Validating the theoretical structure of the Treatment Self-Regulation Questionnaire (TSRQ) across three different health behaviors.

Nearly 40% of mortality in the United States is linked to social and behavioral factors such as smoking, diet and sedentary lifestyle. Autonomous self-regulation of health-related behaviors is thus an important aspect of human behavior to assess. In 1997, the Behavior Change Consortium (BCC) was formed. Within the BCC, seven health behaviors, 18 theoretical models, five intervention settings and 26 mediating variables were studied across diverse populations. One of the measures included across settings and health behaviors was the Treatment Self-Regulation Questionnaire (TSRQ). The purpose of the present study was to examine the validity of the TSRQ across settings and health behaviors (tobacco, diet and exercise). The TSRQ is composed of subscales assessing different forms of motivation: amotivation, external, introjection, identification and integration. Data were obtained from four different sites and a total of 2731 participants completed the TSRQ. Invariance analyses support the validity of the TSRQ across all four sites and all three health behaviors. Overall, the internal consistency of each subscale was acceptable (most alpha values >0.73). The present study provides further evidence of the validity of the TSRQ and its usefulness as an assessment tool across various settings and for different health behaviors.

A self-determination multiple risk intervention trial to improve smokers' health.

BACKGROUND: Little is known about how interventions motivate individuals to change multiple health risk behaviors. Self-determination theory (SDT) proposes that patient autonomy is an essential factor for motivating change. OBJECTIVE: An SDT-based intervention to enhance autonomous motivation for tobacco abstinence and improving cholesterol was tested. DESIGN: The Smokers' Health Study is a randomized multiple risk behavior change intervention trial. SETTING: Smokers were recruited to a tobacco treatment center. PATIENTS: A total of 1.006 adult smokers were recruited between 1999 and 2002 from physician offices and by newspaper advertisements. INTERVENTIONS: A 6-month clinical intervention (4 contacts) to facilitate internalization of autonomy and perceived competence for tobacco abstinence and reduced percent calories from fat was compared with community care. Clinicians elicited patient perspectives and life strivings, provided absolute coronary artery disease risk estimates,enumerated effective treatment options, supported patient initiatives,minimized clinician control, assessed motivation for change, and developed a plan for change. OUTCOME MEASURES: Twelve-month prolonged tobacco abstinence, and change in percent calories from fat and low-density lipoprotein-cholesterol (LDL-C) from baseline to 18 months. RESULTS- Intention to treat analyses revealed that the intervention significantly increased 12-month prolonged tobacco abstinence (6.2% vs 2.4%; odds ratio [OR]=2.7, P=.01, number needed to treat [NNT] =26), and reduced LDL-C (-8.9 vs -4.1 mg/dL; P=.05). There was no effect on percent calories from fat. CONCLUSIONS: An intervention focused on supporting smokers'autonomy was effective in increasing prolonged tobacco abstinence and lowering LDL-C. Clinical interventions for behavior change may be improved by increasing patient autonomy and perceived competence.

Testing a self-determination theory intervention for motivating tobacco cessation: supporting autonomy and competence in a clinical trial.

A longitudinal randomized trial tested the self-determination theory (SDT) intervention and process model of health behavior change for tobacco cessation (N = 1006). Adult smokers were recruited for a study of smokers' health and were assigned to intensive treatment or community care. Participants were relatively poor and undereducated. Intervention patients perceived greater autonomy support and reported greater autonomous and competence motivations than did control patients. They also reported greater medication use and significantly greater abstinence. Structural equation modeling analyses confirmed the SDT process model in which perceived autonomy support led to increases in autonomous and competence motivations, which in turn led to greater cessation. The causal role of autonomy support in the internalization of autonomous motivation, perceived competence, and smoking cessation was supported.

A new tool to assess treatment fidelity and evaluation of treatment fidelity across 10 years of health behavior research.

A. Bellg, B. Borrelli, et al. (2004) previously developed a framework that consisted of strategies to enhance treatment fidelity of health behavior interventions. The present study used this framework to (a) develop a measure of treatment fidelity and (b) use the measure to evaluate treatment fidelity in articles published in 5 journals over 10 years. Three hundred forty-two articles met inclusion criteria; 22% reported strategies to maintain provider skills, 27% reported checking adherence to protocol, 35% reported using a treatment manual, 54% reported using none of these strategies, and 12% reported using all 3 strategies. The mean proportion adherence to treatment fidelity strategies was .55; 15.5% of articles achieved greater than or equal to .80. This tool may be useful for researchers, grant reviewers, and editors planning and evaluating trials.

Examples of implementation and evaluation of treatment fidelity in the BCC studies: where we are and where we need to go.

Treatment fidelity plays an important role in the research team's ability to ensure that a treatment has been implemented as intended and that the treatment has been accurately tested. Developing, implementing, and evaluating a treatment fidelity plan can be challenging. The treatment fidelity workgroup within the Behavior Change Consortium (BCC) developed guidelines to comprehensively evaluate treatment fidelity in behavior change research. The guidelines include evaluation of treatment fidelity with regard to study design, training of interventionists, delivery and receipt of the intervention, and enactment of the intervention in real-life settings. This article describes these guidelines and provides examples from four BCC studies as to how these recommended guidelines for fidelity were considered. Future work needs to focus not only on implementing treatment fidelity plans but also on quantifying the evaluations performed, developing specific criteria for interpretation of the findings, and establishing best practices of treatment fidelity.

Health care practitioners' motivation for tobacco-dependence counseling.

Smoking cessation counseling by practitioners occurs at low rates in spite of strong evidence that counseling increases quit rates and reduces patient mortality. In a preliminary study, 1060 New York State physicians completed a survey concerning use of the Agency for Health Care Policy and Research (AHCPR) Guidelines, perceived autonomy and perceived competence for counseling, perceived autonomy support from insurers, and barriers to counseling. Considered together, perceived autonomy, perceived competence and perceived autonomy support predicted time devoted to counseling and use of the AHCPR guidelines. The primary, longitudinal study of 220 health care practitioners who attended a smoking cessation workshop predicted change in the practitioners' perceived autonomy and perceived competence for counseling as a function of the degree to which they experienced the workshop instructor as autonomy-supportive. In turn, change in perceived autonomy predicted change in time spent counseling and change in use of the AHCPR guidelines.

On the investigation of primed and chronic autonomous and heteronomous motivational orientations.

Four studies examined primed and chronic autonomous and heteronomous motivations. Study 1 showed that autonomy and heteronomy can be primed and influence perceptions and behavior in a way consistent with consciously regulated motives. In Study 2, a measure of chronic motivation was developed and its construct validity and reliability were assessed. In Study 3, the chronicity measure predicted behavior while consciously regulated motives predicted intention but not behavior. Results of Study 4 replicated results of the priming manipulation in Study 1. However, this effect was moderated by level of motivational chronicity. The priming effect was found to be stronger for non-chronics than for chronics. Overall, the findings suggest that autonomous and heteronomous motivations can be regulated automatically as well as consciously.

Self-determination, smoking, diet and health.

A Clinical Trial will test (1) a Self-Determination Theory (SDT) model of maintained smoking cessation and diet improvement, and (2) an SDT intervention, relative to usual care, for facilitating maintained behavior change and decreasing depressive symptoms for those who quit smoking. SDT is the only empirically derived theory which emphasizes patient autonomy and has a validated measure for each of its constructs, and this is the first trial to evaluate an SDT intervention. Adult smokers will be stratified for whether they are at National Cholesterol Education Program (1996) recommended goal for low-density lipoprotein cholesterol (LDL-C). Those with elevated LDL-C will be studied for diet improvement as well as smoking cessation. Six-month interventions involve a behavior-change counselor using principles of SDT to facilitate autonomous motivation and perceived competence for healthier behaving. Cotinine-validated smoking cessation and LDL-C-validated dietary recall of reduced fat intake, as well as depressive symptoms, will be assessed at 6 and 18 months. Structural equation modeling will test the model for both behaviors within the intervention and usual-care conditions.