide the investigator with a number of advantages in designing an effective intervention: it would help to identify the target population, identify the study variables, specify the appropriate times for measuring outcome variables, and clarify the relationships among the treatment, and mediating, moderating, and outcome variables.62

 

 

 

Acknowledgements:
Grateful appreciation is extended to Bruce Paper, John Cornell, and anonymous reviewer for assistance in the preparation of this manuscript.

 


 

 

Table 1 Processes of Change

Process of Change

Description

Consciousness Raising

Increasing information about the problem

Self Re-evaluation

Assessing how one thinks about oneself with respect to the problem behavior

Self-Liberation

Choosing or committing to act

Counter-Conditioning

Substituting alternatives

Stimulus Control

Avoiding the behavior

Reinforcement Management

Rewarding oneself

Helping Relationships

Being open about problems with people who care

Dramatic Relief

Expressing feelings about one’s problems

Environmental Re-evaluation

How one’s problem affects others

Social Liberation

Increasing alternatives for problem behaviors

 

(back to text)

 

Table 2 Summary of Hypothesized Models

Stage  =

Process of Change + Decisional Balance + Self Efficacy

(Full Model)

Stage  =

Process of Change + Decisional Balance

(POC, DB only model)

Stage  =

Process of Change

(POC only model)

Note:  POC = Process of Change; DB = Decisional Balance

(back to text)


Table 3 Model Hierarchy for Stages of Change 

Pre- Contemplation Stage of Change

C2

df

p

O. R.

95% CL

PRE = SE + DB+ POC 

Model – 2LL

13.39

8

0.0992

 

 

 

 

Self Efficacy Subscales

REPOS

0.42

1

0.7247

1.042

0.828

-

1.313

 

 

 

NAST

-0.40

1

0.5114

0.820

0.453

-

1.484

 

 

 

HCST

0.09

1

0.733

1.094

0.652

-

1.836

Decisional Balance Subscales

PROS

0.01

1

0.8928

1.009

0.880

-

1.157

 

 

 

CONS

0.07

1

0.2753

1.070

0.948

-

1.208

Process of Change Subscales

CR

-0.17

1

0.1357

0.846

0.678

-

1.054

 

 

 

SL

0.10

1

0.4293

1.105

0.863

-

1.415

 

 

 

SR

0.15

1

0.2081

1.164

0.919

-

1.476

 

PRE = DB  + POC

Model – 2LL

10.39

5

0.0650

 

 

 

 

Decisional Balance Subscales

PROS

-0.05

1

0.2768

0.947

0.859

-

1.045

 

 

 

CONS

0.07

1

0.2470

1.070

0.954

-

1.200

Process of Change Subscales

CR

-0.18

1

0.0826

0.836

0.682

-

1.023

 

 

 

SL

0.14

1

0.2257

1.152

0.917

-

1.447

 

 

 

SR

0.11

1

0.3072

1.120

0.901

-

1.392

 

PRE = POC 

Model – 2LL

7.94

3

0.0473

 

 

-

 

 

 

 

CR

-0.16

1

0.1132

0.855

0.704

-

1.038

 

 

 

SL

0.19

1

0.0886

1.211

0.972

-

1.502

 

 

 

SR

0.13

1

0.1661

1.141

0.947

-

1.374

 

Contemplation Stage of Change

C2

Df

p

O. R.

95% CL

CONT = SE + DB+ POC 

Model – 2LL

24.70

10

0.0059

 

 

 

 

Self Efficacy Subscales

REPOS

-0.62

1

0.1323

0.54

0.242

-

1.206

 

 

 

NAST

0.30

1

0.5525

1.354

0.498

-

3.685

 

 

 

HCST

0.31

1

0.2416

1.362

0.812

-

2.284

Decisional Balance Subscales

PROS

0.16

1

0.0799

1.178

0.981

-

1.415

 

 

 

CONS

-0.02

1

0.8150

0.983

0.853

-

1.134

Process of Change Subscales

SL

0.52

1

0.0185

1.680

1.091

-

2.586

 

 

 

DR

-0.57

1

0.0040

0.566

0.384

-

0.834

 

 

 

HR

0.39

1

0.0418

1.474

1.014

-

2.142

 

 

 

ER

0.50

1

0.0112

1.657

1.122

-

2.447

 

 

 

RM

-0.52

1

0.0068

0.596

0.410

-

0.867

 

CONT = DB + POC

Model – 2LL

19.14

7

0.0078

 

 

 

 

Decisional Balance Subscales

PROS

0.11

1

0.1184

1.111

0.974

-

1.267

 

 

 

CONS

-0.02

1

0.7876

0.982

0.862

-

1.119

Process of Change Subscales

SL

0.35

1

0.0337

1.417

1.027

-

1.955

 

 

 

DR

-0.42

1

0.0061

0.656

0.485

-

0.886

 

 

 

HR

0.29

1

0.0719

1.331

0.975

-

1.817

 

 

 

ER

0.41

1

0.0176

1.508

1.074

-

2.116

 

 

 

RM

-0.41

1

0.0087

0.661

0.486

-

0.901

 

CONT = POC 

Model – 2LL

16.47

5

0.0056

 

 

 

 

 

 

 

SL

0.27

1

0.548

1.312

0.994

-

1.731

 

 

 

DR

-0.37

1

0.1453

0.688

0.518

-

0.915

 

 

 

HR

0.27

1

0.0716

1.305

0.977

-

1.745

 

 

 

ER

0.33

1

0.0282

1.392

1.036

-

1.872

 

 

 

RM

-0.33

1

0.0175

0.717

0.545

-

0.944


 

Preparation Stage of Change

C2

Df

p

O. R.

95% CL

PREP  = SE + DB+ POC 

Model – 2LL

10.20

11

0.5124

 

 

 

 

Self Efficacy Subscales

REPOS

0.03

1

0.8195

1.029

0.804

-

1.318

 

 

 

NAST

0.08

1

0.8286

1.078

0.545

-

2.136

 

 

 

HCST

-0.10

1

0.7418

0.902

0.490

-

1.662

Decisional Balance Subscales

PROS

0.0002

1

0.9978

1.000

0.867

-

1.154

 

 

 

CONS

0.01

1

0.8622

1.012

0.888

-

1.152

Process of Change Subscales

CR

0.22

1

0.0801

1.249

0.974

-

1.602

 

 

 

DR

0.15

1

0.1980

1.159

0.925

-

1.450

 

 

 

CC

-.014

1

0.2802

0.872

0.681

-

1.118

 

 

 

HR

-0.11

1

0.2979

0.900

0.738

-

1.098

 

 

 

ER

-0.14

1

0.3013

0.879

0.674

-

1.130

 

 

 

SR

-0.18

1

0.2265

0.838

0.629

 

1.116

 

PREP  = DB + POC

Model – 2LL

10.21

8

0.2641

 

 

 

 

Decisional Balance Subscales

PROS

0.001

1

0.9880

1.001

0.897

-

1.117

 

 

 

CONS

0.01

1

0.9076

1.008

0.886

-

1.146

Process of Change Subscales

CR

0.22

1

0.0592

1.252

0.991

-

1.582

 

 

DR

0.15

1

0.1763

1.162

0.935

-

1.444

 

 

CC

-0.14

1

0.2237

0.872

0.700

-

1.087

 

 

HR

-011

1

0.2866

0.900

0.741

-

1.092

 

 

ER

-0.14

1

0.2668

0.867

0.675

-

1.115

 

 

SR

-0.17

1

0.2227

0.848

0.650

-

1.106

 

 

 

 

 

 

 

 

 

PREP  = POC

Model – 2LL

9.99

6

0.1247

 

 

 

 

 

 

 

CR

0.23

1

0.0495

1.256

1.001

-

1.577

 

 

 

DR

0.15

1

0.1763

1.160

0.935

-

1.439

 

 

 

CC

-0.14

1

0.2166

0.871

0.700

-

1.084

 

 

 

HR

-0.11

1

0.2527

0.897

0.745

-

1.081

 

 

 

ER

-0.14

1

0.2377

0.869

0.688

-

1.097

 

 

 

SR

-0.16

1

0.1921

0.854

0.673

-

1.083

 

Keys to abbreviations:

 

PRE  = Precontemplation

SE = Self Efficacy

DB = Decisional Balance

POC = Process of Change

REPOS = Positive Affect Situations

NAST = Negative Affect Situations

SL = Self Liberation

HCST =Habitual Craving Situations

PROS =Pros of Smoking

CONS =Cons of Smoking

CC =Counter Conditioning

CR = Consciousness Raising

DR =Dramatic Relief

HR =Helping Relationships

ER =Environmental Re-evaluation

SR =Self Re-evaluation

PREP  = Preparation

 

(back to text)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Copyright, Southern Nursing Research Society, 2001

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