7305870

UNIVERSITY OF SURREY LIBRARY

 All rights re s e rv e d

IN FO R M A T IO N T O ALL USERS
The q u a lity of this re p ro d u c tio n is d e p e n d e n t u p o n the q u a lity of the c o p y s u b m itte d .

In the unlikely e v e n t that the a u th o r did not send a c o m p le te m a n u s c rip t

and there are missing p a g e s , these will be n o te d . Also, if m a te ria ! had to be r e m o v e d ,
a n o t e will in d ic a te the d e le tio n .

Published by P roQ uest L L C (2 0 1 7 ). C o p y rig h t of the Dissertation is held by the A u th o r.

All rights re s erv e d .

This work is p ro te c te d a g a in s t u n a u th o riz e d c o p y in g under Title 17, United S tates C o d e
M ic ro fo rm Edition © P roQ uest LLC.

P roQ uest LLC.

7 89 E ast Eisenhow er P a rkw a y
P.O. Box 1346
Ann Arbor, Ml 4 8 1 0 6 - 1346
The Application of the Transtheoretical Model to
Dietary Behaviour

Andrew Moore

Thesis submitted for the degree of Doctor of Philosophy

Department of Psychology
School of Human Sciences
University of Surrey
2002
 Abstract

In this thesis the application o f the transtheoretical model (Prochaska and DiClemente 1992) to
dietary change is investigated. Four studies were conducted examining the core constructs o f the
model these are (a) stages o f change, (b) processes o f change, (c) concepts o f change.

An exploratory cross sectional study found that process and concept use differed significantly
between precontemplaters and post action stages. With self efficacy however the main
differences were between preparation and other stages. Semi-structured interviews with then
conducted with 20 participants in the process o f improving their dietary behaviour. Results
showed that strategies similar to those outlined in the transtheoretical model social support and
consciousness raising were strongly emphasised, regarding decisional balance more benefits than
disadvantages were associated with dietary change.

Following this a 6-month longitudinal study tested the effectiveness o f stage matched and
general pamphlets for clients with type two diabetes. 955 participants completed questionnaires
with 327 participants receiving stage matched interventions, 309 receiving general interventions
and 319 participants being allocated to a control group. Intervention copies were distributed at 3
months and a second questionnaire at six months.

Significant differences were found between the pre action and post action stages with low fat
dietary behaviour. Precontemplaters scored significantly lower than other stages with all
processes and with the pros and cons o f decisional balance and contemplaters scored lower than
post action stages with several processes. Maintainers scored highest in self efficacy. The use o f
processes and concepts did not match fully that outlined in the transtheoretical model.
Interestingly when participants were classified on the basis o f low, medium and high fat
behaviour, process and concept use followed a broadly linear pattern.

At follow up detailed analysis was made problematic by high subject attrition. However, higher
scores in consciousness raising were associated with forward stage movement and low scores in
social support with retrograde movement. There was no significant difference in effectiveness o f

stage matched and general pamphlets. There is, however, weak evidence that interventions in
general improve low fat dietary behaviour. The stage classification may however give insights
not available with standard classifications. Indicating advantages in combining stage and
traditional classifications. Suggestions for future studies to investigate the model more
thoroughly are also discussed.
 Acknowledgements
The last three years spent on this thesis have been among the best and the most frustrating I have
known. Without the help o f a number o f people this project could never have been completed
and it is good now to have the opportunity however brief to acknowledge the people who made
this project possible.

Firstly I need to mention my good friends Tony and Derek for encouraging me initially to
undertake study again and who always believed I had the ability and stamina to complete the
project. Their belief helped see me through the good and bad times. Next I have to thank my
supervisor Dick Shepherd for all his support and constructive suggestions for improvement
throughout the last three years and for his readiness to see me sometimes at very short notice,
even during very busy times. Certainly his ideas have played a major role in shaping and
improving this thesis. I also wish to thank Evanthia Lyons co-ordinator o f the research degrees
for her support at crucial times for me personally and the research programme in general. My
thanks goes to Gary Frost, for his work in facilitating the project and allowing me access to a
large sample o f his clients and also the use o f his office and equipment. Special thanks goes to
my fellow research students for their support socially and intellectually, names to mention are
Dina, Charlie, Tanika, Veii, Jane, Karen, Alex and Danny and in particular Naama, who I have
shared an office with for the last three years,

I need also to thank the many participants who took part in all o f my studies. From the students
and staff at the university to the many people who sat patiently in hospital waiting rooms and
gave me their valuable time completing questionnaires, when I am sure they had more
entertaining things to do. Without all o f them I would have achieved nothing

Lastly a special acknowledgement goes to my mother who has been an inspiration to me

throughout my life and who I hope would have been proud o f my achievement in completing this
work. To all I have mentioned and those who helped but I forgot to mention, I thank them all and
hope this thesis and my future work in psychology does them justice and repays their belief and
support in me.
ii
 Table of Contents

Abstract...................................................................................................
Acknowledgements................................................................................ ................................. ii
Table o f contents....................................................................................
Index o f tables........................................................................................ ................................... viii
Index o f figures...................................................................................... ................................... xi

Chapter 1: Introduction and literature review

The need for nutritional change............................................................. ..................................... 1
The effectiveness o f dietary interventions............................................. ..................................... 4
Background to the Transtheorical Model ............................................. .................................. 10
Transtheoretical model: Processes o f change........ .............................. ................................... 12
Stages o f change..................................................................................... .................................... 15
Levels o f change.................................................................................... .................................... 19
Decisional balance................................................................................. .................................... 20
Self efficacy................................................................................................................................ 21
Application o f the Transtheoretical m odel............................................ .................................... 22
Research supporting Transtheoretical m odel........................................ .................................... 28
Criticism o f Transtheoretical m odel...................................................... ....................................30
Application to dietary behaviour........................................................... ..................................... 33
Summary................... ............................................................................ ..................................... 38
Research aims........................................................................................ ..................................... 39
Contents o f thesis.................................................................................. ......................................41

Chapter Two: An exploratory study of the transtheoretical model and its application to low
fat behaviours.

Introduction.................................................................................................................................. 43
Hypotheses............................................................................................. ...................................... 44
Method................................................................................................... ......................................45
Questionnaire structure..................................................................................................................45
Data reduction and scale reliability............................................................................................. 48
Results.......................................................................................................................................... 49

Low fat behaviours.................................................................................................................... 50

Decisional balance..................................................................................................................... 54
Processes o f change.................................................................................................................... 54
Global self efficacy..................................................................................................................... 56
Self efficacy subscales................................................................................................................ 56
Discussion.................................................................................................................................... 57
Analysis based on low fat behaviour groups............................................................................. 63
Hypotheses................................................................................................................................... 64
Results low fat behaviour groups................................................................................................ 64
Decisional balance...................................................................................................................... 66
Processes o f change............................................................................................................. 66
Self efficacy................................................................................................................................... 67
Discussion...................................................................................................................................... 71
Conclusion................................................................................................................................. 74

Chapter Three: The transtheoretical model and dietary behaviour: A qualitative analysis
using semi-structured interviews.
Introduction................................................................................................................................. 76
Interview schedule...................................................................................................................... 77
Method......................................................................................................................................... 80
Results......................................................................................................................................... 80
Strategies used............................................................................................................................ 83
Motivating factors...................................................................................................... 84
Problems and disadvantages........................................................................ 85
Consequences and reactions....................................................................................................... 87
Discussion.................................................................................................................................... 88
iv
Implications for future study....................................................................................................... 93
Conclusion................................................................................................................................... 96
Type two diabetes mellitus......................................................................................................... 97

Chapter four: An in depth study of the application of the transtheoretical model to the low
fat behaviours of a sample o f participants with type two diabetics.
Introduction.................................................................................................................................. 100
Group selection........................................................................................................................... 100
Improvements to questionnaires..................................................................................................100
Dietary behaviour scale............................................................................................................ 101
Staging Algorithm...................................................................................................................... 104
Perceived R isk........................................................................................................................... 107
Dietary knowledge questionnaire............................................................................................... 107
Processes o f change.................................................................................................................... 108
Processes o f change questiomiaire structure............................................................................. 109
Decisional balance...................................................................................................................... I l l
Self E fficacy.............................................................................................................................. I ll
Intervention pamphlets............................................................................................................. 112
Precontemplation pamphlet........................................................................................................ 112
Contemplation pamphlet........................ 113
Preparation pamphlet.................................................................................................................. 114
Action pamphlet.......................................................................................................................... 114
Maintenance pamphlets............................................................................................................... 115
General pamphlet....................................................................................................................... 116
Sources o f pamphlet content....................................................................................................... 116
Hypotheses.................................................................................................................................. 117
Method....................................................................................................................................... 118
Baseline result............................................................................................................................... 119
Demographics.............................................................................................................................. 119
Stage distribution....................................................................................................................... 119
v
Low fat behaviours.................................................................................................................... 120
Perceived Risk............................................................................................................................ 122
Dietary knowledge.................................................................................................................. 123
Data reduction and scale reliability......................................................................................... 124
Processes scale.......................................................................................................................... 124
Transtheoretical concepts........................................................................................................ 125
Use o f transtheoretical processes and concepts atdifferent stages.......................................... 125
Results transtheoretical concepts............................................................................................ 129
Analysis based on split post action stages.............................................................................. 131
Transtheoretical processes...................................................................................................... 131
Transtheoretical concepts o f change........................................................................................ 132
Discussion................................................................................................................................. 136
Analysis based on low fat behaviour scores............................................................................ 142
Transtheoretical processes........................................................................................................ 142
Transtheoretical concepts......................................................................................................... 145
Discussion................................................................................................................................. 147
Conclusion................................................................................................................................ 150

Chapter 5: Longitudinal analysis of the application o f the transtheoretical model to the low
fat behaviours of a sample of participants with type two diabetes.
Introduction................................................................................................................................ 152
Hypotheses..................................................................................................................................153
Method..................................................................................................................................... 153
Results.........................................................................................................................................154
Analysis o f entire group at follow u p ........................................................................................ 156

Analysis o f results o f processes and concepts forstable precontemplaters and forward movers at
baseline and follow up............................................................................................................ 158

Analysis o f results for contemplaters and preparers at baseline who remained stable and
contemplaters and preparers who showed forward movement.............................................. 162

Combined forward movement for all pre-action stages.......................................................... 164

vi
Post action stages.................................................................................................................... 170
Maintenance group................................................................................................................. 172
Stable and retrograde movement post action stages............................................................... 173
Logistic regression stage movement....................................................................................... 177
Low fat behaviour scores ................................................................................................ 179
Movement low fat behaviour.......................................... 179
Logistic regression low fat behaviours.................................................................................. 184
Responses to interventions............................................................. 186
Intervention type and stage movement................................................................................... 187
Intervention type analysis....................................................................................................... 188
Discussion............................................................................................................................... 191

Chapter six: Final discussion

Overview................................ 201
Qualitative study................................................................................................................... 201
Cross sectional studies........................................................................................................... 202
Longitudinal study................................................................................................................. 202
Interventions............................................................................................................. 203
General limitations................................................................................................................. 203
Questionnaire design.............................................................................................................. 206
The validity o f the transtheoretical model in relation to low fat behaviour........................... 209
Future studies.......................................................................................................................... 211
Concluding remarks................................................................................................................ 212

References...................................................................................................................... 214

vii
 Index of Tables

Table 1.1 Stages o f change matched to processes o f change................................................... 23

Table 2.1. Mean scores for transtheoretical processes and concepts for each stage 51
Table 2.2. Mean scores self efficacy subscales for each stage o f change................................ 56
Table 2.3. Level o f low fat behaviour in relation to stage o f change....................................... 65
Table 2.4. Mean scores transtheoretical processes and concepts for different levels o f low fat
behaviours.....................................................................................................................................68

Table 3.1. Number o f people mentioning particular strategies.....................................................84

Table 3.2 Number o f people mentioning particular motivating strategies................ 85
Table 3.3. Number o f people mentioning particular main problems......................................... 87
Table 3.4. Number o f people mentioning particular consequences and reactions..................... 88
Table 4.1. Summary o f Study Outline..................................................................................... 118
Table 4.2. Fat behaviours and stage............................................................................................ 121
Table 4.3. Mean scores transtheoretical processes and stage o f change.....................................127
Table 4.5. Mean scores transtheoretical concepts and stage o f change....................................129
Table 4.6. Mean scores transtheoretical processes for post action split stages....................... 133
Table 4.7. Mean scores transtheoretical concepts for post action split stages....................... 133
Table 4.8. Mean scores transtheoretical processes at level o f low fat behaviour.................. 143
Table 4.9. Mean scores transtheoretical concepts at level o f low fat behaviour..................... 145
Table 5.1. Number o f participants at each stage at baseline and follow u p ............................ 155
Table 5.2. Stage movement for main stages between baseline and follow u p ........................ 156
Table 5.3. Low fat behaviour scores with stages at baseline and follow u p ........................... 157
Table 5.4. Mean scores for processes baseline and follow u p ................................................ 157
Table 5.5. Mean scores o f transtheoretical concepts at baseline and follow u p ......... 158

Table 5.6. F values form two way anovas for stable and forward movement
precontemplaters at baseline and follow up with transtheoretical processes and
concepts, factors time and movement................................................................. 160
Table 5.7. Mean scores for processes and concepts for stable and forward movement
precontemplaters at baseline and follow u p ........................................................................ 161

Table 5.8. Two way anovas F values for stable and forward movement
contemplaters and preparers at baseline and follow up with
transtheoretical processes and concepts, factors time and movement................................... 163

Table 5.9. Mean scores o f transtheoretical processes and concepts

for stable and forward movement contemplaters and preparers............................................ 164

Table 5.10. Two way mixed factor anovas for stable and forward
movers pre-action stages at baseline and follow up for transtheoretical
processes and concepts factors time and movement............................................................. 166

Table 5.11. Mean scores for processes and concepts stable and forward
Movers in pre action stages................................................................................................... 167

Table 5.12. Two way mixed factor anovas for forward movers
and stable retrograde group in the action stage. F values at baseline
and follow up for transtheoretical processes and concepts. Factors time
and movement........................................................................................................................ 171

Table 5.13. Mean scores transtheoretical processes and concepts forward

Movers and stable and retrograde movement action group................................................... 172

Table 5.14. Mean scores o f processes for stable maintainers................................................ 173

Table 5.15: Two way mixed factor anovas for stable and retrograde
group in the post action stages. F values at baseline and follow up for
transtheoretical processes and concepts. Factors time and movement.................. 175

Table 5.16. Mean scores transtheoretical processes and concepts stable

and retrograde movement post action stages........................................................................ 176

Table 5.17. Logistic Regression stage movement................................................................... 177

Table 5.18. Movement fat behaviour groups........................................................................... 179

Table 5.19 Two way mixed factor anovas for forward and
retrograde groups with low fat behaviours. F values for transtheoretical
processes and concepts. Factors time and movement..................... 181

Table 5.20. Mean scores transtheoretical processes and concepts forward

and retrograde movement groups low fat behaviours............................................................... 182

ix
Table 5.21. Logistic regression low fat behaviours................................................................. 184

Table 5.22. Pamphlet item responses........................................................................................ 186

Table 5.23. Movement stage and intervention type pre maintenance stages..............................187

Table 5.24. Movement and intervention type maintenance stage...............................................188

Table 5.25. Two way mixed factor anovas for pamphlet type, F values
At baseline and follow up for transtheoretical processes and concepts.
Factors time and intervention type..............................................................................-•............ 189

Table 5.26. Mean scores transtheoretical processes and concepts with

no interventions, general interventions and stage matched intervention
baseline and follow up............................................................................................................. 190

x
 Index of Figures

Figure 2.1. Bar chart showing stage distribution....................................................................... 49

Figure 2.2. Mean scores transtheoretical processes for each

stage o f change....................................................................................................................... 52
Figure 2.3. Mean scores transtheoretical concepts for each stage......................................... 53

Figure 2.4. Mean scores transtheoretical processes for each level

o f fat behaviour........................................................................................................................ 69

Figure 2.5. Mean scores transtheoretical concepts for each level

Of fat b ehaviour....................................................................................................................... 70
Figure 3.1. Summary o f m odel...............................................................
Figure 4.1. Stage distribution.................................................................................................... 120
Figure 4.2. Mean scores fat behaviours................................................................................... 122
Figure 4.3. Mean scores perceived risk................................................................................... 123
Figure 4.4. Percentage scores knowledge................................................................................. 124
Figure 4.5. Mean scores transtheoretical processes and stage o f change................................ 128
Figure 4.6. Mean scores transtheoretical concepts and stage o f change.....................................130
Figure 4.7. Mean scores transtheoretical processes for split post action stages.........................134
Figure 4.8. Mean scores transtheoretical concepts for split post action stages...........................135
Figure 4.9. Mean scores transtheoretical processes and level o f fat behaviour..........................144
Figure 4.10. Mean scores transtheoretical concepts at level o f fat behaviour.......................... 146
Figure 5.1. Mean scores processes pre action forward movers..................................................168
Figure 5.2. Mean scores decisional balance pre action forward movers............................... 169
Figure 5.3. Mean scores processes post to pre action stages................................................... 178
Figure 5.4. Mean scores process use forward movers low fat behaviours.................................183
Figure 5.5. Process use backward movement low fat behaviours ................................. 185
Diagram 5.1 Transtheoretical process use and concept application
to dietary change..........................................................................................................................198

xi
Appendix 1: Exploratory questionnaire and volunteer poster
Appendix 2: Hammersmith ethics and consent form
Appendix 3: Final questionnaire
Appendix 4: Intervention pamphlets and letters.
Chapter 1

Introduction

The Need for Nutritional Change

The Health o f the Nation document (1992) contains as one o f its main objectives “The reduction
o f the amount o f premature death and ill health related wholly or in paid to eating and drinking
habits” (Lamb and Joshi 1996 p 43). A firm conclusion o f the document is that a large number
o f people throughout the UK eat and drink in a manner, which over time contributes to
significant health problems. The Health in England report (1998 pl21) found that as many as
18% o f adults could be classified as having a less than healthy diet. While it is accepted in both
these documents that food needs to be enjoyable, it is also emphasised that the daily diet should
provide the essential balance o f nutrients and fats. One o f the major eating habits associated with
an unhealthy diet is the intake o f excessive fatty foods, one example o f this being the daily frying
o f foods such as chips in solid fats or the consumption o f other fried foods daily. Indeed the
documents notes that obesity and overweight were increasing health problems with 8% o f men
and 12% o f women being obese and 37% o f men and 24% o f women being overweight. More
recent research found that obesity has reached a point where it claims 30,000 lives annually,
throughout England. A House o f Commons public accounts committee estimated the cost to
economy as a whole o f obesity being £2.5 billion the report also warns that unless effective
action is taken 20% o f men and 25% o f women could be obese by 2005 (http://news.bbc-.co .uk,
2002). Therefore throughout all these reports a strong emphasis is placed in particular on the
benefits derived from a lower percentage o f fat in the daily diet.

Indeed numerous health educators have consistently focused on the relationship between high fat
diets and premature morbidity (Cohen, Brownell and Fellix 1990). Stewart and Brook (1983 )
reviewed 21 studies and concluded that being severely oveiweight is associated with premature
mortality, with strong links being found between a high fat diet and heart disease, stroke,

1
cancers, diabetes and gallstones. Therefore a simple example o f the benefits o f a low fat diet is
the prevention o f heart disease.

In addition to this however there is speculation that a very low-fat diet may actually help reverse
heart disease. This may become increasingly important, as the improvements made with surgical
treatments are often not permanent. With bypass surgery for example approximately 50% o f
bypassed vessels are clogged again within five years and with angioplasty, 33% o f vessels are
blocked again within 6 months, Low fat living (http ://www 1.xe.net/lowfat/articlesA. In addition
to the significant health problems linked with overweight, throughout the western world
significant social stigma is also attached to obesity, (Wardle 1995). Tiggeman and Rothblum
(1988) found that when young students were given a choice o f marriage partner many preferred
to many a shoplifter, embezzler or a blind person than an obese one. Obese people are also rated
as less hardworking, intelligent or active than slimmer people (Hams and Bochnerl982). Not
surprisingly therefore with the social stigma and health problems significant psychological
stresses are also associated with being overweight. Brownell and Wadden (1983) believed the
psychological and social hazards o f obesity are more important to dieters themselves than the
medical problems. Hirsch (1973) summarised the psychological and social effects as ranging
from mild feelings o f inferiority to serious impediments to socialising and sexual activity with
resulting problems in many areas o f a person’ s life including marriage, education and
employment. Brownell (1982) believed that the seriousness prevalence and resistance to
treatment o f obesity make it one o f the most difficult psychological and medical problems in
modem western society.

Not surprisingly therefore with the numerous problems associated with high fat diets, a reduction
in the percentage o f fat in the diet is one o f a number o f key targets contained in Health o f the
Nation document (1992 p 39). With regard to fat intake the goals are that 60% o f the population
derive less than 15% o f their food energy from saturated fats and 50% derive less than 35% o f
their food energy from all fats. With the total proportion o f obese adults in the nation being 7%
or less. This compares with the estimated national average at the time o f 17% o f energy from
saturated fats and 42% from all fats. Yet despite the many major problems associated with high
fat diets and the significant benefits associated with low fat diets the Department o f Health

2
estimates the average contribution made by fat to energy derived from food in the nation as a
whole is still too high. The National Food Survey (2000) estimated the percentage o f energy
derived from fat in the diet remains at 38% still above the maximum intake o f 35%
recommended by the committee on Medical Aspects o f Food Policy (Health o f the Nation 1992).
This is not a problem confined solely to Britain. In America “The Nationwide Food
Consumption Survey” (1987-1988 cited in Greene and Rossi 1994) concluded that only 14% o f
the population reached the more stringent target o f less than 30% o f energy being obtained from
fat. McDonnell, Roberts and Lee (1998) noted that while 80% o f Australians believed that the
high fat content o f their diets is a major concern surveys have shown that the average Australian
still consumes above the recommended level o f fat in their diet.

Why then are dietary habits so resistant to change? One reason may be that food habits
themselves are formed early in life and the risk factors associated with poor diet develop over
many years. An individual for example consuming a high fat diet may not be aware o f the
potential damage o f consistently eating the wrong foods. Therefore an urgent need exists for
increased understanding o f the processes behind dietary change and for the creation o f improved
new interventions to enhance adherence to dietary regimes.

3
The effectiveness of Dietary Behaviour Interventions

The Health o f the Nation document (1992) showed that dietary change remains stubbornly
difficult to bring about for many people The question to be addressed is firstly how effective are
present interventions for dietary change and how can their effectiveness be improved?
Undoubtedly many well designed treatment and self-help programmes either attract very few
participants, or are subject to a high percentage o f dropouts.. Prochaslca, DiClemente and
Norcross (1992 pi 105) illustrated the poor response rate using the example o f two extensive
studies conducted in the late eighties. One conducted on the west coast aimed at smokers, found
that despite initial interest shown by 70% o f the target population only 4% actually enrolled.
Recruitment rates o f only 3-12 % were also found among those eligible for home based weight
control programmes. Undoubtedly therefore the vast majority o f people who could profit from
health interventions do not avail o f them. A significant and worrying problem therefore exists in
getting people who could profit from interventions to partake.

In addition to this individuals adopting or intending to adopt dietary change face a variety o f
problems from individuals making changes in more straightforward health behaviours such as
addictions. This makes dietary behaviour one o f the more difficult health behaviours to improve
and maintain. Sternberg (1998 p521) commenting on the particular difficulties associated with
dietary change pointed out that dietary change in particular low fat dieting calls for “ controlled
food use” , however as a concept this is vague and difficult to define. For many health
behaviours, for example quitting smoking and addictions to chemical substances abstinence is
the goal. A smoker for instance knows when they are observing abstinence they are simply
smoking or they are not; similarly an alcoholic abstains from alcoholic drinks. For the person on
a low fat diet, however, controlled food use is not as clear cut. McDonnell, Roberts and Lee
(1998) commented that consumers require specific nutrition information and the general public
often misunderstands implementing dietary advice and the many concepts related to food and
nutrition. Very few people can say with confidence for example when the total fat content in
their diet falls below 35%. hi addition to this many o f the behavioural goals in dietary change are
multifarious, that is improvements are required in food selection, preparation and purchasing
techniques (Kristal, White, Shattuck, Curry, Anderson 1992 p554). Also an almost infinite
number o f combinations o f foods can lead to the desired target behaviour; for example two

4
people on totally different diets may still have less than a total o f 35% o f fat in their daily intake.
Kristal White, Shattuck and Curry (1992 p554) commented that long term significant dietary
change is extraordinarily difficult to achieve and maintain. They found the main exceptions to
this were research studies that provided the necessary food to participants, or used intensive or
expensive intervention protocols such as one to one counselling. Beresford, Curry, Kristal and
Laxovich, (1997 p610) noted that many dietary research studies are targeted at individuals at
particularly high risk, with the interventions being based on intensive individual or group
counselling. However, the provision o f this type o f intervention to the large target groups where
dietary interventions are acutely needed is often expensive and impractical. A good example
would be a group o f perhaps 4,000 people with type 2 diabetes attending an outpatient clinic at
an established imier city hospital. Clearly in depth interventions are highly unlikely in this
scenario.

The question then arises as to what type o f interventions could be used and how might their
effectiveness be enhanced? Beresford et al (1997) suggested that low intensity interventions such
as self-help materials might have an important role to play. It is possible to make these materials
available to a wide range o f people at comparatively low cost therefore having a greater overall
effect than highly intensive changes being made available to a small percentage o f a target
population. The next question, which then arises, is how such self-help materials may be
improved? One approach, which has received increased attention in recent years, is the tailoring
o f messages as closely as possible to each participant’ s individual requirements. Petty and
Cacioppo (1981) elaboration likelihood model (E.L.M) suggest that information, which is
personally relevant to an individual, is more likely to be processed thoughtfully. Kreuter, Bull,
Clark and Oswald (1999 p 488) believed that messages tailored to individuals have a greater
chance o f being successful as they promote more issue relevant thinking, self assessment and
modify the intention to take action.

Health interventions to date are based largely on either continuum or stage models o f behaviour
(Weinstein , Lyon, Sandman and Cuite 1998). Weinstein Rothman and Sutton (1998) illustrated
the concept o f a stage model using the example o f AIDS prevention. With safer sex behaviour a
large number o f variables are involved including efficacy beliefs, social norms and risk

5
perception. Individuals may also fit into certain specific categories for instance with those not
considering behaviour change may need to be made more aware o f their vulnerability whereas an
individual considering change may need training in the skills negotiating condom use. Stage
theories address issues such as these by classifying individuals into categories and addressing the
issues relevant to advancing individuals from one category to the next, hr contrast with this
Weinstein et al (1998) commented that with continuum models an individual is placed at a
particular point on a continuum and the goal o f the intervention is to move the person along this.
Quantitative differences between people are acknowledged, however there are not the distinct
qualitative categories outlined in stage models in which different interventions at different points
are deemed necessary. A simplistic explanation o f this may be seen in the Health Locus o f
Control Model (Wallston, 1992) and Self Efficacy theory (Bandura 1977). To improve health
behaviours participants are encouraged to either increase their self efficacy or switch from
internal to external locus o f control. When these beliefs and cognitions are transformed and
maintained to a significant degree the likelihood o f improved health behaviours is greatly
increased. The concept o f either distinctly different concepts being introduced at separate points
or that the use o f the intervention at certain points may be more destructive than constructive is
rarely considered. In contrast to this in stage models it is implied that individuals are at distinct
stages with specific varying barriers to progress at each stage. For example it may be o f no
benefit to increase the self efficacy o f an individual who has no intention o f changing, it may
however be o f value to increase their awareness o f the danger o f their habit to themselves or
others. Likewise with an individual who has recently taken action there may be little point in
increasing awareness o f the dangers o f a habit but every point in introducing frameworks for
social support and increasing self efficacy. Issues such as this are addressed in the stage models,
which at present enjoy increasing popularity. Three o f the main models in current use will now
be discussed.

As a method o f enhancing adherence to numerous health behaviours ranging from the adoption
o f preventative measures, stopping unhealthy behaviours, and using medical services, stage
models are attracting increasing interest. To date the four stage models developed in relation to
health behaviours are the transtheoretical model (Prochaska, DiClemente and Norcross 1992),
the precaution adoption process model (Weinstein 1988) the health action process model

6
(Schwarzer 1992) and the health behavioural goal model (Gebhardt 1997). O f these the three
most popular models to date are the transtheoretical model, the precaution adoption process
approach and the health action process approach. A brief summary and comparison o f these
three models now follows. All models consist o f several stages. The transtheoretical model
contains 5 stages, these are (1) precontemplation, (2) contemplation, (3) preparation, (4) action
and (5) maintenance. Later research introduced an additional stage o f termination meaning there
is no prospect o f a relapse to old behaviours. The precaution adoption model consists o f 7, these
are (1) being unaware o f the health action, (2) aware but not personally engaged, (3) engaged and
trying to decide what to do (4) deciding not to act, (5) deciding to act but not having yet acted (6)
acting and (7) maintaining. The health action process model (Schwarzer 1992) consists o f at least
2 stages (1) a motivation phase, and (2) volition phase, with the volition phase possibly dividing
into planning action, action and maintenance phases. All models contain a division between
stages in which the person has no intention o f taking action, is thinking about taking action and
taking action and maintaining it.

It is also implied in all models that participants go through the stages in a fixed sequential order
from 1-5 or 1-7 and that distinct barriers exist at each stage with different strategies necessary for
forward movement. For example, with the transtheoretical model cognitive affective processes
are emphasised in the pre-action stages with behaviour orientated processes being introduced in
the post-action stages. In addition to processes o f change the psychological concepts o f
decisional balance and self efficacy also play a crucial role. With decisional balance an increase
in the pros and a decrease in cons is predicted with stage movement. With self efficacy a high
score in the pre-action stages is predictive o f success in the later post-action stages.

Similarly in the precaution adoption model individuals’ perceptions o f their personal

vulnerability are crucial in moving individuals between stages 3 and 5, with situational variables
being more influential in movement at the later stages, for example from intention to change to
actually changing (Weinstein et al 1998). Support for the model found in research with home
radon testing (Weinstein and Sandman 1992) and hepatitis B vaccination (Hammer 1997). With
home radon testing risk treatment interventions were more effective in getting undecided people
those in stages 4-5 to order a test, than getting decided to act people those in stages 5-6 to order.

7
In the motivational stage o f the health action process model (Schwarzer 1992) it is predicted that
individuals assess their priorities that is the pros and cons o f behaviour change. Emphasis is also
placed on the formation o f intentions with self efficacy and outcome expectancies being major
predictors. These concepts are also emphasised in the transtheoretical model, hi the volition
(action) phase o f the health action process model emphasis is placed 011 cognitive, behavioural
and situational concepts. This is in contrast to the transtheoretical model, which focuses on
behavioural concepts at this point. To date however the health action process model has not been
tested in field studies.

It is acknowledged in all o f these models that participants may relapse to early stages. In the
transtheoretical model participants may relapse from maintenance to preparation or
contemplation 01*perhaps right back to precontemplation. A similar process is also possible in
the precaution adoption model and the health action process approach. This means that change
may in fact be a spiral rather than sequential movement. However, the central concept o f the
effectiveness o f different interventions at each stage remains unaffected by relapse. In other
words with the transtheoretical model interventions are the same for first time contemplaters as
those who have relapsed into contemplation from either maintenance or action.

A crucial factor o f a stage model is that it accepts movement before actual behaviour change, hi
the transtheoretical model a move from precontemplation to contemplation or preparation or in
the precuation adoption model a move from being unaware to being aware is regarded as
movement forward. However, cognitive changes such as these will go unacknowledged when
behaviour change is regarded as an all or nothing phenomenon, meaning that a potentially
beneficial intervention may be abandoned, hi fact, Oroford (1992) likened the development o f
stage models to a “Kuhnian paradigm shift” . O f the current stage models the transtheoretical
model perhaps because o f the simplicity o f the model has received the greatest attention being
tested empirically with a range o f behaviours. In a key paper Prochaska, Velicer, Rossi,
Goldstein and Marcus (1994), foimd commonalties in the pattern o f change in decisional balance
and stages o f change consistent with the transtheoretical model in 12 problem behaviours
ranging from smoking cessation, high fat diets, delinquent behaviour and mammography
screening. With the research and theories being developed the exciting prospect is being

8
forwarded that stage models may have the potential to offer a clear account o f how people
change and in turn greatly increase the effectiveness o f interventions.

However, further investigation o f stage models is essential if their full value is to be assessed, hi
deciding to investigate stage models the question arises as to which model to focus on? A wide-
ranging investigation focusing on all three models is impractical and may leave unanswered
questions with all three models. Therefore a thorough examination o f one model is proposed.
Also assessing the validity o f one model may in fact shed light on the validity o f the remaining
models or assist in the shaping o f future models. All the above models are based on established
psychological theories and contain an instinctive sense o f being applicable to health behaviours.

However o f all the models the transtheoretical model possesses the most established pedigree.
Prochaska and DiClemente (1992) noted that initial research on this model commenced in 1977
when a thorough analysis seeking out the commonalties within the various theories of
psychotherapy was embarked upon. Yielding the first o f basic components o f the
transtheoretical theory in 1984. The transtheoretical model has been applied to a wide range of
health behaviours, therefore an investigation o f its validity in relation to dietary behaviour will
assist in establishing its validity in similar areas such as exercise or weight control. Also
establishing the validity o f stage interventions in relation to this model will add to the knowledge
regarding the validity o f existing or future stage models.

Therefore the focus o f this thesis will be on the transtheoretical model and its application to
dietary behaviour as opposed to either the precaution adoption model or the health action process
approach. As with all stage models the underlying principle is that a number o f psychological
processes and concepts are linked to specific stages o f change thus enabling interventions to be
targeted more effectively. However, to understand how this is to be achieved in relation to the
transtheoretical model a detailed understanding o f this model is necessary, therefore a thorough
review o f the underlying theory and literature regarding the background and application o f the
transtheoretical model is included in the following section.

9
Background to the Transtheoretical Model

Prochaslca in 1977 with the aid o f his students began a search examining numerous
systems o f psychotherapy in an attempt as he put it to identify “The commonalties across
the most rigid boundaries o f the most popular theories o f Psychotherapy” . In 1984 this
cumulated in the first step in the forming o f the transtheoretical model, with the
identification o f 10 separate processes o f change common to all theories of
psychotherapy. At this point Prochaslca acknowledged that while this theoretical construct
had appealing face validity it remained a theoretical construct with no empirical basis.
However, in a breakthrough paper, reviewing evidence in relation to self initiated and
professionally assisted change in relation to addictive behaviours, a model was proposed,
which contained 3 major components. These were (A) 10 processes o f change, (B) 5
stages o f change and (C) 3 levels o f change (Prochaslca, DiClemente and Norcross 1992).
O f interest at this point is a brief summary o f the factors, which prompted Prochaslca et al
to initiate this quest for a transtheoretical system o f change.

A debate arose in the psychotherapeutic community in the late 1970’s and early 1980’ s
regarding the ability o f specific systems to address the total needs o f clients. This is
summarised in a quote by Raimy (1976) who noted that “ Many schools drive their
therapists to develop their thinking and their techniques but also imposed limited
horizons, which clamped their proponents into rigid moulds” . Indeed several
psychoanalytic researchers at the time commented on the possible benefits to
psychoanalysis in incorporating strategies from other approaches. Applebaum (1979)
believed psychoanalysists could leam significantly from gestalt therapy and Alexander
(1963) predicted a successful integration between psychoanalytic therapy and learning
theory leading to advances in the practice o f both psychotherapies.

Goldfiied (1980) in a landmark paper, which summarised psychotherapy approaches,

questioned whether all the answers could be found in any one therapeutic system. He
argued that many common strategies existed across different approaches, the two
examples he gave o f this were the provision o f new corrective experiences and the offer

10
o f direct feedback between patient and client. Goldfried’ s wish was for a more integrated
approach to be developed, with the practitioners o f the many different therapeutic
approaches working towards some consensus o f the steps necessary to bring about
improvement in clients. Goldffied suggested an examination o f the processes o f change
across all therapies as a starting point. Prochaska and DiClemente (1992) commented that
the proliferation o f psychotherapeutic systems confronts the clinician with a daily
dilemma in deciding the proper approach to clients with differing problems. In response
to this development in psychotherapy with no one therapeutic system being perceived as
adequate they attempted to establish an integrative perspective to accomplish 5 main
goals. These were (a) preserving the insights o f the major systems o f psychotherapy, (b)
providing practical answers for clinicians, (c) bringing order to the chaotic diversity in
psychotherapy (d) offering an alternative to the single system and comparative types (e)
developing a systematic approach which at the same time retained the flexibility to
promote collaboration, creativity and choice.

Prochaska and DiClemente in addition to examining the principles, which promoted

successful change in professional treatment, believed it was vital to include also the
principles, associated with successful change without formal psychotherapy. The purpose
in including self-changers being to give insight into a significant group which may often
be ignored in traditional studies o f therapeutic interventions, hi a demonstration o f this
Scliachter (1982) found that the overwhelming professional consensus with opiate use,
cigarette smoking and obesity was that these complaints were highly resistant to long
temi change. Scliachter, however questioned this overly pessimistic stance commenting
that many individuals in eveiyday life in fact work through these problems without
recourse to professional help. Indeed, Scliachter argued that two factors might account for
the high failure rate in professional treatment. Firstly individuals resorting to this may be
encountering significantly more problems than the average person might. Secondly the
inferences made regarding therapeutic effectiveness are often based on a single attempt
whereas many individuals make repeated attempts before quitting successfully.

11
As previously stated Prochaska and DiClemente5s research resulted in a model consisting
o f processes, stages and levels o f change. The first concept in this model the processes of
change will now be discussed.

Transtheoretical Model: Processes of Change

Prochaska and DiClemente (1992 p302) defined a process o f change as “Any activity
initiated or experienced by an individual in modifying thinking, behaviour or affect
related to a particular problem” . They emphasised that a process differed from a coping
mechanism, in that while a large number o f coping mechanisms existed, processes
represented the basic principles underlying coping mechanisms.

The first step in discovering the processes involved in change consisted o f an

investigation o f 24 o f the most widely used forms o f psychotherapy (Prochaska 1979).
The selection o f these recommended change techniques across different theories resulted
in the term “Transtheoretical Model” . Analysis showed 10 major processes playing a
significant role in behaviour change. These were consciousness raising, self reevaluation,
self liberation, counter conditioning, stimulus control, reinforcement management,
helping relationships, dramatic relief, environmental revaluation and social liberation.
The use o f these processes is further supported in research with 872 smokers and ex­
smokers in the Rhode Island area over two years (Prochaska and DiClemente 1985). The
same sample also completed questionnaires on techniques they used for coping with
weight control and psychological distress. Principal component analysis showed a stable
component structure consisting o f 10-12 processes which accounted for at least 68% of
variance in each problem area, hi addition to the original processes 2 additional processes
o f substance use and interpersonal systems control were also identified. The veiy similar
structures emerging across problems suggest that the model can be generalised across
health behaviours, hi relation to dietary behaviour (low fat intake), Bowen, Meischlce and
Tomoyasu (1994) found 8 processes resembling those identified by Prochaska and
DiClemente to be associated with change. Prochaska and DiClemente acknowledged that
they may not have isolated all possible processes o f change, but they believed the main

12
processes they identified to be applied across mixed problem behaviours. However future
researchers may locate additional processes particularly in relation to more diverse
problems. A brief description o f each o f the ten original processes identified by Prochaska
and DiClemente now follows.
Consciousness Raising: Increasing information about self and problem, an individual
using consciousness raising might actively pursue and recall knowledge regarding the
problems associated with their behaviours. Overall the person becomes more aware of
their problem.
Dramatic Relief: Accessing the feelings regarding problem behaviour, and using these to
motivate the person and bring about change, hi attempting to move people emotionally
role playing and personal testimonies are often used.
Self Reevalnation: How maintaining problem behaviour makes the person feel about
themselves, for example do they feel disappointed or upset if they continually smoke,
drink etc. Person may be encouraged to look back firstly and evaluate their past life with
problem behaviour and secondly to look forward and imagine their life free from
problem.
Self Liberation: Recognising the freedom associated with change in addition to making
positive commitments to change. Person may be encouraged to make public rather than
private commitments and also to become aware o f the options available to them. For
example with obesity different low fat foods, support groups and friends available to help
them.
Environmental Reevaluation: Noting the impact o f problem behaviour on society in
general but also the impact on person’ s social environment for example strains put on
family friends an local community. Smokers might be made more aware o f the problems
the loss o f their health causes not only to themselves blit to those around them and also
the dangers from passive smoking to others.
Social Support: Enlisting the help o f someone close to tackle problem, or possibly the use
o f support groups or networks familiar with problem to assist. Person may be encouraged
to build his or her own social skills to enlist social support.

13
Reinforcement Management: The use o f rewards or punishments to encourage adherence
to health regime. Self or others can make rewards or punishments. Emphasis however is
on reinforcement for progress. Prochaska (1999) in particular encouraged participants to
make their own reinforcements, rather than dependence on others. Lack o f reinforcement
from others who may take progress for granted might lead to relapse, but if reinforcement
is under participants own control this is less likely.
Counterconditioning: The substitution o f problem thoughts or behaviours with helpful
ones, examples include desensitization or positive self-statements to counter distress-
provoking cognition.
Stimulus Control: Restructuring one’ s social and physical environment to trigger more
healthful behaviours. Participant might remove all triggers to smoking or high fat foods
from their home and replace with stimuli that promote positive behaviour'.
Social Liberation: Becoming more aware o f the alternatives available in society to
improve and maintain health behaviours. Issues such as smoking not being socially
acceptable or the availability o f low fat alternatives to high fat foods.

Prochaska and DiClemente (1985 p324) hypothesised that the ability o f individuals to
utilise these processes is directly related to cessation success, with successful changers
employing a co-ordinated use o f all processes. Further to this, failure to change or to
successfully maintain change is the result o f possibly three problems with process use.
These are firstly individuals may be unaware o f several o f these processes, resulting a
restricted range o f options. Secondly even when an individual is aware they may not
employ the majority o f these processes and thirdly even if all processes are used they may
be applied inappropriately at different points in the modification attempt.

Prochaska and DiClemente (1992) commented that most systems o f therapy used only
two or three o f these processes with their clients, however their earlier studies indicated
that clients changing on their own engage in all these processes. An example o f this is the
processes used to modify problem behaviors such as smoking (Prochaska 1984). They
pointed out that this indicates that many therapists are using only a limited set o f

14
processes in comparison to the processes used by self changers and therefore that many
therapists are not as cognitively complex as the majority o f their clients when conducting
therapy. Also as previously stated improper or lack o f use o f these processes may result in
unsuccessful behaviour change. A crucial aspect o f the transtheoretical model is that
processes are appropriately applied at different points in the modification attempt. This
leads to the next major component o f the model, the stages o f change.

Stages of Change
Early research by Beitman (1987) and Egan (1986) indicated that intentional change was
not an all or nothing phenomenon but a movement through different stages. Prochaska
and DiClemente (1992) suggested that this might be a serious flaw made by many
therapists in that they assume that clients presenting for therapy are at a similar point, hi
their initial work with a group o f 67 ex-smokers they noted that the importance o f each
process o f change varied in relation to their progress in quitting the habit. These recent
quitters differentiated between four distinct stages o f change. These were (1) Thinking
about stopping (2) Becoming determined to stop, (3) Actively modifying their habit and
environment and (4) Maintaining change (Prochaska and DiClemente 1985 p325). In
addition to these stages Prochaska and DiClemente included a stage for individuals who
displayed no intention o f changing their behaviour. This classification was further
supported in empirical research. McComiaughty, Prochaska and Velicer (1983) found
support for this stage classification using self-report measures and discrete measures.
DiClemente and Hughes (1990) also verified this model o f stages o f change with
outpatient therapy clients and self-changers suffering with alcoholism. Regarding the
generalisation across problem behaviours o f this model, Prochaska, Velicer, Rossi,
Goldstein and Marcus (1994) found similarities and support for the validity o f the model
across twelve problem behaviours; these included addictive, non addictive and
preventative behaviours. On the overall basis o f these and other studies behaviour change
is believed to consist o f five distinct stages. These are precontemplation, contemplation,
preparation, action and maintenance. Distinct characteristics and patterns o f process use
are believed to be associated with each stage, hi order to move from one stage to the next

15
the issues associated with each stage need to be addressed fully. The next step in this
thesis will be to summarise the characteristics associated with each stage. However, a
final point to note is that while Prochaslca, DiClemente and Norcross (1992) and
Prochaslca et al (1994) emphasised the application o f this model across problem
behaviours, they also stressed that their theory focused on the process o f intentional
change or voluntary change and not societal, developmental or enforced change.
However, awareness o f the model may still be helpful to professionals working in for
example correctional institutes if the long-term goal o f releasing individuals back into the
community were to be achieved. This might be accomplished by encouraging clients to
enter the change process at the contemplation stage. Prochaslca et al (1992) summarized
the characteristics associated with each stage as follows.

Precontemplation: Individuals at this point have no intention o f changing their behaviour

in the fore-seeable future. They may even be unaware they have a problem, or if they are
aware they tend to dismiss it believing perhaps it is no greater than the problems o f others
and there is no real need to change. However, associates are often aware o f difficulties.
Usually when precontemplaters attend therapy it is often because o f the pressure from
peers or an employer. Change may even apparently take place but once this pressure is
finished there is strong likelihood old destructive habits will be resumed. Individuals are
categorized, as precontemplators if they show no serious desire to change their behaviour
within the next six months. It is acknowledged, however, that even precontemplaters
may show a vague wish to change at times. But this cannot be equated with a serious
intention to change. The explanation for the timeframe associated with precontemplation
being 6 months, is that this is about as distant into the future as most people plan who are
seriously committed to behaviour change. The initial goal in therapy with a
precontemplater is to enable them to progress to the next stage in which they at least
consider change. The following stage is contemplation.

Contemplation: At this point the person takes ownership o f the problem in that they
recognize that it exists and that it would be beneficial to change it. Again the timeframe

16
associated with this is six months. This indicates the person is thinking about changing
their behaviour but will not have made any firm commitments. Prochaska et al (1992)
summarised this as the person knowing they need to make changes but feeling they are
not quite ready to go forward yet. DiClemente (1991) pointed out that contemplators
struggle with the pros and cons o f their behaviour. Balancing the problems caused by
their behaviour with the effort and sacrifices needed to change it. Again within the
transtheoretical model the goal is to make the person more aware o f the benefits of
change and to make a definite commitment to change. At this point they move to the next
stage, preparation.

Preparation: Individuals are classified as being in preparation when they have made a
definite commitment to change. The timeframe for this is intending to take action within
the next month but in addition to this they may have unsuccessfully taken action within
the last year. There may be some behavioural changes with for example smokers reducing
their intake by 50% or changing to low tar cigarettes. Alcoholics may also reduce their
intake at this point. Individuals at this point see themselves as working hard to change.
Prochaska et al (1992) called this a decision making stage and some researchers believe it
to be the early beginnings o f the next stage which is action.

Action: hi the action stage significant change such as abstinence from an addictive
behaviour takes place. The timeframe for action is that the required behaviour change is
maintained from 1 day to 6 months. It is essential at this point that the actual behaviour
criterion is reached and not just steps taken toward it which for example may take place
in preparation or contemplation. Prochaska et al point out the dangers o f equating action
with having achieved permanent change or success. This is a trap that they believed many
including professional practitioners fall into. This in turn leads to the neglect o f the steps
needed to consolidate progress and move the individual into the final stage o f
maintenance.

17
Maintenance: The hallmark o f maintenance is the successful adoption o f the necessary
behaviour criterion for at least six months. Prochaska and DiClemente perceived
maintenance as a point in which interventions are still necessary and with addictive
behaviours in particular this could last for an indeterminate period perhaps even for a
lifetime. The essential factor is not to see this as a static stage but a point where clients
actively work to prevent relapse and build on the breakthrough made in action.
Individuals at this point may comment that “They may need a boost now to maintain
changes” . Prochaska and Norcross (1999 p497) give stabilizing behaviour and the
prevention o f relapse as the significant factors in maintenance. Wolfe (1992) believed that
to maintain maintenance, that is to avoid any relapse, it was necessary “To have a sense
o f self that is highly valued by oneself and at least one significant other” . This introduces
a point at which the concept o f social support, which is one o f the key processes in the
transtheoretical model, may be particularly beneficial. An important aspect o f the model
therefore is that maintenance like action is not seen as the end point but a stage where a
close examination o f conditions likely to lead to relapse is advised.

The stages summarised above are the five stages, which ideally represent the five points
an individual adopting health behaviour will sequentially pass through. However, an
important aspect o f health behaviour change, which is also addressed in the
transtheoretical model change is relapse. Brownell Marlatt Lichtenstein and Wilson
(1986) estimated that the rate o f relapse with addictive behaviours might be high as 90%,
while the rate with obesity is unclear but is undoubtedly a significant problem also.
Brownell et al pointed out that figures might overstate the problem as many are based on
clinical cases and only one attempt at change is investigated, hi fact for the majority of
people relapse may be a necessary part o f change. Acknowledging the concept o f relapse,
Prochaska and Norcross (1999) also commented that this may be the rule rather than the
exception with many health behaviours. Prochaska, DiClemente and Norcross (1992) in
acknowledging this dimension o f change concluded that a spiral pattern o f change rather
than a sequential one may be more representative o f health behaviour change in the real
world, hi this individuals may go for example from the later stages such as action and

18
maintenance to earlier stages such as preparation or perhaps even right back to
precontemplation. Schachter (1982) found that with many smokers 3-4 attempts at
quitting were necessary before long - term maintenance was achieved. So while linear
progression from precontemplation to maintenance is the ideal, this may rarely be
achieved in reality. On a positive note, however, research by Prochaski and Di Clemente
(1984) showed that the 85% o f self-changers that relapse move back to the contemplation
or preparation stages to consider plans for their next action attempt. This may explain the
several attempts at change, which Schachter noted.

In a later publications, Prochaska and Norcross (1999 p498) introduced the concept o f
termination o f a problem behaviour, defining it as “ When a person no longer experiences
any temptation to return to troubled behaviours and no longer has to make any efforts to
keep from relapsing” . No specific criteria are given for identifying when this takes place,
though Horwath (1999) suggests this may take approximately 5 years. Prochaska and
DiClemente believe that therapy is often terminated too early and as a result o f this clients
may suffer unnecessary anxiety and distress. Their recommendation therefore is that the
client and their therapist discuss thoroughly the termination o f therapy in order to avoid
unnecessary relapses.

Levels of Change
hi discussing health behaviour change, Prochaska and DiClemente (1992) commented
that it might not always be possible to approach it as a single well defined problem,
recognising that it may take place in the context o f difficulties at different levels. In their
research they identified 5 distinct but interrelated levels o f change. These are (1)
Symptom / Situational problems, (2) Maladaptive cognitions, (3) Current inteipersonal
conflicts (4) Family systems conflicts (5) Intrapersonal conflicts. Again therapists are
criticised for focusing interventions solely on one o f these levels. A family therapist for
example would focus at the family systems level, a behaviourist at the level o f symptom
or situation or a cognitive therapist on the level o f cognitions. Prochaska and DiClemente
accepted those problems requiring interventions at deeper levels, for example, family

19
systems and intrapersonal conflicts will require longer and more complex therapies.
Prochaslca and DiClemente accepted that initially the preference is for an intervention to
be focused at the highest contemporary level, that is the situational symptom level. Firstly
this usually represents the primary reason an individual enters therapy and it is the point
that clinical assessment and judgement can initially be justified. In addition to the stages
o f change, levels o f change and processes o f change two other concepts, decisional
balance and self efficacy, are central to the transtheoretical model and require further
explanation.

Decisional Balance
The concept o f decisional balance was first examined in the Janis and Maim (1977)
decision-making model, where decision-making is conceptualised as a conflict model, hi
this model there is a careful scanning o f the potential gains and losses o f any behaviour.
Four categories o f the major consequences o f gains and losses were formalised. These
were (a) gains and losses for self (b) gains and losses for significant others (c) approval
and disapproval from significant others (d) self approval or self disapproval. Velicer,
DiClemente, Prochaslca and Brandenburg (1985) tested the decisional balance concept
with a 24-item questionnaire on 700 participants across the stages for smoking. Analysis
o f results found that there are two critical constructs the pros and cons o f behaviour rather
than 8, which need to be balanced in measuring the consequences o f a decision. Similar
results found by Marcus, Ralcowski and Rossi (1992) and O’ Connell and Velicer (1988).
A significant element in the decision to move from one stage to the next is the importance
given to the pros or cons associated with change, hi matching this concept to the
transtheoretical model, Prochaslca, Velicer, Rossi, Goldstein and Marcus (1994) believed
that those in precontemplation would see the pros o f a problem behaviour as outweighing
the cons, while those in action and maintenance would view the cons as outweighing the
pros. Thus a smoker in precontemplation would see more problems associated with
giving up smoking than keeping it up. As the pros and cons are perceived as equal the
person will move into contemplation, resulting in a vague commitment to change.
Prochaslca et al concluded therefore that the pros and cons o f a problem behaviour should

20
cross over in the contemplation or preparation stages, at this point the pros begin to
outweigh the cons and a decision for definite behaviour change is made. Participants in
action and maintenance would still see more problems associated with relapsing to a
problem behaviour, than continuing to abstain. Prochaska and DiClemente (1985 p333)
noted, however, the longer the health behaviour is maintained the less importance is
attached to this concept, as it simply becomes a non-issue to the person. Therefore
participants at the maintenance stage might score lower than participants in the late pre
and early post action stages on questionnaires, which measure these concepts.

Self Efficacy
Self efficacy is a person’ s judgement o f their ability to cope effectively in a given
situation (Bandura 1977). A central construct o f social cognitive theory, it has been found
to strongly predict behaviour change (Ling and Horwath 1999). A simple example o f this
is that a smoker who does not believe they can give up smoking will simply not bother to
try. Clark, Abrams and Niaura (1991) found high self efficacy to be predictive o f change
in numerous studies o f addictive behaviours, in particular problem drinking and tobacco
use. Bernier and Avard (1986) found with obesity that pre and post treatment self
efficacy was significantly related to weight loss in a 6 week follow up. Velicer, Prochaska
(1998 www.uri.edu/researcli/cprc ) found in relation to smoking cessation that self
efficacy monotonically increased across the stages, that is participants in contemplation
scored higher than those in precontemplation, with participants in maintenance scoring
highest. Regarding dietaiy behaviour, Glanz, Patterson and Kristal (1994) found in a
study o f 17, 121 employees in the Working Well Trial that participants in the later stages
i.e action and maintenance had the highest levels o f self efficacy, with participants in
contemplation or preparation showing the lowest. Research by Brug, Hospers and Kok
(1997) and Brug, Glanz and Kok (1997) broadly supported this with participants in the
post action stages again showing higher levels o f self efficacy than participants at pre­
action stages. Oimpuu, Woolcott and Rossi (1999) noted that self efficacy may be useful
as a means o f monitoring and predicting stage transition for eating behaviours. The
particular points where they believed it may be o f benefit being the transition through

21
preparation, action and maintenance. Overall the research evidence shows this to be a
construct which can be successfully matched to distinct stages.

Application of Transtheoretical Model

Undoubtedly the transtheoretical model is an exceptionally detailed model which in

addition to emerging from empirical research contains a strong element o f common sense
rationale in suggesting that the problems confronting and interventions required by
individuals at different points in change vary considerably. The next step therefore is to
examine in detail the strategy recommended by Prochaska and DiClemente (1992) for
applying the model to health behaviour change, in this instance initially to addictions.

Undeniably the most promising concept to emerge from transtheoretical theory is the
matching o f different processes and concepts o f change to the separate stages o f change
(Prochaska and DiClemente 1983). Prochaska, DiClemente and Norcross (1992) using
smokers as an example suggested that one o f the major reasons clients drop out o f therapy
is because the processes suggested are not matched to the stage o f the client. A consistent
problem being that many treatment programmes are orientated towards or take for granted
that a client is either in the action stage or close to it. Also many programmes measure
success as whether or not a client changes behaviour totally, for example if a smoker or
alcoholic achieves abstinence or not. With the transtheoretical model, stage movement
such as moving a client from precontemplation to contemplation itself is regarded as a
major step towards a successful outcome. In addressing the first problem that in reality
many clients do not enter treatment ready for change and open to programmes orientated
to the preparation or action stages, Prochaska et al suggest that to optimise treatment,
processes o f change should be matched to stage o f change in the manner suggested in
table 1.1. With this the cognitive and affective processes are deemed to be more
effective in the pre-action stages and the behavioural processes particularly suited to the
post-action stages. Therefore in the early stages greater insight on the part o f the client
requires development, with the therapy being focused on the client’s maladaptive

22
cognition but when the client moves towards action the initiation o f behaviour therapy for
specific interventions at the symptom situation level is most effective.

Table 1.1: Stages of Change matched to Processes of Change

Precontemplation Contemplation Preparation Action Maintenance

Consciousness raising
Dramatic Relief
Environmental reevaluation
Self Reevaluation
Self Liberation
Reinforcement Management
Helping Relationships
Counterconditioning
Stimulus Control

While the initial research by Prochaslca (1979) concluded 10 processes existed.

Prochaslca et al (1992) in matching the processes to stages did not specify at which point
social liberation is most effective. Bowen et al (1994) in relation to low fat dieting
suggested it might be most salient to individuals in long term maintenance. However in
relation to weight control (Cancer Prevention Centre www.iuf.edu/researcli/cprc) it has been
suggested that it may be most beneficial between contemplation and action, hi a recent
review o f the model Prochaslca (1999) however again did not stipulate at which point
social liberation is effective. Prochaslca focused on the benefit o f matching nine
processes to specific stages. It is unclear therefore as to the role o f social liberation in
relation to the model, but the specific matching o f nine processes provides researchers
with sufficient detail to test the validity o f the model in future research. However, before
focusing on the research for and against this model it is necessary to thoroughly develop

23
the theory regarding the matching o f processes to stage. Therefore a summary o f the
idealised interaction between processes, constructs and stage movement as outlined in the
model now follows.

Precontemplation - Contemplation
hi their research on matching stage to process, Prochaska and DiClemente (1983) found
as expected that pre-contemplators used processes o f change significantly less than any
other group. Obviously if therapists were to use processes associated with movement
from preparation to action on a group o f precontemplators then the results may not be
very rewarding. Factors such as this may explain results such as those found by Schmid,
Jeffrey and Hellerstedt (1989) in which recruitment rates for smoking cessation
programmes were only 1 -5% o f eligible participants, with similar results in weight loss
programmes when less than 12% o f those eligible enrolled. With this model the ideal is
the matching o f stage o f change to the correct processes o f change to enhance the
retention rate and effectiveness o f therapy. Prochaska and DiClemente (1992 p304) noted
that to move a client from precontemplation to the contemplation stage, it may be most
productive to use consciousness raising strategies, that is making the person aware o f the
causes and consequences o f their situation, and the cures which are available to them. In
conjunction with this dramatic relief could be used in which clients are provided with
helpful affective experiences to raise emotions related to problem behaviours. For
example, problem related events such death or serious illness o f a friend or family
member may move precontemplaters emotionally. Also environmental evaluation, in
which the client assesses the impact the behaviour is having on the lifestyle o f family and
friends, is o f value. Initially therefore the goal is to move a client from precontemplation
to contemplation rather than expecting a dramatic leap to the action or maintenance
stages.

Contemplation to Preparation
Once the client moves into the contemplation stage processes such as consciousness
raising, dramatic relief and environmental reevaluation are still o f significant value.

24
Prochaslca and DiClemente (1992) believed that contemplaters in particular benefit from
the effects o f environmental reevaluation. With this they become more aware o f the
damage their behaviour is causing to those close to them. A typical question put to them
may assess their feelings regarding the deteriorating environment they are putting their
family and friends in. It is at this point when the client awareness o f the their problem has
increased that they experience increased freedom to evaluate themselves cognitively and
affectively. Therefore self reevaluation in which the client reassesses their sense o f self in
relation to maintaining or changing their behaviour, that is their worth or value as a
person is emphasised at this point. Increased awareness o f and use o f these processes is
recommended to move them into the preparation stage. Prochaslca and DiClemente
(1992) also noted that at this point a balance must be struck between forcing premature
change and allowing the person to become a chronic contemplator.

Preparation - Action
hi the preparation stage clients have demonstrated a willingness to change in the near
future. As many individuals at this point will have previously relapsed, this is an
important point where they reflect on the mistakes and helpful strategies from past
attempts. DiClemente, Prochaslca, Fairhurst and Velicer,W.F.,( 1991) recommend the
setting up o f an action plan, or taking small steps towards action, such as stimulus
control. An example o f this is people with addictive habits reducing the situations where
they come into contact with or are reminded o f addictive substances. Also during this
stage many people will take the first small steps towards action. Crucially on entering into
action individuals need to develop a sense o f self liberation, that is the belief that they
have the autonomy to change their lives (Prochaslca and DiClemente 1992). It is also
recommended they set up a clear action plan and if necessary focus on the behavioural
processes that will soon be required in action. Overall in the first three stages it is
recommended that cognitive and affective measures are used.

25
Action - Maintenance
The timeframe for action stage is the maintaining o f the health behaviour for 6 months.
Prochaska and DiClemente (1992 p306) point out that when the person moves into the
action stage greater use needs to be made o f behavioural processes such as counter
conditioning, stimulus control and reinforcement management. This can be an
exceptionally stressful time for the client, in which they experience new limits on their
personal freedom. Helping relationships and social support become increasingly
important, as it may be vital in stressful times that there is at least one person who is
freely available to help. With this in mind the therapist may take the role o f a friend and
in this way reduce the stress o f the many changes the client needs to make. The role of
self- help groups is also emphasised at this point.

Maintenance
After six months in action the client moves into maintenance. Prochaska and Norcross
(1999 p503) stress the importance o f preparing the client for maintenance. In maintenance
they recommend that all o f the previous processes be built on. The emphasis however is
still on the behavioural processes, that is stimulus control, helping relationships,
reinforcement management and counterconditioning the same processes as used in the
action stage. It is also important at this point that the client makes a full assessment o f
factors likely to cause relapse. This should involve an open assessment o f the alternatives
they have for coping with problem situations rather than relapsing into their problem
behaviour. A crucial aspect at this point is the instilling in the client o f the sense that they
are developing into a person they are happy to be. For example an ex smoker needs to
derive a greater sense o f self worth from being a non-smoker than being a smoker. Wolfe
(1992) also commented that in order for behavioural processes to be most effective this
greater sense o f self worth should also be shared with one significant other. The pattern
above is an ideal stage transition, however, as previously mentioned health behaviour
change may consist o f several attempts with participants recycling through stages.
DiClemente and Prochaska (1985 p338) commented that this should not be regarded as a

26
completely negative situation. Pointing out that many individuals who relapse move back
to contemplation seriously considering an attempt to alter behaviour again in the future,
hi their two-year study with smokers 27% o f those who relapsed initially were no longer
smoking. While no exact distinction is made between contemplators and preparers who
have relapsed from earlier attempts and those entering contemplation and preparation for
the first time, DiClemente and Prochaska recommended particular attention to the
cognitive measures o f self efficacy and decisional balance to reassure participants who
have relapsed that future attempts can be successful.

In addition to being o f benefit in therapy itself Velicer and Prochaska (1999) suggest that
the transtheoretical model may also greatly increase the numbers participating in and the
effectiveness o f interventions, hi a review o f the literature, Brug, Campbell and Assema
(1999) found three criteria necessary for effective interventions. These were (1) Attention
being givern to motivators and reinforcers which are particularly relevant to people in the
target group, (2) Personalised self evaluation or self assessment techniques, (3)
Participants being given the opportunity to actively participate in the intervention.
Undeniably the most effective method o f intervention which provides all o f these criteria
is face to face counselling. The application o f the transtheoretical model will enable face
to face counselling to be addressed effectively to meet these requirements. Unfortunately
as face to face counselling is expensive and time consuming it may never become
available to large groups o f people. However, an alternative approach which may be o f
benefit is the use o f self help pamphlets as these can be distributed to a large percentage
o f any eligible population.

Prochaska and DiClemente (1992), Velicer, Fava, Prochaska, Abrams and Emmons
(1995) and Velicer and Prochaska (1999) noted that the biggest problem with many
interventions is that they are designed for people ready to quit. However, in reality as
research based on the transtheoretical model points out this is only a small proportion o f
participants. Therefore tailoring information on the basis o f stages o f change may address
the issues raised by Brug et al (1999) and this will enable interventions particularly self-

27
help pamphlets to be tailored to the stage o f the person and in this way increase
participation rates. Research to date shows that tailored interventions may be more
effective in numerous ways. Kreuter, Bull, Clark and Oswald (1999) found that tailored
information tended to be processed more thoughtfully as the person felt it was more
relevant. Brag, Steenliaus, Assema and De Vries (1996) found tailored information was
more likely to be read and remembered, discussed with others, perceived as interesting
and more relevant. Therefore if valid, the transtheoretical model offers the opportunity to
improve not only face to face counselling but also the quality, quantity and effectiveness
o f readily available self-help pamphlets. Velicer and Prochaslca (1999) in a comparison
o f the advantages and effectiveness o f clinic based programmes, home based
programmes, community based interventions and public health policies, noted that while
clinic based interventions such as one to one counselling have the highest success rate
they are very limited in the amount o f people they can reach. However, self-help
pamphlets in particular those designed to reflect an individual’ s stage o f change have the
potential to be available to large groups o f people at low costs which in reality will yield
better results in terms o f health behaviour change.

Research Supporting The Transtheoretical Model

The potential o f the transtheoretical model to dramatically increase adherence to health

behaviours has led to considerable research regarding its validity. A summary o f the
general research regarding the model now follows.

Early research on stages o f change was conducted mainly with smokers (Prochaslca and
DiClemente 1983) and other addictive behaviours (DiClemente and Hughes 1990).
Prochaslca and DiClemente’ s research in a cross sectional study o f 872 smokers changing
their habits on their own found in line with theoiy that different processes were
emphasised at different stages, with precontemplaters using the least amount o f processes.
Those in contemplation focused on consciousness raising with self reevaluation being
used in both contemplation and action. Also in action self liberation, reinforcement

28
management and helping relationships scored highly. Those in maintenance scored highly
on counterconditioning and stimulus control, with these processes also being used highly
in the action stage.

hi a later study Prochaska and DiClemente (1992) found that with 570 smokers assigned
to home based treatment programmes stage o f change was predictive o f successful
treatment, with only 3% o f precontemplaters taking action after six months. However, if
the precontemplaters moved to contemplation by 1 month their chance o f success
doubled. Similar results were found with contemplaters. Research at the Rhode Island
Cancer Research Unit, also found that computer generated interventions based on the
transtheoretical model performed significantly better than the standard manuals o f the
American Lung Association. Therefore if treatment is specific to stage it appears the
chances o f success can double. Medieros and Prochaska (1993) found that stage o f
change was the highest predictor o f drop out from psychotherapy with again
precontemplaters being more likely to drop out. The same study also found that
participants in the action stage at onset were more likely to terminate therapy quickly but
also appropriately. These studies lend support to the model but a key question is whether
the model will generalise across health behaviours.

Perhaps the most dramatic demonstration o f the model across health behaviours is the
research by Prochaska, Velicer, Rossi and Goldstein (1994) with 3,858 participants
demonstrating a range o f problem behaviours. The behaviours studied were smoking
cessation, quitting cocaine, weight management, high fat diets, adolescent delinquent
behaviour, safer sex, condom use, sunscreen use, radon gas exposure, exercise
acquisition, mammography screening and physicians preventive practices with smokers.
Prochaska et al commented that the behaviours covered were both addictive and non
addictive, with some socially acceptable and others not, with some being illegal and
others not. However all o f the behaviours required long term adherence to improved
health behaviour. Prochaska et al (1994) focused on the commonalities with stages of
change and decisional balance across groups. The results partially supported the pattern

29
outlined in the transtheoretical model. With the 12 behaviours the cons were higher than
the pros with precontemplaters. However, in the action stage with 11 behaviours the pros
outweighed the cons. Interestingly with all behaviours the pros were higher for
contemplaters than precontemplaters. However, the point o f crossover between the pros
and cons was not fully consistent. With 8 behaviour's in line with the model this took
place between contemplation and preparation. On the other hand with sunscreen use,
delinquent behaviours, high fat diets and mammography screening crossover did not
occur until action. Disappointingly no research was conducted on the processes o f
change. However Steptoe, Doherty, Rink, Kerry and Kendrick (1999) found brief
behavioural counselling based on the model to be effective in reducing smoking, dietary
fat intake and regular physical activity.

Laforge, Velicer , Richmond and Owen (1999) in further support for the model found
similarities with stage distribution for 5 health behaviours (smoking, low fat diets, regular
exercise, reducing stress and losing weight) in samples in the United States and Australia.
Suris, Carmen Trapp, DiClemente, Cousins. (1998) concluded the model was applicable
to Mexican American women suffering with obesity. Lopez, Gonzalez, Mateos, Kearney
and Gibney (2000) found stage classification to be applicable to nutrition attitudes in
Spanish populations. These studies imply that the model may offer a useful tool for the
classification o f participants and the pattern o f interventions across cultures. However not
all researchers have accepted the validity o f the transtheoretical model in relation to either
addictive or non-addictive behaviours. A brief summary o f their research and
conclusions now follows

Criticism of the Transtheoretical Model

Several researchers most notably Bandura (1997), Sutton (1996, 2000, 2001), Ashworth
(1997) and Whitlaw, Baldwin, Bunton and Flynn (2000) have criticised the concept o f a
stage model and its validity in relation to even addictive behaviours. Bandura (1997)
points out that human function is simply too diverse to fit neatly into discrete sequential

30
stages. Criticising the transtheoretical model directly Bandura claimed that the first two
stages were merely differing degrees o f intention, with the remaining stages simply being
“ Gradations o f regularity or duration o f behavioural adoption rather than differences in
kind” . For example Bandura pointed out someone exercising regularly for less than six
months is suddenly propelled from one stage (action) to another stage (maintenance) once
they continuing exercising for more than six months. Bandura argued this is not a valid
distinction as one is merely a continuation o f the other and therefore not a qualitative
transformation to another point. The concept o f relapse inherent in the transtheoretical
model is also criticised by Bandura. In a hue stage model he argued this is not possible.
For example in nature a butterfly cannot return to being a caterpillar, or in Piaget’ s theory
o f cognitive development a formal operational person cannot revert to a pre-operational
person. Overall Bandura believed that in classifying people on the basis o f those who
have no intention to change, those who have some intention to change and those
maintaining change for varying lengths o f time the theory revealed little not already
known to practitioners. Also as the stage classifications were faulty any interventions
based on them must also be inherently defective or certainly weaker than full
interventions which covered all o f the determinants o f health behaviour.

Sutton (1996) in agreement with Bandura and in an extensive criticism o f the

transtheoretical model, pointed out again that the categorisation o f individuals into
different stages in which it is assumed at certain times individuals cross certain thresholds
and start using different processes is highly artificial. Sutton again agreed with Bandura
that there was no evidence to suggest that a smoker having spent 6 months in the action
stage will suddenly make a qualitative change to the processes used in maintenance.
Sutton suggested that the only time such thresholds might apply is in clinical treatment
programmes when on a given date a relapse prevention programme is introduced.

Sutton (1996) also criticised the early evidence supporting the transtheoretical model. For
instance in the McConnaughy et al (1989) study using the University o f Rhode Island
change assessment questionnaire it was found in support o f the theory that the

31
correlations between adjacent stages were higher than the correlations between non
adjacent stages. Sutton criticised this on 2 points, firstly in the McConnaughy et al (1989)
study correlations were almost as high between non adjacent stages, perhaps showing no
significant differences with the correlations between adjacent stages. Also in later
research Abellanas and McLellan (1993) found high correlations between adjacent stages
and a negative correlation o f -.5 between precontemplaters and contemplaters. Sutton
(2000) again criticised the cross sectional evidence for stages o f change suggesting that
the use o f processes in many studies follows a linear pattern. Meaning they are in fact
pseudo stages and not true stages. Budd and Rollniclc (1996) in a study with 174 heavy
drinkers also found a lack o f discriminative validity between the first 3 stages. Suggesting
that these 3 stages may really be one stage, which indicates a willingness or readiness to
change. Sutton argued that data such as this showing that individuals could have high
scores on 2 stages simultaneously, which in effect indicates that they were at 2 stages
simultaneously, contradicts the entire theoiy o f the model. Sutton (1996) believed it to be
more helpful to think in terms o f states o f change rather than stages in that states carry no
order o f sequencing.

Sutton (1996) also criticised the second major dimension o f the transtheoretical model
that is the matching o f the stage with different processes. Sutton argued that because
different processes are emphasized at different stages this does not mean they may
necessarily be helping the person move between stages. With an individual at the
contemplation stage who was using consciousness raising for perhaps 2 years, it could be
argued that this process was not helping them change. Sutton also criticised the methods
used by Proschaska, Velicer, Guadagnoli., Rossi,. DiClemente, (1991) pointing out that
comparisons were not made between contemplaters who did not progress and those who
did. Concluding that it was only by comparisons such as this that it would be possible to
infer that consciousness raising was truly influential with contemplaters. In addition
Sutton queried the sample sizes in the initial studies in that the precontemplation to
contemplation and contemplation to action groups consisted o f 14 and 17 participants.

32
Sutton also queried whether in fact stage matched interventions were more effective than
standardized interventions. He pointed out that in studies by Prochaska et al (1993) and
Velicer et al (1993), with smokers 110 significant difference emerged between stage
matched treatments and standard treatments. Differences in fact only emerged when
contact was increased with the participants. Therefore any improvement may be more due
to the repeated contact rather than any difference in interventions, hi a later paper Sutton
(2000) in evaluating the current research on the transtheoretical model pointed out that
many o f the studies are cross sectional and therefore not true tests o f a stage model. Also
in studies that compared scores on self efficacy across the first three stages
(precontemplation, contemplation and preparation) the pattern o f scores in several studies
did not follow a discontinuity pattern expected o f a stage model, but in fact followed a
linear pattern more suited to a pseudo - stage model. Overall Sutton describes the theory
as an ideal model which may have some value in designing interventions in treatment and
clinical or highly controlled settings, but it is not a model which describes how people
change particularly outside o f treatment programmes. Ashworth (1997) called for more
studies comparing stage based and non-stage based interventions. Whitelaw et al (2000)
called for increased quality quantitative studies in conjunction with practitioner orientated
qualitative case studies, hi addition they queried whether the current popularity o f the
model based largely its simplicity might lead to the neglect in the study or application of
other interventions
Having covered the general background o f the model as the focus o f this thesis is dietary
behaviour a review o f the research in relation to dietary behaviour now follows.

Application to Dietary Behaviour

As the application o f the transtheoretical model to areas outside o f the addictions has
increased several researchers have examined the validity o f the model in relation to
dietary behaviour. The results o f several o f the core studies are now summarised. Curry,
Kristal and Bowen (1992) found in two samples consisting in total o f 1241 participants in
a cross sectional study that fat intake decreased with progress through stages. Scores for
those in precontemplation and contemplation did not differ significantly but differed

33
significantly from scores in preparation action and maintenance, with scores in these
stages again not differing significantly. Greene, Rossi, Reed, Willey and Prochaslca
(1994) again in a cross sectional study found that fat intake decreased linearly with
progress through the stages however it appeared many in the action and maintenance
stages still consumed above the recommended level o f fat. Steptoe, Wijetunge, Doherty
and Wardle (1996) in a sample o f 366 south London residents again found that total fat
intake tended to decrease with stage progression, with 75.8% o f participants in
maintenance and 70% o f participants in action scoring exceptionally low on fat intake.
Steptoe et al also noted however that many participants in precontemplation also scored
low with fat intake. Therefore problems may arise in some cases with stage classification.

Brag, Hospers and Kolc (1997) again in a cross sectional study with fat intake found again
that while it decreased across stages many in maintenance still consumed above the
recommended level. Greene and Rossi (1998) in a longitudinal study with 296
participants over 18 months found that interventions targeted to stage had the potential to
accelerate fat intake reduction but not always to less than 30% o f dietary intake.
McDonnell Roberts and Lee (1998) with a cross sectional sample found that dietary fat
intake differed significantly between those in maintenance and all other stages. Simmons
and Mesui (1999) in a sample o f 105 Pacific islanders found that those in the
maintenance and action stages rated the advantages o f a low fat diet as greater than the
disadvantages with the reverse true for those in the pre-action stages. Nitzlce, Auld and
McNulty (1999) found that dieticians were more likely to be in the action or maintenance
stages for fat intake.

In addition to fat intake, Campbell, DeVillis and Strecher (1994) researched the intake o f
fruit and vegetables in relation to the model. Glanz, Patterson, Rristal and DiClemente
(1994) found fibre intake to increase in the post action stages this again a cross sectional
study. With the more general concept o f healthy eating Graff, Gaag, ICaftos (1997)
concluded that the stages in the transtheoretical model made a useful distinction between
people with different attitudes to diet and as such could be o f benefit to nutrition

34
education. It is worth noting that the vast majority of these studies were cross sectional
with only one Greene and Rossi (1998) completing an 18-month follow up. Some support
for the transtheoretical model was demonstrated, overall in all studies with it being found
that fat consumption reduced with stage progression.

With regard to the constructs associated with the transtheoretical model Steptoe et al
(1996), McDonnell et al (1998) and Simmons and Mesui (1999) found in relation to low
fat dieting that decisional balance broadly followed that outlined in the model with the
pros increasing and cons decreasing with stage progression. Brng Hospers and IColc
(1997) found social support in line with the model to score highly in action, with self
efficacy being low in preparation and contemplation. Implying that these are points in
which interventions focused on self efficacy may benefit future change. To date regarding
the application o f the model to dietary behaviour is inconclusive and is perhaps best
summed up by Steptoe et al (1996) who concluded that support for the model is at best
moderate. At this point it is o f interest to focus on some o f the unique problems
associated with applying the transtheoretical model to dietary change.

Firstly dietaiy behaviour unlike smoking is non-addictive, therefore in applying the model
considerable methodological and conceptual problems arise. Whereas addictive
behaviours require elimination, Glanz et al (1994) point out that dietaiy behaviour merely
requires modification, it is not for example advisable for participants to eliminate fat
intake completely. Sternberg (1985) commented that the concept o f controlled food use
is difficult to define as no clear demarcation exists between the controlled and
uncontrolled use o f food. As a consequence o f these, it is unclear how to properly
measure a change o f behaviour. Brug et al (1997) observed that many participants in the
action and maintenance stages though having lower fat intake were still above the
recommended levels. This may be a crucial factor as Brng, Van Assema, IColc, Lenderinlc
and Glanz (1994) noted that individuals who rate their fat intake as high are more likely
to reduce consumption. Therefore it appears likely that individuals who in reality need to
change dietaiy behaviour further may in fact classify themselves in post action stages.

35
Brag et al (1994) found that up to 55% o f participants who assessed their fat intake as
low, that is below 35% o f total intake, were unrealistic in their assessment, with the
majority underestimating badly. Therefore while such individuals may rate themselves as
maintaining a low fat diet, in reality it could be argued that they are precontemplaters who
are unaware o f their problem. However, arguing against this approach Rristal and Glanz
(1999) suggested that many individuals will make clinically important change, which if
stage classification were based simply on strict dietary criteria would be lost. For example
if a participant in a dietaiy trial reduced their fat intake from 40% to 32% and maintained
this for a year, could it be properly argued that this person was still in precontemplation
because they had not reached a strict 30% fat intake criterion. Kristal and Glanz believed
a strict dietaiy nutrient classification might mean an intervention which brought about
considerable improvements being disregarded simply because it did not reach a
mandatory cut off point. Mhurchu, Margetts and Speller (1997 p i4) in discussing this
point queried whether the model itself might be comprehensive enough to completely
encompass dietary change. The transtheoretical model is in theoiy a sequential model
meaning that once an individual has progressed beyond one stage they cannot be
simultaneously at another stage. That is they should not have made change and at the
same time be contemplating further change, this would imply they were in maintenance
and contemplation at the same time. Again this is impossible with addictive behaviours
like smoking where clearly someone who is abstaining from smoking cannot be thinking
o f abstaining further.

Jeffery and French (1999) in a study o f weight change with 228 women over 3 years
found that stage o f change did not predict success in weight control, hi fact while the
results were not significant they were the opposite o f that predicted with participants in
action initially actually gaining more weight over three years than participants initially in
precontemplation. There was however limited support for the model with participants in
contemplation recording more weight loss than those in precontemplation. Significantly
this is one o f the few longitudinal studies conducted in relation to dietaiy change. Jeffery
and French believed this called into question the generality o f the stages classifications

36
across behaviours. They pointed out that with addictive behaviour abstinence for more
than 6 months is an indicator o f success with the person less likely to relapse. Smoking
for example is a difficult and stressful process in the short term, which becomes easier
over time. Therefore the concentrated use o f processes in the short term may be predictive
of success. However, with weight control a need exists for a complex use o f processes
over the long term. Therefore after six months process use decreases in addictions, but
this is the point where in fact weight loss is more difficult to maintain and the individual
is in fact more likely to relapse perhaps necessitating increased process use.

Povey, Conner, James and Shepherd (1999) also criticised the time scales used as cut off
points to categorise stages, e.g. the 6 months used to define movement from action to
maintenance. They argued that the classification o f people into different stages purely on
the basis o f time scales is contrary to one o f the main conditions for stage models that
people at different points are qualitatively distinct, suggesting that dietary behaviour
consists o f a series o f changes rather than set changes. They called for more longitudinal
studies which included the comparison o f stage matched interventions with unmatched
interventions in order to test the validity o f the model further. However, it is concluded
that even when this takes place many o f the questions related to applying the model to a
complex behaviour such as dietary change will still be unanswered.

Horwath (1999) in a review o f the literature o f the application o f the model to dietary
change found that overall 30 cross sectional studies and four longitudinal studies had
been conducted to date. Horwath however pointed out that veiy few studies focused on
the totality o f the model and instead focused on single constructs such as the stages o f
change and their association with nutrient or food group intake. While it is undoubtedly
o f interest that certain stages indicate dietary habits this does not demonstrate the validity
o f the model as a whole. In fact o f the 30 cross sectional studies 11 focused solely on
stage, five on stages and decisional balance, five on stages and self efficacy, five on
stages and processes, two on stages self efficacy and processes and two on stages self
efficacy and decisional balance. With only study Horwath and Gulliver (1998) examining

37
all o f the concepts stages, processes, self efficacy and decisional balance contained within
the model. The four longitudinal studies focused on the relationship o f stage to either fat
intake fruit and vegetable intake 01* fibre intake. Horwath argued that this paucity o f
research 011 the model as a whole and in particular on the processes o f change is a major
failing on research related to the model in relation to dietaiy behaviour. Additional
criticisms are the lack o f proper longitudinal studies containing comparisons between
stage matched and general interventions. Horwath (1999) in addition commented that it
could not yet be stated with certainty that dietaiy behaviour followed a stage process.
Horwath believed, however, that the potential o f a model such as this to target large
groups o f people and perhaps greatly improve participation in studies means that further
investigation is merited.

Overall with dietaiy behaviour it appears the transtheoretical model if applicable will
require modification and that further research including longitudinal studies and
comparisons between stage matched and general interventions is necessary to establish
how extensive that modification needs to be.

Summary
The transtheoretical model was developed originally in the treatment o f addictions
(Prochaska and DiClemente 1992) but since then it has been applied to many fields
including exercise adoption (Lee 1993), HIV prevention (Prochaska, Redding, Harlow,
Rossi and Velicer 1994) and dietary change ( Povey and Conner 1999). Research appears
to support its validity in many fields. Prochaska et al (1994) found evidence supporting its
application across 12 problem behaviours. Researchers such as Sutton (1996) and
Bandura (1997) have criticised the model overall for being too artificial, and too ideal a
concept o f how people change. Without doubt the model needs further examination and
development and this applies particularly in the areas other than addictions. Certainly
with dietary behaviour where it is not 100% clear when behaviour changes and where the
individual’ s perceptions are often inaccurate the model faces significant problems.
However, the possible significant advantages o f tailored information and fitting processes

38
to stage means the model should not be dismissed as the potential benefits are
considerable.

The next step therefore is an examination o f the steps necessary to test the validity o f the
model in relation to dietaiy change. With this in mind the first step in this research will
be an exploratory cross sectional study. This will focus on dietaiy fat intake and how the
concepts o f stage o f change, processes o f change, self efficacy and decisional balance
interact with stage o f change and level o f fat intake. The purpose o f this exploratory study
is to establish a basis on which to research the transtheoretical model further in a more
extensive longitudinal study. However before embarking on this study a brief summary o f
the overall research aims and contents o f this thesis follows

Research Aims
(A) As stated in the introduction there is a pressing need for greater understanding o f the
factors surrounding dietaiy behaviour. Despite the destructive consequences to health
and the cost to the nation in lost productivity maladaptive dietaiy behaviour, such as
high fat intake is veiy resistant to change. Therefore a central aim o f this thesis is
gather information on the processes used by successful changers and to gain an
insight into the factors which prevent the initiation and maintaining o f dietary change.

(B) Linking in with this is the requirement for research on the infonnation necessary to
design effective interventions. In particular the content o f widely available cost
effective self help brochures, which crucially because o f their availability have the
potential to influence a substantial group o f people and in so doing perhaps have the
potential to outperform more time consuming interventions such as one to one
counselling. A comparison will be made o f the effectiveness o f a standard
intervention and a stage matched intervention.

fC) The current debate in psychology regarding the nature o f health behaviour change
and whether this follows a continuum or stage pattern model o f change needs further

39
 investigation. Therefore a cross sectional and longitudinal investigation o f the
processes and concepts associated with dietary change will be conducted. This will
focus thoroughly on the processes and concepts o f change associated with the
transtheoretical model with the aim o f testing the validity o f this model in relation to
dietary fat intake in addition to the pattern o f low fat behaviour change over time.

(D) This thesis also provides the opportunity to assess the usefulness o f the
transtheoretical model in a sample o f suffering a specific health problem in this
instance type two diabetes which necessitates dietary change as part o f it’s successful
treatment. The successfirl strategies adopted by this group and their assessment of
dietary interventions will hopefully provide insights into dietary behaviour change,
which are transferable to other populations.

(E) The measurement o f dietary behaviour and the processes associated with dietary
behaviour are areas constantly developing and requiring research, hi assessing the
issues involved with dietary change and in assessing dietary fat intake an aim o f this
thesis is the development o f items and questionnaires, which will contribute to future
accurate measurement o f these concepts.

(F) A final aim o f this thesis is in addition to advancing the knowledge concerning
dietary behaviour change is produce new questions regarding the nature o f dietary
and health behaviour change, in particular issues regarding the staged or continuum
nature o f change which can be tackled by future researchers.

Contents of Thesis
The present chapter has introduced the background information regarding the benefits o f
dietaiy behaviour change and the research to date supporting the transtheoretical and
other stage models and the views o f those researchers opposing the concept o f a staged
approach to health behaviour change. The unanswered questions arising from both these
viewpoints and the question mark over the validity o f a model developed with addictive

40
behaviours being applied unaltered to a range o f health behaviours demonstrated the need
for further research.

Chapter two covers a quantitative exploratory study at the University o f Surrey, testing
the processes and concepts associated with the transtheoretical model in a sample o f staff
and psychology students. The study examines the relationship between stages o f change,
the processes o f change, self efficacy, decisional balance and a short low fat behaviour
questionnaire. The purpose o f this study being to gain an initial insight into the
psychological processes and concepts associated with dietaiy change and from this to
form a basis to conduct more detailed research, hi addition to analysis on the basis o f
stages o f change comparisons are also made using classifications o f medium low and high
fat intake based on the results o f the low fat behaviour questionnaire.

hi chapter three a qualitative investigation builds on the data from the quantitative study.
The study contains 20 semi-structured interviews conducted with staff and students at the
University o f Surrey. Qualitative interviews give a more detailed insight into dietaiy
behaviour change providing additional material for the revised questionnaires to be used
in the main studies.

Chapter four consists o f analysis o f the results o f a cross sectional study with clients with
type two diabetes at a west London hospital followed by a detailed discussion. Analysis
o f results was conducted on the basis o f stages o f change and again on the basis o f level
of low fat behaviours. A pattern similar to the exploratory study at the University o f
Surrey emerges with process use increasing linearly as low fat behaviours increase.
However more differences are found between stages with process use. Similarities and
differences emerging with the pattern o f process use outlined in the transtheoretical
model are discussed.

Chapter five details the results o f a 6 months longitudinal study with type two diabetics at
Hammersmith hospital and the reactions o f clients to stage matched and general self-help

41
pamphlets. Analysis is conducted within and between subjects. A picture emerges of
specific cognitive and behavioural processes being significant in the pattern o f dietaiy
change. Interventions based on stages o f change were not found to be more effective than
general interventions.

Chapter six gives a detailed discussion o f the research findings and an integration o f the
conclusions from all the studies. Implications for the application o f the transtheoretical
model to dietaiy behaviour arising form this thesis are outlined and the direction for
future research in relation to the model and dietaiy behaviour in general are discussed.

42
Chapter 2

An exploratory study of the transtheoretical model and its application

to dietary fat intake

Introduction
This aim o f this exploratory study is to conduct a preliminary investigation o f the issues
arising from research regarding the transtheoretical model and dietary behaviour, in this
instance dietary fat intake. However, the first step is to discuss briefly the methods used
in the past to investigate the transtheoretical model and dietary change.

As mentioned in the literature review Hoiwath (1999) in a review o f the research

regarding the application o f the model to dietary behaviour, found that 30 cross sectional
studies and four longitudinal studies had been conducted to date. However, only one
study Hoiwath and Gulliver (1998) examined all o f the concepts related to the
transtheoretical model that is stages o f change, processes o f chagne, self efficacy and
decisional balance. O f the remainder some focused solely on stage o f change, or on
stages and perhaps one or two concepts, for example self efficacy and decisional balance.

Hoiwath commented that while many o f these studies undoubtedly raised interesting
points for example that certain stages indicate differing dietary habits, or that decisional
balance pros increase with stage progression they have not demonstrated the validity o f
the model as a whole. Horwath argued that this lack o f research on the entirety o f the
model is a major failing in research related to the model. An additional criticism made by
Sutton 1996 regarding the transtheoretical model in general is the lack o f proper
longitudinal studies and the overabundance o f cross sectional studies. Sutton argued to
support the model it is necessary to demonstrate as outlined in the model that someone in
precontemplation or contemplation actually uses consciousness raising to move foiward.
There are also veiy few studies with comparisons between stage matched and general
interventions.

43
The first step in this thesis is to establish the means to address these problems. That is to
design questionnaires focusing on all these aspects suitable for a longitudinal study. This
will be done by firstly conducting an exploratory cross sectional study examining the four
central constructs o f the transtheoretical model discussed in the previous chapter. These
are stages o f change, processes o f change, self efficacy and decisional balance. The study
will test the following hypotheses:

Hypotheses
1: It is predicted that low fat behaviours will differ significantly between the stages. It is
expected that differences between the pre action stages (precontemplation, contemplation
and preparation) will not be significant but differences between pre and post action
(action and maintenance) will be.

2: Regarding decisional balance, it is predicted that significant differences will be found

between the perceived benefits and perceived obstacles between the stages. Research to
date shows that in the early stages the cons or obstacles score higher than the benefits or
pros in the precontemplation and contemplation stages with a cross over occuning in
preparation with the benefits scoring higher in action and maintenance.

3: Process use will mirror that outlined in the transtheoretical model. That is cognitive
and affective processes will be emphasised in the pre action stages and behavioural
processes emphasised in the post action stages.

4: Self efficacy will show significant differences between the stages. In particular it is
expected that self-efficacy will be lower in the pre than post action stages.

This exploratory study will examine these issues using a simple staging algorithm
containing 5 possible responses to a question regarding fat intake, a decisional balance
questionnaire consisting o f 20 items, a process o f change questionnaire consisting o f 42
items and a self efficacy questionnaire containing 20 items. The following section

44
consists o f an outline o f the study with a description o f the rationale and construction o f
the questionnaires and items used.
Method
Sample:
The sample consisted o f 133 students and staff at the University o f Surrey, with the
sample o f students including undergraduate, postgraduate and research students.
Procedure:
Participants were approached in lectures and asked if they were willing to complete a
questionnaire examining attitudes to dietary behaviour. Several staff were approached in
the psychology staff room and asked if they were willing to participate.
Materials
One questionnaire was used consisting o f 6 sections, constructed as follows.

Section one
This section focused on demographics. Participants gave details o f their age, sex,
education level and either their occupation 01* if they were under 24 their parent’ s
occupation. Copy in appendix one.

Section two
This consisted o f the staging algorithm developed at the Cancer Prevention Research
Centre Rhode Island and used by Greene and Rossi (1998). This contained one question
“Do you consistently avoid eating high fat foods” . Participants had the option o f one of
five replies and were allocated to a particular stage on the basis o f their reply. For
example, a participant who responded “Yes I have been for more than 6 months” would
be allocated to the maintenance group. Copy in appendix one.

Section three
This consisted o f a brief food behaviour questionnaire consisting o f seven items selected
from a 12 item scale developed by Bowen et al (1994). With item number 5 the American
term broil was replaced with its English equivalent grill. Responses were measured on a

45
1-5 Likert scale. Sample item “I buy low fat foods to follow a low fat eating plan” . Full
copy in appendix one.

Section four
This section was adapted from the “Decisional Balance” questionnaire for weight loss
developed by O’ Connell and Velicer (1988). Throughout the questionnaire the term
“Losing Weight” was replaced with the term “ low fat diet” . The questionnaire consisted
o f 20 items rated on a 1-5 Likert scale. Ten questions focused on the benefits o f a low fat
diet and ten questions focused on the problems with a low fat diet. Sample item benefits
“My self respect would be higher on a low fat diet” . Sample item problems “ Going on a
low fat diet would be hard work” (Full copy in appendix one).

Section five
The fifth section examined the processes o f change. It contained 42 items again rated on a
1-5 Likert scale. The questionnaire consisted o f items drawn from 2 questionnaires: the
“Processes o f Change” for weight loss questionnaire o f the university o f Rhode Island
Cancer Prevention Research Centre (Greene and Rossi 1998) and “Processes o f Change”
questionnaire from Bowen et al (1994).
Items 1-5 focused on consciousness raising and were taken from Bowen et al (1994).
Sample item “ I pay close attention to television programmes about low fat diets” .
Items 6-10 focused on social support and helping relationships. Items 6, 7, 8 and 10 were
taken from Bowen et al (1994) and item 9 was taken from the Cancer Research Centre
Scale. Sample item “I have someone in my life who cares about my diet” .
Items 11-15 focused on dramatic relief. Items 11 and 12 were taken from Bowen et al
(1994) and items 13-15 from the Cancer Prevention Research Centre scale. Sample item
“I react emotionally to health warnings about high fat foods” .
Items 16-20 focused on environmental reevaluation and were taken from Bowen et al
(1994). Sample item “I think about the need for more people to understand the
importance o f a low fat diet” .

46
Items 21 -25 examined self reevaluation. All items were taken from Bowen et al (1994).
Sample item “Choosing low fat foods gives me a feeling o f control” .
Items 26 -30 focused on reinforcement management. Items 27 and 29 were taken from
Bowen et al (1994) and items 26, 28 and 30 from Cancer Research Centre Scale. Sample
item “I am rewarded by others when I keep to low fat foods” .
Items 31-34 focused on self liberation. All items were taken from Cancer Research
Centre Scale. Sample item “I make commitments to eat low fat foods” .
Items 35-38 focused on counter conditioning. Item 35 was taken from Bowen et al
(1994). Items 36-38 were taken from Cancer Research Centre Scale. Sample item
“Instead o f eating high fat foods I engage in physical activity” .
Items 39-42 focused on stimulus control. All items taken from Cancer Research Centre
Scale. Sample item “I remove things from my home that remind me o f eating high fat
foods” (Copy o f complete questionnaire in appendix one).

Section six
Section six examined self efficacy in relation to the 5 primary factors for weight control
identified by Clark and Abrams (1991). It consist o f 20 items, for each item participants
rated their confidence for avoiding high fat foods on a scale from 1-9. The questionnaire
was adapted from the Clark and Abrams (1991) “ Self Efficacy in Weight Management
Scale” . Items 1, 6, 11 and 16 measured negative emotions, items 2, 7, 12 and 17
measured availability, items 3, 8, 13 and 18 measured social pressure, items 4, 9, 14 and
19 physical discomfort and items 5, 10, 15 and 20 positive activities. The phrase “ eating
high fat foods” was introduced into each item. Sample items “I can resist eating high fat
foods when I am at a party” and “I can resist eating high fat foods even when I have to say
no to others” (Full copy in Appendix one).

Prior to data analysis an examination o f the factor structure o f the questionnaires and their
reliability is necessary. The results o f this analysis are as follows.

47
Data reduction and scale reliability
The validity and reliability o f questionnaires were assessed using a principal component
analysis o f the processes, self efficacy and decisional balance scales and an alpha
reliability analysis o f the subscales. Firstly with the processes o f change questionnaire a
principal component analysis using direct oblimin rotation converged in 38 rotations
giving 9 factors with eigen values greater than one which in total explained 71% o f the
variance (copy in appendix one). The factors loaded broadly in line with the structure of
the questionnaire. Items 1-5 consciousness raising with the exception o f item 2 loaded on
a single factor (<a=.79). Items 6-10 social support again loaded on a single factor (#=.80).
Items 11-15 dramatic relief loaded on a single factor ( a =.87). Items 16-20 environmental
reevaluation loaded on a single factor with the exception o f item 20 (a=.72). Items 21-25
self reevaluation loaded on a single factor (a =.90). Items 26-30 reinforcement
management however did not load as a single factor, 3 items loaded with social support
and 2 with counter conditioning. However, alpha reliability equaled .84. Items 31-34 self
liberation with the exception o f item 34 loaded as single factor (a = .84). Items 35-38
counter conditioning loaded as single factor (a = .76) Items 39-42 stimulus control loaded
as single factor (a=.89).

With decisional balance principal components analysis giving 2 factors converged in 6

iterations explaining 50% o f variance (copy in appendix one). The pro items numbers 2,
4, 6, 8, 10,12, 14, 16, 18, 20 loaded on to a single factor (#=88). The con items numbers
1, 3, 5, 7, 9, 11,13, 15, 17, 19 loaded a single factor with the exception o f item 17
which although it scored above .3 on the pros scored higher on the con scale and therefore
is included in the con scale (#=.86). Self efficacy consisted o f a unitary factor a= .93.

The results o f data reduction broadly supported the structure o f the scale as outlined in the
literature discussed. Therefore analysis was conducted on the results on the basis
outlined in the questionnaire.

48
Results

Of the 150 questionnaires distributed 133 were returned. Participants had a mean age o f
25, minimum age 18, maximum age 54. 106 were females and 22 were males with 5
participants failing to complete this item. 56 o f the participants were educated to A level
standard, 18 to O level standard, 40 to degree level and 15 to MSc level, with 4
participants failing to answer this item. With stage 45 participants or 34% were in
precontemplation, 17 or 13% were in contemplation, 8 or 6% were in preparation, 15 or
11% were in action and 48 or 36% were in maintenance all respondents answered this
item. Distribution for stages summarized in figure 2.1.

Figure 2.1: Bar chart showing Stage Distribution

60 -

50 J

40 -
w
| 30-
H
20 -

10 -

0-
Precon Con Prepare Action Mainten
Stages

Precon = Precontemplation Con = Contemplation Prepare = Preparation, Action = Action Mainten =

Maintenance

49
Differences between the five stages in terms o f processes, decisional balance pros and
cons , self efficacy and low fat behaviours were analysed using one way anovas. hi each
case Levenes test for equality o f variance was used to test for o f applying anova tests, hi
all cases except for stimulus control the data were suitable for analysis by anova tests. For
the analysis o f stimulus control a Kruskal Wallace test was used. These results are shown
in table 2.2 and figures 2.2 and 2.3.

Low fat behaviours

The scores on the 7 items measuring low fat behaviours were combined to give an overall
score for each individual (range o f 7-35 for overall score). As expected precontemplaters
scored lowest they were followed by preparation, then contemplaters followed
maintainers and lastly by action. Significant results were found for the interaction
between stage and fat intake, F(4) = 21.04, p< .001. However the Scheffe post hoc tests
found significant differences only between the precontemplaters and contemplaters
(p<.01), precontemplaters and action group (p<.01) and precontemplaters and maintainers
(pc.Ol), differences between precontemplaters and preparers were not significant, nor
were there any significant differences between any other groups. Results summarised in
table 2.1.

50
Table 2.1: Mean scores for transtheoretical processes and concepts for each stage

Process Precontemplation Contemplation Preparation Action Maintenance F value

*

in
77

cb
.—i
Consciousness raising 14.0(4. l)b 13.3 (3.25) 13.9(4.2) 13.4(3.7)
OS
CO
CO

Dramatic relief 9.3(3.1) 11.9(4.6) 10.3(4.0) 12.1(4.6) 11.1(4.5) 2.09

Environmental reevaluation 11.3(3.6) 12.8(4.8) 10.6(3.5) 12.9(3.3) 12.5(3.8) 1.22

ot

O
sic# LL L

77

CO
Self reevaluation 15.6(5.8)” 15.2(5.7) 17.0(3.8)” 14.0(5.4)”
*
*

£>
T

oo
VO

T—(
oo'

vq"
Self liberation 12.0(3.0) 14.9(2.6)” 11.8(3.9)”

i—*
CO
r—
““<
K

43

a
*
#

43

l>
CO ooo

3 ,
S '

x—t
vq

Reinforcement management 10.1(3.3) 11.4(3.0)

(
—(

CO r—H
7p
T—<
CO

CO CO
OO
T—

"St
o'
I
Social support 13.78(5.5) 11.8(3.3) 14.87(5.6) 12.7(4.5) 2.26

r—<
*

s
c7
'sf
in

cb
9.5(3.1)

'— '
7.1(2.9)

77
Counter conditioning

77
CO

CO S
S
CO N

cb
CO cb

CO cb
CO i—H

02

x—I
Stimulus control 5.2(1.9)a 6.4(3.2) 13.18 (Chi)**
77
S ' CO

PT
*
*
q

Low fat behaviours 14.7(4.6) 21.0(4.3) 18.7(6.0) 24.0(4.5) 23.0(4.9)

t-H

d
S
43

s
CO s

o
43
S
-*
oo

cy
in
in

cb
27.6(7.3)

O)
Decisional balance pros
77
CO

CO
CO
CO

CO
43^
OO

(4
*
’

cb
ON
■K

Decisional balance cons 29.3(5.5) 33.0(6.4) 25.7(9.0) 25.5(7.7)b

CO
*
*

SXJ
ca

co CO r—
CO
in

cb x—I VO
in

-t
cb
cq

cn
+}-
i

Self efficacy 114.0(27.0) 82.7(31.4)b 119.13(28.4)

77 CO c7
t—<
—

77 CO
OO o o CO
r*H

---N
P<.05; **P<.01; Standard Deviation in brackets. Means with same superscript do not differ at p<.05.
 Figure 2.2: Mean scores transtheoretical processes for each stage of change

_1
a

r
ci
A
i

0 J O O S UB01A1
dduimwoiwdM
C C D i t t l K j S c o O O

C O C O r t C M O C O C O r t C M O
r

<

o
o
C L
c
c

c
c
c

0-
o

0
0
.2

05
0

oi—

Q_
'cc

0
0

€0
O)

I
I

O
o

k
ci
Pi
it

3
Pi
o

a
(D
Pi
o

Q
Pi
is

U
w

U
>
<L>
rCO
%

e4
_o

m
Pi
H

C
.B
00

M
J3

c3
00
00
rS

t/i

3
P4

C4

a>

ti£
pT

a->
<u
y-A
1(U

pf
pr

Management, S.S. = Social Support, C.C. = Consciousness Raising, S.C. = Stimulus Control
Precon = Precontemplation, Con = Contemplation, Prepare = Preparation, Action = Action, Mainten = Maintenance
 = Maintenance
Q>
D)

Mainten
C
ro
o c
CD
'+-j

Action,
<D C
D) O
ro CD ro
w o
JZ M
Mm
m
o W
ro

-
ro Mm
Id
c 0Q

Action
y> o
CL o 8
a> < O
o

= Preparation,
c M
Mmm
o P
o
w f
ro 0 (D
o SP
+C3D
L- S 05
o
0 0 iS >
sz ro
00
■4->
w CL OT •H

Prepare
c P
ro <d
o
§
c 'ro
o
= Contemplation,

pq
O a
o
o
<D
co c P
<N o
0
l. o fl
3 0 o
D> O
UU
Con

M3
<D
= Precontemplation,

s
PQ
<D
O

e.ioo$ uee|/\|
I
PQ
13
a
o
o<D
P
Precon

O
1M
Ph
Decisional Balance

Following the recommendations for the decisional balance questionnaire (O’ Connell and
Velicer 1988) all pro or benefit items were combined to give an overall pros score and all
con or negative items were combined to give an overall cons score (range o f 10-50 for
each concept). With the pro items precontemplaters again scored lowest, followed by
maintainers, then participants in action followed by contemplaters, with the highest score
in the preparation group. Results o f a one way analysis o f variance showed a significant
effect for stage F(4) = 7.38, p< .001. Scheffe post hoc tests found significant differences
between the precontemplaters and contemplaters (p<.01), precontemplaters and
preparation (p<.01) and preparation and action (p<.05) . There was no significant
difference between the precontemplaters and the maintenance group, or between the other
groups. With the cons or disadvantages, the preparation group scored highest, followed
by precontemplaters then contemplaters followed by participants in action and then
maintenance with a mean o f 25.6. A one way analysis o f variance gave a result o f F(4)
=3.92,p<.01 showing a significant difference in cons between stages. Scheffe post hoc
tests found a significant difference only between precontemplaters and maintainers (p.
<.01).

hi a comparison between the pros and cons paired sample t test found significant
differences with precontemplaters t(44) = -6.51,p<.01, with the cons scoring significantly
higher than the pros. Differences with the action group also approached significance
t(14) = 1.87, p=08 in this instance the pros scored higher than the cons.

Processes of change

The measures for consciousness raising, social support, dramatic relief, environmental
reevaluation, self reevaluation and reinforcement management consisted o f 5 items on a
1-5 Likert scale. These were combined to give a range o f scores for each process o f 5-25.
The measures for self liberation, counter conditioning, and stimulus control consisted o f

54
four items again on a 1-5 Likert scale. These were combined to give a range o f scores for
each process o f 4-20. As Levenes test for equality o f variance was insignificant for all
processes with the exception o f stimulus control a one way analysis o f variance was
conducted all processes with the exception o f stimulus control where a Krusal Wallace
test o f variance was conducted. Results are previously summarised in table 2.1 and figure
2 .2 .

One way anovas were conducted and significant differences found between the stages
with consciousness raising, self reevaluation, self liberation, reinforcement management,
counter conditioning, and stimulus control. Scheffe post hoc tests were conducted to
locate significant differences between groups. With consciousness raising the test was not
sufficiently sensitive to locate differences however the greatest difference was between
precontemplation and contemplation and this difference was confirmed as significant in
an independent t test t(59) =-2.24,p<.05. With self reevaluation Scheffe post hoc tests
found significant differences between precontemplation and contemplation (p =.01),
precontemplation and action (p<.01) and precontemplation and maintenance (p =.01) .
With reinforcement management Scheffe post hoc tests found significant differences
between precontemplation and contemplation (p =.05), precontemplation and
maintenance (p <.01), with the differences between precontemplation and action close to
significance (p =.09). With self liberation Scheffe post hoc tests found significant
differences between precontemplation and contemplation (p<.05), precontemplation and
action (p<.01) and precontemplation and maintenance (p<.01), the differences between
action and maintenance approached significance (p = .08). With stimulus control as a
Kruskal Wallace test o f significance was conducted this test does not specify at which
point significant differences emerge but the greatest differences were between
precontemplation and contemplation. Overall therefore significant differences emerged
only between precontemplation and later stages.

55

/
Global Self Efficacy
To obtain a global self efficacy score, all items were combined (Range 9-180).
Maintainers scored highest followed by participants in action, surprisingly
precontemplaters were next then contemplation with the lowest score in preparation. One
way analysis o f variance found significant differences in global self efficacy between the
stages. Scheffe post hoc tests found significant differences between preparation and
precontemplation (p = .05) and preparation and maintenance (p<.01), scores between
preparation and action close to significance (p = .08). Results summarised in table 2.1.

Self Efficacy Subscales

All efficacy subscales consisted o f a combination o f 4 items (Range 9-36). Levenes test
o f equality o f variance proved insignificant for all subscales, meaning the data was
suitable for analysis o f variance tests. Results are summarised in table 2.2.
One way analysis o f variance found significant differences between stages for all self
efficacy subscales. Scheffe post hoc tests found significant differences between
preparation and maintenance for available efficacy (p<.01), social efficacy (p =.01),
physical efficacy (p =.01) and positive efficacy (p<.01) with emotional efficacy Scheffe
post hoc test close to significance (P = .06). With available efficacy differences between
preparation and precontemplation were also close to significance (p=.07). With positive
activities efficacy Scheffe post hoc test found significant differences between preparation
and precontemplation (p =.01), preparation and contemplation (p =.01) and preparation
and action (p =.01).

56
Table 2.2: Mean scores self efficacy subscales for each stage of change
Subscale Precon Con • Prepare Action Mainten F ratio
Emotion 20.55(8.5) 19.81(8.1) 13.50(7.8) 21.00(8.7) 22.92(7.5) 2.50*
Available 22.47(7.6) 20.94(6.4) 16.63(7.2)a 23.40(5.9) 26.50(5.3)b 5.67**
Social 23.70(7.9) 20.63(6.8) 16.38(8.l)a 22.20(7.1) 25.96(5.9)b 4.30**
Physical 23.60(6.8) 25.56(4.2) 18.38(7.4)a 24.93(7.0) 27.04(5.7)b 4.08**
Positive 25.93(6.7)*’ 27.13(6.0)*’ 17.88(6.6)a 27.60(4.4)b 28.98(5.3)b 6.24**

* p<.05, ** p<.01 Means with the same superscripts do not differ at p<05
Precon = Precontemplation, Con = Contemplation, Prepare = Preparation, Mainten = Maintenance.
Emotion = Emotional Efficacy, Available = Available Efficacy, Social = Social Efficacy, Physical =
Physical Efficacy, Positive = Positive Efficacy.

Discussion

O f the four initial hypotheses none was fully supported. With hypothesis one regarding
low fat behaviours this was expected to increase with stage progression. While this was
supported to a degree the increase however was not linear or as expected with the
transtheoretical model. To be in line with the model low fat behaviours are expected to
significantly increase only after the preparation stage, with no significant differences
between the three pre action stages. In this sample, after a significant increase from
precontemplation to contemplation, low fat behaviours decreased again in preparation
before increasing again in action and maintenance. To be fully in line with the model
significant differences are expected to occur also between action and maintenance on the
one hand with contemplation and preparation on the other. It is impossible to say from
this sample why this may be but there are two possible explanations. Firstly this may be
an artifact o f the measure, which only contained seven items and therefore may not have
been sensitive enough to detect changes. Assema, Brag and Brants (1992) and
McDonnell, Roberts and Lee (1998) measured dietary behaviour with questionnaires
containing 25-20 items. This number o f items may be required to accurately assess a

57
participant’ s dietary fat intake. A second explanation may be that with a dietaiy behaviour
unlike an addictive behaviour, which is an all or nothing phenomenon, individuals may
commence behaviour change in the early intentional pre action stages with the behaviour
being fully adopted in the post action stages. Clearly this is an issue which requires
examination in more detail in the following studies in this thesis.

With hypothesis two decisional balance this broadly followed the outline indicated in
literature. Research by McDonnel et al (1998) and Steptoe et al (1996) found that the
perceived benefits associated with low fat diets increased across the stages though this
was not significant mitil the later stages, hi the present study decisional balance pros
scored lowest in precontemplation, with scores significantly different from those in
contemplation, preparation and action. Scores, however, showed an unexpected decrease
again in action and were lower again in maintenance. In fact unexpectedly there were no
significant differences between maintainers and precontemplaters. A possible explanation
for this is that individuals undertaking or about to undertake action may need to be more
aware o f the need to constantly reinforce the benefits associated with their behaviour.
However, once in action the necessity to do this may decrease and may decrease even
further in the maintenance stage. At this point the behaviour is well established and the
need to reinforce the benefits may not be as crucial. It is also possible that maintainers
may see the benefits in a maimer not covered by the questionnaire. Results with the cons
or disadvantages were also erratic, while they were broadly lower across the stages being
lowest in maintenance followed by action and highest in precontemplation which is
broadly in line with the model, the decrease from precontemplation to contemplation, was
followed by an unexpected increase in preparation. While this difference was not
significant, it is interesting in that cons could be expected to decrease at this point, just
before action is taken and a person is more aware o f the benefits associated with change.
It may be with dietaiy behaviour that the benefits and disadvantages are particularly
emphasized at the preparation stage, as this is the point when an individual is acutely
aware o f the steps and disadvantages associated with behaviour change. Overall,
however, crossover did take place with an increase in pros and decrease in cons as

58
expected taking place at the contemplation stage and being maintained until the post
action stages which, indicates that decisional balance may play a significant role in
dietary change. This needs to be investigated further and in particular at which points in
the transtheoretical model the crossover between pros and cons takes place.

Results for the differences in the use o f processes in the different stages o f change were
not fully in line with the transtheoretical model. With social support, dramatic relief and
environmental reevaluation no significant differences were found between the stages.
However, in line with the model scores for social support were highest in action, and
counterconditioning scores were highest in maintenance. With environmental
reevaluation scores were higher in contemplation as the model predicts, but they
remained high in action and maintenance where lower scores are expected. In line with
the model scores for the majority o f processes were lowest in precontemplation, the
exceptions being environmental reevaluation and coimterconditioning, which scored
lowest in preparation though these differences, were not significant.

Results for consciousness raising, self liberation, reinforcement management, stimulus

control counterconditioning and self reevaluation while showing significant differences
between stages only achieved this mainly between precontemplaters and other stages. For
results to be in line with the transtheoretical model significant differences should appear
between the later pre-action stages and action and maintenance. For example, with
reinforcement management significant differences are expected between preparation and
action but were not found here. With stimulus control, a behavioural process, while
precontemplation scored lowest, unexpectedly participants in contemplation scored
highest, whereas the model predicts stimulus control to be most effective between action
and maintenance. Several processes scored highest in the action stage but not all were the
expected behavioural processes. Scores for consciousness raising were virtually identical
in action and contemplation, with consciousness raising being a cognitive process this
should score significantly higher in contemplation. Self liberation which is predictive of

59
movement between preparation and action and self reevaluation which is predictive o f
movement between contemplation and preparation both scored highest in the action stage.

The results for self liberation were the closest to being in line with the model with the
highest scores in preparation and action. A significant difference was also found between
two pre action stages, precontemplation and contemplation, and the difference between
the post action stages action and maintenance was also close to significance. The
transtheoretical model predicts that this process is most beneficial between preparation
and action and that use is lower in maintenance. Self reevaluation a process believed to be
most effective between contemplation and preparation, in fact scored highest in action.
However, in partial support for the model it also showed a significant difference between
precontemplation and contemplation. It may be with low fat behaviour that self
reevaluation is still emphasised in action when the person has made an initial change and
may still be preparing for more change.

Overall with process use an unclear picture emerges. Clearly processes are used and play
an important role in behaviour change but results in this study show significant increases
mainly between precontemplation and other stages with the differences between the
remaining stages where significant differences should emerge not being as clear cut.
Clearly further research with more detailed questionnaires is necessary.

The results with self efficacy proved to be the most interesting. Research by Brag et al
(1997) and Glanz et al (1994) showed self efficacy increasing throughout the stages and
peaking in action with a slight decrease in maintenance. However, in this sample while
scores in maintenance and action were the highest, they were not significantly different
from scores in precontemplation and contemplation. With total self efficacy and all
subscales, scores dipped dramatically lower in preparation and increased again
dramatically in action and maintenance, hi the present study, however, self efficacy was
measured using 20 items whereas in the Glanz et al (1994) study and in Brag et al (1997)
it was measured using two items. This implies that more detailed assessment o f self

60
efficacy may give more detailed and different results. An explanation for this extreme dip
in preparation scores may be that individuals in preparation are particularly alert to
situations and emotions in which they will not resist fat intake. With regard to
interventions it may be crucial at this point to plan a programme to reinforce participant’ s
self efficacy. Unfortunately the results suggest that participants in this study are unlikely
to maintain low fat behaviours, as previous research demonstrates that individuals with
low self efficacy scores are unlikely to maintain health behaviours (Abrams and Niaura
1987). Again the concept o f self efficacy and dietary fat behaviours needs further research
before any final conclusions are made.

However, before discussing the results further or suggesting improvements to the design
for future studies problems with the specific sample in this study will be discussed. Firstly
the sample was predominately female and consisted almost entirely o f students. The
lifestyle o f students and the young age o f the participants suggest a group with different
attitudes and outlooks from the average person. While this may mean a homogenous
lifestyle for participants partaking in this particular study, it is most certainly a different
lifestyle and attitude from for example clinical populations where the transtheoretical
model originated. It is expected that a clinical sample attempting to change their diet may
have a more focused approach than students who may at best be mildly interested in
dietaiy improvement. The distribution o f the present sample across the stages was
extremely uneven, with the smallest group (preparation) containing 8 participants and
consisting o f less than 10% o f the total sample. This, however, is in line with the results
found by previous researchers, for example Graaf, Gaag, Kaftos, Lennemas and Kearney
(1997) found in a sample o f 14,331 participants across the European Union that only 10%
were in the contemplation, preparation or action stages. The percentage distribution of
participants in the present study is actually a slight improvement on this. However for the
type o f analysis used ideally samples need to be o f equal size and with similar
demographics.

61
On closer examination o f the data, scores were extremely low on some subscales
indicating that several processes were virtually irrelevant to participants at any stage.
With stimulus control for instance the highest scores were in the contemplation group at
7.7, indicating that it is virtually never used. Similar scores with reinforcement
management and counterconditioning indicate again that these processes are rarely used
at any stage. Scores on social support, environmental reevaluation, dramatic relief and
consciousness raising are used only occasionally at best. Only self reevaluation achieved
a score which indicated regular use. So while these processes play a part in promoting
dietary change, other unknown strategies may also be playing a greater role. However, it
is also possible that questionnaire items may not have fully measured the options or
situations in which the process is applicable. Scores on decisional balance and self
efficacy, which contained more items, produced results showing more than occasional
use. hi future studies it may be necessary to extend the process questionnaire, to contain
at least 6 items to measure each process.

hi conclusion this exploratory study suggests that while processes are used across the
stages, many are only used occasionally with the majority o f significant differences
emerging between precontemplaters and the later stages. The remaining concepts o f
decisional balance and self efficacy also play a role with significant differences being
found. However, improvements for future studies will include an improved dietaiy fat
questionnaire, an extended process o f change questionnaire and groups o f equal size. This
will be discussed further in the baseline study with a sample o f type 2 diabetics at a west
London hospital presented in chapter four. However the next step in this thesis is to
examine the results o f this study from another perspective in this instance participants
level o f low fat behaviour.

62
Analysis based on low fat behaviour groups

Following the preliminary analysis based on the stages o f change it was decided to
analyse the results from another more traditional direction, that is simply on the basis o f
low fat behaviours. As previously stated the transtheoretical model developed initially
with the treatment o f addictions. With addictions it is clear to the individual when they
have ceased the addictive behaviour and when they relapse into it. However, with dietary
behaviour the situation is not as clear cut, with many individuals being unaware of
whether or not they are following recommended dietaiy guidelines. For example Greene,
Rossi, Reed and Willey (1994) questioned how many participants in the average
population could determine when their diet reached the recommended dietary intake o f
less than 30% fat. In support o f this argument Lechner, Brag, De Vries, Van Assema and
Mudde (1998) found that while as many as 52% o f participants classified themselves as
being on a low fat diet using self-assessment. When a more rigorous classification was
made based on the results o f a proper food frequency questionnaire only 17% could
clearly be classified as on a low fat diet.

To examine further the relationship between low fat behaviours processes and concept
use, participants were divided into high, medium and low fat behaviour groups on the
basis o f their responses to the dietaiy behaviour questionnaire. Dietary behaviour
questionnaires were used to assess dietary intake in studies by Greene et al (1994), Kristal
Shattuck and Henry (1990) and Hargreaves, Schlundt, Buchowslce, Hardy, Rossi and
Rossi (1999). By focusing on the behaviours associated with diet, they are easier to
administer and may give an overall picture o f the individual’ s dietaiy intake whereas food
frequency questionnaires focus on the intake o f specific foods. However, Beerman and
Dittus (1994) while accepting the advantages o f dietaiy behaviour questionnaires and
acknowledging that they distinguish between high and low fat intake, believed their
ability to distinguish between high and medium fat intake is not as clear-cut.

63
The present questionnaire consisted o f 7 items with responses measured on a 1-5 Likert
scale, giving a range o f scores from 7-35. Participants were divided into the 3 groups
using the following criteria. Participants scoring from 7-14 were using very few o f the
processes and assigned to a high fat behaviour group. Participants scoring from 15 -24
were using the processes to a degree and assigned to a medium fat behaviour group and
participants scoring 25 - 35 were using most o f the processes and assigned to a low fat
behaviour group. Three hypothesises were tested, these were

Hypotheses

1. Process use will differ significantly between the groups, with participants in the low
fat behaviour groups using processes significantly more than participants in either the
medium or high fat behaviours groups. It was expected that process increase would be
lineai*, that is as low fat behaviours increase process use will increase.

2. Significant differences will emerge between these groups with decisional balance pros
and cons, with the pros increasing significantly as low fat behaviours increase and the
cons decreasing significantly as low fat behaviours increase.

3. The scores for self efficacy will be significantly different between groups, with scores
increasing as low fat behaviours increase.

Results: Low fat behaviour groups

The majority o f participants, 79 in total, were in the medium fat behaviours group, 24
were in high fat behaviours group and 29 in low fat behaviours group, hi the post action
groups, action and maintenance, there were no high fat behaviour scores. Both groups
however, contained medium fat behaviour scores, 30 in maintenance and 10 in action.
Additionally there were 18 low fat behaviour scores in maintenance and 5 in action.
Overall both groups consisted o f people who appeared to be making some effort to

64
control their high fat dietary behaviour, hi the pre action groups, however, the picture was
not quite so clear. The precontemplation group consisted o f 21 high fat behaviour scores,
23 medium and 1 low, apparently even in precontemplation many individuals were talcing
steps to control their high fat behaviours. A similar pattern was found in the
contemplation and preparation groups. The contemplation group consisted o f 1 high fat
behavioiur score, 11 medium and 5 low, while preparation consisted o f 2 high fat scores,
5 medium and 1 low fat. It appears therefore that regarding low fat behaviours even
individuals in the precontemplation stage may initially adopt fat reducing behaviours,
with these behaviours increasing as expected in contemplation and preparation. It is,
however, in the post action stages that the majority o f low fat behaviour scores are
located. Results are summarised in table 2.3.

Table 2.3: Level of low fat behaviours in relation to stage of change

Stage High fat Medium fat Low fat

Precontemplation 21 23 1
Contemplation 1 11 5
Preparation 2 5 1
Action 0 10 5
Maintenance 0 30 18
Total 24 79 30

Where appropriate one way anovas were conducted comparing participants’ scores on the
processes and concepts on the basis o f their fat behaviour score rather than their stages o f
change. Results are summarised in table 2.4 and figures 2.4 and 2.5. Levenes test o f
homoogenity o f variance was used to test the applicability o f anova tests for each o f the
processes and concepts, hi all cases it was not significant except for stimulus control
where Kruskal Wallace test was used.

65
Decisional Balance

Significant differences were found between groups for both decisional balance pros and
cons. With the pros F(2) = 5.40, p<.01 and the cons F(2) = 5.8, pc.Ol. Overall the pros
increased and the cons decreased as low fat behaviours increased. Scheffe post hoc tests
showed the difference with the pros to be significant between the high and medium fat
behaviour groups (p=.01) and high and low fat behaviours groups (p=.01). Differences
were not significant between the low and medium fat behaviours groups. With the cons a
different pattern emerged with differences being significant between the low and medium
fat behaviour groups (p<.05) and the low and high fat behaviour groups (p<.01). Paired
sample t tests found significant difference with the low fat behaviour group in the rating
o f pros and cons t(28) = 3.08,p<.01 with the pros being rated significantly higher than the
cons. With the high fat behaviour group paired sample t test also found significant
differences t(23) = -4.60, p<.01. But this time it was in the opposite direction with the
cons being rated higher than the pros. This is the pattern o f scores expected if these
concepts play a significant role in dietary behaviour change. The crossover pattern is
shown clearly in figure 2.5.

Processes of change
Results for the processes are summarised in table 2.4 and figure 2.4.
Significant differences were found between groups for all processes, except for dramatic
relief which was close to significance (p = .06). Scheffe post hoc tests found significant
differences between all groups for consciousness raising, differences between high and
medium groups, p<.01 between high and low groups p<.01, and between medium and
low groups p =.01. With self reevaluation Scheffe post hoc tests found significant
difference between all groups, differences between high and medium groups p<.01, high
and medium groups p<.01 and medium and low groups p = 01. With reinforcement
management Scheffe post hoc test found significant differences between all groups,
differences between high and medium groups, p<.01, between high and low groups p<.01

66
and medium and low groups p<.01. With self liberation Scheffe post hoc tests found
significant differences between all groups, differences between high and medium groups
p<.01, between high and low groups p<.01 and medium and low groups p<.01. With
counterconditioning Scheffe post hoc tests found significant differences between all
groups, differences between high and medium groups pc.Ol, high and low groups p<.01
and medium and low groups p<.05. With social support Scheffe post hoc tests found
significant differences between the low and medium groups p<.01 and low and high
groups pc.Ol. With stimulus control Scheffe post hoc tests foimd significant differences
between low and medium groups pc.Ol and low and high groups, pc.Ol. With
environmental reevaluation Scheffe post hoc tests found significant differences between
high and medium groups, pc.05 and high and low fat groups pc.Ol.
Self efficacy
A one way analysis o f variance found no significant differences between groups, F(2) =
.189 p>.05.

67
 16.3** chi square
** -*X- ■
■S
X’-" #■
X ** **CO *■X **OO os
F value

14.53*
in in
GO o H m
in ci N in C N oo H; OO
S O
t-H
CN in
in t— o in
i CN i Xci“H
t
— in in r*H

<0
Table 2.4. Mean Scores: Transtheoretical processes and concepts for each level of fat behaviour

o
V
O
o CO a
Ph
C o o o X) o x_^Xs! x/>--Ns
CN Os' s t-H O OS' CO OO IN td
Low fat

£
cd cd ^•ri — 1cd £ +, cd, ocd IN, £ CN, M
•+
CO TC—O CO VO tS a< o CO CO IN cf O t—
s
1 • l—C

lO t 1
-H cd
t-H S O
t-H cd
t-H ci
t-H so
t-H o’
t
— i IN OS CN C N
T3
4->
x—< C
N x-H o
p
*§
co
p<
'C
a
2
(D
pD
Pi x> x> X >d XI d s
Ph
Medium fat

S'
n CO S o' s (o' s Xs> dS »n O OoCO CO

cd cd in cd, 6 +, cd vcd cd £
_' nf CO os'
0

O o CO o' o IN c? m
ON
ccJ
S t-H t-H cd os
ci cd o CN os
C/5

t-H 00 sd CN tt-H
—i
H t-H t—
ri
t—
H t-H t-H t-H rP

Pi d a d d d d d d d O O (D
O
oos' o' tH r-H S in' s t-H £ in +
High fat

CO ^—
cd * £ cd cd, s ci, r-H £ C O CO 1M
ci
in O)
in oo o
o os CO cN C> ci
CN
o'
tC
—
iS *P
1 sd
os t-H oo IN IN r-H »n H O t-H
t-H
P
•pH
P
o
>
<D
0p 1 CO cpo Q
•0U0 0-H op P s? 8 00
p t— 4 2Pt O o T3
’E 3 <
HOT—
IC D
H< D •xH
t3 0
•rH u o
t •a
o 0
0 0o
o
0 P •-P 1
co (H 0IH p 1 a 9< <rd o 1 1 o 00
Process

h cd
o p 0 c o P C
0 p 73
Cp O‘S 'S i§ 1 73 ,3 rH
P
o O tp tP <+
0
H O
p <4-1 1 •rH
oCOCPJh 0 iH e t-H cd 73 V
*»
o— lM oo 1§h P
o
O-i
t—H Ph
0 0
00 00 1
h-> '•tH
co . 0
§tH 00 #
p a o 00 o C
*t—
O
4 *
O
O •srH 00 <8 .a0 o 0 o
0 <n
o
P Q V
1 P4 Ph
*
 \
+
:
(Z ££ CC QL _i
O D UJ (0 W
+
Dl.
CO o o
CO O CO
{1 I

C.R = Consciousness Raising, D.R= Dramatic Relief, E.R. = Environmental Reevaluation, S.R. = Self Revaluation, S.L. =Self Liberation, R.M. = Reinforcement
Management, S.S. = Social Support, C.C. = Consciousness Raising, S.C. = Stimulus Control.
High = High fat behaviours, Medium = Medium fat behaviours, Low = Low fat behaviours
 A
o
o
o
A

3
c
0
2
0

oi
•4-1
3

0
>
sz
>

o
0

+3
ro
■*->

iq

LL
(0
O
O

■4~>
03
03
O

.03

os.
JC

Q.

O)
CD
CD

OS
</>

CM
00
CO

0 J O O S ue0|/\|
CM
0

_C
"D

CD
IM

o
3

>
JC
O

22
(D

Pros = Decisional Balance benefits, Cons = Decisional Balance disadvantages, Efficacy = Self Efficacy. High = High fat Behaviour,
Medium = Medium Fat Behaviour, Low = Low Fat Behaviour
Discussion

The first hypothesis that processes would be significantly different across the three groups
was supported with 8 out o f the 9 processes, the exception being the use o f dramatic
relief, which was close to significance. With 5 processes significant differences were
found between all three groups this indicates that as low fat behaviours increase process
use also increases, regardless o f whether it is a cognitive or behavioural process. The
second hypothesis regarding decisional balance was also supported as significant
differences were found with the pros and cons o f low fat behaviours. With the pros the
significant difference only occurred between the high fat behaviour and both other
groups. With participants in the medium fat behaviour group there was no significant
difference from the low fat behaviour group. With the cons significant differences only
emerged between participants in the low fat behaviour and other groups. This suggests
that low fat dietary behaviours need to be strongly established before there are no
perceived disadvantages but only moderately established before there are perceived
benefits. Crossover took place marginally after medium fat behaviour were established.
Overall the results demonstrate that increases in decisional balance pros and decreases in
decisional balance cons may be fundamental to dietaiy change. The third hypothesis,
however, was not supported, as there were no significant differences regarding self
efficacy. The role o f self efficacy in dietaiy behaviour change on the basis o f these results
remains unclear.

One o f the first issues arising from the results is if participants’ stage classification
matched their level o f dietary fat intake? For example it is expected that the maintainers
group to consist mainly participants on low fat behaviours and precontemplaters would
consist mainly o f participants on high fat behaviours. With the extreme scores this was
the case; no participants who rated themselves as in the high fat group classified
themselves in the post action stages and only one low fat behaviour participant was
classified in the precontemplation group. However, with medium fat intake the picture
was not as clear with many participants with similar levels o f low fat behaviours being

71
classified in precontemplation and maintenance. This suggests that many participants,
particularly those in action and maintenance may regard themselves as being on a low fat
diet, while in fact maintaining a level o f low fat dietaiy behaviours equivalent to many
participants in pre action stages, for example precontemplation and contemplation. This is
in line with the research by Lechner, Brug, De Vries, Assema and Mudde (1998) which
found that a large percentage o f participants wrongly classify themselves in post action
stages. It may therefore be necessaiy to reclassify many participants on the basis o f their
responses to dietaiy behaviour questions rather than their response to a staging
questionnaire. Kristal, Glanz Curry and Patterson (1999), however, criticised this
approach commenting that it may mask clinically important change, in that for example it
may classify an individual who had cut their fat intake from 45% to 36% as a
precontemplater. The results in this study lend support to this viewpoint, as participants
in maintenance and action were at a minimum in the medium fat behaviour group
indicating an attempt to limit their fat intake. However many participants making similar
changes still regarded themselves as being in precontemplation. Clearly a future study
with a more detailed dietaiy behaviour questionnaire is needed to clarify this issue
further.

The second issue arising from the reclassification on the basis o f fat behaviour is that
more significant differences were found than with the stage o f change classification, hi
the classification based on the stages o f change significant differences only emerged
between stages with 6 o f the 9 processes and mainly only occurring between
precontemplation and the post action stages. However, when the participants were
reclassified on the basis o f fat intake, significant differences were found for 8 o f the 9
processes and with 5 showing significant differences between all three groups. All
processes also showed linear movement in that they were used least in the high fat
behaviours group, their use increased in the medium fat behaviours group and increased
further in the low fat behaviours group. This suggests that there may not be a tailing off of
particular processes as implied in the transtheoretical model, but that the use o f all
processes continues to be an active component even in later stages such as maintenance.

72
For example it is implied in the transtheoretical model as an individual increases their
low fat behaviours, cognitive processes such as consciousness raising decrease and
behavioural processes such as social support increase. However, these results suggest this
may not be the case with low fat dietaiy behaviours as increases in all processes continues
suggesting that some cognitive processes such as consciousness raising are emphasised at
the earlier and later points in dietaiy change.

However, moderate support for the transtheoretical model is found with the use o f two
processes environmental reevaluation and social support. With environmental
reevaluation a cognitive process significant changes were found only between high fat
behaviours and medium, and high fat behaviours and low fat behaviours. There was no
significant difference between low and medium fat behaviours. The move from high to
medium is similar to the movement from precontemplation to contemplation or
preparation where it is suggested the use o f this process is most effective. Also social
support a behavioural process only showed a significant increase between medium and
low fat intake, but not between high and medium; this again gives limited support to the
pattern outlined in the transtheoretical model. This point is similar to the move into action
and possibly maintenance when social support and helping relationships are expected to
be most beneficial. However, consciousness raising a cognitive process increases
significantly across all three groups whereas like environmental reevaluation the expected
increase is between high and medium. It may be that with dietary behaviour, which
requires constant modification and monitoring, some cognitive strategies such as
consciousness raising in combination with behavioural strategies continue to play a role
even when dietaiy change is established.

The results regarding decisional balance and low fat behaviour were as expected broadly
in line with what was expected with the pros increasing and cons decreasing as fat intake
was reduced. The pros, however, increased significantly earlier when fat behaviours
reached a medium level, while the cons did not significantly decrease until the low fat
behaviour group. Overall in both classifications it was demonstrated that decisional

73
balance concepts play a strong role in dietaiy behaviour change. The classification based
on low fat behaviours found no significant differences between groups with self efficacy.
The stages o f change classification did pinpoint differences between those in preparation
and other stages, which demonstrates how the transtheoretical model may have
advantages in some areas over a simple low, medium and high fat behaviour
classification.

Conclusion

Overall many questions remain unanswered, but it appears that while many o f the
processes are used only occasionally their use does increase as individuals become more
serious regarding their dietaiy behaviour with both behavioural and cognitive processes
being increasingly emphasised. However, questions such as which processes are
necessary to move individuals from early stages like precontemplation into post action
stages such as action cannot be fully answered in studies such as this. Clearly, more
detailed questionnaires giving more accurate information on the processes and stage
classification are needed. If used in combination with longitudinal studies involving
active interventions based on staged messages it will become clearer as to how applicable
the transtheoretical model is to dietaiy behaviour.

As discussed following the exploratory study further investigation is necessaiy o f the

constructs underlying dietary change. At this point a more detailed study giving an in
depth insight is necessaiy. With this in mind a qualitative study consisting o f a semi-
structured interview will be conducted. This will give participants greater scope to talk
about the processes used, why they decided to make dietary changes and how they
maintain them. The end result o f this will be a richer source o f information to design
further questionnaires and interventions. On completion o f the qualitative interviews
research it will be possible to complete more detailed questionnaires for use in the main
studies in this thesis. Therefore the next chapter in this thesis consists o f an analysis of
20 qualitative interviews conducted at the University o f Surrey. The interviews will focus

74
on all o f the aspects associated with the transtheoretical model, that is the processes o f
change, concepts o f change and self efficacy. However, it is hoped that in addition to
providing richer information on these topics any additional strategies participants use
which may not normally emerge in questionnaires will be uncovered.

75
Chapter 3
The transtheoretical model and dietary behaviour: A
qualitative analysis using semi-structured interviews.

Introduction
To gain a more in depth insight it is proposed to conduct an exploratory qualitative study
using semi-structured interviews focusing on issues concerning the transtheoretical model
and the problems encountered with dietaiy change. Firstly however the advantages of
qualitative research will be discussed briefly.

The debate within psychology regarding the scientific basis, effectiveness and validity o f
qualitative data is ongoing. Robson (1996 p228) noted that interviews provide the
opportunity to investigate and follow up responses in a manner which postal and self
administered questionnaires do not. However a criticism o f qualitative methods is their
lack o f scientific objectivity in that they frequently do not test 01*reject hypotheses (Burt
and Oaksford 1999). Burt and Oaksford also recognised that one o f the main advantages
o f qualitative analysis may be its ability to generate hypotheses. They compared the
standard psychological approach, that is the generating o f hypotheses by trawling through
the literature as being like an individual sitting in an armchair and attempting to generate
hypotheses for example on child abuse. Whereas a more direct approach in this case the
qualitative approach may be to approach individuals with actual experience o f child
abuse. Then by talking to them directly factors and experiences may emerge which do not
appear in the literature reviews thus generating totally new hypotheses. It is o f course an
advantage if the researcher has some theoretical model such as the transtheoretical model
to guide the process and obviously any theories developed in this way can then be tested
further by more objective quantitative methods.

Grounded theory developed by Glaser and Strauss (1967) introduced a more rigorous
analysis into qualitative research. Pidgeon (1996 p87) recommends it as being suitable for
any form o f qualitative data. Unstructured materials for example interview data are firstly

76
coded, secondly wider links themes or conceptual understandings are developed and
thirdly wider conceptual or theoretical understandings are conceived. With these
objectives in mind a number o f semi-structured interviews were conducted investigating
the transtheoretical model in relation to dietary behaviour. The interviews included 6
questions designed to open up areas relevant to the transtheoretical model to discussion.
This provided a loose structure to the interview content while still examining the relevant
areas. Once questions were introduced participants were allowed to talk freely with
prompts being introduced occasionally to clarify issues or promote further conversation.
The study examined the issues frequently associated with the transtheoretical model, that
is stages o f change, decisional balance, processes o f change, behavioural strategies and
self efficacy. Firstly the content o f the interview is described and explained. Once
completion o f the interviews the main themes or any particularly relevant data is drawn
out and suggestions for improvements to future research discussed. Several sample items
are also generated for inclusion in future questionnaires.

Interview Schedule

Question One: How did you come to be on your present diet?

Prompts
Any particular factors influential ?
Were these planned or unplanned ?
Tell me what was happening around the time you changed your diet?
What was going through your mind?
This question attempts to look at overall background, at the factors which prompt people
to change dietaiy behaviour and how they maintain dietary change, hi particular in
looking at the background the person may give insights into whether they took a gradual
or instant decision. This will test the validity o f the concept o f stages o f change with
dietary behaviour. Do people tend to go through stages such as precontemplation,
contemplation, preparation, action and maintenance and if there are factors such as these,

77
what are the time scales involved? Or it may be that instant dramatic decisions are made
for example like an individual might suddenly decide to improve their diet with no long­
term preparation. This question may also shed light on decisional balance. That is were
there certain factors or problems which suddenly became very prominent making the
person see that changing their diet was worthwhile bringing more advantages than
disadvantages into their lives ?

02: How do you feel about your quality o f life now?

Prompts
What are the biggest or most noticeable effects ?
Areas in your life where you are more relaxed, at ease where it feels good to be 011 a diet.
Areas in your life where you feel tense, where it feels particularly difficult to be 011 a diet.
Anything you regret, anything you feel particularly good about, situations you feel
happiest about, situations where it is awkward. Have new areas or abilities opened up to
you?
This question again looks at decisional balance, if the person believes on overall balance
their life has improved or worsened. Simply it examines if they believe there are more
benefits than disadvantages to dietaiy change. Again with decisional balance being a
crucial concept with the transtheoretical model this question examines the specific pros
and cons o f interest. What are the crucial areas they see problems in? With people
currently in the process o f change this will give insight in to recent problems and how
worthwhile it has been overcoming them. With participants on diets for some years will
they comment on definite advantages or disadvantages?

03: Looking back over the time you have been on a diet, if you had to make the same
decision again how would you feel?

Why do you feel this?

78
This question again looks at decisional balance if the person believes overall that
changing dietaiy habits is worthwhile. While this item examines decisional balance again,
it is intended to be more focused perhaps making the participant give a more definite
answer as to whether or not they feel their life has improved as a result o f their changed
dietaiy habits. Also it may give greater insight into exactly why a participant believes they
have made gains or losses indicating if they believe the change worthwhile in total. It may
also be possible to build on responses to the previous question and gain a thorough
insight into the role decisional balance plays.

04: There are many methods or techniques people use to help them stay on diets. Can you
tell me about techniques which you use?

Prompts
Which do you feel are particularly helpful?
Which do you feel are particularly unhelpful?
Which techniques do you use most?
Which do you use least?
Are these affected by situations you find yourself in?
This question looks at the processes people use; attention will be paid in particular as to
whether or not this matches the process use outlined in the transtheoretical model. The
transtheoretical model outlines nine main processes. It is o f interest to discover if people
use as many processes as this, or are perhaps one or two processes particularly crucial.
The use o f additional processes or strategies may also come to the surface, hi the
exploratory study it was found that though these processes are used, most are not used
frequently by people, even by participants in the later stages where the use o f behavioural
processes might be expected, hi fact with some processes no significant differences were
found between stage and with others significant differences only emerged between those
in precontemplation and the later stages. However, it may not in reality be the case that
process use is infrequent but merely that the questionnaire was faulty. The interview may

79
help identify the processes used more clearly allowing for the development o f a more
accurate questionnaire allowing for a wider, more detailed examination o f process use.

05: With time do you feel the processes or techniques you have used have worked?
Prompts
Have different situations and circumstances affected you?
Have you favourite strategies you have stuck with?
Do you find certain techniques have worked and others have not?
This question again looks at the strategies used and how these changed over time. The
transtheoretical model o f change proposes that different processes are applicable at
different stages. With the interview it may be helpful to compare people at different
stages 01*participants may give an account o f any stages they feel they went through. This
could be times they spent thinking about changing their diet 01* any relapses they may
have had. It is also o f interest to see how people themselves feel the processes they have
used have changed over stages or time. For example this could address whether there
were any big changes in the techniques they used when they first started on their diet and
when they had maintained it for longer than 6 months.

06: How do you feel about your future progress?

Prompts
Will more changes be necessary?
If new changes are necessary how will you go about them?
Will you cope better with situations?
This question focuses on the remaining central concept o f the transtheoretical model self
efficacy; that is the person’ s belief that they can maintain or improve their dietary
behaviour further. For example, if there are problems ahead do they have any plans for
coping with them and how successful do they feel they will be? Do they for example
believe they can maintain their dietary change for the long-term future? Is their level of
belief something that has grown over time 01*are there situations which they believe they
may not be able to cope in?

80
Method
Posters were displayed at various sites in the University o f Surrey (copy in appendix two).
Individually addressed invitations (copy in appendix two) for volunteers to participate in
a semi-structured interview were distributed to postgraduate students in the School o f
Human Sciences at the University o f Surrey. An internal e-mail asking for volunteers to
take part in a nutrition related study was circulated to staff in the Psychology Department
at the University o f Surrey. The sample used was an opportunity sample o f staff and
students at the University o f Surrey.

Results
20 participants took part, 3 men and 17 women, ages ranged from 18 to 40. 10
participants were in the action stage (made major changes in their diet in the last 6
months) and 10 were in maintenance (maintaining dietaiy change for over 6 months).
Participants were on a range o f diets, 11 were specifically watching fat intake. The
primary concern o f the remainder was maintaining a healthy diet. In most cases this
meant increasing their daily intake o f fruit and vegetables while at the same time
monitoring their fat intake. One participant was a type 2 diabetic which involved him
maintaining a diet, low in fat and refined sugars. Analysis o f results focused on four main
areas. These were strategies used, motivating factors, problems and disadvantages and the
consequences good and bad o f dietary change.

Response Coding
Participant’ s responses were transcribed and examined for responses under 4 headings.
These were (a) Strategies used (b) Motivating factors (c) Problems and disadvantages and
(d) Consequences and reactions. These themes were chosen as they related closely to the
concepts being examined in the transtheoretical model.

Strategies used will give insight into the processes used during dietaiy change, motivating
factors will examine the reasons participants changed and possibly if they followed a
stage pattern with participants for example contemplating and preparing for change

81
before actually undertaking change. Problems and disadvantages as a theme will give
insight into the concept o f decisional balance, for example will participants associate
many problems with dietary change or will they believe there are more benefits. With
consequences and reactions this again may give insight into the level o f decisional
balance and also into self-efficacy. Will participants feel for example they will maintain
their improved dietary regimes into the future or will there be circumstances in which
they will relapse into their old dietaiy habits. On transcription o f the interviews
participant’ s replies were analysed and coded under these four headings.

With strategies the seven response codes were social support, reading articles or watching
television programmes on dietaiy change, food lapses, focus on benefits, substitute foods,
planning and keeping a diaiy. Examples o f response coding as follows participants
mentioning using Weight Watchers or depending heavily on the support o f a friend this
were coded under social support. With motivating factors the four response codes were
health, appearance, specific event and environmental concerns. Examples o f response
codes as follows participants mentioning a general concern for health as a primary factor
or participants mentioning a specific event for example a wedding or family occasion.
These responses were then coded accordingly imder health concerns, specific events or
appearance. With problems and disadvantages the response codes were social events,
extra workload, anxiety and stress, lack o f support, food availability and poor
information. For example participants mentioned the high workload and those stressful
times such as just before exams when the extra workload caused problems this was coded
under stress and anxiety. Under consequences and reactions response coding were feeling
good, diet worthwhile, looking better, feeling empowered, feeling healthy and negative
emotions. Participants for example who commented that they felt a sense o f achievement
or more control over their lives were listed as feeling more empowered. Participants may
also have stated if they felt dietaiy change overall was worthwhile and responses coded
under this heading.
The coding o f responses in this way will group the relevant concepts giving an insight
into the patterns, which emerge during dietaiy change.

82
Strategies Used
One o f the most widely used strategies was social support with 14 participants
mentioning its use. With many this was a major factor involving regular attendance at
groups such as Weight Watchers. At Weight Watchers and similar groups a specific goal
is provided each week. One particularly stringent goal would be an expected weight loss
every week tested with a weigh in before every class. One participant described it as “A
force in your head telling you that you will be found out ” while another described it as a
competition and a goal. While the focusing on a target weight and the recognition o f it by
others was a positive stimulus for many, one participant mentioned a negative side in that
if gains were not recognised this had negative consequences. In this instance they
commented how a lack o f recognition o f a loss o f several pounds led to them losing heart,
leaving a group and going back to old dietaiy habits. With social support not all
individuals depended on support groups like weight Watchers many mentioned close
friends, family members or some significant person in their lives being a major factor in
making them improve their dietaiy intake.

The second most widely used strategy was the seeking out o f information. Prochaska and
DiClemente (1992) identify this as a cognitive strategy under the term consciousness
raising, hi the model strategies such as this are more closely associated with the early
pre-action stages o f change. While 14 participants mentioned using this, many used it
only occasionally, for example if they came across an article, or if a programme happened
to be on television, rather than actually seeking sources o f information. Indeed some did
appear to use it as a form o f social identification. Pointing out that it made them realise
they were not on their own, they also found success stories uplifting and that they were a
source o f information on how other people cope.

Another strategy matching a process outlined in the transtheoretical model was the use of
rewards (reinforcement management) at particular points. However the major difference
between dietaiy behaviour and addictive behaviours is that several individuals mentioned

83
actively rewarding themselves with the wrong foods if they had stuck to their diet for
some time. One participant commented “I promise myself if I eat well I will have a piece
o f chocolate” . Another said “I stick to my programme regardless o f whether or not I have
binged” . Only one participant saw breaking their diet as a problem in that it meant a loss
o f focus or serious intent with their programme. This meant that having broken the diet
once it was more likely they would break it again.

Stimulus control was also widely used with participants mentioning that they substituted
foods, or avoided places where high fat foods were widely available. Other strategies used
were encouraging others to alter their diets, exercising more, focusing on the benefits,
writing in diaries and diet simply becoming a routine. The strategies mentioned in the
interview are summarised in table 3.1.

Table 3.1: Number of people mentioning particular strategies

Strategy Social Reads Food focus on Substitute Planning Diary ;

Support Television Lapses benefits Foods
Number 14 14 9 7 9 7 3

Motivating Factors
hi examining the issues which motivated individuals to change, the majority o f
participants mentioned health reasons. Some mentioned a specific reason for example a
bacterial infection or the onset o f a major health problem such as arthritis or diabetes.
However, the majority mentioned an overall concern about their health. For example
comments included “I had better not eat this if I want to stay healthy, there is the heart
and that sort o f thing” . Or “I never used to worry about my health but in the last few years
I think my heart must be screaming because o f all the cholesterol all the fatty foods” .

Several o f the participants were students studying health psychology at the college and
this made them particularly aware o f the health issues involved and the importance o f
maintaining health behaviours. One person commented that on listening to lectures they

84
realised how many unhealthy habits they had and they decided to change something, in
this instance changing to a healthier diet. Appearance was also a strong factor for
motivating individuals to change. One person summed it up as “Well my clothes were
getting tighter and tighter, I just woke up one morning and had had enough o f it” or “The
thought o f coming into summer and not being able to fit into my summer clothes” .
Specific events were also mentioned by several individuals; one participant mentioned
their wedding, which was combined with appearance “I am getting married next year and
I want to fit into my wedding dress” .

A particular lifestyle change taking place such as moving away from the parental home
and making their own choices regarding lifestyle could also influence dietaiy choice.
Initially this may have had a negative effect, but over time the person accepts
responsibility for their health and takes steps to improve their diet. Another factor
mentioned was the belief that an improvement in diet would help the person cope with
stressful times. One participant mentioned ecological reasons in that mass produced food
was damaging the environment. Factors causing change are summarised in table 3.2.

Table 3.2: Number of people mentioning particular motivating factors

Motivation Health Appearance Specific Event Environment ;

Number 15 11 7 1

Problems and disadvantages

The most common problems were going out and special occasions such as Christmas.
The reaction o f participants to these situations varied, the majority appeared to regard it
as inevitable that the diet would be broken at certain times. One participant remarked “It
does not effect me I would just see it as a relapse and forget it” another spoke o f “Leaving
a space to eat anything she wanted to” . Only one participant had an organised strategy for
dealing with eating out in that they made a point o f going to the good restaurants, where
the food is not previously prepared and changes can be made to the menu.

85
Another strategy mentioned is making it clear to the peer group the reason for the dietary
changes which may lead to acceptance and respect. One participant described it as “They
give you credibility for doing it, they understand it that there is a reason you are doing
it rather than a lot o f pernickety changes for nothing” . One mentioned that while these
times were a problem there could also be a positive side when a particular effort was
made to include them. One commented regarding one Christmas “A partner o f mine went
out o f his way to give me the right foods so sometimes I am made to feel good....
but at other times I feel excluded” . Others mentioned that on these occasions they are
pressured to break their programme. With comments being made to them such as “ Go on
eat it you have been really good this week” .

Nine participants mentioned the work involved as being a problem; one commented “It is
harder to do healthier food .... It is easier just to get something out o f the freezer. It is
harder trying to vary it more and keep it low in fat” . This in particular appeared be a
problem in stressful or high demand situations. One student commented “ when I have
exams and essays to hand in.... I know there will be times when I will not have the time
to go out and buy vegetables or do the cooking 01*anything” . Another commented “When
I come to university I just cannot be all night cooking and preparing” another commented
011 the work involved in preparing separate meals at home. Nine participants experienced

heightened feelings o f anxiety, stress, boredom or guilt. One mentioned a feeling o f

disappointment if they did not lose weight each week, another mentioned that outside
stressors such as feelings o f anxiety caused her to break her diet.

These were the main problems mentioned by participants. Other issues were feelings o f
stress and lack o f social support, for example when a significant other such as a partner
believes the problem is purely one o f self esteem, then proceeds to make it difficult for
the person by bringing a lot o f high fat and sweet foods into the house. Missing a
favourite food, contradictory information regarding diet and poor availability o f proper
nutrition generally were also included. Overall people are aware o f the problems and 110

86
one saw dietaiy change as all benefits. This was the case even with individuals who had
maintained an improved diet for several months or years. A conflict with decisional
balance appears to be ongoing with dietary change. The main problem areas summarised
in table 3.3.

Table 3.3: Number of people mentioning particular mam problems

Problem Social Extra Anxiety Lack o f Food Poor

Events Workload Stress Support Availability Information
Number 16 9 9 5 2 1

Consequences and reactions to dietary change

The vast majority o f participants expressed a range o f positive feelings and benefits
associated with maintaining and improving their diet. These ranged from participants
saying they just felt good or better in themselves to being more healthy and alert.
Negative emotions, however, were also expressed but these were mainly in relation to
breaking a dietary programme. Only 1 participant believed overall that there were more
negative than positive emotions associated with dietary improvement.

The positive emotions expressed included increased feelings o f self control and pride, one
commenting “It is the first thing I have done that I have really stuck to I am really
proud o f myself’. Another described the time when she was oveiweight as “ like being in
a trance” while another described the excitement o f watching the pounds come off, and
others felt satisfaction on fitting into their clothes again. Outside reinforcement in the
shape o f praise from friends was also a strong factor, for example “People come up to me
and say “ Gosh you have lost a lot o f weight and this makes me feel really proud” .
Another mentioned increased attention from the opposite sex and another feeling good
when she was praised for her inventiveness with food. Two participants mentioned,
however, that they still believed a bigger improvement was necessary, in that they needed
to be more organised and more into the diet. Some negative emotions were also expressed

87
these involving participants being disappointed with themselves for breaking their diet.
One described it like this: “That while it is not a sin it is a sign o f a lack o f mental
toughness and there will be a bad physical response” . Another described it as feeling like
she was battering herself when she ate the wrong foods.

The majority had high self efficacy believing they would stay on their present diet. The
majority did not believe, however, they needed to significantly improve on their diet.
Some expressed doubts, however, if a major lifestyle change for example getting married
or having children came along as to how they would cope with it, believing that it could
adversely effect their dietaiy programme. So while self efficacy was strong it was
possible for it to be undermined in exceptional circumstances. Consequences and
reactions summarised in table 3.4.

Table 3.4: Number of people mentioning particular consequences and reactions

Reaction Feeling Diet Looking Feeling Feeling Negative

Good Worthwhile Better Empowered Healthy Emotions

Number 6 6 4 5 6 6

Discussion

The processes and concepts used loosely matched several o f those outlined in the
transtheoretical model. They were mainly behavioural processes but consciousness
raising, a cognitive strategy, also played a part. With virtually all participants the benefits
tended to outweigh the disadvantages and with the exception o f dramatic changes in their
lifestyle participants expressed belief in their ability to maintain their improved diet. As
all the participants were at a point corresponding to the action stages o f the
transtheoretical model, the predominance o f behavioural processes along with the high
perception o f the benefits and a sense o f self efficacy is as expected.
The most significant strategy appeared to be social support, indicating that successful
dietaiy change may mean actively working with others. This was to some extent
supported by the identification o f social situations and special occasions as situations
where pressure to relapse was strong, hi these situations there is perhaps very little social
support to maintain behaviour and perhaps some encouragement to break it. This
indicates that in encouraging individuals to take up diets and follow health programmes a
necessary skill in successful maintenance may be the ability to encourage peers and
family to support the improved behaviour, or with providing suitable support groups. One
participant did, however, emphasise the negative aspect o f this pointing out how a lack o f
recognition in her Weight Watchers group caused her to leave which led to a deterioration
in health behaviour. This shows the negative consequences to social support when it is
expected but not delivered. But overall the evidence o f this study shows it to be a helpful
factor.

An equal number o f participants reported using consciousness raising as social support,

for example by reading magazines or watching television programmes. However for
many this was not a central strategy as it was only used occasionally. Interestingly the
exceptions to this were several students on the health psychology course. They reported
the infonnation received on this course and the consistency o f its delivery as a major
factor in encouraging their improved diet. This is broadly in line with the transtheoretical
model, which suggests that, conscious raising may be beneficial in initial movement from
pre-action to post action stages or in eveiyday terms from inaction to action. However,
the infonnation on a health psychology course is intensive, and delivered on a daily basis
with individuals studying it carefully. Infonnation in this fonn is not normally available
to the general public and also on a health course strong social support may be available
among the participants encouraging further change.

Apart from social situations and special occasions the second major problem identified
was the extra workload associated with dietaiy change. This involved greater efforts in

89
selecting, preparing and storing foods. This appeared to be particularly the case in
stressful or exceptionally heavy workload situations. This implies that organisation and
proper planning may also be skills, which will need to be included to maintain dietaiy
improvement. This is slightly out o f line with the transtheoretical model, which suggests
that the cognitive strategies such as planning ahead are most beneficial in the pre-action
stages. However, while this may mainly be the case with addictive behaviours with a
simple cut off point, the more complex nature o f dietary behaviour change may mean
regular strategy reviews.

Again broadly in line with the transtheoretical model several participants mentioned
using, reinforcement management, that is rewarding one’ s self or being rewarded by
others for behaviour change. However, this was not in a manner idealised by the model in
that several participants rewarded themselves by making a point o f breaking their diet.
Greene, Rossi and Richards (1993) suggested that behaviours such as this may not be a
problem and can in fact be a positive coping strategy providing they do not lead to a full
relapse. Ideally rewards should consist o f behaviours such as buying new clothes, or
special treats and not eating the wrong foods. It may be necessary to encourage people to
reward themselves with behaviours other than eating the wrong foods. Again broadly in
line with the model, which recommends strategies such as counter conditioning and
stimulus control, being used in the action stages several participants mentioned stimulus
control in that they substituted or stored only the proper foods at home. One participant
placed reminders o f the benefits o f low fat behaviours around their home in this instance
for example a photograph o f themselves when they were slim on their fridge door. Indeed
one participant mentioned that when all the wrong foods are available in her home it is
virtually impossible to maintain a diet suggesting that stimulus control may be a crucial
factor for some people. Overall the interviews with the emphasis on behavioural and
some cognitive strategies demonstrated that the transtheoretical model is at least partially
valid in relation to dietaiy change.

90
The next issue emerging is the factors or situations, which initially encouraged
participants to partake in improved dietaiy behaviour. The model suggests to move
individuals from precontemplation to contemplation or action, strategies such as
consciousness raising, dramatic relief and environmental reevaluation are the most
effective. The majority mentioned becoming aware o f health problems associated with
poor diet and one participant also in line with the model improved their diet purely on
environmental grounds. The remaining strategy associated with initial change in the
model is dramatic relief. This involves role playing and experiencing and expressing
one’ s feelings, this did not appear to be actively used by any o f the participants in this
study. However, outside factors also appeared to play a part, in initiating change, many
participants included a specific event such as a wedding or a concern for their appearance
at some particular time as sparking change. This implies that while consciousness raising
is important, it may not 011 its own be enough unless perhaps it is veiy intensive for
example attendance at a health course. To a degree this supports the research o f Keenan,
Abuhshaba, Sigman-Grant, Achterberg and Ruffing (1999) which found that dietary
change was often initiated by unplanned factors and the research by Novotny, Han and
Biemacke (1999) which found that appearance also played a part in dietaiy behaviour
change.

In examining the consequences 01* reactions to maintaining dietary behaviour, the

majority described this in terms o f positive feelings. For example feeling good, feeling
empowered, overall positive emotions were used to reinforce the behaviour with only a
small number stating they used negative emotions as reinforcement. This perhaps fits
loosely with self reevaluation, which is ideally the acquiring o f a positive concept of
oneself. In the transtheoretical model this is emphasised as an effective strategy in
moving participants from contemplation to preparation. However, it is also associated
with the person evaluating himself or herself negatively to activate change. Perhaps when
change is maintained reevaluations become more positive. Positive feelings and
evaluations may become crucial in maintaining health behaviour, by enabling the
behaviour to be perceived as being more positive than negative. In this instance the pros

91
o f decisional balance appeared to be more associated with positive feelings than practical
considerations, which in fact were often seen as more difficult, that is involving more
work. Interventions may need to take this into consideration perhaps emphasising the
positive benefits in terms o f feelings and suggesting methods o f overcoming the practical
difficulties associated with dietary change.

Perhaps the data overall from the interviews can be best summarised in the form o f a
loose model. It is implied firstly that consciousness raising is necessaiy to make the
individual aware o f the benefits o f improved diet, however unless this is very intensive, it
may also be necessary for some outside event to kick start the behaviour. Once having
changed the behaviour the majority o f individuals may then seek some fonn o f social
support for maintenance, behavioural rewards including lapses into poor diet are also
used. Strategies such as consciousness raising and planning may still play a part but to a
lesser degree once the behaviour is established. Problem areas are situations where the
individual starts to lose control, for example social occasions, times o f heavy workload,
stress or even when there is social pressure to break their diet. However, once the
individual maintains the improved behaviour a major benefit is that they consistently
perceive themselves as healthier and more attractive in addition to experiencing positive
mental states for example feeling more empowered. A summary o f the model is given in
figure 3.1.
Figure 3.1: Summary o f model

92
However while this proposed model is o f interest, it is based solely on the results o f this
small qualitative study, it will be o f interest if in the later studies in this thesis any
information emerges which lends support to this model. The remaining studies however
will continue to analyse the strategies and concepts central to the transtheoretical model
as this is the model with the more established pedigree.

Implications for future study

An initial aim o f conducting this qualitative study was to generate items for inclusion in
further questionnaires examining the transtheoretical model and dietaiy behaviour. Firstly
in looking at decisional balance pros and cons it will be necessary for items to focus on
the feelings associated with maintaining improved dietaiy behaviour. Is the person
feeling more energetic, more empowered or simply better all round as a result o f staying
011 an improved diet? Items such as the work involved and having to cut out foods are o f

interest, but in themselves may not be sufficient to imcover the significant processes
within the person. On the basis o f the results in the this study it is suggested that in
addition to the standard items, items similar to the following be included in decisional
balance pros and cons questionnaires
“ I feel better on an improved diet”
“I feel more in control o f my life on an improved diet”
“ Overall my mood would improve on an improved diet”
“I would have to miss out on or I would not enjoy social occasions on an improved diet”
“I would need to read a lot and work hard to maintain an improved diet”
“ When I think o f the work involved in maintaining an improved diet, I believe it is not
worth the trouble”
The deletion o f items, which focused on more superficial processes such as eating less
appetising foods or having to cut down on favourite snacks, is an option as they may not
give the necessary insight into the processes which make a significant difference to
people.

93
Focusing on the process side o f the questionnaire is more difficult, in that the majority o f
the participants in this study were in the action and maintenance stages therefore using
mainly behavioural strategies. However, one clear issue arising from the interviews is that
the vast majority o f participants used social support in some way. Five items in the
original questionnaire focused on this, it is recommended that items similar to the
following are included in future questionnaires
“I find the encouragement o f friends to be a major factor in the improvement o f dietaiy
behaviour”
“I make a point o f talking to someone at least once a week about dietary improvement”
This may point out those who are following a more active role in social support from
others.

Another process, which emerged throughout the interviews, is reinforcement

management. Unfortunately one o f the strategies individuals used to reinforce their diet
behaviour was the occasional breaking o f it. Sample items to be included to examine this
process further are:
“ Occasionally if I have stuck to my diet for at least a week I reward myself by eating my
favourite high fat food”
“If I break my diet I do not see it as a problem provided it does not happen more than
once a week.”

Self reevaluation was also used in that many participants reported feeling good about
themselves if they stayed on an improved diet. This aspect to a degree is covered in the
pros and cons questionnaire and the self reevaluation aspect was covered by five items in
the original questionnaire. However, items similar to the following could also be included
in future questionnaires:
“I feel that by improving my diet I will be a much healthier and happier person”
“I feel that by improving my diet I will be able to deal with difficult or stressful situations
much better”

94
This perhaps will focus on the more positive aspects o f self reevaluation rather than
some o f the negative aspects contained in the original questionnaire. Consciousness
raising issues may be dealt with by focusing 011 aspects other than the gathering o f
information about diet such as focusing on whether people gather information on how to
maintain improved dietaiy behaviour. Though one item on the original questionnaire
deals with this, additional items to examine further this process are:
“I read articles about the techniques people use to stay on low fat diets”
“I malce a point o f talking to people about the methods they use to stay on low fat diets”
“At least once a month I seek out information on improving my diet”

Overall the interviews point to dietaiy change being a process in which individuals use a
mix o f strategies, therefore using interventions based rigidly on the transtheoretical model
may not be ideal. However, to a degree in support o f the model, interventions in the later
stages may be largely behavioural strategies, with some emphasis still being placed on
cognitive strategies such as consciousness raising and planning ahead. This may be
necessary because unlike behaviours such as smoking which simply require the
elimination o f a specific behaviour, improved dietaiy behaviour accepts occasional
relapses. It may also be necessary for individuals to constantly update themselves
regarding dietary knowledge as dietary habits even if improved are not fixed with the
individual often having to adapt their diet in a variety o f situations. For example the
quality o f food itself may not be stable. In extreme cases issues such as “mad cow
disease” or “ genetically modified foods” effect dietary choice and even the amount o f fat
an individual can take may vary over time.

The most successful strategy coming from the interviews for social situations is for
individuals to either plan to avoid such situations, or to explain to friends clearly before
such an event that they will not be eating certain foods and act accordingly. Unfortunately
one factor which promoted dietary change, that is the occurrence o f an outside event or
some particular target is outside the power o f any intervention. However, once these

95
events occur it is essential that the other supports are put in place to enable adherence to a
dietary regime.

Conclusion

In summary research to date and the information gathered in both the exploratory study
and this qualitative study demonstrates that the transtheoretical model may be loosely
applicable to dietaiy change but this may not be in a manner identical to that tested with
addictive behaviours. Further research looking at the processes involved and how to use
them effectively over time is still needed. These exploratory studies have also provided
additional items for inclusion in future questionnaires. Unfortunately due to constraints of
space it is not possible to include all these sample items in the revised questionnaires
however a sample o f them will be used which will enhance the questionnaires in the
following studies.

The next step in this thesis therefore is to build on the information in these studies and
research thoroughly the strategies o f a group o f people actively involved in monitoring
their dietaiy behaviour. The sample used will be clients at an out patients unit o f a west
London hospital with type two or late onset diabetes. A brief discussion o f the
background to the complaint is covered in the next section before the two major studies
are introduced.

96
Type 2 Diabetes Mellitus

The high incidence o f high fat intake and its role as a factor with numerous health problems
including heart disease, cancer and arthritis is undoubtedly a cause o f increased concern for
health educators. However the increased incidence o f obesity has in particular been associated
with a greater risk o f people developing type 2 diabetes. Type 2 diabetes is a potentially fatal
illness with many possible complications such as kidney disease, strokes, blindness and heart
disease. Latest figures estimate that 151 million adults worldwide now live with this condition
(http://news.bbc.co.uk). It is also estimated this figure will possibly double in the next 25 years.
Alberti (2000) pointed out that the increased westernisation o f people’ s lifestyles in particular in
developing countries may be leading to a rapid spread o f this disease. In the U.K alone 1.4
million people are officially diagnosed with this condition but diabetes U.K estimates 1 million
more may unknowingly be victims also. The high incidence o f this condition is therefore placing
an enormous burden on the economy o f this coimtry and countries worldwide. Before
progressing further however a precise definition o f diabetes and in particular type two diabetes
will now be given.

Watkins, Drury and Howell (1996 p3) defined diabetes as “A disorder in which the level o f
blood glucose is persistently raised above the normal range. Occurring either because o f the lack
o f insulin or because o f the presence o f factors, which oppose the action o f insulin. It is a
permanent condition in all but the few situations in which it is transient” . Diabetes itself exists in
2 forms; type 1 and type 2. With type 1 diabetes the body is unable to produce any insulin. This
usually starts in childhood or young adulthood and is treated with insulin injections and dietary
control. In Type 2 diabetes not enough insulin is produced or the insulin that is made does not
work properly, hr the past this was associated with affecting people as they get older. Usually
appearing after the age o f forty. It used to be known as 'maturity-onset diabetes' or 'non-insulin
dependent diabetes Clark (2001 p i) defined type 2 diabetes as “Being associated with patients
who do not depend on exogenous insulin treatment to remain alive” . Clark while acknowledging
this disease is commonly diagnosed in middle aged or elderly people, pointed out that it is now
increasingly developing in younger people particularly those in highly susceptible populations
perhaps rendering the term maturity onset diabetes obsolete.

97
Hansen and Roberts (2000) noted that the connection between type 2 diabetes and obesity
consisted o f several factors. Firstly in relation to developing type two diabetes initially the more
oveiweight a person is the greater their risk and the longer a person is overweight also the higher
the risk. With individuals already suffering from type 2 diabetes while low fat dieting is not a
cure it can play a crucial role in maintaining glucose levels near normality. Hansen and Roberts
estimated that a 10 to 20 pound loss in body weight might be enough for many people with type
two diabetes to improve glucose level control meaning fewer health complications. Also as a
genetic component may be a factor in disposition, the changes in the health routine o f one family
member can have a knock on effect making it less likely others perhaps already at increased risk
will also develop diabetes. Hansen and Roberts explained that obesity might be a precursor to
type 2 diabetes because o f its interaction with insulin resistance. With an obese person the excess
fat causes the cells not to respond to insulin meaning glucose in the blood is not absorbed as
quickly as it should be. While the body is producing insulin the glucose remains in the blood and
when this build up passes a critical level type 2 diabetes is diagnosed.

Numerous research studies have also supported this link. Bennet, Rushfort and Miller (1976
cited in Felber Achesonl993) in a study with a population o f Pima Indians noted a significant
increase in weight 30-60 months prior to the diagnosis o f diabetes. Hansen and Roberts (2000)
noted that in an intervention study in Sweden that participants with glucose intolerance (a factor
which often precedes type 2 diabetes) who lost weight were significantly less likely to progress
to type 2 diabetes than an control group whose average weight increased. Therefore a clear
connection between excessive fatty foods, overweight, the onset o f type 2 diabetes and the
prevention o f further complications associated with type 2 diabetes exists. Watkins Drury and
Howell (1996) believed the teaching o f good dietaiy principles to be the key to successful
diabetic treatment. However, in addition to obesity being a predisposing factor a family history
o f diabetes and being Asian or Afro-Caribbean are also associated with increased risk o f type 2
diabetes.

Therefore as a strong element o f dietary behaviour change is associated with successful

treatment o f type 2 diabetes it is a good area to test the applicability o f a model such as the

98
transtheoretical model. Peyrot (1999) in a review o f behavioural models applied to diabetes
education concluded that the transtheoretical model had not yet been adequately tested in relation
to diabetes care. The long term effects o f brief behavioural interventions on diabetes is unclear,
However Glasgow, La Chance, Toobert, Brown and Hampson (1997) found that interventions
consisting o f touch screen computer assessment, along with back up phone calls and a video tape
intervention produced a significant improvement in dietary behaviour change over usual care. It
will be o f interest therefore to measure the effect o f a brief behavioural intervention based on the
transtheoretical model to a client group with type 2 diabetes.

The next chapter covers the baseline results o f a longitudinal study with type 2 diabetics
attending a London hospital. The methods used for example the structure and design o f
questionnaires and the results o f this initial study are thoroughly discussed.
Chapter 4
An in depth study of the application of the transtheoretical model to the low fat behaviours
of a sample of participants with type two diabetes.

Introduction

The exploratory studies in particular- the quantitative study left many unanswered questions.
Firstly as a consequence o f the small sample size some stages contained very few participants.
For example the preparation group contained only eight people. Also while the stages o f change
model is supposedly applicable to all groups the young age o f students, their different lifestyle
and the fact that 80% the group were female, meant the sample was far from ideal for-
generalizing the results to wider more diverse groups. Both exploratory studies however, were o f
value in that they indicated improvements necessary in the design o f the questionnaires for the
main study.

Group Selection

To obtain a more representative sample o f individuals actively engaged with dietary change,
clients with type two diabetes at a West London hospital were selected. As part o f their treatment
clients with type two diabetics are recommended to stay on a low fat diet. It was felt therefore
)
that the majority o f people in this sample will have attempted at some time to improve their diet,
or at the very least it would have been recommended to them to do so and that they will be
motivated to adopt to a low fat diet. Clients in this group will also be knowledgeable regarding
the requirements o f a low fat diet, as all have received dietary advice from a nutritionist during
the course o f their treatment. This partly answers the criticism o f Brug et al (1994) regarding
objective and subjective assessment o f fat intake in that they believed many participants under
estimate the level o f fat in their diet.

Improvements to Questionnaire

As discussed in the previous chapters several improvements were necessary to the questionnaires
in order to gain a more accurate insight into the processes used and assessment o f dietary change.
The demographic details however were similar to the first questionnaire, participants gave details
o f their age, sex, and level o f education. The participant was asked if they were responsible for
buying and preparing their own food , indicating the degree o f control over their dietary intake.

100
Dietary Behaviour Scale

Assessing dietary intake accurately is a fonnidable problem. It is an issue, which any dietary
investigation needs to address thoroughly. Therefore there now follows a detailed discussion o f
the background information on this topic and justification for the method used for assessment in
this study which is a dietary behaviour questionnaire consisting o f 14 items.

Unfortunately the measurement o f dietaiy intake has proved to be a difficult task. Indeed in
comparison to the measurement o f other health behaviour's such as smoking or alcohol
consumption the measurement o f nutrition intake is enormously complicated. Improvement in an
addictive behaviour is straightforward, the end goal is for the addictive habit to be eliminated or
reduced significantly. Dietaiy improvement, however, involves a series o f changes and very
often it is undesirable to entirely eliminate a class o f food. For example a totally fat free diet is
not desirable, though a diet containing less than 30% fat is. The most favoured techniques to
date for measuring dietaiy intake are food frequency questionnaires, daily recall and four, five-
day or seven day recall (Glasgow, Perry, Toobert and Hollis 1996). However, significant
disadvantages exist with the administration o f these methods. They are all particularly unsuited
to situations common to many research projects where assessment needs to be done quickly and
inexpensively and are sometimes completed over the telephone.

Many food frequency questionnaires are particularly time consuming, o f necessity they must
contain lists o f many foods and no matter how detailed inevitably many items are not included.
A long and complex questionnaire is also unlikely to encourage the involvement o f voluntary
participants the majority of whom are usually required to give their time freely. An added
disadvantage with health interventions is that it often needs to attract individuals uninterested in
change, for example people in the pre action stages o f Prochaska, DiClemente and Norcross
(1992) transtheoretical model. Individuals such as these are perhaps even less likely to complete
lengthy complex questionnaires. Similar problems exist with daily and four to five day recall in
food diaries, these may also have the additional problem that trained dietitians are needed to code
and possibly interview subjects to assess the validity o f records. Van Assema, Brug, and Brants
(1992) point out that for many studies it is not necessary to measure nutrient intake in such a
precise manner. Often the ranking o f a subject or the ability to predict an improvement in a

101
dietary behaviour for example fat intake is all that is required. In an attempt to overcome these
problems researchers have adopted strategies such as targeting the foods central to the sample
population. Van Assema et al (1992) and Kristal, Shattuclc, Henry and Fowler (1990) used this
method for assessing fat intake. Brief telephone assessments using a questionnaire based on core
foods produced significant correlations with a more detailed questionnaire in the Kristal et al
(1990) study and 7 day food diaries in the Van Assema et al (1992) study. The finished
questionnaires had the significant advantage o f talcing approximately 5 minutes to administer.
This fonn o f assessment however still initially involves a detailed analysis o f the standard diet o f
the target group. With the Kristal et al (1990) study data were obtained from the Women’ s
Health trial and in the Van Assema et al (1992) study the questionnaire was based on data from a
more detailed telephone survey conducted in 1988. Therefore while the latter questionnaire is an
improvement in terms o f administration on the initial assessment, considerable resources and
commitment are still required and therefore the problems o f participant compliance and
interpretation still exist.

Another option which may give a broader and perhaps more accurate indication is the
measurement o f a dietary behaviour associated with a given area, for example fat intake or fruit
and vegetable intake. Kristal, Shattuclc, Henry and Fowler(1990) summarised the process o f a
low fat diet as consisting o f 4 core dimensions or processes. These are (A) avoiding high fat
foods ( B) modifying commonly available foods to make them lower in fat ( C ) substituting high
fat foods with a lower fat version o f the same food (D) using different preparation techniques.
In their study an initial pool o f 86 items was reduced to 28 by an expert panel o f nutritionists and
psychologists. The questionnaire was then distributed to a sample o f 400 women who also
completed two four-day diet records; any item, which correlated less than 0.5 with the diet
records, was eliminated. This final dietary behaviour questionnaire consisted o f 18 items. Kristal
et al (1990) have since evaluated the questionnaire in a variety o f clinical and research conditions
with satisfactory results. Beerman and Dittus (1994) further validated the questiomiaire in a
study with a group consisting o f men and women, again finding a high correlation with fat
intake. However while they found the questionnaire could identify participants with a high fat
intake, they questioned its ability to distinguish between participants with medium or low fat
intakes. In a more extensive test o f the questionnaire with 1,006 employees in a worksite
intervention Glasgow, Perry, Toobert and Hollis (1996) found the food behaviour questionnaire
to correlate well with more expensive and time consuming methods o f dietary assessment.

102
Interestingly Kristal, Andrilla, Koepsell, Diehr and Cheadle (1998) found no significant effect of
intervention bias with a food behaviour questionnaire, while social desirability effects were
found with two high fat food frequency questionnaires. However die questionnaires used in this
study were quite short. Kristal et al suggested that qualitative reports o f dietary habits such as
those used in a dietaiy behaviour questionnaire might be less subject to intervention bias than
quantitative recall. Overall limited research suggests that a brief behavioural assessment may
have value where assessment needs to be completed quickly and when it is necessary only to
measure an improvement in a participant’ s dietary behaviour rather than a detailed assessment o f
all their dietary habits, for example in community settings. However if more detailed assessment
is needed a dietary behaviour questionnaire can still be combined with food diaries or a more
detailed questionnaire. This will give insight into areas in which participants need to bring about
an improvement, for instance do they need to improve at modifying or substituting their dietary
intake.

The questionnaire in the following study attempts to address these issues by including a wide
range o f behaviours, which will give a broad indication as to the dietary behaviour o f the
participants. The questionnaire regarding fat intake consists o f 14 items from 2 sources, Bowen
et al (1994) and Hargreaves et al (1999). Items 1-7, were taken from Bowen et al (1994). Bowen
et al (1994) tested the validity o f the stages o f change model with 720 members o f an outdoor
folic music festival audience. Dietary behaviours were assessed under the term nutritional
strategies. The original questionnaire consisted o f 12 items. However 5 o f these items could be
rephrased under counterconditioning as identified in the transtheoretical model. The nutritional
strategy scale used by Bowen et al showed an increase in low fat behaviours throughout the
stages. With those in the post action stages using strategies most and participants in
precontemplation using them the least. The items loaded as a single factor with an eigen value o f
4.12. While only used in one study the items were generated following a series o f focus groups
and interviews some with individuals who had spent up to one year on a fat reduction
programme.

Items 8-14 in the present questionnaire were taken from the eating styles questionnaire
developed by Hargreaves et al (1999). This is a 16-item questionnaire, which focuses on the
behaviours related to low fat intake and high fruit and vegetable intake. The 7 items chosen
specifically related to fat intake. Items on this questionnaire were generated following cluster

103
analysis o f 53 items in an exploratory questionnaire administered to 174 participants. In follow
up analysis greater use o f the low fat behaviours was associated with progression through the
stages o f change. The combination of these groups o f items associated with progression through
the stages in previous studies implies that they may be accurate measures o f movement through
the stages in the present study. The questionnaire also focuses on the 4 aspects associated with
dietary behaviour, items 1,3, 4 and 6 focused on substitution, sample item “I substitute low fat
dairy foods for high fat dairy foods” . Items 2, 5 and 12 examined preparation sample item “ I
grill or bake instead o f frying foods” . Items 7, 8, 9, 10 and 13 focused on avoidance items
sample item “I avoid eating hamburgers and other high fat foods at fast food restaurants” . Items
11 and 14 focused on modification sample item “When I eat meats I choose low fat cuts or trim
off the fat” . Also the length o f the questionnaire, 14 items, adds to ease o f administration
particularly as the dietary questionnaire is followed by a lengthy processes o f change, self
efficacy and decisional balance questionnaires. Overall it is felt that this broadly based dietary
behaviour questionnaire will give an accurate and rapid assessment as to whether or not the
individual is maintaining or attempting to maintain a low fat diet. Responses are assessed on a 1-
7 lilcert scale ranging from never to always.

Staging Algorithm

To date the debate regarding the classification o f the stages o f change for dietary habits has
followed a similar pattern to the debate regarding dietary behaviour however with stage
classification no conclusive answer has yet been reached. As with the measurement o f an
addictive behaviour such as smoking, stage classification for an addictive behaviour is
straightforward as a participant will know if they are smoking or not. Or if they intend to give up
smoking or not. Following on from this classification into the different stages is a clear-cut
matter. Obviously other addictive habits such as alcholol and substance abuse follow a similar
pattern. However low fat dietary behaviour as previously discussed is not as explicit particularly
if a statutory cut off point such as 30-35% o f dietary energy is used. Only a small percentage o f
participants will be able to say with confidence when they have reached such a target.

As the transtheoretical model has been applied to behaviours many o f which do not have explicit
cut off points it is o f interest to look at the methods used for stage classification. One behaviour
which is similar to dietary behaviour is exercise acquisition. Reed,Velicer, Prochaska, Rossi and

104
Marcus (1997) in a comparison o f 3 staging algorithms for exercise acquisition concluded that it
critical to accurately stage individuals for each target behaviour. Reed et al in classifying
participants with exercise recommended giving a clear definition o f the target behaviour with a 5
choice reply format. For example a target behaviour may be “ exercise includes activities such as
brisk walking, jogging or swimming ........ being undertaken at least 3 times a week” .
Participants rated their present behaviour* or their intended behaviour on a 1-5 scale (strongly
disagree-strongly agree).

To date unlike with exercise there has been no detailed assessment o f the most accurate staging
algorithm for dietary behaviour. Many researchers simply use the participant’ s perceptions,
(Prochaska and Diclemente http://www.uri.edu/research/cprc/ 2000), Lamb and Sissons 1996,
Glanzet al 1994). Brng et al (1994) however queried this approach pointing out the dangers o f
participants wrongly classifying themselves as maintaining a low fat diet. O f the 1,507
participants interviewed in their* 1994 study a majority (55%) proved to be unrealistic about their
dietary fat intake with the vast majority (76%) underestimating their fat intake. Greene et al
(1994, 1998) introduced a 5 item behavioural criterion to be classified in a post action stage
participants were required to respond positively to at least 4 items.

Kristal, Hedderson, Patterson and Neuhauser (2001 p764) focused on stage o f change and dietary
behaviour from a different viewpoint, emphasising a person’ s subjective belief o f their
engagement with dietary change. For example should an individual who has reduced fat intake
from 50% to 38% and has maintained this change for more than 6 months be classified as a
precontemplater simply because they have not reached the criterion o f less than 35% fat intake.
This again pinpoints the problems with applying the model too rigidly to dietary behaviour,
which is on a continuum, unlike explicit addictive behaviours. Kristal et al argued for a different
interpretation o f the model citing studies showing that individuals already engaged with the
dietary process can and are more likely to adopt additional healthful habits. Kristal et al (2001
p764) therefore argued in favour o f a simple 5 item staging algorithm as this measures a
participant’ s engagement with the dietary process and not a cut off point. Clearly this is an issue,
which requires further investigation, and it is hoped the research in this study will contribute to
answering some o f the questions.

The exploratory study, staging algorithm contained five yes no response items and a 7 item

105
dietary behaviour scale. Paticipants who classified themselves in the post action stages (action
and maintenance) on the basis o f the staging algorithm did not score highly on dietary fat
behaviours. However the majority scored medium low fat behaviours indicating that while some
attempt was being made to reduce fat intake in many areas participants may need to reduce fat
intake further. Also many participants who classified themselves in the pre action stages
(precontemplation, contemplation and preparation) on the basis o f the staging algorithm also
classified themselves on a medium fat behaviours. Therefore individuals classifying themselves
in post or pre action may in fact be on approximately the same fat intake. This indicates that
many participants who classify themselves as being in post action may still be above the
recommended level o f fat intake. Also participants on similar levels o f fat intake perceive their
dietary status differently. However in support o f such a simple algorithm only 1 participant in the
precontemplation stage classified themselves as being on low fat behaviours overall and no
participants in the action or maintenance stages classified themselves as being on high fat
behaviours. Therefore with the extremes o f the stages this very basic algorithm appears to have
some validity. However methodological problems exist in that insights o f the group used
(psychology students may not be accurate). Also the dietary behaviour scale consisting o f 7
items may not contain the sensitivity to detect the difference between high and medium fat intake
in a large percentage o f cases.

In the light o f the research and experience in the pilot study several adjustments were made to
both the staging algorithm and as previously discussed the low fat behaviour measure. The
principle change to the staging algorithm being the addition o f 2 extra items. These items
allowed participants in action and maintenance to indicate their intention regarding future fat
intake. In this instance whether they intended to reduce their fat intake further. Individuals
therefore who have started to reduce their fat intake, but may not have reached the recommended
level could indicate if they intended to take steps to reduce their fat intake further. This is in line
with the Kristal et al argument that clinically important change needs to be recognised, and
individuals at this point should not be classified for example as precontemplaters or
contemplaters purely because they have not reached a behavioural cut o ff point. The participants
in this study, type two diabetics have all received advice from a qualified nutritionist on how to
maintain a low fat diet meaning they should have a clearer understanding than the students in the
pilot study o f the low fat dietary behaviours expected. The researcher believes that overall the
sensitivity o f these two scales (dietary behaviour and staging algorithm) will have increased

106
significantly from those used in the exploratory study.

Perceived Risk

Kristal, Hedderson, Patterson and Neuhauser (2001 p762) commented that many community
interventions to promote dietary change have at best had modest effects. An explanation put
forward is the concept o f unrealistic optimism (Weinstein 1982). Weinstein found in surveys
with students and the general public that many people believed they were less susceptible to
health problems compared with a sample o f other adults o f their own age and sex. Clearly if
people feel they are not at risk then perhaps they are less likely to adopt the behaviours which
prevent the problem arising. A strong association exists between diabetes - obesity and in turn
heart disease. The perception o f people with diabetes o f their risk o f heart disease and its
relationship to stage is o f interest. For example will precontemplaters or maintainers perceive
themselves as being most or least at risk. A single item was included asking participants to rate
on a 1-10 scale the extent to which they perceived themselves at risk o f developing heart disease
due to their intake o f fatty foods.

Dietary Knowledge Questionnaire

The relationship between dietary knowledge and actual behaviour change is unclear. Levy, Fein
and Stephenson (1993 p33) in an analysis o f data gathered between 1983 and 1988, found that
general public knowledge was low regarding dietary fats and cholesterol. The groups most
likely to have appropriate knowledge were those on a self prescribed lower cholesterol diet and
well educated middleclass whites. Individuals on a physician recommended cholesterol lowering
diet did not show good levels o f nutrition knowledge. Stafleu, Staveren, Graaf and Hautvast
(1996) in a sample o f 2052 Dutch women across 3 generations did not find any significant
correlation between nutrition knowledge and percentage o f energy derived from fat. McDonell,
Roberts and Lee (1998) however found in a sample o f 1,081 university employees that dietary
knowledge increased with stage progression. The sample o f participants with type two diabetes
in this study at the west London hospital are expected as part o f their treatment to maintain a low
fat diet. It will be o f interest to establish the level o f dietary knowledge regarding fat intake
participants will have and its relationship to stage o f change. Will for example as in the
McDonell et al (1998) study participants show increased knowledge as they progress through the

107
stages? One item concerning the recommended level o f energy to be derived from fat in the diet
was included. The Health o f the Nation document and numerous researchers estimate this at
35%. The scales used by McDonell et al (1998), Levy et al (1993) and Stafleu et al (1996)
consisted o f at least 11 items. Pressure o f space made inclusion o f a detailed questionnaire
impossible in this instance. However knowledge o f a general question regarding level o f fat
intake may give an insight into participant’s overall level o f dietary knowledge.

Processes of change

Greene, Rossi,Rossi,Velicer, Fava and Prochaska (1999 p675) in a summary o f the processes in
relation to dietaiy change listed 11 processes in total. These were divided them into experiential
and behavioural categories, 9 o f which are summarised in the following diagram.

Diagram: Processes of change

Experential Behavioural
Consciousness Raising Increasing awareness of Social Support Seeking others’ support
unhealthy dietary behaviour
Dramatic Relief Using feeling to help Reinforcement Being rewarded by yourself
motivation Management or others
Self Reevaluation Reassessing thoughts, feelings Counterconditioning Substituting healthful
and knowledge about oneself thoughts or behaviours for
unhealthful ones
Self Liberation Recognising choices and Stimulus Control Avoiding situations or
using will power, making places that trigger
commitments unliealthful behaviours
Environmental Assessing impact on family
Reevaluaton and friends

Greene et al (1999) included an additional experiential process o f Social Liberation

(becoming aware o f the changes in the environment that influence dietary behaviour plans) and
an additional behavioural process o f interpersonal systems control (avoiding other people who
encourage consumption o f high fat foods or act as a barrier to low fat behaviour patterns).
This questionnaire focused on the five experiential and four behavioural processes identified in

108
the original model (Prochaslca and DiClemente 1992), these processes were emphasised as the
processes central to change by Prochaska again in 1999. A thorough examination o f these will
give a detailed insight into the use o f experiential and behavioural processes whereas a less
thorough examination o f additional processes which may not play as crucial a role will not give a
worthwhile insight.

The exploratory study processes scale consisted o f 42 items measured on a 1-5 likert scale. Items
were selected from Bowen et al (1994) and the University o f Rhode Island web site
( www.uri.edu/researcli/cprc). Scores were exceptionally low on several subscales with participants

overall rarely scoring more than occasional use with any process. The highest score for example
with self reevaluation in the maintenance stage o f 15.2 indicates at best occasional use. There
are two possible interpretations o f this either these processes are not used very often or that the
scale lacked the sensitivity to detect their use. These problems were addressed in two ways firstly
by including additional items, seven items per process increasing the scale in total to 63 items.
Secondly participants were given more options on the scale by increasing it to 1-7 from 1-5.
Items were selected from Bowen et al (1994) and the University o f Rhode Island website with an
additional 20 items from participant’ s comments in the qualitative interviews. Copy in appendix
three.

Processes of change questionnaire structure

Firstly each process was measured by 7 items, giving a range o f scores from 7 to 49. Details o f
the source o f the items and a sample item for each process follows (complete questionnaire in
appendix three).

Consciousness Raising: Items 1-5 were taken from Bowen et al (1994) and items 6 and 7 were
adapted from information in the qualitative interviews. Sample item “I talk to people about the
systems or tricks they use to stay on low fat diets” .

Social Support: Items 8, 9, 10 and 12 were taken from Bowen et al (1994) and item 11 from the
University o f Rhode Island web site. Items 13 and 14 were taken from information in the
qualitative interviews. Sample item “ The encouragement o f others is a major factor in the
lowering o f fat in my diet” .

109
Dramatic Relief: Items 15 and 16 were taken from Bowen et al (1994). Items 17, 18 and 19 were
adapted from the University o f Rhode Island web site. Items 20 and 21 were taken from
information in qualitative interviews. Sample item “News reports and official figures about the
dangers o f high fat diets upset me” .

Environmental Reevaluation: Items 22, 23, 24, 25 and 26 were taken from Bowen et al (1994).
Items 27 and 28 were taken from the qualitative interviews. Sample item “I believe I can do
more for family and friends if I stayed on a low fat diet” .

Self Reevaluation: Items 29, 30, 31 and 33 were taken from Bowen et al(1994). Item32 was
adapted from the University o f Rhode Island web site. Items 34 and 35 were taken from
information in the qualitative interviews. Sample item “I believe that by eating a low fat diet I
will become a healthier and happier person” .

Reinforcement Management: Items 36 and 38 were taken from the University o f Rhode Island
web site. Items 37, 39 and 40 were taken from Bowen et al (1994). Item 41 and item 42 were
adapted from the qualitative interviews. Sample item “Eating high fat foods is not a problem
provided it does not happen too often” .

Self Liberation: Items 43, 44, 45 and 46 were taken from the University o f Rhode Island web
site. Items 47 and 48 were adapted from the qualitative interviews. Sample item “ I tell myself I
can make the necessary changes to maintain a low fat diet” .

Counterconditioning: Items 50, 51, 52 and 53 were taken from the University o f Rhode Island
website. Item 54, 55 and 56 were adapted from information in the qualitative interviews. Sample
item “ I find keeping myself busy is a good way to avoid eating high fat foods” .

Stimulus Control: Items 57, 58, 59 and 60 were adapted from the University o f Rhode Island
web site. Item 61 was taken from Bowen et al (1994). Item 62 was adapted from information
provided in the qualitative interviews. Sample item “When I shop I avoid areas where there are a
lot o f high fat foods” .

110
Decisional balance

Janis and Mann (1977 cited in Prochaska and Velicer 1994 p 40) conceptualized decision making
as a conflict model, consisting o f a careful examination o f the comparative gains and losses.
Prochaska and Velicer (1994 p41) theorised that decisional balance followed a fixed pattern in
relation to the stages o f change. In precontemplation the pros o f the problem behaviour will
outweigh the cons and in action and maintenance the cons will outweigh the pros. The crossover
between pros and cons takes place in either contemplation or preparation.

Different researchers have used varying measures with decisional balance in relation to dietary
change. Prochaska et al (1994) used a 24 item measure (12 items pro and 12 items con), while
Simmons and Mesui (1999) used 8 cons and 6 pro items. Steptoe, Wijetunge, Doherty and
Wardle (1996) in a postal survey o f South London residents used a 12 item questionnaire. The
pilot study questionnaire consisted o f 20 items, ten focused on cons and ten on pros. However
shortage o f space and the increase in the amount o f items in the low fat behaviour scale and the
processes o f change scale meant the amount o f items in the decisional balance scale needed to be
decreased. In order to make the new scale practical and having increased the number o f items in
the processes o f change scale it was decided to decrease the number o f items in the decisional
balance scale to 10 items overall. The new scale consisted therefore o f 5 pro items and 5 con
items. Again these were measured on a 1-7 likert scale with 1 meaning no importance at all and
7 meaning extremely important. While not matching the detail o f the Prochaska et al (1994)
study it is comparable with the measures used by Simmons and Mesui (1999) and Steptoe et al
(1996) and will be a valid measure o f decisional balance. Items were selected from University o f
Rhode Island website fwww.nri.edu/researcli/cprcl . Sample item for decisional balance pros “My
self respect would be higher on a low fat diet” . Sample item for decisional balance cons “A low
fat diet takes the pleasure out o f meals” .

Self efficacy

Bandura (1977) expected that individuals with high efficacy expectations, will cope with
difficult or high risk situations related to their changed behaviour. For example a smoker that

111
believes they can give up smoking has an improved chance o f success. In relation to dietary
behaviour Bernier and Avard (1986) found that pre treatment self efficacy scores were
significantly related to weight loss during treatment and post treatment efficacy predicted
maintenance o f weight loss at a 6 week follow up. The questionnaire in the exploratory study
consisted o f 20 items and focused on self efficacy with regal'd to negative emotions, availability,
social pressure, physical discomfort and positive activities. Pressure o f space in this
questionnaire necessitated the number o f items be reduced to 10. The new scale consisted o f the
2 items from each subscale with the heaviest loading in the factor analysis o f the pilot study data.
Subscales covered negative emotions (items 1,4), availability (items 2,7), social pressure (items
5,8), physical discomfort (items 6,9), positive activities (items 3,10). As in the exploratory
study the source o f items was Clark and Abrams (1991) “ Self Efficacy in weight management
scale” . Sample item “I can resist eating high fat foods when others are pressuring me to eat
them” . Items were measured on a 1-7 likert scale with 1 meaning not confident and 7 meaning
very confident.

Overall the use o f additional items in the low fat behaviour and processes o f change scales, the
inclusion o f the additional concepts o f perceived risk and dietary knowledge alongside the most
relevant items for decisional balance and self efficacy makes this set o f questionnaires a greatly
improved tool than that used in the exploratory study.

Intervention pamphlets

Central to the transtheoretical model is the belief that interventions matched to the stages o f
change are more effective than general interventions. A central aim o f this thesis is to research
this area and test stage matched interventions against a general intervention and against no
intervention. Five interventions matched to stage and one general intervention were designed.
The information contained in each intervention and its source are now explained.

Precontemplation pamphlet

In the transtheoretical model three processes consciousness raising, dramatic relief and
environmental reevaluation are linked with initiating progress from precontemplation (Prochaska

112
1992, 1999). Consciousness raising in theory consists o f observations, confrontations,
interpretations, feedback and education. While in an interview or clinical situation techniques
such as these are possible, Prochaska (1999 p 241) did acknowledge that a problem with
strategies such as confrontation is their high risk for retention. Therefore realistically in a
pamphlet which participants read for approximately 10 minutes, the best option is to encourage
participants to think and read further. Consciousness raising in the pamphlet consists o f making
participants aware that while some fat is necessary the majority o f the British population still
consumes too much fat in their diet and it is this excess fat which causes many problems. It is
also pointed out that a strong link exists between many serious health complaints and high fat
intake. Consciousness raising is covered in the first page o f the booklet.

The second strategy linked with movement from precontemplation is environmental re-
evaluation. This involves assessing how a person’ s behaviour is affecting their social
environment and how changing their dietary behaviour will improve this. Prochaska (1999
p242) in relation to smoking uses a dramatic example o f how ill health has an adverse impact on
other family members. The message in the pamphlet is similar making the person aware that it is
not just their health which is involved but also an improved quality o f life for those close to
them.

The third and final strategy at this point is dramatic relief, Prochaska (1999) defines this as
“Emotional arousal regarding one’ s current behaviour and the relief that can come from
changing” . Strategies such as role playing, personal testimonies and grieving are recommended,
but again many o f these are suited to interviews and one to one counselling. In the pamphlet this
is covered by encouraging the person to think o f someone they know who has lost weight and
imagine the feeling o f satisfaction and relief that goes with improved health.
The inteivention is kept brief as precontemplaters are not intending to change and are therefore
unlikely to spend time reading detailed booklets. It is hoped a brief dramatic booklet will
encourage them to at least think about changing. The goal at this po.int is to move them forward
to contemplation (copy o f pamphlet in appendix four).

Contemplation pamphlet

At this point in the change process participants are firstly congratulated for taking the first steps

113
to an improved diet, that is thinking about change. Prochaska (1999 p 240) pointed out that with
contemplaters an increase in the pros and a decrease in the cons is necessary before participants
will move from contemplation to later stages. Evaluating the pros and cons is a simple exercise
in which the participant is asked to list the advantages o f a low fat diet in one box and
disadvantages o f high fat diets in another one. The participant is instructed at the end to focus on
the advantages o f a lower fat content in the diet. The process emphasised at this point is self
reevaluation. With this the participant needs to evaluate how they will feel once they have
started a low fat diet. This is addressed in a simple exercise, requesting participants to list how
they will feel if they change on to a low fat diet and how they will feel if they remain on a high
fat diet. Overall it is hoped that an improvement in decisional balance and in greater use o f self
reevaluation will move the participant forward from contemplation (Copy in appendix four).

Preparation pamphlet

Again firstly the participant is congratulated for making a definite commitment to change. The
process emphasised to move participants onward from the preparation stage is self liberation.
This consists o f recognising choices, using will power and making commitments to change. Self
efficacy is also acknowledged as an important factor as a strong belief in the ability to change is
associated with increased incidence o f success. In the pamphlet firstly self efficacy is addressed
by asking the person to think o f problem situations associated with maintaining low fat
behaviours a list o f coping strategies used by others is also provided. Participants are then asked
to list situations in which they might find it difficult to adhere to low fat foods and following this
to list methods helpful to coping. The strategy is for the participant to be prepared for problems
and to develop a belief in their ability to cope with them. The participant should also see they
have a choice in that alternative behaviours are available to eating high fat foods. The next step
is to make a definite commitment to change, this means deciding on a firm starting date and
listing some o f the steps which they intend to take. The participant is also encouraged to think
ahead to the action stages and to have the back up o f at least one helping relationship (Copy in
appendix four).

Action pamphlet

At this point the participant is actively involved in improving their diet, but they have maintained

114
the behaviour for less than six months and so considerable process use is encouraged to maintain
and improve dietary behaviours. The processes targeted at this point are reinforcement
management, helping relationships, counterconditioning and stimulus control. Reinforcement
management implies the person reward themselves or at least acknowledges that they have made
a step forward. They are encouraged to do this by firstly reading through a list o f the rewards
other people have given themselves and to then make a list o f rewards they would like and a
timetable for receiving them. Overall they are encouraged to enjoy their improved diet. With
regard to helping relationships, participants are encouraged to make a list o f people who will be
supportive o f them and to list ways in which their support can be utilised. With
counterconditioning participants are encouraged to substitute harmful behaviours or interests
with beneficial ones. Participants are provided with a sample list o f substitute behaviours and
interests others have used for example in circumstances where it is difficult to maintain low fat
diets people may instead eat some fruit or take up alternative behaviours like exercise.
Participants are then encouraged to make a list o f alternative behaviours or interests they can
partake which will help them maintain a low fat diet and to list when they intend to start them.
With stimulus control, that is avoiding situations which trigger unhealthfi.il behaviours,
participants are advised to surround themselves with stimuli which encourage them to maintain a
low fat diet such as putting a list o f the benefits o f low fat foods where they can be clearly seen.
They are also encouraged to choose a starting date for putting the new stimuli in place (Copy in
appendix four).

Maintenance pamphlets

The strategies emphasised in maintenance are identical to those in action, that is reinforcement
management, helping relationships, counterconditioning, and stimulus control. Again
participants are congratulated for maintaining their low fat diet for some time. While the
strategies used at this point are similar to those used in action, participants are encouraged to
continue to reward themselves, for example, to have helpful supportive people whom they can
contact, to have a list of alternative behaviours and interests available to them, and to have
stimuli around them which will encourage them to maintain their low fat behaviours. However,
while people in action are expected to be enthusiastic it is accepted that those in maintenance
will be more comfortable with their behaviour and may occasionally break their diet.

115
Additional sections are introduced in the pamphlet. The first covers slips in their dietary
programme pointing out that infrequent brief slips in then diet need not be a cause for concern.
They only become a problem when they are maintained for some time. The final section reminds
them to think o f the benefits they have gained by maintaining their low fat diet and to list them
down. The emphasis at this point is more on consolidation o f behaviour and appreciation o f the
benefits gained. The cover sheets differed slightly acknowledging if a participant indicated they
intended to reduce their fat intake further still (Copy in appendix four).

General pamphlet

While this pamphlet was not designed to be specific to any one stage information was included
which covered all stages in that it consisted o f a cognitive processes (consciousness raising and
self reevaluation) a behavioural component (counterconditioning) and a decisional balance
section. With this combination o f processes and concepts participants received information
matched and mismatched to their relevant stage. The section on consciousness raising was
identical to that given to precontemplaters. The section on decisional balance matched that given
to those in contemplation, the section on counterconditioning matched that in the brochures for
action and maintenance. The content o f a half page section focusing on the benefits o f low fat
behaviours contained similar strategies to that given to participants in preparation or
contemplation (Copy in appendix four).

Sources of pamphlet content

The content of the pamphlets was adapted from Mija nutrition website (2000
www.cse.unl.edu/~mjia/nutrition) Hesonline nutrition ( http://www.hesonline.com/brochures.html).

Diet and Nutrition and the Prevention o f Chronic Diseases, The Health o f the Nation Document
Health and lifestyles, The commonsense guide to weight loss for people with diabetes (Hansen
2000). Several quotes were also introduced from the qualitative interviews conducted at the
University o f Surrey. Pamphlets were matched as closely as possible for style and size. However
o f necessity the pamphlets for the behaviour orientated stages, action and maintenance were
slightly larger. The precontemplation pamphlet contained five pages, contemplation pamphlet
four, preparation five, action pamphlet six pages and maintenance pamphlet seven pages. The
generalised intervention contained six pages. (Copies o f all brochures in appendix four).

116
Hypotheses

The hypotheses to be tested were similar to those previously examined in the exploratory study.
In total 8 hypotheses were included, the first five related to the transtheoretical model examining
the processes and concepts o f change. The last three focused on the processes and concepts in
this instance in relation to low fat behaviour. Hypotheses are summarised below.

1 Low fat dietary behaviour will be significantly higher in the post action stages (action and
maintenance) than the pre action stages (precontemplation, contemplation and preparation).

2 Processes o f change will match those outlined by the model. Specifically cognitive processes
will be emphasised in the pre action stages and behavioural in the post action stages.

3 Significant differences will be found with decisional balance pros and the decisional balance
cons between the stages. It is expected that the pros will score higher than the cons in the post
action stages and the cons higher than the pros in the early pre action stages with crossover
taking place in contemplation.

4 Self efficacy will be significantly different between the stages. Specifically post action stage
groups will score higher than pre action groups.

5 With perceived risk participants in precontemplation will see themselves less at risk o f
developing health problems from their intake o f fatty foods than participants in other stages.

6 Process use will be significantly different between the low fat behaviour groups. Specifically
those scoring higher on low fat behaviours will have higher scores on process use.

7 Scores on decisional balance pros and decisional balance cons will be significantly different
between the low fat behaviour groups. Specifically pros will be higher and cons lower for those
in the higher scoring groups,

8 Scores on self efficacy will be significantly different between groups. Specifically a higher

117
score on low fat behaviours will relate to a higher score on self efficacy.

Method

Questionnaires were distributed in 2 outpatients clinics for diabetics at South London hospitals,
between December 2000 and July 2001. Patients were approached in the waiting rooms and
asked if they would be willing to complete a questionnaire focusing on attitudes to dietaiy
change. They were informed it was part o f a six-month study with a follow up questionnaire in 6
months time. Participants received an information sheet detailing the purpose o f the study and a
consent form, which they signed to indicate their willingness to take part (copy o f ethics form in
appendix two). They were not advised however as to which type o f intervention they would
receive.

On completion o f the questionnaire participants were given either a matched brochure based on
the transtheoretical model, or general information brochure; participants in the control group
received no intervention. Pre-paid envelopes were distributed to participants, who could not
complete the questionnaire immediately, to allow completion and return o f the questionnaire at a
later date. Three months following the start date participants were posted a copy o f the brochure
they received at baseline. A second questionnaire with a pre-paid return envelope was mailed to
their home address six months after the start date. In summary an independent group design was
used with participants divided into 3 groups, a summary o f the study is included in table 4.1.
Table 4.1: Summary of Study Outline

Baseline Mid Point 3 Months Follow Up 6 Months

Questionnaires and intervention Repeated interventions Final questionnaires

pamphlets distributed. distributed distributed and
Total N = 955 returned

Stage matched pamphlet N = 327 Stage matched N = 327 Stage matched N = 60

General pamphlet N = 309 General N - 309 General N - 60

Control group N = 319 Control N = 319 Control N = 108

118
Baseline results

O f the 1273 questionnaires distributed, 858 were completed at the clinics, 97 were returned by
post, 15 were completed incorrectly in a manner which made them unusable, 308 taken by
participants were not returned. In total 955 questionnaires were returned making a return rate o f
75%. The general intervention was distributed to 309 participants, stage matched interventions
to 327. The control group receiving no intervention consisted o f 319.

Demographics

The final sample consisted o f 955 participants. However, not all participants answered all o f the
questions and therefore the total number on particular variables may be lower than this. Sample
consisted o f 510 males, 443 females, 2 participants did not answer, ages ranged from 1 8 - 9 0
with a mean o f 57. 584 participants were responsible for preparing and purchasing their own
food and 314 were not, 57 participants did not answer this item. With regard to education 381
did not hold any o f the listed qualifications, 188 held O levels, 73 A levels, 52 HND’ s or HNC’ s,
132 held first degrees and 75 Higher degrees (Masters or PhD), 54 did not answer this item.

Chi square analysis o f intervention type yielded a value o f .572 p>.05, therefore the important
issue o f equal distribution o f the intervention type has been achieved. Chi square regarding sex
was also significant yielding a value o f 4.9 p<.05. The sample therefore has a significantly
larger group o f males than females.

Stage Distribution

The first analysis will use the traditional classification o f the transtheoretical model using the
traditional algorithm containing five stages. Therefore those in action who indicated they
intended to reduce their fat intake further were combined with those who indicated they had been
on a low fat diet for less than 6 months. Those in maintenance who indicated that while on a low
fat diet they intended to reduce their fat intake further were combined with those who simply
indicated they had either been on a low fat diet for more than six months. Stages distributed as
follows, precontemplaters 159, contemplaters 57, preparation 57, action 107 and maintenance
575. Data summarised in figure 4.1.

119
 Figure 4.1: Stage distribution

stage

Low Fat Behaviours

954 participants completed this scale: Range 14-101, mean score 64.49, standard deviation 16.7.
Scores were divided into 3 groups, low, medium and high fat behaviour. High fat behaviour - 14-
42, medium fat behaviour - 43-71, low fat behaviour scores - 72-98. 3 scores were above 98,
this indicated the participants had scored 8 on items 3, 10, and 11 meaning they did not take
dairy products or eat meat. These participants were all in the low fat behaviour group. 93
participants fell into high fat behaviour scores, 497 medium fat behaviour and 364 low fat
behaviour.

120
Stage distribution and low fat behaviours:

Table 4.2 shows the numbers o f participants classified into each o f the 5 stages and into each o f
the 3 levels o f fat behaviours (high, medium and low). It can be seen that there is an association
between these two classifications, with the majority o f the participants in pre action stages being
classified as high or medium fat behaviours, while the majority o f those in post action stages are
in medium or low fat behaviours. Data summarised in table 4.2.

Table 4.2: Fat behaviours and Stage

High Medium Low

Precontemplaters 44 102 13
Contemplaters 10 44 3
Preparation 12 38 7
Action 8 66 33
Maintenance 19 267 287

Analysis o f fat behaviour scores showed a skew o f -.30, and kurtosis o f -Vindicating the data
is distributed close to normality and suitable for analysis using parametric tests. A one way
analysis o f variance showed F(4) =76.79 p>.001. Scheffe post hoc tests were conducted.
Significant differences between precontemplation versus action (p<.01) and maintenance
(p<.01), contemplation versus action (p<.01) and maintenance (p<.01), preparation versus action
(p<.05) and maintenance (p<.01), and action versus maintenance (pc.Ol). Mean scores
precontemplaters = 51.20, contemplation = 51.17, preparation = 55.35, action = 63.03 and
maintenance = 70.67. Meaning all pre action stages as expected differed from Action and
Maintenance, but there were no significant differences between the pre action stages. There was
however unexpectedly a significant difference between action and maintenance. Mean scores
summarised in figure 4.2.

121
 Figure 4.2: Mean scores low fat behaviours

stage

Perceived Risk

899 participants responded to this item. Analysis o f data showed a skew o f -.192 and kurtosis o f
-1.25, indicating the data are not normally distributed. A log transformation while reversing the
Kurtosis (.363) gave a negative skew (-1.109). A distribution o f this nature may be inevitable in
a sample with a chronic condition which may feel it has a higher than average risk o f developing
significant health problems. Two tests o f significance were nm. A one way analysis o f variance
F(4) =5.716 p<.001. Scheffe post hoc tests found significant differences between
precontemplaters and action (p<.05) and maintenance (p<.01) with differences with
contemplation and prepartion being close to significance (p<.10). Kruskal Wallis a non
parametric test suitable for unusually skewed data yielded chi square (4) 22.02; p<.001.
Precontemplaters were ranked lowest, meaning they perceived themselves at least risk o f
developing a significant health problem, despite their low fat behaviours being lower which
implies they are at greater risk. The mean scores are shown figure 4.3.

122
 Figure 4.3: Mean scores perceived risk

•o
> jsc:
<D (/)
2 S
Q)
CL

Stage

Dietary Knowledge

594 participants responded, 361 did not, 243 scored item 1, 178 item 2, 104 item3, 31 item 4, 35
item 5, 2 item 6 and 1 item 7. Therefore less than 20% answered correctly (item 2 correct
answer), 38% failing to answer the item at all. Within the stages correct answers were
precontemplation 31(19%), contemplation 15(26%), preparation 13(22%), action 19(17%),
maintenance 100(17%). Data summarised in figure 4.4.

123
Precon = Precontemplation Contem = Contemplation Prepare = Preparation Action = Action
Mainten = Maintenance

Data reduction and scale reliability

The validity and reliability o f questionnaires were assessed using a principal component analysis
o f the processes, self efficacy and decisional balance scales and an alpha reliability analysis o f
the subscales. With the processes questionnaire a principal components analysis using direct
oblimim rotation converged in 27 iterations. Nine factors with eigen values greater than one
accounting for 66% o f the variance emerged (copy in appendix one). Factors loaded broadly in
line with that outlined in the structure o f the questionnaire and the reliability estimates for each
subscale were acceptable. Results as follows.

Processes Scale

Items 1-7 measuring consciousness raising loaded as a single factor all with loadings greater than
.3. However item 2 also loaded on factor 7 (environmental reevaluation). Alpha reliability
equaled .86 and would not have been increased with the deletion o f any item. Items 8-14
measuring social support again loaded broadly as a single factor, however items 8 and 12 also
loaded on other factors. The alpha reliability was acceptable at .87, and this would not have been
improved by deleting any items. Items 15-21 measuring dramatic relief loaded as a single factor,
alpha reliability was acceptable at .94. Items 22-28 measuring environmental reevaluation loaded
mainly as a single factor but three items also loaded on other factors. Alpha reliability was

124
acceptable at .89 and this would not have been improved by removing any items. Items 29-35
measuring self reevaluation loaded as a single factor with the exception o f one item which did
not load on any factor. Alpha reliability was acceptable at .92, which again would not have been
improved by deleting any item. With items 36-42 measuring reinforcement management the
results were unclear: overall items did not load on any single factor but alpha reliability was
acceptable at .83; this would have improved slightly to .85 with the deletion o f item 42. Items
43-49 measuring self liberation loaded as a single factor with the exception o f item 49 which
only loaded at .24. Alpha reliability was acceptable at .87. Items 50-56 measuring counter
conditioning loaded as a single factor with the exception o f item 56. Alpha reliability was
acceptable at .88, which would not have been improved by deleting any item. Items 57-63
measuring stimulus control loaded as asingle factor with the exception o f item 62 which did not
load on any factor. Alpha reliability was acceptable at .89 and this would have improved slightly
to .90 with the deletion o f item 62. Overall the factor loadings and reliability scores are
acceptable matching broadly the processes outlined in the transtheoretical model. Therefore no
items were deleted or adjustments made to the process scale structure.

Transtheoretical concepts

With decisional balance a principal components analysis with direct oblimin rotation converged
in 6 iterations. Two factors emerged with eigen values greater than one explaining 60% o f
variance(copy in appendix one). All the decisional balance pro items loaded on one factor, alpha
reliability was acceptable at .86. All decisional balance con items loaded as single factor, alpha
reliability was acceptable at .86. Self efficacy was measured as a single concept it’s alpha
reliability was acceptable at .92.

Again with the concepts the structure broadly matched that outlined with the transtheoretical
concepts and the reliability levels were acceptable, analysis was therefore conducted on the basis
o f the original structure o f the questionnaire.

Use of transtheoretical processes and concepts at different stages

Scale items were combined to give a total score for each process or concept. In order for a
participant’ s score to be included at least 80% o f the subscale items had to have been completed.

125
Each process o f change consisted o f 7 items (maximum 49, minimum 7), self efficacy 10 items,
(maximum 70, minimum 7), pros o f change 5 items (maximum 35, minimum 5) cons o f change
(maximum 35, minimum 5). Individual scores and probability levels follow with overall results
summarised in table 4.3 and figure 4.5.

Processes o f change
Analysis o f skew and kurtosis for all processes with the exception o f self reevaluation gave
values less than one showing results to be suitable for analysis with parametric tests.
Accordingly scores for self reevaluation were log transformed, making the results for skew and
kurtosis less than one meaning scores on the trailsfonned variable were suitable for analysis
using a parametric test. One way analysis o f variance were calculated for each o f the processes
o f change with one factor o f stage. Significant differences were found with the use o f all
processes between stages.
Results are summarised in table 4.3 and figure 4.5.

Scheffe post hoc tests were conducted. With self reevaluation, environmental reevaluation and
self liberation significant differences were found between precontemplation and all other stages.
With consciousness raising differences were significant between precontemplation versus
preparation (p<.01), action (p<.01) and maintenance (p<.01) and contemplation versus action
(p<.05) and maintenance (p<.01). With social support differences were significant between
precontemplation versus action(p<.01) and maintenance(p<.01), contemplation versus action
(pc.Ol) and maintenance (pc.Ol) with differences between preparation precontemplation and
contemplation approaching significance p=.08. With dramatic relief significant differences were
foimd between precontemplation versus preparation (pc.Ol) action (pc.Ol) and maintenance
(pc.01). Differences between precontemplation and contemplation approached significance p
=.07. With reinforcement management significant differences were found between
precontemplaters versus preparation (pc.05), and maintenance (pc.Ol). With counter
conditioning differences were significant between precontemplation versus action (pc.Ol) and
maintenance (pc.Ol), and contemplation versus maintenance (pc.Ol). Differences between
contemplation and action and preparation and maintenance were close to significance p=.06 for
both. With stimulus control differences were significant between precontemplation versus action
(pc.Ol) and maintenance (pc.Ol), contemplation versus action (pc.05) and maintenance (pc.Ol).
Differences between preparation and maintenance were close to significance p=.06.

126
 ** ** 4
** *f ** *
*
*
*
•S'
*
*
*
0 VO cn O cn 00 m CN o
in o vq p
O
Q\ ■d* in p ON
4 + CN On cn CN + +
cn on
CN CN cn IN
CN
> CN CN

Ph

X
OO CN cn O in O
on
VO
O) On cq ON IN ON cn
CN CN ©
8 On v— '
OO cn vo cn OO
•i cn vo cn cn in CN vo VD
+ o ON + IN in
cn CN cn cn CN CN CN CN

X
in
H- (o O
CN
O
O
IN
on ON O On On

OO
CN o IN On
ON,
d
o m vr-H
— ✓
ON O n,
in 00
p in in'
oo IN OO VO
•tHo
o o in p p
in o CN ON CN 00 in CN
<1 cn CN cn cn CN CN CN CN CN

d
o vo ON
CN
o
CN
O 00
in cn IN T
“H vo
3 On ON, oo ON
Table 4.3: Mean scores transtheoretical processes and stage of change

c3 CN in 00 On' cn IN cn x-H on'

& oo vq cn O IN rt- p cn oo
*H N in 00 CN vd •+ cn r-H 00 LO
Ph CN CN CN cn CN CN CN CN o
V
Q.

127
d
0 it
t§ in 4?
3—\ IN IN ON ON
TD
r-H
vq in t-H in p O
vd 00 c
1 cn
ON
CN
ON,
cn of
ON,
(o '
OO ON,
o
3o o IN o p O\
t- H TD

id cn IN 00 vd CN r —f IN Q.
U CN CN CN CN CN CN CN O
£
oQ2.
d o0
<
o
0
E
cn IN ro
vo CN CN V)
IN
CN 00 cn 00 0
OO t-H O n, ON, oo sz
d n'
o
o VO IN o'
0 00
Jh t-H
cn t-H
o oo
oo
ON
p
+
Ph CN CN CN

IN
H- H* in
cn cn
cn in o o
ON On ON
CN
ON ON
CN
On
CN
ON
o
V
a.
*
ID
O
V
do
CL
0
<+h • t-H
0
’td Id § 0
d ■H 1 too O
2 o
•§ Cl 2
t§ 1 3 JO
d & 0 CO
c
0
o ■0I0f cd <|
H 0
a 8P I TD
d Id 4-j 1—I 0 Lh o o H->
2
Ph
o
O ■B Q 1 0
2 oo 00 P^ s
O
00 o 1o 00
co
 tr
ID
(
tJ)

o;a:a:a:_j2cooo
( j d i u c o w i f c o d c o

\ HI H 11 1
3
Pi

c
CD■
-i— p4
c +
CD 1<u
a
0 <+-<
D> rco
53
C
ro it
JC P
o oo
H-
o c rf

Precon = Precontemplation, Contem- Contemplation, Prepare = Preparation, Action = Action, Mainten = Maintenance
0 o o
D)
ro 4—»
0 o £
TS < CD
C
ro
0 ——(
<u
0 oo
0
0
0
o pi
o CD od
ef
o
£ O) g
o
§ • JS ■§
><u
J
0
40C
4 £ w Pi
Is!
S.S. = Social Support, C.C. - Counter Conditioning, S.C. = Stimulus Control.

c
2
4-»
0 0
£
o
o
0
c
0
11 1
1
w
ro C
0 Pi
S o w
to O
Pi
2
3
D)
iZ
c Q
o II
o
0 p
.f
•1
r~ ~T~
LO o lO o LO LO §
C/3

00 00 CM CM • rH
o
a
o
e jo o s u e e iA i U

Pi
0
Results Transtheoretical concepts

Scale items were combined to give a total score for each section, hi order for a participant’ s
score to be included at least 80% o f the subscale items had to have been completed. Self efficacy
consisted o f 10 items, (maximum 70, minimum 10), decisional balance pros o f change consisted
o f 5 items (maximum 35, minimum 5), decisional balance cons o f change also consisted o f 5
items (maximum 35, minimum 5). Results are summarised in table 4.5 and figure 4.6.

Analysis o f skew and kurtosis gave values o f less than one for decisional balance cons and self
efficacy. For decisional balance pros however the value for kurtosis was greater than one, and
therefore data were log transformed to reduce kurtosis to less than one and analysis conducted on
the transformed variable. Scheffe post hoc tests conducted and significant differences were found
between stages for all concepts using one way analysis o f variance. With decisional balance pros
and cons differences were significant between precontemplaters and all other stages (p< ,01).
With self efficacy differences were significant between maintainers and all other groups (p<.01).

Table 4.5: Mean Scores transtheoretical concepts and stage of change

N Precoii Con Prepare Action Mainten F

Pros 875 14.10(8.03)a 19.25 (7.2)b 20.79 (8.20)b 20.90 (8.35)b 20.18 (8.62)b 19.44**
Cons 878 15.90(7.25)a 20.60 (5.8)b 21.48 (5.79)b 19.13 (6.60)b 18.28 (7.49)b 8.23**
S.E. 856 48.08(17.25)a 45.08(13.04)“ 46.63(13.04)“ 46.98(15.61)“ 55.32(12.50)a 18.87**

** p <. 01 Precon = Precontemplation, Con = Contemplation, Prepare = Preparation, Action = Action, Mainten =
Maintenance,
Pro = Decisional balance pros, cons = Decisional balance cons, S.E = Self efficacyJMeans witli_same superscript do
not differ at p<.05.

129
 £
«
c
o
o
o

e
o
o

C
0
a

3
0
T3

0
a
C

fi
c
03

c
o

co
M—

2!
o
+j
■+-»

“cc
w

(0
ro
<1)

O
O
4(0

i—
+3

ro
D
in
in

in
x:

O)

D)
-»
CD

ejoos ued[/\|
<
c

o
o

o
O
0

0
it
C

o
C

c:

O
4-J

£Z
CO

5% o•)
§■ JS
OT

Precon = Precontemplation Con = Contemplation Prepare = Preparation Action = Action Mainten = Maintenance
Pros = Decisional balance pros Cons = Decisional balance cons S.E = Self efficacy
Analysis based on split post action stages

The staging algorithm used in this study differed from traditional staging algorithms in that it
offered participants in action and maintenance the option o f stating if they intended to reduce
their fat intake further. With dietary behaviour not being an explicit cut o ff behaviour it is
possible that participants who classify themselves in action or maintenance may intend further
behaviour change. It is o f interest if differences emerge between these groups on low fat
behaviours or any o f the transtheoretical concepts or processes. O f interest firstly is the number
o f participants who classify themselves in these additional stages when given the opportunity. Of
the 107 participants in action 77 or 71% classified themselves as intending to reduce their fat
intake further. O f the 575 participants in maintenance 256 or 44.5% classified themselves also as
intending to further reduce their fat intake. Analysis was conducted on the scores in these four
groups. Results are now summarised firstly with low fat behaviours and perceived risk.

With low fat behaviours significant differences were found between stages. Scheffe post hoc
tests were conducted. These found there were no differences between the two action or two
maintenance stages but between both action and both maintenance stages (p<.05). Participants in
maintenance showed more low fat behaviours than those in action which is in agreement with the
classification in the traditional stage o f changes where significant differences were found
between action and maintenance overall.

Results with perceived risk also found significant differences between stages F(3) = 3.81, p<.01.
Scheffe post hoc tests conducted significant differences found between those in maintenance
indicating further change and those not indicating further change (p<.05). Those in maintenance
wishing to increase their low fat behaviours saw themselves as more at risk than those indicating
no further change.

Transtheoretical processes

One way analyses o f variance were conducted and surprisingly significant differences were
found between stages for all processes (p<01) with the exception o f social support. Scheffe post
hoc tests conducted these found with consciousness raising, dramatic relief, environmental
revaluation, self reevaluation, counterconditioning and stimulus control differences were

131
significant between action and action further change, between maintenance and maintenance
further change and between maintenance further change and action. With environmental
reevaluation differences also significant between action and maintenance. With self liberation
and reinforcement management differences were significant between action and action further
and action and maintenance further change and with reinforcement management differences
between maintenance further change and maintenance were close to significance. Overall those
indicating further change tended to score higher on process usage whether they were in action or
maintenance. Results are summarised in table 4.6 and figure 4.7.

Transtheoretical concepts of change

With decisional balance pros and cons one way analysis o f variance found significant differences
for the cons between action and action further change (p= .01) and maintenance and maintenance
further change (p=.05), while differences between action and maintenance further change were
close to significant (p = .06). With decisional balance pros significant differences were found
between action further change and maintenance (p<.05) and maintenance further change and
maintenance (p<.01). Participants thinking o f further change scored higher on both pros and
cons. Interestingly these differences were not found in the initial analysis when significant
differences only emerged between precontemplaters and other stages. With self efficacy
significant differences were found between both action stages and both maintenance stages, in
line with the results in the analysis based on the initial stage classification where participants in
maintenance scored higher overall. Results are summarised in table 4.7 and figure 4.8.

132
 * * ■55- *
^^£5 01
*

13.31**
■3v *
F value

* * *

F value
* * * * * * * * * #

0.31
CO <N VO M 0 CO CO CO C
OO
O t-H
on oo p p t-M p MO MO OO
mo ON VD M0 VO oo vd vd rcd
—
H ON

X x/—\ X X X X &
X^I—\ T
--s X

71.53 (14.92)b
rt_^ o X
Maintenance

to'

Maintenance
CO /o' TO TO' o ?-N m ✓—\ o I'
/o' vo o p M0 On vq FT' G G VO
vq 1 O M p t-M p vo
CO1 pH cd
d T— y—1/ tC—
''—
O<
r—
H
✓
T
—
V_'1 1—1
t-M
p~H
t-H
oo,
Ss T
—^
(N o ont> O o VO o VO
i—i p On P p
T-H TO CO 00 °) MO CO
MO oo 00
d cd OO on 00 cd ld
t—1 t-H t> vd
CO <N CO CO <N CO CO TO
<o CO T
-1 MO
Maintenance further

Maintenance further
ort ortort ort X
rt_^

69.58 (14.59)b
/—\ rt 00 —s /—s
CO (O 00 TO' G 00s r- O G O
O ON
iH p vo p on oo T-H TO o' T—H OO
cd d— p td
ON cd d T-H TH O t-H
oo cd
. Table 4.6: Mean scores transtheoretical processes for post action split stages

r—HT-✓
-H 6 T-1 r-H T—(
K
OO <N oo OO oo ON CO CO oo t-T MO CO
V; T -1 ON °) p l> t-M TO vq <o p
CO id Y
—< CO d M0 td 1+ r—H O
N
CO CO CO CO CO (N <N
CO
MO
CO co T—1 TO
M O

X✓
)—\ X) N x>
/— X X X ✓ -t X X X rt rt
00 t-> /o' G G CO CO ON' rM G G
/o' G

p < .01 Means with same superscripts do not differ at p<.05

VO TO­ TO; on oo ON M0 t> ON P p
VO P
Action

d
Action

SS ON, 00 on on
V—' td
'w' T—1' ON^ OO M O oo T O
''— t-m t-H
oo
p CO1 VO CO CO M O O CO M0 O
P T
— p p CO rM CO CO t> p CO ON
vd OO CO MO CO d 00 d tdH id TO 00
CO T—I CO CO CO (N CO CO t— T-1 M O
t-m vd d
TO vo
rt rt rt rt rt rt rt a
Action further

CO ON /o' o ✓—\ rM—

Os rt
G OO p vo co CO rt rt
Action further

63.87 (14.63)“

p oo MO p oo o MO rM
oo r—t d d On✓
on 00 V-
M+ G P
T—I rH T-H 'w' ON p TO
'w' vd T O*
<N •TO
­ o oo o CO TO On TO SS rM
'— '
p CO p 00 T—< oo p TO p V O TO -H
t—H id CO TO cd VO 00 td MO rM vo t
CO
CO CM CO CO CO CO CO CO <o cd d id
CO CO TO
Reinforcement management
Environmental reevaluation
Consciousness raising

Counter conditioning

Decisional balance cons

Decisional balance pros
Self reevaluation

Stimulus control
Dramatic relief

fl
•1o—
< B
Low fat behaviours

§ &
flZ)
<
.-2
r— H
M m «73
pH
r—H o
<D o
CO 00
Ifl
dl
o
M
1
— m
H
<D
GO
 P4
£
0
fl fl A C£ CO o o 1is
O Q LU C/D CO c£ CO O CO rS
t— (
iw
I f + t 11} 11 <u
rH
CO

Q
0
.
CO
£
o
O ‘5
+00J *§
o
a
Id
B
tM
1—1
<d
CO
0
0
0
0 00
0
o
o fl
0
1
0
o 00 1
£ D)
0
o 0
2 r±
CO
0 73
JZ flD
4J
0 <
C
0
0
0.
b
o Iw
a
0
£
0
P4
0 P4
<<+D-t
•H
pH
<D
S~i
Tfr O
■rH
0
k_
3 0
.2? u
iZ Q
i f i i i r----- ~~
II
o L O O L O O L O O I j O O &
CO CO CN CM T- 'r-
Q
ojoos uee|/\|
.If
CO
’3
»-<
CO
CO
<D
fl
CO
fl
O
§
o
II

d
 2
£

p
c
c
" ra

o
c

o
c
o

3
2
0
2
a

2
0
0
a
a
0
0

0
H<
&

o
o

■+->

00
(/)

o
o
o

w
(!)
h -i

w
O

ii
L-
</)

'<5
+-»

J
CL

D)
U)

-/>
</>
<1>

0IO O S UB0|/\|
<
<

o
o
o
c
c

o
*4
0

c
c
.E
«fmJ

‘cs

1£3
‘ra
—i

0
0

*f-»
CO
CD

Pros = Decisional balance pros Cons = Decisional balance cons Efficacy = Self efficacy
Action-!- = Action further change Action = Action Mainten+ = Maintenance further change Mainten = Maintenance
Discussion

The unequal distribution o f participants across the stages is a problem common to the majority o f
stage o f change research studies. As referred to earlier Graaf, Gaag, Kafatos Lennemas and
Kearney (1997) found in a sample o f 14331 subjects across the European Union that 52% were
in precontemplation and 31% in maintenance, leaving 16% distributed across the remaining
stages. Greene et al (1999) estimated at any one time only one quarter o f the population is ready
to take meaningful action to change health behaviour. Therefore the distribution o f participants
in this sample with 23% about to or having recently taken action matches the distribution in
previous studies. However 44% o f the maintenance and 77% o f the action group indicated that
they still intended to reduce their fat intake further. The analysis concerning these groups will be
discussed following discussion o f the results based on the traditional stage classification.

The results were as expected with low fat behaviours showing significant differences existed
between the pre action and post action stages. In pre action the behaviour did not significantly
change at different stages, participants at these points are still thinking about change while
maintaining the old dietary behaviours. Unexpectedly a significant difference existed between
those in action and maintenance. Perhaps maintainers continue to reduce their fat intake to a
level lower than those who only recently adopted a lower fat diet. This again emphasises the
danger Prochaska and DiClemente (1992) pointed out o f equating action with maintenance.
Further interventions may still be necessary in action firstly to maintain change and secondly to
accelerate it. The first hypothesis was therefore supported as significant differences were found
between the pre and post action stages. Also overall the results show the revised 14 item dietary
behaviour scale to be a more sensitive measure than the seven item scale used in the exploratory
study which failed to locate change after precontemplation.

With perceived risk the low score in precontemplation is o f interest in that these participants
scored low on low fat behaviours meaning they are at higher risk o f health complications.
However their perception o f this happening to them is quite low. Maintainers see themselves as
being most at risk. The result with maintainers is slightly confusing, it may have been expected
that as they are on a low fat intake their perceived risk would have been less than for example
participants in contemplation and preparation and certainly less than those in precontemplation.
However another factor may be that their health has deteriorated significantly already and they

136
are in reality at greater risk. Therefore further examination as to how much at risk either group
actually is would be necessary before commenting further on the accuracy o f these results while
noting that participants pursuing high risk behaviours see themselves as less at risk. The
hypothesis regarding perceived risk was therefore supported to the extent that precontemplaters
scored significantly lowest. However more detailed research may be necessary with this concept.

The most interesting factor regarding the dietary knowledge scale is the number o f participants
who simply did not answer it a total o f 361 participants that is approximately 39%. This high
abstention rate makes proper interpretation o f the scores difficult. The main conclusion perhaps
is that the question used is not a suitable question for this type o f study. Many participants as
seen in their dietary behaviour scores are aware o f the proper low fat behaviour's yet they may
not have interpreted these into a percentage o f their energy derived from fat. Perhaps dietary
knowledge needs to be explored in a more direct fashion, for example asking participants which
foods contain the highest fat levels. Mcdonnell et al (1998) examined this area with 11 items
asking for example if participants knew the difference between saturated and unsaturated fats
and what products these were found in. A more direct approach like this might prove more
productive.

With the transtheoretical processes o f change, as expected precontemplaters scored lowest with
all processes. Significant differences also existed between precontemplaters and other stages
with each process. Again this differs from the pilot study which found no significant differences
between stages in the use o f social support, dramatic relief and environmental reevaluation, with
differences only emerging between precontemplation and the post action stages with
consciousness raising, self reevaluation, reinforcement management, self liberation,
counterconditioning and stimulus control. The most likely explanations for this difference is the
greater numbers in all stages and the increased sensitivity o f the present questionnaire, which
contained more items and used a 1-7 likert scale. However again overall the pattern expected o f
process use in the transtheoretical model did not emerge with for example cognitive processes
such as consciousness raising not decreasing in the post action stages. However results for
stimulus control a behavioural process were closest to the model with differences in all the pre
action stages being significant or close to significance with post action stages. Overall however
the second hypothesis was not fully supported.

137
With decisional balance significant differences were found between precontemplaters and a ll.
other groups with pros and cons. The difference with pros was as expected with
precontemplaters scoring lowest, but with the cons the precontemplaters also scored lowest,
where it might be expected they should score highest on these items. Precontemplaters scored
highest with cons in the exploratory study. However in comparing the scores on the pros and
cons the expected pattern emerged in that scores on the cons were higher than the pros for those
in precontemplation, contemplation and preparation, with this pattern changing in action and
maintenance. Therefore while the score for cons was higher in maintenance at 18.28, than it was
in precontemplation at 15.90, the score with the pros has also increased significantly in
maintenance reaching 20.18 as opposed to 14.10 in precontemplation. This indicates that to
initiate dietary change the crucial factor is that the pros outweigh the cons rather than simply
reducing the cons and increasing the pros. Also the measure used in this analysis was not as
detailed as the measure used in the exploratory study which may have emphasised the change
over in pros and cons more thoroughly. However it was comparable with the measures used in
previous research. Previous research shows a decisive shift to be necessary in decisional balance
before change is achieved (Prochaska et al 1992, McDonnell et al 1998). In the stages where the
participant is considering change contemplation and preparation, the score for cons increased
considerably, which is not in line with the transtheoretical model. This suggests a decrease in the
cons at these points but even at these points the pros were also increasing, though they had not
overtaken the cons. The third hypothesis therefore was not fully supported.

Regarding self efficacy maintainers scored significantly higher than all other groups, the
dramatic drop in preparation shown in the pilot study was not repeated. The scores indicate that
precontemplaters have approximately the same belief as those in contemplation, preparation and
action in their ability to maintain a low fat diet. Only in maintenance when an individual has
maintained low fat dietary behaviours for some time does their belief in their ability to maintain
a low fat diet increase substantially. Therefore the fourth hypothesis that self efficacy would
increase with stage progression was supported with one post action stage.

The scores show a different picture emerging in this study than the exploratory study, in
particular regarding low fat behaviours and the processes o f change. The results regarding the
pros and cons and self efficacy indicate that differences only emerge at the extreme ends o f the
stages, that is between either precontemplaters or maintainers compared to the other stages. This

138
raises questions regarding the value o f classifying participants in the other stages with regard to
these concepts. For example if a participant in preparation has the same level o f self efficacy as
a participant in precontemplation should interventions be tailored differently regarding this
concept?

The next question, which arises, is whether or not the results fit the pattern outlined in the
transtheoretical model. To fit the model it is expected firstly that the cognitive processes such as
consciousness raising, dramatic relief, environmental reevaluation and self reevaluation will be
used significantly more at the pre action stages from precontemplation to preparation, with the
more behaviourally orientated processes coming into use in the post action stages. Firstly with
consciousness raising this does not fit the pattern outlined in the model, in that scores are lowest
in precontemplation and increase linearly until maintenance. To fit in with the model scores
should be highest at contemplation or preparation and decrease in the post action stages where
the need to be aware should already be well established. A similar pattern is seen with
environmental reevaluation with again the highest scores being found in the post action stages.
However with dramatic relief that is using feelings to motivate dietary fat reduction and self
reevaluation that is reassessing thoughts feelings and knowledge about unhealthy dietary
behaviour (Greene et al 1999 p675) the highest scores were in preparation. The pattern with
these processes follows the classic “Mount Change” Greene et al (1999 p676) in that processes
are used as the person initiates action and then tail o ff once the action is established. This
supports the model which suggests making people aware o f these feelings will motivate them to
change, implying that interventions aimed at these processes will be more effective in promoting
or supporting change than general interventions.

Regarding the behavioural processes these loosely follow the pattern outlined in the model, with
the highest scores being foimd in the post action stages. With social support differences were
significant between the post action stages and precontemplation and contemplation,
counterconditioning was also approaching significance up until contemplation, with stimulus
control differences were close to significance between all post action and pre action stages, a
similar pattern emerged with reinforcement management. With self liberation however this was
not the case though the scores were highest in action which is as expected in the transtheoretical
model. Therefore some support emerges for the model in that the behavioural processes in
particular appear to be suited to the post action stages and some cognitive processes may be

139
particularly suited to the earlier stages. This again indicates value in interventions at these stages
focusing on these processes and in particular avoiding putting emphasis on the behavioural
processes in the pre action stages perhaps with the exception o f preparation. To a lesser degree
these results were supported in the exploratory study, in that consciousness raising and
environmental reevaluation increased throughout the stages. However so also did dramatic relief
and self reevaluation, though self reevaluation did show a dramatic increase in contemplation. In
the exploratory study however self efficacy did show a dramatic fall in preparation which was
not repeated in this study.

Overall a number o f questions need to be answered. Firstly does classifying participants on the
basis o f a simple staging algorithm limited to five stages supply useful information, that cannot
be obtained with other classifications? It would be expected that precontemplaters would score
lowest on all processes and concepts with the exception o f decisional balance cons. However, to
allocate participants to precontemplation it would simply be necessary to ascertain if participants
were on a low fat diet and if not if they intended changing in the future. O f value are the low
scores in perceived risk in precontemplation indicating that participants at this point may need to
be made more aware o f the risks associated with high fat intake. The value o f cognitive
interventions as opposed to behavioural ones for the pre action stages cannot be fully explored in
a cross sectional study such as this. However this study shows that cognitive processes such as
consciousness raising are still used in the post action stages and may therefore be a crucial factor
in maintaining and improving behaviour throughout the stages. This supports the conclusion
made in the qualitative exploratory study that cognitive processes still play a part in dietary
change at all stages. Therefore classifying participants on the basis o f stage may not mean
interventions can be tailored solely on the basis o f cognitive and behavioural processes,
particularly for the post action stages, although it may be o f value to emphasise the cognitive
processes in the pre action stages.

The additional classification o f participants in the action and maintenance stages into participants
intending and not intending further dietary fat reduction provided interesting insights. With all
processes and concepts with the exception o f self efficacy participants intending further change
scored highest. With self efficacy participants in maintenance not intending further change
scored highest. Interestingly although these were all post action stages the increase was not
solely with behavioural processes as might be excepted as in the transtheoretical model

140
behavioural processes are emphasised at this point, but all cognitive and behavioural processes
showed an increase. Also consciousness raising a cognitive process remained one o f the highest
scoring processes. For those in action intending further change it was in the cognitive processes
scored highest and for those in maintenance intending further change they also scored highly.
These results demonstrate again that action and maintenance may not be fixed stages with dietary
behaviour but stages subject to further behavioural change. For example even in maintenance
where low fat behaviours have been maintained for more than 6 months people may decide to
initiate further change. These are factors which future researchers will need to take into account
in designing future staging algorithms for behaviours without clear cut o ff points and more
importantly in designing interventions.

To fully evaluate the transtheoretical model however further analysis is necessary examining
results for the transtheoretical processes and concepts across levels o f fat intake. This will help in
deciding if the stage concept can pinpoint differences in a manner which traditional methods o f
classification may not. Analysis in the exploratory study showed that process use simply
increased linearly with reduced fat behaviours. It will be o f interest to examine whether or not
this pattern repeats itself in this larger study.

141
Analysis based on low fat behaviour scores

Participants were divided into low medium and high fat intake groups on the basis o f their low
fat behaviour scores. The scores possible on the low fat behaviour questionnaire ranged from 7-
98. Those scoring highest showed the greatest number o f low fat behaviours. However the actual
results ranged from 1 4 -9 8 . Accordingly participants were divided into low, medium and high
fat behaviour's groups as in the exploratory study. Participants scoring 14-42 showed the least
low fat behaviours and were included in the high fat behaviour group. Participants scoring 43-71
showed medium low fat behaviours and were included in the medium fat behaviour group.
Participants scoring 72 - 98 showed the highest low fat behaviours and were included in the low
fat behaviour group. The majority o f participants (54%) were in the medium category, 36% into
low and 10% into high. Therefore 90% o f participants are taking some steps toward reducing
their fat intake including a large number o f precontemplaters. This is as expected in a group with
type two diabetes as low fat dieting is a central strategy and most participants will have taken
some steps to reduce their fat intake even slightly. A wide range o f scores however is contained
within the low, medium and high categories, meaning they may not totally match the detail
contained in the stages o f change concept. This classification however will give an indication as
to whether or not process use increases with adoption o f low fat behaviours.

Processes of change

Analyses o f variance were conducted firstly with the transtheoretical processes on the basis of
low fat behaviour groups. Analysis o f variance results were highly significant for all processes
with the exception o f reinforcement management. Scheffe post hoc tests found significant
differences for the use o f all processes between all three groups. Results are summarised in table
4.8 and figure 4.9.

142
 «■ *
0 * ■X * * •& *
a VD * * * •X- on
45- 4 *
H © ON © lN CN ©
75 vo © OO t-H
s. CN IN
t> r-H
vb in ON IN cb ON t-H
Ph CN x—H
r-H H* CO VO 'vf VO

O o o o o O o
✓— \
H 00 CO VO cf S t-H S
Os © OO vo © co vo CO CO
OO cb © T—H © © t-H t-H t-h
£
Q s— ^
r-H
r-H x—H r-H t-H t-H t-H
*■— '
t-h t-H
V_ '
t— CO CN VO © VO vo
r-H CO CO OO ON IN © vo
H*
CO NO CN cb t-H CO ON IN vo
CN CO CO CO CN CN CN CN

„o
£
X
r-H
©
XI
t-H
1(0
X
©
©
X
©
CO
CO
CO
X
t-h
VO
^—N
NO
X
of
T-H
OO CN © CN o © © ON ©
r-H t-H r-H t-H t-H t-H
'"C T-1
CN S
0 ON ft' of ON vo
W— OO CN s
IN r-H CN On 00 © NO
NO CN
CN CN IN 00 VO CN CN ON
CN CN --1
Table 4.8: Mean scores transtheoretical processes at level of low fat behaviour

CN CN CN CN

CO
cd
CTj IS) cd CD CD CD ■q-
/— s
cD t-H © N t-H
N
H*
CN
CN
VO © IN
CO
'O' CN
s
©
CN
<rH
OO
T— 1
r-H
r-H
in'
t-H
t-H

NO
CN
t-H

OO
©
t-H
t-H
CO
on,
OO
©
x-H
of
©
r-H
ff
©
T-H
CO
o NO
NO IN CN CN NO CO
CN OO
y—{ t-H t-H On
t-H
CN ON
x—H
NO
r-H
b
t-H
CN CN

t-
0
NO
H
ON
CO
CO
ON
CO
ON
CN
CN
ON
CO
t-H
rt
CN
©
T7t-
©
t-h
'sf
©
on On ON On ON

a 'S
o 0
bo
■a
S3
CO <+H
0
a
0
'•§ s
0
s? t; If
-
T 1

•g ’r0a & '9 g o O

CO +-! l
CO
0
o
C
C
0
O
O tH 2
aO ■rH 73 *§
0 s a &
w OT
o
o
C 10 rS
v4 1
o
o -2
a a 75
•IH
P-t •oH 0 tH

a Q § »( CO
<+H a

CO 2
o th
V
0
r-H
0 §
2
o
o
00 9 ’■4->
+H
00
Oo
10
00
Oo

1 p4
 2
A

«
2

c
A

o
o
A

2
£

k.

k.
0
0
3

to
4-

0
0
0

o
o
o

0
0
c
i—

TO
1

iZ
U)
0

ro
ro
ro

O
O
(0
w

4->

O)
<0

4->

cr>
4->

</>

O
toJ-
00
LO o
CM 00
LO
\

o
CM
8J00S UBQ[/\I
LO
qcqcqcqC- j

Hll

LO
d d L L i c b d o f d d d
S cooo

X
TD
3

0
E

J=
Q)
0
0
e

>
-C
O
3

LL
<0

C.R. = Consciousness raising, D.R. = Dramatic Relief, E.R. = Environmental Reevaluation, S.R. = Self Reevaluation, S.L = Self Liberation, R.M. = Reinforcement Management,
S.S. = Social Support, C.C. = Counter Conditioning, S.C. = Stimulus Control.
High = High fat behaviours, Medium = Medium fat behaviours, Low = Low fat behaviours
 Concepts of change

Analysis o f variance were conducted on the transtheoretical concepts and significant differences
were found with self efficacy and decisional balance pros. Scheffe post hoc tests found
significant differences between all groups (p<.01). With perceived risk analysis o f variance was
again significant. Scheffe post hoc tests found significant differences between high fat
behaviours with medium and low (p<.01), there were no significant differences between medium
and low fat behaviours. Also analysis o f variance was not significant for decisional balance cons.
Results are summarised in table 4.9 and figure 4.10.

Table 4.9 : Mean scores transtheoretical concepts at level of low fat behaviour

j Concept High Medium Low F

Pros 15.59 (8.7)a 18.60 (8.2)b 21.20 (8.9)c 17.14**
Cons 17.94 (7.90) 18.34(6.7) 18.40 (7.8) .13
Efficacy 42.27 (16.89)a 50.07 (14.19)b 57.42 (11.8)c 49.31**
Perceived Risk 5.13 (2.6)a 6.17 (2.8)b 6.44 (3.3)b 6.68**

* p<.05, ** p<01. Means with same superscript do not differ at p<.05

Pros = Decisional balance pros Cons = Decisional balance cons Efficacy = Self efficacy
Perceived Risk = Perceived risk

145
 £
5

o
o
o
o

0
0

£
X

0
0
£

£
c
o
0
a
0

V)
0
0
0
0
0
JZ

0
3

c
>

75

•4-J
>

3
U)

iZ
Z

O)
O

4->

<n

ojoos
ueaiAj
0

sz
3
E

3)
'!
£
3

Li.
0
0
O

£ X2
75 x:

Pros = Decisional balance pros, Cons = Decisional balance cons Efficacy = Self efficacy
High = High fat behaviours Medium = Medium fat behaviours Low = Low fat behaviours
Discussion

All o f the transtheoretical constructs with the exception o f the cons in decisional balance and
reinforcement management in the processes showed significant differences across levels o f low
fat behaviours. Perceived risk showed a significant difference between those on high fat
behaviours and those on medium and low fat behaviours. Implying that once the individual
perceives themselves at risk action starts however those on medium fat behaviours may need to
reduce their fat intake further as it is unlikely to be below 35% o f dietary intake. This again
emphasises the dangers pointed out by Brug et al (1994) in a participant’ s perceptions o f their
diet being unrealistic. Self efficacy showed a linear increase, with participants maintaining low
fat behaviours showing the highest level o f belief. With the transtheoretical model those in the
last stage maintenance had the highest level o f self efficacy. However no significant differences
existed across the other stages including surprisingly precontemplation and action. This implied
that participants in action and precontemplation have a similar level o f belief but the results with
low fat behaviours contradict this showing that as the person’s level o f engagement with the
dietary change increases so too does their belief in their ability to maintain their behaviour.

With the transtheoretical processes and low fat behaviours consciousness raising showed a linear
increase, indeed this is similar to the results in the stages which showed increased use o f
comisciousness raising as a participant progressed through them. Dramatic relief also showed a
linear increase, however progression in stages showed a slightly different pattern, increasing up
until preparation and then showing a slight fall off. This is in line with the model in that
dramatic relief should be more effective in the pre action stages. Stage o f change algorithms may
show more sensitivity with this concept perhaps pinpointing where it is most effective.
Environmental reevaluation also showed a linear increase, which is similar to the pattern shown
across the stages. Self reevaluation also showed linear increase, again not quite in line with the
stage analysis which showed increase up until preparation, tailing off in action and maintenance,
the difference at that point however was not significant. With reinforcement management no
significant differences were found across levels o f low fat behaviours, however with the stages
classification significant differences were found between precontemplaters and other groups, this
may be another area where the stages classification is more sensitive. As a process reinforcement
management is supposed to be emphasised in the post action stages therefore it is somewhat
surprising that it is not emphasised in for example low fat behaviours. With self liberation again
the increase was linear; this is similar to the pattern on the stage classification though with this

147
significant differences only emerged between precontemplation and the other stages.
Connterconditioning again showed a linear increase, a similar pattern to that shown with the
stages. The same pattern emerged with stimulus control showing a linear increase across the fat
behaviour groups and across the stages.

The results for decisional balance with low fat behaviours showed a linear increase with the pros,
and significant differences between all groups. This is as expected as a person becomes
increasingly engaged with low fat behaviour that the advantages will become increasingly
apparent to them. The results with the cons were not as expected however showing these
remained virtually the same at all three levels o f low fat behaviours. Participants on medium fat
behaviours scored virtually identically on the pros and cons. However the standard pattern in
comparing pros and cons was maintained in that participants with high fat behaviours rated the
cons higher than the pros, at medium they are virtually the same and when the individual moves
into low fat behaviours the pros score higher than the cons. Overall the results with pros are
similar to those found using stage classification, precontemplaters scoring lowest and those in
later stages scoring higher. With the cons the stages o f change classification also showed a
difference between precontemplaters and all other stages, indicating that a stage o f change
classification may be more sensitive with this construct than a simple level o f engagement with
the dietary process.

The results with perceived risk were similar with fat behaviours and stages o f change
classification. Participants with high fat behaviours perceived themselves as least at risk and
those in precontemplation also perceived themselves as least at risk. However once the
participant started to think about change or initiated some change as in the medium fat
behaviours group their perception o f risk increased significantly. This demonstrates perhaps that
it is only when the perception o f risk is higher that engagement with the dietary process
increases. This implies that an intervention may need to make a participant acutely aware o f the
dangers o f high fat intake. This becomes clearer with the fat behaviours classification than the
stages classification. With the stages classification it appeared only to be necessary for the
person to be intending to change that is be in contemplation for awareness o f the risks involved
with high fat behaviours to increase.

The next question that arises as to the advantages o f classifying individuals by stage and

148
designing interventions based on this concept as opposed to simply classifying individuals on the
basis o f fat behaviours and giving interventions based on all the processes. Brag et al (1994)
found that a majority o f participants underestimated their fat intake. Lechner and Brag (1998)
found with an initial classification based on stages o f change placed 14% o f participants in
precontemplation, however when classification was based on a strict dietary estimate this
increased to 55% many o f whom were unaware that they needed to make further changes.
However the pattern emerging in this study is the transtheoretical model actually showing a
sensitivity which may be lost with a simple classification based on level o f dietary intake. With
for example cognitive processes such as self reevaluation and dramatic relief peaking more in
preparation. The more sensitive measures in this study, show a pattern in the stages o f change
which is closer to fat behaviours than that shown in the exploratory study which only showed
differences emerging between precontemplaters and others groups with a few processes. More
sensitive measures again containing more items may match closer the outline suggested in the
transtheoretical model.

However in a comparison with the processes between low fat behaviour and stage groups,
consciousness raising for example which showed a linear increase across the stages still had a
slightly higher mean score in the low fat behaviour group than in the equivalent group in the
stages classification that is maintainers. This is as expected as the maintainers group (stage
classification) also contained a small group o f people with high fat behaviours. This raises the
question as to whether classifying participants purely on the basis o f dietary intake as in the fat
behaviour group is a good decision. Classification purely on the basis o f low fat behaviours may
mask clinically important change as suggested by Rristal et Al (1999). With the transtheoretical
model,which focuses on the individuals cognitive engagement with their dietary behaviour and is
not simply a matter o f measuring dietary intake this aspect o f clinically important change is
included. For example an individual in maintenance who still has high fat behaviours may have
in fact reduced their dietary fat intake considerably from where they were one year* ago.

Classification on the basis o f stages o f change may give that extra insight. For example
participants in action scored highest in social support, before tailing o ff slightly in maintenance.
A factor like this may go unnoticed in a simple high medium low fat behaviours classification,
which shows a linear increase. A similar pattern emerged with dramatic relief and self
reevaluation, peaking in preparation. Stages classification also gave insights into reinforcement

149
management, and decisional balance cons where significant differences were found between
precontemplaters and other stages while differences were not found with the low fat behaviours
classification. Overall classification based on stages appears to give valuable insights into the
use o f processes rather than a simple classification based on the assumption that for example all
individuals on less than 35% fat are at the same point and therefore require the same
intervention. In fact the stage classification shows that many such individuals in the post action
stages wished to reduce their fat intake further.

Perhaps a combination o f both classifications is advisable, with the designing o f interventions

based on the results from both. For example an individual in the pre action stages using a stages
classification may benefit from interventions emphasing the use o f cognitive processes and an
individual in the post action stages may benefit from an intervention emphasising the use o f
behavioural processes. However if it became apparent that significant dietary change was still
required after using a dietary classification, interventions may need to be adjusted accordingly.
For example to initiate significant dietary change to reduce an individual’ s fat intake from 50%
to 40% cognitive processes such as consciousness raising may be appropriate. Indeed such an
individual may be classified as being in either the maintenance or action stages where
behavioural processes become more appropriate. However a dietary behaviour measure would
show that further fat reduction may be necessary, in which case interventions using a mix a
cognitive to initiate further and behavioural to maintain previous change may be necessary. A
simple classification based on either dietaiy measures or stages could not encompass all these
areas.

Conclusion

To summarise the results suggest that in the pre action stages (precontemplation, contemplation
and preparation) the theory o f the cognitive processes being o f most value appears to hold,
however there is no evidence o f these being disregarded in favour o f behavioural processes in the
post action stages in fact cognitive processes appear to be playing a major if not the major role at
this point. Therefore from the evidence in this study cognitive processes are o f value throughout
the process o f dietary improvement and therefore need to be emphasised at all stages, perhaps in
conjunction with behavioural processes in the post action stages. However in the pre action
stages the emphasis from this study suggests that cognitive processes may be the primary

150
catalysts for change. However as previously stated in this thesis and emphasised by researchers
such as Weinstein (1998) the true test o f a stage model can only be established with longitudinal
studies. Therefore this brings us to the next point o f this study the 6 month follow up analysis o f
returned questionnaires which will be discussed in the following chapter.

151
Chapter 5: Longitudinal analysis of the application of the transtheoretical
model to the low fat behaviours of participants with type two diabetics.

Introduction

Despite its application in a wide range o f health areas the transtheoretical model has been
criticised by numerous researchers. One o f its most prominent critics Sutton (1996) describes it
as an ideal model o f how people should change which may not be applicable outside o f clinical
settings. As previously stated a key component o f the model is that the use o f processes follows
a specific pattern, implying that interventions matched to that pattern will be more effective than
general interventions. However, the evidence for this is somewhat contradictory. Prochaska et al
(1993) found for example that self help materials matched to stage were more than twice as
successful as standard action orientated interventions. However, research by Dijkstra, De Vries,
Roijackers and Van Brueklen (1998) and Quinlan and McCaul (1999 cited in Sutton 2001 p 183)
again with smokers was not as conclusive. This therefore is a key area in which further research
is essential to establish the validity o f the model.

Sutton (1996) also argues that serious concerns exist with sequential movement through the
stages, another key area o f the model. Sequential movement implies that for example individuals
in precontemplation will most likely progress to contemplation, before preparation and from
there to the post action stages. However, Sutton doubts if this is the case and cites the Prochaska
(1991) study with 960 self changing smokers in which less than 16% showed stable progression
over two years, with apparently no participants progressing sequentially through 3 or more
stages. Horwath (1999 p307) in a review o f the model in relation to eating behaviour, points out
that many o f the longitudinal intervention studies examining the transtheoretical model are not in
fact matched to the stages o f change, but have merely included an assessment o f stage as an
indicator o f change. Horwath also emphasises the need for more research into the use o f
processes rather than single constructs such as stage.

152
Therefore the longitudinal study o f the present research will provide a valuable insight into these
crucial areas, following participants over time to discover if movement is sequential and if
process use matches that outlined by the transtheoretical model. Several hypothesises are tested.

Hypotheses

(A) Stage progression will follow the predicted pattern across six months.

(B) The use o f processes will follow that outlined in the model, specifically cognitive processes
will decrease and behavioural processes will increase with progress from pre to post action
stages.

(C) The decisional balance pros will increase and cons decrease with progress through the
stages.

(D) Self efficacy will affect stage movement.

(E) Interventions based on the transtheoretical model will be more effective then general
interventions or no intervention at all.

Method

The method was outlined in detail in the previous chapter (pi 16), to revise briefly, stage matched
and general interventions were distributed at baseline and three months, with questionnaires
being completed at baseline and six months with participants in the intervention groups receiving
an additional questionnaire on the effectiveness o f the interventions they received at six months
(Copy questionnaire in appendix 3).

153
Results

The first analysis concerns the rate o f return o f questionnaires. The expected result in line with
the transtheoretical model is that participants who received matched interventions will respond in
greater numbers than participants who received the general intervention and that intervention
group participants will respond better than no intervention. However, the results did not confirm
this, hi fact in the control group 108 participants returned completed questionnaires at follow up,
in the matched intervention 60 returned completed questionnaires at follow up, and in the general
intervention 60 returned questionnaires at follow up, giving an overall return rate o f 24%.
Intervention type had no effect but the control group responded in higher numbers than the
intervention groups. This difference was significant (chi 27.23 (2) pc.Ol).

Comparisons were also conducted with the response rate o f different demographic groups. With
gender o f the 512 males at baseline, 124 responded at follow up, with the 443 females at baseline
104 responded difference not significant (chi 0.04 (l),p>.05). With stage o f the 159
precontemplaters 40 responded, o f the 57 contemplaters 14 responded, o f the 57 preparers 7
responded, o f the 107 in action 27 responded and o f the 575 in maintenance 140 responded.
Differences were not significant (chi 3.06 (4) p>.05). With age participants were divided into
those over and under 60. With the 470 participants over 60 129 responded,of the 484 participants
under 60, 99 responded this difference was close to significant (chi 3.93(1) p = .06).

The most interesting data to emerge from a longitudinal study with regard to the TTM is the
sequence o f movement across stages. Will this be in line with the movement predicted in the
model? The first step is to look at the group in total, that is the 228 who replied at time 2. Table
5.1 shows clearly that over a six-month time frame there are no dramatic changes in the number
o f participants at each stage; chi square tests showed no significant differences.

154
Table 5.1:Number of participants at each stage at the baseline and follow up
Stage A Number baseline Stage follow up Number Follow Up
Precontemplater 40 Precontemplater 35
Contemplater 14 Contemplater 13
Preparation 7 Preparation 8
Action +* 21 Action + 12
Action 6 Action 10
Maintenance +* 49 Maintenance + 57
Maintenance 91 Maintenance 93

* Participants in action and maintenance indicating further dietary change

The next issue to be addressed is the movement o f individuals at different points in the stage
model. Will for example someone in contemplation move to preparation or even action in line
with the model? The present data shown in table 5.2 does not fully support this. Of the 40
participants in precontemplation at baseline 25 were still in precontemplation at follow up, 1
moved to preparation, 3 were in action and 11 were in maintenance. Forward movement had
taken place, but no precontemplaters moved to contemplation. It is, however, possible those
showing forward movements had previously passed through contemplation, though none
remained there for 6 months as suggested in the transtheoretical model. With the 14 participants
in contemplation at baseline, at follow up 8 were in contemplation, 2 in action and 4 in
maintenance. Again forward movement had taken place but no participants were in preparation,
though it is again possible those showing forward movement had already passed through this
stage. Of the 7 in preparation at baseline, 3 remained in preparation at follow up, 2 moved into
action, 2 into maintenance. With the 27 people in the action stages at baseline at follow up 5
were still in action, one moved back to preparation, 5 to precontemplation and 15 moved forward
to maintenance. Movement is expected at this point and the majority move in the direction
predicted, that is forward to maintenance. With the 141 participants in maintenance at baseline,
the majority 118 remained in the maintenance stage at follow up, ten were in action, three in
preparation, five in contemplation and five in precontemplation. Overall the majority o f
participants 164 remained in the same stage over the six months with 69 showing movement, 40
foiward and 29 backward. The results are summarised in the table 5.2.

155-
Table 5.2: Stage Movement for main stages between basline and follow up

Baseline Stage N Pc C Pr Ac M Forward Back

Pc 40 25 1 3 11 15
C 14 8 2 4 6
Pr 7 3 2 2 4
Ac 27 5 1 1 5 15 15 7
M 141 5 4 3 10 118 22
Total 228 35 13 8 22 150 40 29

Pc-precontemplation, C-contemplation, Pr - preparation, Ac - action, M - maintenance

Analysis of entire group at follow up

The next step is the examination o f behaviour and process use longitudinally. The first factor to
be examined is the low fat behaviour scale. 225 participants completed this at baseline and
follow up. The mean score at baseline was 66.09 and at follow up was 67.95. Across the group as
a whole this difference was close to significance t (224)= -1.82 p = .069, indicating there was an
increase in low fat behaviours overall.

Analysis o f the data within the follow up group showed significant differences across stages. A
one way anova conducted across stages yielded the following results F (4)=20.42 pc.01.
Significant differences were found between precontemplaters versus action and maintenance,
and between contemplaters versus action and maintenance. This indicates again that the scale is
valid in discriminating between those on high fat diets and those on low fat. The small number in
preparation at time two may have effected the results possibly being the reason why no
significant difference was found between preparation and the post action stages.

156
Paired t tests were conducted for each stage between baseline and follow up. Participants were
grouped according to stage classification at time 2. A significant difference was found with the
maintenance group only t(147)= -2.21 p<.05. Results are summarised table 5.3.

Table 5.3: Low fat behaviour scores with stages at baseline and follow up

Stages at follow up N Baseline Follow up t value

Precontemplation 35 53.38 50.62 .954

Contemplation 13 56.17 57.75 -.43
Preparation 7 64.35 59.12 1.06
Action 22 67.22 72.92 -1.91
Maintenance 148 69.87 72.62 -2.21*

• *p<.05
With the processes o f change across the entire follow up group differences were significant
from baseline to follow up in the use o f social support t(222)= 2.14, p<.05, self liberation t(218)
= 2.23 p<.05 and counter conditioning t(219) =2.50 p<.05. Results are summarised in table 5.4.
Table 5.4 : Mean scores for processes baseline and follow up

Process No Baseline Follow Up t value

Conscious Raising 218 29.12(9.7) 28.2 (9.57) 1.44
Social Support 223 24.72 (10.96) 23.46 (11.31) 2.14*
Dramatic Relief 220 22.14(11.57) 21.81 (12.58) 0.48
Environmental 223 28.17 (10.68) 27.49 (11.23) 1.16
Self Reevaluation 220 28.77 (12.02) 28.05 (12.38) 1.16
Reinforcement 223 22.59 (9.75) 22.07(9.57) 1.01
Self Liberation 219 27.58(11.02) 26.12(11.23) 2.23*
Counter Condition 220 24.17 (10.61) 22.64 (11.42) 2.50*
Stimulus Control 215 20.56 (10.05) 20.83 (11.41) 0.45
*p<.05

157
With the remaining concepts in the transtheoretical model are decisional balance (pros and cons
o f behaviour) and self efficacy. No significant differences were found with these concepts
between baseline and follow up among the group as a whole. The scores for perceived risk while
not specific transtheoretical concept are also included differences were not significant. Results
are summarised in table 5.5.
Table 5.5: Mean scores of transtheoretical concepts at baseline and follow up
Concept No Mean Baseline Mean Follow Up t Value

Cons 211 17.49 (7.40) 17.78 (7.17) -.53

Pros 209 18.16 (8.16) 18.51 (8.69) -.69
Efficacy 202 52.89 (13.75) 53.55 (13.83) -.64
Perceived risk 203 6.31 (2.95) 6.13(3.03) .69

Cons = Decisional balance cons, Pros = Decisional balance pros, Efficacy = Self efficacy
Perceived risk = Perceived risk

However, o f greater importance is the use o f processes in each individual stage longitudionally.
Therefore an analysis o f process use in each stage was conducted. The first analysis focused on
precontemplaters.

Analysis of results of processes and concepts for stable precontemplaters and forward
movers at basline and follow up.

Participants who were in precontemplation at baseline were split into two groups, those who
remained in precontemplation at follow up (stable precontemplaters) and those who moved
forward (forward movers). Two way mixed factor anovas were conducted for each process
between forward and stable precontemplaters at baseline and follow up. The F ratios from these
analyses are shown in table 5.6 and the means at baseline and follow up are shown in table 5.7.
Consciousness raising for the factor movement was close to significance F(l) = 3.49 p = .07.
For the interaction between time and direction F(l) = 5.07, p<.05. Further analysis with
independent t tests showed a significant difference at follow up between stable and forward
movers, t(36) = -2.44 p<.05 with forward movers using consciousness raising more. The factor

158
movement, for self liberation was close to significance F(l) = 3.46, p=.07. Independent t tests
found differences between stable and foiward movers were close to significance at follow up
t(37) = -1.82, p=. 07 with again foiward movers using the process more. Results for social
support, dramatic relief, environmental reevaluation, self reevaluation and reinforcement
management were not significant.

Decisional balance cons differences were not significant but for decisional balance pros the
factor movement was significant F(l) = 4.57 p<.05, independent t test found pros were greater
for forward movers than stable precontemplaters at follow up but not baseline, t(34) =-2.47
p<.05.

A central concept with the transtheoretical model is that the scores o f decisional balance pros
will outweigh the scores on decisional balance cons with progress from precontemplaton to later
stages. To examine the difference within groups paired sample t tests were conducted with stable
and foiward movers. Significant differences were found between the pros and cons o f decisional
balance for stable precontemplaters t(22)=3.24, p<.01, with this being repeated again at follow
up t(22) =2,50, p<.05. The cons were rated significantly higher than the pros at each point. With
forward movers however, no significant differences were found for decisional balance pros and
eons at baseline or follow up. However the pros were rated higher than the cons at each point.

Self efficacy was greater for stable precontemplaters than for forward movers F(l) = 7.07 p<.05.
Interestingly this was not in the expected direction, this is similar to the results in the pilot study
which found those about to make change scored low on self efficacy. With fat behaviours
movement anova there were significant effects for movement, F(l) = 4.78 p<.05 and the
interaction between time and movement was also significant F(l) = 4.96, p<.05. Independent t
test found foiward movers scored higher than stable precontemplaters at follow up t(37) = 2.74
p<.01. A significant differences was also foimd with foiward movers between baseline and
follow up t(13) = 3.50 p<.01. There were however no significant differences for stable
precontemplaters between baseline and follow up. With perceived risk anova was close to
significance for movement F(l) =3.15, p =.08 and the interaction time and movement F(l) = 3.15

159
p = .08. Independent t test found differences between stable and forward movers close to
significance at follow up t(31) = -1.82 p = .08. Analyses are summarised in table 5.6 and 5.7.

Table 5.6: F values from two wav anovas for stable and forward movement
precoiitemplaters at baseline and follow up with transtheoretical processes and concepts.
Factors are time and movement.

Variable Time Movement Interaction Time and Movement

C.R 1.41 3.50a 5.07*
S. S. 0.54 1.15 0.60
D. R. 0.13 0.85 0.24
E.R 0.38 1.03 0.83
S.R 0.72 2.63 0.18
R.M 0.28 0.12 1.55
S.L 0.1 3.46 0.74
C.C 0.62 2.79 0.01
S.C 1.23 2.71 1.61
Cons 2.18 0.14 0.72
Pros 5.79* 4.57* 2.00
Efficacy 1.34 7.07* 2.39
Low Fat 3.43 4.78* 4.96*
Perceived risk 1.41 3.15a 3.15a

* p<.05, ap<.10.
C.R= Consciousness Raising, S.S= Social Support, D.R= Dramatic Relief, E.R= Environmental Reevaluation,
S.R =Social Liberation, R.M= Reinforcement Management, S.L,= Self Liberation, C.C= Counter Conditioning,
S.C = Stimulus Control, Cons = Decisional Balance Cons, Pros = Decisional Balance Pros, Efficacy = Self
Efficacy, Low Fat = Low Fat Behaviours, Perceived risk = Perceived risk

160
Table 5.7: Mean scores for processes and concepts for stable and forward movement
precontemplaters at baseline and follow up.
Stable Forward Movement

Process N Base Follow T Value N Base Follow t Value

C.R. 24 20.67 19.21 0.91 14 23.42 27.89 -2.11*

S.S 25 19.12 17.69 0.95 14 21.61 22.39 0.77
D.R 25 17.00 16.12 0.64 14 20.14 19.78 0.09
E.R 25 21.52 21.08 0.27 14 23.71 26.00 0.09
S.R 25 19.32 17.48 1.7 14 25.15 24.77 0.17
R.M 25 18.56 17.60 0.60 14 17.80 20.23 -1.08
S.L 25 17.48 16.55 0.61 14 21.07 23.07 -0.54
c.c 25 15.88 14.80 0.84 14 20.80 19.50 0.38
S.C. 22 13.54 13.32 0.18 14 16.50 19.85 -1.08
Cons 24 17.09 18.00 0.89 14 14.49 18.30 -1.51
Pros 23 13.26 14.60 -0.96 12 16.80 22.00 -1.95
Efficacy 22 55.60 55.45 0.31 12 39.99 48.00 -1.87
Low Fat 25 49.14 48.16 0.28 14 53.47 64.09 -3.50**
Risk 22 4.91 4.91 0 11 4.55 6.82 -1.59

* p<.05, ** P<.01
C.R= Consciousness Raising, S.S= Social Support, D.R= Dramatic Relief, E.R= Environmental Reevaluation,
S.R =Social Liberation, R.M= Reinforcement Management, S.L.= Self Liberation, C.C= Counter Conditioning,
S.C = Stimulus Control, Cons = Decisional Balance Cons, Pros = Decisional Balance Pros, Efficacy = Self
Efficacy, Low Fat = Low Fat Behaviours, Risk = Perceived risk

161
Analysis of results for contemplaters and preparers at baseline who remained stable and
contemplaters and preparers who showed forward movement.

Unfortunately the numbers in the contemplation and preparation stages initially at baseline and
who again completed follow up questionnaires were exceptionally small (stable contemplaters
n=8, stable preparation n=3, foiward contemplation n=6, forward preparation n=4). Therefore in
order to gain insight into the changes in process use it was necessary to combine the scores o f
both stages for stable and forward groups. The reasoning was that both groups consist o f
participants who had indicated a willingness to change.

Two way mixed factor anovas were conducted for each process between stable and forward
movers combined contemplaters and preparers. The results are summarised in table 5.8 and 5.9.

The difference with time was close to significance for consciousness raising F(l) = 3.63,p=.07,
with greater use o f consciousness raising at follow up. With dramatic relief the difference in
movement that is between stable and forward movers was significant F(l) = 6.83, p<.05.
Independent t tests were conducted and significant differences found at baseline t(18) = -2.33,
p<.05 and follow up t(18) =2.22 p<.05, with forward movers scoring higher at baseline and
follow up. With self reevaluation the difference with movement was significant F(l)
=4.47,p<.05. An independent t test found differences in follow up scores between stable and
forward movers to be close to significance t(18) = -1.90, p = .07 with the foiward movers scoring
higher. With reinforcement management a significant differences was found with movement F(l)
= 5.62, p<.05. An independent t test found significant differences at follow up t(18) = -2.53,
p<.05 again forward movers scored significantly higher. With self liberation a significant
differences was found with movement F (l) = 4.32, p = 0,05. The difference in follow up scores
between stable and forward movers was close to significance t(18) = -1.80, p = .08. again
foiward movers scored higher. With counterconditioning, environmental reevaluation and
stimulus control no significant differences were found.

With the transtheoretical concepts no significant differences were found with decisional balance
cons, decisional balance pros, self efficacy and perceived risk. With low fat behaviours the

162
interaction between time and direction was significant F(l) = 4.15, p = .05, and differences were
close to significance for time F(l) = 3.44, p = .08. There was an increase from baseline to follow
up but only for the forward movers, as would be predicted.

Table 5.8. Two wav Anovas. F values for stable and forward movement contemplaters and
preparers at baseline and follow up with transtheoretical processes and concepts. Factors
time and movement.

Variable Time Movement Interaction Time and Movement

C.R 3.63a 0.13 0.05
S.S 0.03 0.45 0.01
D.R 2.32 6.83* 0.09
E.R 0.38 1.74 0.11
S.R 1.29 4.47* 0.71
R.M 0.66 5.62 0.50
S.L 2.92 4.35* 0.00
C.C 0.45 0.50 0.17
S.C 0.33 0.98 1.37
Cons 0.41 0.14 1.55
Pros 1.92 1.39 0.09
Efficacy 1.01 0.21 0.28
Low Fat 3.44 0.96 4.15*
Perceived risk 0.17 1.20 0.02

a p <.10, * p < .05

C.R= Consciousness Raising, S.S= Social Support, D.R= Dramatic Relief, E.R= Environmental Reevaluation,
S.R =Social Liberation, R.M= Reinforcement Management, S.L.= Self Liberation, C.C= Counter Conditioning,
S.C = Stimulus Control, Cons = Decisional Balance Cons, Pros = Decisional Balance Pros, Efficacy = Self
Efficacy, Low Fat = Low Fat Behaviours, Perceived risk = Perceived risk

163
Table 5.9: Mean scores of transtheoretical processes and concepts for stable and forward
movement contemplaters and preparers

Stable Forward Movement

Process N Base Follow T Value N Base Follow t Value

C.R. 10 24.20 26.80 -1.01 10 24.80 28.13 -1.88a

S.S 10 18.80 17.80 0.58 10 17.10 18.80 0.47
D.R 10 17.30 20.00 0.76 10 26.72 30.80 -1.48
E.R 10 24.18 24.70 -0.15 10 28.50 30.20 -1.14
S.R 9 28.11 23.33 1.36 10 33.20 33.50 0.21
R.M 9 18.78 16.40 1.25 10 24.86 24.70 0.06
S.L 10 23.88 19.63 1.30 10 29.30 25.30 1.12
C.C 10 21.40 19.00 0.74 9 22.66 22.11 0.18
S.C. 10 16.90 15.95 0.47 9 17.77 20.66 -1.06
Cons 9 20.61 19.88 0.63 9 18.44 20.69 -1.07
Pros 9 19.66 21.44 -1.02 9 16.55 19.33 -0.99
Efficacy 10 39.80 45.70 -1.59 10 43.66 45.50 -0.27 1
Low Fat 10 56.64 55.86 0.25 10 51.43 58.23 -2.14
Risk 11 6.64 6.82 -0.16 10 7.40 7.80 -0.48
a p < .10

C.R= Consciousness Raising, S.S- Social Support, D.R= Dramatic Relief, E.R= Environmental Reevaluation,
S.R =Social Liberation, R.M= Reinforcement Management, S.L = Self Liberation, C.C= Counter Conditioning,
S.C = Stimulus Control, Cons = Decisional Balance Cons, Pros = Decisional Balance Pros, Efficacy = Self
Efficacy, Low Fat = Low Fat Behaviours, Risk = Perceived risk

Combined forward movers for all pre action stages

In order to research further the role o f process use in general those in the three pre action stages
who moved forward were combined to form a forward movement group and a comparison was
made with those who remained stable. The results are summarised in table 5.10 and 5.11 and
figures 5.1 and 5.2. Overall there was a general effect across processes such that participants who

164
moved forward were likely to use processes more than participants who did not move forward.
This was significant for consciousness raising, dramatic relief, self reevaluation, self liberation,
counterconditioning and was marginally significant for environmental reevaluation. For
consciousness raising this effect was tempered by a significant interaction and a marginally
significant effect for baseline versus follow up, such that forward movers increased the use o f
consciousness raising from baseline to follow up but stable participants did not.

With the transtheoretical concepts no significant differences were found for the decisional
balance cons. However decisional balance pros increased significantly over time F(l) = 7.54,
p<.01. A paired sample t test found a significant difference over time with forward movers t(21)
= 2.19, p<.05. For self efficacy a significant difference was found with movement F(l) = 5.09,
p<.05. This however was not in the expected direction with forward movers scoring lowest. With
low fat behaviours there were significant main effects for time and movement and a significant
interaction between the two. With forward movers there was a significant increase between
baseline and follow up t(23) = 3.60, p<.01. While for those remaining in their original stage
there was no significant change t(34) = .34,p>.05. With perceived risk differences for movement
were close to significant F(l) = 3.23, p = .08, independent t test found significant differences
between stable and forward movers at follow up t(52) = -2.26, p<.05. With forward movers
perceiving themselves as being at greater risk.

165
Table 5.10: Two wav mixed factor anovas for stable and forward movers pre action stages
at baseline and follow up for transtheoretical processes and concepts. Factors time and
movement.

Variable Time Movement Interaction Time and Movement

C.R 3.59a 4.01* 4.43*

S.S 0.004 0.43 1.20
D.R 0.37 5.36* 0.25
E.R 0.69 3.02a 0.97
S.R 1.79 7.03** 0.66
R.M 0.01 2.84 1.76
S.L 0.39 8.23** 0.62
C.C 0.32 3.87* 0.85
S.C 1.64 4.04* 2.86
Cons 2.74 0.06 1.44
Pros 7.54** 2.46 1.75
Efficacy 1.83 5.09* 0.80
Low Fat 7.67** 6.55* 10.16**
Perceived risk 2.37 3.23a 1.99

lp<.10 *p<.05 **p<.01

C.R= Consciousness Raising, S.S= Social Support, D.R= Dramatic Relief, E.R= Environmental Reevaluation, S.R
=Social Liberation, R.M= Reinforcement Management, S.L.= Self Liberation, C.C= Counter Conditioning, S.C =
Stimulus Control, Cons = Decisional Balance Cons, Pros = Decisional Balance Pros, Efficacy = Self Efficacy, Low
Fat = Low Fat Behaviours, Perceived risk = Perceived risk

166
Table 5.11: Mean scores for processes and concepts stable and forward movers in pre
action Stages
Stable Forward Movement

Process N Base Follow T Value N Base Follow t Value

C.R 34 21.71 21.50 0.15 24 24.00 27.99 -2.85**

s.s 35 19.03 17.72 1.12 24 19.73 20.89 0.54
D.R 35 17.08 17.22 -0.10 24 22.88 24.37 -0.59
E.R 35 22.28 22.11 0.11 24 25.70 27.50 -1.20
S.R 34 21.64 19.02 2.13* 24 28.50 27.86 0.27
R.M 35 18.62 17.25 1.09 24 20.05 22.09 70.81
S.L 35 19.30 17.43 0.19 24 24.50 24.00 0.19
c.c 35 17.45 16.00 0.26 23 21.53 20.52 0.43
S.C 34 14.53 14.09 0.43 23 17.00 20.17 -1.49
Cons 33 18.05 18.51 -0.35 22 16.37 19.28 -1.89
N Pros 31 14.74 16.16 -1.^3 22 16.70 20.90 -2.19*
Efficacy 32 51.35 52.40 -0.37 22 41.66 46.86 -1.37
Low Fat 35 51.28 50.36 0.34 24 52.12 65.82 -3.60**
Risk 33 5.48 5.55 -0.18 21 5.90 7.29 -1.62

* p<.05, **p<.01

C.R= Consciousness Raising, S.S= Social Support, D.R= Dramatic Relief, E.R= Environmental Reevaluation, S.R
=Social Liberation, R.M= Reinforcement Management, S.L.= Self Liberation, C.C= Counter Conditioning, S.C =
Stimulus Control, Cons = Decisional Balance Cons, Pros = Decisional Balance Pros, Efficacy = Self Efficacy, Low
Fat = Low Fat Behaviours, Risk = Perceived risk.

167
 3

o
o

0
o

2
0
o

3
0

0
2

c
o
S

ro
2a

ro

IT)
ro
ro
ro
ro
ro

O
k-

CD
as

O
TL3.

LL
0

\
1
1
i
CO Q

T
X
1

+
Cd CO PL CL DL

\ I

seaoos uee|/\|
LU CO Cd w o
_i o

1
o

1
CO

0
0
C
O

CD
LL

CO
13
Q.

0
3
(0

CO
C.R - Consciousness raising, S.S = Social support, D.R = Dramatic relief, E.R = Environmental reevaluation, S.R = Self reevaluation,
R.M = Reinforcement management, S.L = Self liberation, C.C = Counterconditioning, S.C = Stimulus control
£
o
E
■E Q_
0 3

£ O
.2
*3 O
O
0

£
a
o
u
£
0 G )
0 (/) CD

X 3

Cons = Decisional balance cons, Pros = Decisional balance pros

73
£
O +J
’w CO
o
0
T3
0
k.
O
0
c/>
£ CD
0 c
0
2 a3
C/5
01 03
to CD
0
&MI
3
U)
iZ

S 9 J I0 3 S U B 0 [/\|
Post action stages

The next step is to examine the use o f processes and concepts in the post action stages. As
expected at the action stage movement forward and backward in stages took place. However,
only 27 (25%) participants in action at baseline replied at follow up. O f these, 7 moved
backwards, and 15 forward while 5 remained in action. The small numbers moving backward to
the pre action stages or remaining in the action stage made data analysis o f these individual
groups impossible. Therefore those in action at baseline who either moved backward in stages or
remained stable were combined into one group consisting o f 12 participants making some data
analysis possible.

Between subject anovas were conducted to examine interactions at baseline and follow up
between forward movers and a combined group o f stable and retrograde movers with the
transtheoretical processes and concepts. Results are summarised in tables 5.12 and 5.13. Use o f
counterconditioning significantly decreased over time F(l) = 4.43, p<.05. There was a similar
decline with consciousness raising over time which was close to significance F(l) = 3.49, p = 07.
The interactions between time and direction with decisional balance cons and low fat behaviours
were significant. For decisional balance cons F(l) = 4.21,p=.05, with forward movers showing a
decline, while the stable retrograde group showed a slight increase. Differences between baseline
and follow up for forward movers were close to significance t(14) = 1.79, p= 09. Interaction for
time and direction for low fat behaviours was also significant F(l) = 4.46, p<.05. Differences at
follow up between stable and retrograde group and forward movers was close to significance
t(25) = 1.87, p =.07 with forward movers scoring higher on low fat behaviours as would be
expected. With the 15 participants who moved foiward to maintenance no significant
differences were found in either the use o f processes or concepts between baseline and follow up,
the decrease in decisional balance cons did approach significance at t(14) =1.79,p=.09.

170
Table 5.12: Two wav mixed factor anovas for forward movers and stable retrograde group
in the action stage. F values at baseline and follow up for transtheoretical processes and
concepts. Factors time and movement.

Variable Time Movement Interaction time and movement

C.R 3.49a 0.16 0.36

s.s 0.16 0.57 0.92
D.R 0.23 0.22 0.62
E.R 0.14 0.51 0.51
S.R 0.17 0.65 0.54
R.M 0.36 0.04 0.63
S.L 3.14 0.37 0.05 ]
C.C 4.43* 0.91 0.15
S.C 0.17 1.10 0.56
Cons 0.17 1.40 4.21*
Pros 0.64 0.73 0.21
Efficacy 0.61 0.79 0.55
Low Fat 0.22 0.93 4.46*
Perceived risk 2.49 0.0 0.01

ap<.10 * p<05

C.R= Consciousness Raising, S.S= Social Support, D.R= Dramatic Relief, E.R= Environmental Reevaluation, S.R
=Social Liberation, R.M= Reinforcement Management, S.L.= Self Liberation, C.C= Counter Conditioning, S.C =
Stimulus Control, Cons = Decisional Balance Cons, Pros = Decisional Balance Pros, Efficacy = Self Efficacy, Low
Fat = Low Fat Behaviours, Perceived risk = Perceived risk

171
Table 5.13: Mean scores transtheoretical processes and concepts forward movers and
stable and retrograde movement action stage.
Stable and Retrograde Forward

Process N Base Follow T Value N Base Follow t value

rt
11 30.06

ITO
OO
C.R 28.09 0.91 15 32.36 28.52
S.S 12 31.04 28.77 0.91 15 29.13 26.55 1.10
D.R 12 30.66 29.00 0.56 15 26.40 22.40 1.14
E.R 12 33.25 28.66 1.51 15 29.53 27.06 0.73
S.R 12 33.86 30.03 1.65 15 30.68 29.20 0.58
R.M 12 29.91 29.16 0.37 15 23.46 21.00 0.91
S.L 12 33.16 30.33 1.65 14 29.92 26.21 1.20
c.c 12 27.66 23.08 1.83 15 26.53 23.38 1.22
S.C 11 24.18 25.90 0.87 15 21.10 20.80 0.11
Cons 12 19.50 22.08 -1.14 15 19.90 16.00 1.79a
Pros 12 21.16 21.83 -0.32 15 20.31 17.36 1.56
Efficacy 12 45.72 50.72 0.80 15 49.20 58.86 -0.15
Low Fat 12 66.58 62.22 1.67 15 65.35 72.00 -1.66
Risk 9 7.56 6.44 0.98 14 7.5 6.57 1.22

ap<.10
C.R= Consciousness Raising, S.S= Social Support, D.R= Dramatic Relief, E.R= Environmental Reevaluation, S.R
^Social Liberation, R.M= Reinforcement Management, S.L.= Self Liberation, C.C= Counter Conditioning, S.C =
Stimulus Control, Cons = Decisional Balance Cons, Pros = Decisional Balance Pros, Efficacy = Self Efficacy, Low
Fat - Low Fat Behaviours, Risk = Perceived risk

Maintenance group
The next step is analysis o f the maintenance group. The first step is analysis o f the scores for
stable maintainers across time. With stable maintainers no significant differences were found
between baseline and follow up for processes or concepts although consciousness raising was
close to significance t(112) =1.70,p =.09. Again the most interesting observation was the slight
decrease in most scores suggesting that as individuals remain in maintenance process use starts

172
 to decrease. Low fat behaviour scores, however, showed a slight increase. The results are
summarised in table 5.14.

Table 5.14:Mean scores of processes for stable maintamers

Process No Mean base Mean follow up t value

C.R 113 32.15(9.07) 30.62 (8.78) 1.70a

S.S 116 25.78 (10.63) 24.49 (11.00) 1.49
D.R 113 22.28 (11.57) 22.03 (12.25) 0.25
I E.R 116 29.65 (10.19) 29.85 (11.11) 0.83
S.R 114 29.85 (11.46) 30.66 (11.56) -1.03
R.M 116 22.97 (9.49) 22.64 (9.34) 0.43
S.L 115 29.49 (10.63) 28.43 (10.94) 1.19
C.C 114 26.03 (10.46) 25.28 (11.99) 0.87
S.C 113 22.88 (10.69) 23.14(11.41) -0.30 |
Cons 109 17.42 (7.33) 16.93 (7.17) 0.70
Pros 108 18.82 (8.06) 18.43 (8.57) 0.58
Efficacy 101 57.07 (10.79) 57.03 (12.31) 0.03.
Low Fat 117 72.45(14.39) 73.21 (13.50) -0.59
Perceived risk 105 6.31(3.13) 5.87 (3.18) 1.15

ap<.10
C.R= Consciousness Raising, S.S= Social Support, D.R= Dramatic Relief, E.R= Environmental Reevaluation, S.R
=Social Liberation, R.M= Reinforcement Management, S.L.= Self Liberation, C.C= Counter Conditioning, S.C =
Stimulus Control, Cons = Decisional Balance Cons, Pros = Decisional Balance Pros, Efficacy = Self Efficacy, Low
Fat = Low Fat Behaviours, Perceived risk = Perceived risk

Stable and retrograde movement post action stages.

On reaching maintenance the only possible movement is retrograde or remaining in maintenance.
As the same processes are emphasised in both action and maintenance it is feasible to combine
the scores in these groups and compare the scores between those remaining in post action (i.e.
action and maintenance) and those regressing to pre action (i.e. precontemplation, contemplation

173
and preparation). Two way mixed factor anovas were conducted between stable and retrograde
movers from post action to pre action stages. The results for these analyses are shown in table
5.15 and 5.16 and the changes in process use are shown in figure 5.3. Use o f consciousness
raising was significantly higher for the stable post action F(l) = 14.09, p<.01. With social
support there was a significant decrease in use over time F(l) = 6.57, p<.01. Paired sample t test
found significant differences between baseline and follow up with retrograde movement group
t(17) = 2.75, p<.05. With reinforcement management significant differences were found over­
time F(l) = 4.24, p<.05, and the interaction between time and movement was close to
significance F(l) = 3.33, p = .07. Paired sample t tests did not find significant differences
between baseline and follow up for stable or retrograde movers. However there was a decrease in
use for the retrograde group which approached statistical significance t(17) = 1.73,p=.10. With
self liberation, use decreased significantly over time F(l) = 4.88, p<.05 the biggest decrease over
time being in the retrograde movement group, however paired t test did not find a significant
difference t(17) = 1.64, p—.11. With counterconditioning significant differences were foimd with
time F(l) =12,11, p<01, with movement F (1) = 5.14, p<.05 and the interaction between time and
movement F(l) = 6.78, p<.01. Paired sample t tests found significant decrease between baseline
and follow up with retrograde movement group, t(17) =3.30, p<.01 and independent sample t test
found the retrograde group to show lower use at follow up t(160) = 3.02, p<.01. With low fat
behaviours significant differences were found with movement F(l) = 12.54, p<.01 and the
interaction between time and movement F(l) = 3.65, p<.05. Stable maintainers showed higher
scores for low fat behaviours and the difference between the stable and retrograde groups was
greater at follow up than baseline.

174
 Table 5.15: Two wav mixed factor anovas for stable and retrograde group in the post
action stages. F values at baseline and follow up for transtheoretical processes and
concepts. Factors time and movement.

Variable Time Movement Interaction time and movement

C.R 2.10 14.09** 0.00

S.S 6.57** 0.69 2.04
D.R 0.95 0.12 0.36
E.R 0.99 2.03 0.01
S.R 2.81 2.63 3.09
R.M 4.24* 0.01 3.33a
! S.L 4.88* 0.89 1.44
c .c 12.11** 5.14* 6.78** |
S.C 1.14 3.14 2.33
Cons 0.66 0.90 1.47
Pros 0.23 0.00 0.00
Efficacy 0.80 3.49 1.54
Low Fat 0.99 12.54** 3.65*
Perceived risk 2.19 0.29 0.45

**p<01 * p<.05.a p<.10

C.R= Consciousness Raising, S.S= Social Support, D.R= Dramatic Relief, E.R= Environmental Reevaluation, S.R
=Social Liberation, R.M= Reinforcement Management, S.L.= Self Liberation, C.C= Counter Conditioning, S.C =
Stimulus Control, Cons = Decisional Balance Cons, Pros = Decisional Balance Pros, Efficacy = Self Efficacy, Low
Fat “ Low Fat Behaviours, Perceived risk = Perceived risk

175
Table 5.16: Mean scores transtheoretical processes and concepts stable and retrograde
movement post action stages.

Stable post action Retrograde movement

Process N Base Follow t value N Base Follow t value

C.R 143 32.23 30.51 2.17* 17 25.00 22.29 1.01

S.S 146 26.72 25.47 1.67 18 26.22 21.79 2.75*
D.R 143 23.16 22.61 0.61 18 22.94 20.90 0.96
E.R 146 30.18 28.97 1.61 18 26.61 25.62 0.64
S.R 144 30.58 30.67 -0.23 18 28.16 24.38 1.56
R.M 146 23.50 23.24 0.36 18 25.72 21.53 1.73
S.L 144 29.92 28.72 1.53 18 29.05 25.00 1.64
C.C 144 26.30 25.32 1.30 18 23.48 16.82 3.30**
S.C 141 22.67 23.04 -0.50 17 19.94 16.82 1.46
Cons 138 17.50 17.10 0.60 18 17.77 19.77 0.92
Pros 137 19.02 18.60 0.70 18 18.94 18.50 0.24
Efficacy 131 55.75 55.14 0.54 17 48.32 52.05 0.80
Low Fat 147 71.95 73.51 -1.37 19 64.99 60.03 1.38
Risk 131 6.47 6.09 1.14 18 7.11 6.11 1.31

** p<.01, * pc.05.
C.R= Consciousness Raising, S.S= Social Support, D.R= Dramatic Relief, E.R= Environmental Reevaluation, S.R
=Social Liberation, R.M= Reinforcement Management, S.L - Self Liberation, C.C= Counter Conditioning, S.C =
Stimulus Control, Cons = Decisional Balance Cons, Pros = Decisional Balance Pros, Efficacy = Self Efficacy, Low
Fat = Low Fat Behaviours, Perceived risk = Perceived risk

176
Logistic regression stage movement

To gain further insight into the processes and concepts used logistic regressions were conducted
t6 identify the processes and concepts associated with foiward and backward movement between
stages. Participants were classified on the basis o f whether they moved from pre to post or post
to pre action stages. The dichotomous value with forward or backward movement meant logistic
regression was the suitable method o f analysis. Results are summarised in table 5.17. Analysis
yielded a chi square value o f 17.01, p<.05, indicating the model as a significant fit. Analysis
showed overall the likelihood o f forward movement was stronger for those scoring highly in
social support. Overall comparison o f scores indicates that it is mainly influential in predicting
backward movement, from the post action stages (action and maintenance) to the pre action
stages (precontemplation, contemplation and preparation).

Table 5.17. Logistic regression stage movement

Number Process / Concept Wald Value Odds Ratio

41 Consciousness raising 0.57 1.05
41 . Social support 4.52* 0.87 S

'-4 1 Dramatic relief 1.38 1.09 |

41 Environmental reevaluation 1.21 .1.09 I
41 Self reevaluation 0.53 1.06
• 41 Reinforcement management 2.10 0.88
41 Self Liberation 1.51 0.88 .
41,. Counterconditioning . ■- 0.73 1.08
41 Stimulus control 1.09 0.93
41 Decisional balance Cons 0.02 • 0.98

41 Decisional balanee pros 0.21 0.97

41 Self Efficacy 0.73 :098

* p<.05

177
 2
c

LL
o

i-
o
o
o

3
0
2

0
c

0
0

co
o
+->
0

ro
ro
ro
ro
ro
ro
ro
ro

O
O
w
w
O
w

ir>
13

Q.

D)
O)

Q.
</>
o CO a
m f
1
L U

ejoos ue0|/\j
cd CO DL DL DL 2
CO DL

{
c o
-1

o
o

1
o

<

a .
<

c
o
o
c

o
o

o
CO

CO
CL

H—>
3
0
+j
CO
</>

C.R —Consciousness raising, S. S = Social support D.R = Dramatic relief E.R = Environmental reevaluation S.R. = Self reevaluation
R.M = Reinforcement management, S.L = Self liberation C.C = Counterconditioning, S.C. = Stimulus control
Low fat behaviour scores

In line with the analysis conducted at baseline the scores o f those on low, medium and high fat
behaviour scores were also examined. Participants scoring 14-42 were included in high fat
behaviour group, participants scoring 43-71 were included in medium fat behaviour group,
participants scoring 72-98 were included in low fat behaviour group. O f the 19 participants in
high fat behaviours at baseline, 14 showed forward movement. O f the 115 in medium fat intake
29 showed forward movement and 5 backward. Of the 91 in low fat behaviours 21 showed
backward movement. Overall therefore 43 participants showed forward movement and 26
backward movement. Movement across low fat behaviour groups is summarised in table 5.18.

Table 5.18: Movement across fat behaviour groups

Behaviour Base N High Medium Low Forward Back

High 19 5 11 3 14
Medium 115 5 81 29 29 5
Low 91 3 18 70 21
Total 225 13 110 102 43 26

Movement low fat behaviours

Analysis showed that 43 participants overall showed forward movement from high or medium
fat behaviours with the majority 32 moving to low fat behaviours and 26 showed backward
movement, the majority 18 going from low to medium fat behaviours. Two way mixed factor
anovas conducted between forward and backward movers, revealed the following results. The
results are summarised in tables 5.19 and 5.20 and figure 5.4. There were significant interactions
between time and movement for all o f the processes except for self liberation and self
reevaluation. These interactions were all o f the same form. With consciousness raising, social
support, dramatic relief, environmental reevaluation, counter conditioning, reinforcement
management and stimulus control those participants showing backward movement showed a
decrease in process use, while those showing forward movement showed an increase. In

179
addition there were main effects for time with social support and reinforcement management
with an overall decrease from baseline to follow up but t tests showed this effect was only
significant for the retrograde group (table 5.20). Use o f self reevaluation was also found to be
significantly higher for those moving foiward than those moving backward but it did not change
with time.

With the transtheoretical concepts there were no significant effects for decisional balance cons.
With decisional balance pros however movement and the interaction were close to significance.
Independent t tests found differences at follow up were significant t(66) = -2.18, p<.05 with
retrograde movers scoring less than forward movers. With self efficacy significant differences
were found with movement but this was not in the expected direction with those showing
retrograde movement scoring higher than those showing forward movement.

180
Table 5.19: Two wav mixed factor anovas for forward and retrograde groups with low fat
behaviours. F values for transtheoretical processes and concepts. Factors time and
movement.

Variable Time Movement Interaction time and movement

C.R 1.75 0.27 19.41**

S.S 4.22* 0.46 8.45**
D.R 0.85 3.73* 5.06*
E.R 0.78 3.01 6.96**
S.R 0.42 3.76* 0.57
R.M 4.41* 2.07 6.82**
S.L 0.57 1.94 2.96
C.C 3.29 3.29 4.53*
S.C 0.00 1.41 5.15*
Cons 0.29 1.93 0.79
Pros 0.85 3.38a 3.18a
Efficacy 0.19 6.34** 0.05
Perceived risk 0.26 1.58 0.58

*p<.05, **p<01. ap<.10

C.R= Consciousness Raising, S.S= Social Support, D.R= Dramatic Relief, E.R= Environmental Reevaluation, S.R
=Self Reevaluation, R.M= Reinforcement Management, S.L.= Self Liberation, C.C= Counter Conditioning, S.C =
Stimulus Control, Cons = Decisional Balance Cons, Pros = Decisional Balance Pros, Efficacy = Self Efficacy,
Perceived risk = Perceived risk.

181
Table 5.20: Mean scores transtheoretical processes and concepts forward and retrograde
movement groups low fat behaviours.

Forward Retrograde

Process N Base Follow T Value N Base Follow t value

C.R 43 27.27 30.53 -2.60* 30.76 24.68 3.45**

25
S.S 43 24.98 25.82 -0.63 26 25.88 20.99 3.82**
D.R 41 24.31 26.21 -1.03 26 . 22.07 17.53 2.17*
E.R 43 28.4 31.06 -1.94 26 26.78 23.57 1.80
S.R 42 30.65 30.78 -0.07 26 25.69 23.96 1.10
R.M 43 23.50 24.04 -0.42 26 22.96 18.00 2.92**
S.L 42 26.96 28.17 -0.73 26 25.57 22.43 1.76
C.C 42 25.19 25.51 -0.24 26 22.65 18.57 2.69**
S.C 41 20.36 22.77 -1.84 25 19.68 17.30 1.45
Cons 41 19.16 18.86 0.26 26 15.82 17.05 -0.79
Pros 41 18.94 21.19 -2.02* 26 16.57 15.86 -0.62
Efficacy 37 49.82 50.02 -.06 26 57.08 58.25 -0.92
Risk 40 6,37 6.07 -0.53 24 5.21 5.67 0.53

*p<.05 **p< .01

C.R= Consciousness Raising, S.S= Social Support, D.R= Dramatic Relief, E.R= Environmental Reevaluation, S.R
=Self Reevaluation, R.M= Reinforcement Management, S.L.=Self Liberation, C.C= Counter Conditioning, S.C =
Stimulus Control, Cons = Decisional Balance Cons, Pros = Decisional Balance Pros, Efficacy = Self Efficacy.
Risk = Perceived risk

182
 Figure 5.4: Mean scores process use forward movers low fat behaviours

CO
CO
CM
\
‘I1

CM
!
4

x—
+

sejoog ueey\|
'
*
t
01 CO OC 01 01 2 - j o
O GO O LLi CO o: CO O

1 1
o
CO

CM

c
o
o

“3
Z)

CD
U)
LL.

C5
Q.

CD
C.R - Consciousness raising 8.8 = Social support D.R = Dramatic relief E.R = Environmental reevaluation S.R = Self reevaluation
S.L = Self liberation C.C = Counterconditioning S.C = Stimulus Control
Logistic Regression of Fat Behaviours

Participants were classified on the basis o f forward or backward movement in terms o f fat
behaviours, backward movement = high to medium or medium to low, forward movement = low
to medium and medium to high. Results are summarised in table 5.21.
While 69 participants initially showed forward or backward movement according to level o f fat
behaviour, 8 were eliminated from the analysis because o f missing data. Analysis yielded a chi
square value for the model o f 16.90, p>.05, indicating the model was not a good fit. Results
indicate that an increase in consciousness raising at baseline indicates a liklehood o f forward
movement with a decrease indicating a likelehood o f backward movement. Use o f self
reevaluation at baseline was also close to significance (p = .06) therefore this too might be
influential again with greater use increasing the liklehood o f forward movement and decrease
increasing the liklehood o f backward movement. Overall in this analysis cognitive processes are
again emphasised. Interestingly social support is not emphasised here, while it was with stage
movement.
Table 5.21 Logistic regression low fat behaviours

Nmnber Process Wald Value Odds Ration

61 Consciousness raising 3.73* 0.89

61 Social support .00 0.99

61 Dramatic relief .13 0.98

61 Environmental reevaluation .53 1.05

61 Self reevaluation 3.40a 1.12

61 Reinforcement management 1.39 0.92
61 Self Liberation .52 0.95

61 Counter conditioning .75 1.05

61 Stimulus control .17 1.02

61 Decisional balance Cons .14 1.02

61 Decisional balance pros 1.45 0.91

61 Self Efficacy 1.92 0.96

Table 2. .p < 0 5 a p<.10

184
 *0
GO

Reevaluation, R.M. = Reinforcement management, S.L = Self liberation, C.C —Counterconditioning, S.C. —Stimulus control.
&
GO
d
o

0£ C0 0£ 0£ Cd 2 _l0 0 ■i
Ql. CO O &
O C/3 D 111 CO CO
p4
\ ^ f f + \1 1 1 73
Vi
0
Figure 5.5: Process use backward movement low fat behaviours

(3

CL w
3 G-f
CN 0
5 •©J
o
oH
•r
o
LL.
(-H
P

e4
Q
tf
o
S
dH
C/3

0 73
C 'o
■■ ■ o
GO
"0
(I)
m 00
DO: CO

.CfO
‘E3
C/3
0
d
C/3
d
o
oC/3
•rH

CO CO CN CN d
o
O
sejoos uee|/\|
pa
d
Respouses to interventions.

One o f the hypotheses predicted that participants would respond more positively to interventions
based on the transtheoretical model than to general interventions. Analysis o f participant’s
responses to the brochures they received showed that o f the 120 participants who received
brochure assessment questionnaires 110 returned completed the questionnaires. O f these 55 had
received the general intervention and 55 received the matched intervention. Results are
summarised in Table 5.21.

Overall the results were virtually identical between matched and general intervention, Essentially
those receiving interventions matched to stage did not respond more positively than those
receiving general interventions did.

Table 5.22: Pamphlet items responses

Matched yes General yes 1Matched no General no

Read Brochure (Item 1) 50 46 4 8

Save Brochure (Item 2) 30 27 24 27
Brochure Help (Item 3) 37 37 17 15
Brochure Discuss (Item 4) 11 12 43 42
All Exercise (Item 5) 19 14 35 40
Some Exercise (Item 6) 31 30 23 24

Regarding response rates o f the 328 brochures distributed to the matched group, 55 were
returned completed, o f the 309 distributed to the general group 55 were returned. Malting a
return rate o f 16.7% for the matched group and 17.7% for the general group, therefore the return
rate o f the matched and general groups was virtually identical.

186
Intervention type and stage movement

Another key hypothesis is whether or not intervention type made a difference to stage
movement. Unfortunately due to the mixed response rate it was not possible to conduct a
thorough analysis o f this hypothesis with each stage. With contemplation and preparation
combined group and the action group the data sets were too small with one cell in each case
containing only one participant. Chi square tests were possible with the precontemplation and
maintenance groups. However the results were not significant for either group. With the
precontemplaters chi(2) =1.02,p>,05, with maintainers chi(2) = 0.01,p>.05. In order to evaluate
the scores contained in the combined contemplation and preparation group and action group to a
degree the scores from both these groups were combined with the precontemplation group and
chi square conducted across the stages as a whole. Again no significant differences were found
chi(2) = 1.03,p>.05. While the data sets are very small even when an acceptable number was
present as for example in the maintenance group and combined stages group the type o f
intervention made no significant impact on movement. Results are summarised in table 5.21 and
5.22.

Table 5.23: Movement stage and intervention type pre maintenance stages

Stage Match Match General General Control Control Chi

Foiward Stable Foiward Stable Foiward Stable Square

Precon 4 4 4 10 7 11 1.02
Con +Pre 3 1 2 5 5 5 Not poss
Action 5 5 5 1 5 6 Not poss
Totals 12 10 11 16 17 22 1.03

187
Table 5.24. Movement and intervention type maintenance stage

Stage Match Match General General Control Control Chi

Backward Stable Backward Stable Backward Stable Square

Maint 6 32 5 28 11 58 .011

Intervention type analysis

Two way mixed factor anovas were conducted on the transtheoretical processes and concepts,
with factors o f brochure type and time. Results are summarised in tables 5.23 and 5.24.
Significant F values were found over time with social support, counterconditioning and low fat
behaviours with the value for self liberation being close to significance the interaction for self
liberation was also close to significance. With social support all groups showed a slight decrease
over time though none o f the decreases were significant when analysised for the individual
groups. With counterconditioning the decrease between baseline and follow up in the no
intervention group was significant. With self liberation the decrease in the no intervention group
was significant with the decrease in the general intervention group being close to significance,
there was however a slight increase in the matched group but this was not significant. A one way
anova found differences were significant between the three groups at follow up, F(2) = 3.16,
p<.05 but not at baseline F(2) =.14, p>.05. Post hoc tests showed differences between matched
and no intervention group close to significance at follow up (p=.06 ). With low fat behaviours
both the general intervention and the matched intervention groups showed a significant increase
between baseline and follow up, but there was no significant effect for the no intervention group.
Although this effect could be as predicted with improved dietary behaviour for the two
intervention groups but not the control group, this must be heated with caution given the non
significant interaction in the anova.

188
Table 5.25. Two wav mixed factor anovas for brochure type, F values at baseline and follow
up for transtheoretical processes and concepts. Factors time and intervention type

Variable Time Brochure Interaction Time and Brochure

C.R 1.28 j 0.47 0.49

S.S 5.86* 0.44 0.91
D.R 0.36 1.26 0.77
E.R 1.17 0.68 0.25
S.R 1.66 0.11 0.46

R.M 0.51 0.94 0.47

S.L - 3.31a 0.23 2.59a

C.C 5.52* 0.46 0.02

S.C 0.14 0.95 0.16

Cons 0.49 0.14 2.21

Pros 0.45 0.20 2.28a

Efficacy 0.37 0.91 0.16
Low Fat 4.91* 1.46 1.44

Perceived risk 0.08 0.60 2.55a

*p<.05 ap<.10
C.R= Consciousness Raising, S.S= Social Support, D.R= Dramatic Relief, E.R= Environmental Reevaluation, S.R
=Self Reevaluation, R.M= Reinforcement Management, S.L.=Self Liberation, C.C= Comrter Conditioning, S.C =
Stimulus Control, Cons = Decisional Balance Cons, Pros = Decisional Balance Pros, Efficacy = Self Efficacy.
Low Fat = Low Fat Behaviours, Perceived risk = Perceived risk

189
Table 5.26 Mean scores transtheoretical processes and concepts with no intervention^ general intervention and stage matched

a
a

a
n

0
i

.9
0
d
C3

d
d
3
'3!/3

•<§
e
o
0

0
d

8
73
■8
rrd

%
1
£

£
%
Process Base Follow t Value Base Follow t Value Base Follow t Value

rtm
m
zvo

00

00
t-H

r"H
C.R 28.87 27.37 28.74 28.31 0.39 59 29.92 29.75

0 0
x—I t-H

GO
GO
23.34 1.63 60 25.89 23.99 1.53

m
23.65 23.22 0.56 58 25.46

m
00

©
t- h
oro-

CN
D.R 21.24 21.34 21.36 21.05 0.20 60 24.44 23.33 0.82
1

©
09 IV 6 Z

©
©
d-

r-H
28.22

in
E.R 28.28 27.55 0.94 58 26.68 26.63 1 0.91

©
LYLZ

t-H
CN
S.R 28.51 28.08 0.49 58 28.86 | 1.52 60 29.13 28.85 0.22

©
m

§
rH
09

©
OVZZ
21.24 1.43 58 21.91 21.85 23.67 23.62 0.04

*
*
in a
©

T S

©
c-

© r-H

r-H
CN

d-
O)
28.25 29.24

vq
27.32 25.05 59
©1

27.34 24.94 58

*
©

S
t-H

CN
23.65 0.97

T—H
c.c 24.20 22.54 57 23.25 21.78 1.21 59 25.01

©
r-H
S.C 20.13 20.56 0.53 54 19.51 20.06 -0.46 58 22.30 22.01 0.22

CO
O

O
I

t- h
r-H

t-H
CO
in
17.07 0.95
vq

Cons 17.44 17.50 0.09 16.99 19.07 56 18.04

*

Z J 'I

©
m
t

t-H
r-H

t-H
ON
in

O
18.05 18.53 52 16.93 18.87 55 19.51 18.15

©1
Pros

00
ON
Efficacy 54.06 54.68 -0.47 53 50.99 52.49 0.67 50 52.62 | 52.47 0.07
*

©
*

00
00
©
r-H

96
vo

in

71.31
1

Low Fat 65.69 65.74 -0.02 59 64.77 68.50 59

OO

VO

96 99*1 01*9
Risk 6.67 6.06 52 5.73 -1.68 55 5.87 6.62 0.66

*p<.05 ** p< .01 ap<10

C.R- Consciousness Raising, S.S= Social Support, D.R= Dramatic Relief, E.R= Environmental Reevaluation, S.R =Self Reevaluation, R.M= Reinforcement
Management, S.L.=Self Liberation, C.C= Counter Conditioning, S.C = Stimulus Control, Cons = Decisional Balance Cons, Pros = Decisional Balance Pros,
Efficacy = Self Efficacy. Low Fat = Low Fat Behaviours, Risk = Perceived risk
Discussion

None o f the initial hypotheses were fully supported and stage progression did not follow exactly
that outlined in the transtheoretical model. However, o f the 61 participants in the pre action
stages at baseline 25 showed forward movement at follow up. With the precontemplaters who
moved forward 11 were in maintenance, whereas logically the furthest stage movement possible
is to action. A similar pattern emerged with those in contemplation. It could be that participants
simply skipped some stages, meaning that precontemplaters may have suddenly adopted low fat
behaviours, similar to the smoker whom suddenly gives up cigarettes. It is unclear how dramatic
behaviour changes such as this fit in with the transtheoretical model. Interestingly mean scores
for fat behaviours in the pre to post action group showed significant differences, indicating that
participants who say they have changed stage have matched this with actual behaviour.
However, the picture for those who relapsed from post action to pre action stages is
contradictory. Here no significant differences were found in fat behaviour scores, though the
mean score at follow up was less showing some relapse into poorer dietary habits. It is possible
that some participants in the post action stages as indicated by Brug, Van Assema, Kok,
Lenderink and Glanz (1994) initially held an unrealistic view o f their fat intake and in fact
movement to pre action stages may indicate a positive intention to change and not a relapse to
old dietary habits. The strongest support for stage movement as outlined in the transtheoretical
model took place in the action stage, with 15 (55%) showing forward movement to maintenance.
Individuals at this point having made significant changes are more likely it appears to maintain
them. Response rates also did not differ significantly on the basis o f stage or gender, however the
difference in response rate between those over and under 60 was close to significance. It may be
that participants over 60 are perhaps more conforming and therefore ready to respond to
questionnaires.

Process use did not fully match that outlined in the transtheoretical model meaning that
hypothesis two is also rejected. However, partial support did exist in that consciousness raising, a
cognitive process showed a significant increase in participants who progressed from the pre
action to post action stages. With the third hypothesis that concerned decisional balance, partial
support for the model was demonstrated, participants who moved from pre action to post action

191
stages significantly increased their scores with the pros o f change. But while scores on the cons
were lower this difference was not significant. With self efficacy there were no significant
changes in scores between those who moved forward or backward, rejecting fully the fourth
hypothesis. Interventions based on the transtheoretical model were no more effective than
general interventions rejecting the fifth hypothesis. A more detailed discussion o f the results
now follows.

The return rate from the matched and general interventions was disappointing, with virtually
50% o f the total questionnaires coming from the control group. This may be due to the fact that
those who received brochures were sent follow ups 3 months later and participants may have felt
too much nuisance mail was coming their way and expecting more follow up questionnaires
simply withdrew from the study. They may also, however, as Prochaska (1999) pointed out have
found the strategies in the brochures confrontational, and simply decided to withdraw rather than
take paid in a study, which they perceived as too demanding. The results o f this study show that
once an intervention is introduced response rates decrease significantly. This may be o f interest
to future researchers who may wish to simply conduct longitudional studies without
interventions on the stages o f change or indeed in any other area.

With movement across stages, 159 (70%) participants remained in the same stage, but o f those
that showed movement the majority 40 showed forward movement, with 29 moving backward in
stages. With the dietary behaviour scales, participants in action and maintenance at follow up
increased their low fat behaviours from baseline and while scores for those in action were close
to significance, scores for maintainers were significant. However with stable maintainers the
increase in low fat behaviours was not significant. This may indicate that these stages are not
fixed with regard to low fat behaviour, as for example, behaviour is in the addictions where
abstinence is simply adopted and maintained. With dietary behaviour change is still taking place
and this may influence the other areas o f the transtheoretical model for example process use.
With cognitive processes, consciousness raising may not be completely abandoned with
movement to the post action stages and the pros o f decisional balance may need to increase
further in post action to promote more change. For participants in the pre action stages dietary
behaviour scores remained reasonably static. Scores in precontemplation and preparation did

192
show a slight decrease, which is broadly in line with expected results. Participants at these points
had not adopted low fat behaviours initially and have obviously not changed their dietary
behaviour significantly in the interim 6 months.

With process use overall it is o f interest again that social support, dramatic relief, reinforcement
management, counter conditioning and stimulus control are not used very frequently. This is in
line with the results o f the pilot study at the University o f Surrey where again many participants
indicated infrequent process use. The four processes that are indicated as being used usually at
baseline and follow up are consciousness raising, environmental reevaluation, self reevaluation
and self liberation. The remaining processes are at best used occasionally at both times,
indicating that perhaps not all processes may play an equally significant role in dietary change.
Also o f interest is that the use o f the processes across the group as a whole decrease at follow up
with the exception o f stimulus control, which shows a small insignificant increase. Decreases in
the scores for social support, counterconditioning and self liberation were significant showing
that some process use may vary considerably as situation and dietary behaviour changes.
Possible explanations are that social support is less necessary once improved health behaviour is
established, with counterconditioning substitute or alternative behaviours may already have been
found and with self liberation there may be no need to make further commitments to change.
However, the decreases may be due to a particular group o f participants for example a relapse
group showing an exceptional decrease.

Within the individual stages, precontemplaters as predicted showed minimal use o f processes.
No significant differences were found longitudionally with stable precontemplaters but
precontemplaters showing forward movement scored significantly higher in consciousness
raising. In the transtheoretical model consciousness raising is associated with movement from
precontemplation to later stages. Therefore support for the model is demonstrated in this study
with at least one cognitive process. Significant differences were found between stable and
foiward movers in precontemplation at follow up in dramatic relief, self reevaluation,
reinforcement management and self liberation, with the forward movement group scoring
significantly higher with all four processes. This indicates that increased process use causes
change and in a pre action stage mainly cognitive processes. Further support is found in

193
participants moving from pre action to post action stages. Highly significant differences were
found in the use o f consciousness raising, with the pros o f change also showing a significant
increase. Both these concepts are central to the transtheoretical model. The use o f cognitive
processes combined with an increase in the pros o f change is predictive o f forward movement
from pre to post action stages. However other major differences emerge between the results and
the predicted results based on the transtheoretical model. Significant increases could be expected
with dramatic relief, environmental reevaluation and self reevaluation in forward moving
precontemplaters, but these however were not found. There is also a large increase in the cons o f
change; these are expected to decrease as the participant adopts improved dietary behaviour.
However, initially individuals may become more aware o f the advantages and disadvantages, the
crucial factor perhaps being that the increase in pros more than matched the increase in cons.

With participants moving from action to maintenance use o f all processes decreases although
none o f the decreases was significant. This is partly in line with the transtheoretical model in that
the use o f processes in particular the cognitive processes should decrease as in maintenance the
same emphasis will not be put on process use. Participants at this point may become secure with
their behaviour and it is therefore not necessary to take steps to constantly reinforce it. The
decrease in cons is also in line with the model, but the decrease in the pros is surprising as it is
expected these will increase when low fat behaviours are maintained. However scores for the
cons also decreased meaning at follow up pros still score higher than the cons.

With participants who moved from post action to pre action stages, that is showed backward
movement, the highly significant decreases in social support and counterconditioning are in line
with the transtheoretical model. These are behavioural processes, which are emphasised in the
model as o f importance in maintaining the post action stages. However, to fully support the
model significant decreases need to take place also in reinforcement management and stimulus
control. Overall backward movers scored lower on all processes at baseline than stable
participants, with the exception o f reinforcement management. At follow up, however all
processes scored lower for backward movement, with the differences between groups for
consciousness raising and counterconditioning being significantly lower. Again this shows that a
mix o f cognitive and behavioural processes continue to play a part. With the transtheoretical

194
concepts no significant differences were found. Interestingly, however, with self efficacy
backward movers showed a slight increase at follow up showing they believed more strongly in
their ability to maintain low fat behaviours despite relapse. Again this could be due to some
participants already maintaining a low fat diet partially deciding to make further alterations. The
results o f the logistic regression showed social support as a crucial factor in stage movement.
Again with the transtheoretical model social support is seen as a crucial factor in the post action
stages and the results overall in this study are in agreement.

For participants showing forward movement in terms o f fat behaviours that is from high or
medium fat behaviours to low fat behaviours, there were significant increases in scores for
consciousness raising and the scores for environmental reevaluation were close to significance.
These are again the processes emphasized for forward change in the transtheoretical model.
While fat behaviour scores are not directly related to stages outlined in the transtheoretical
model, a degree o f additional support for the model is provided with these results. No significant
increases were found for behavioural processes, with scores for stimulus control being the closest
to significance. With dietary behaviour altering significantly at this point increases in for
example social support and counterconditioning may also have been expected to take place but
were not found. With the concepts the significant increase in decisional balance pros is as
expected, the decisional balance cons did not however show a significant decrease.

With participants showing backward movement in terms o f fat behaviours that is moved from
low fat behaviours to medium or high fat behaviours, significant decreases were found with
reinforcement management, social support and counterconditioning and consciousness raising,
partially supporting the transtheoretical model. The first three are the behavioural processes
associated in the transtheoretical model with maintaining improved health behaviours. Therefore
interventions centered on them may help in preventing relapse. However, with consciousness
raising, a cognitive aspect, also showing a significant decrease a mix o f behavioural and
cognitive interventions may be required to maintain improved low fat behaviours. The results
suggest that the same processes may not be involved in preventing relapse as promoting forward
movement, with cognitive processes being associated with forward movement and a combination
o f behavioural and cognitive processes associated with preventing relapse. The finding o f

195
significant differences between groups at follow up in three cognitive (dramatic relief,
environmental reevaluation and self reevaluation) and one behavioural process
(counterconditioning), demonstrates again that cognitive and behavioural strategies continue to
play a crucial role.

One o f the first questions that needs to be addressed, is why the stage matched intervention did
not work? Weak support was found for the general concept o f an intervention being more
effective than no intervention, in that for both the general and stage matched groups low fat
behaviour scores increased significantly between baseline and follow up while those in the no
intervention group remained the same. The sole support for the matched intervention brochure
was found with self liberation which showed a significant decrease in the no intervention group
and a close to significant decrease in the general intervention group while showing a small but
insignificant increase in the matched group. Overall however no strong endorsement o f the use
o f stage matched interventions is found in this study though a case may be made for the
introduction o f self help pamphlets generally as the results show these may crucially promote
low fat behaviours.

Possible reasons why the stage matched interventions were not effective are firstly that the
interventions were too brief, consisting o f only 5-6 pages and therefore not detailed enough to
impact significantly on participants. Another factor may be that the majority o f studies
demonstrating the effectiveness o f stage interventions have been conducted with smokers and
substance addiction. However, Campbell et al (1994) with dietary behaviour found with tailored
messages that while there was no increase in fruit and vegetable intake, there were reductions in
fat intake. Another explanation may be that the sample, clients with type two diabetes having
already received numerous interventions concerning dietaiy behaviours simply did not respond
to another booklet. Also the interventions based on stage in the previous research showing
improvement were computer tailored and therefore more highly personalised and more detailed.
A central concept o f the transtheoretical model is that interventions based on it will be more
effective than general interventions but with this study this has not been the case. It is however,
problematic to generalise from this study to interventions in general. However, if exceptional
attempts are necessary to increase the effectiveness o f stage based interventions for example by

196
making them highly personalised, this may become a significant drawback as the cost and
expertise involved will invalidate the practical usefulness o f the model. The interventions based
on the transtheoretical model may simply prove too costly and time consuming to produce and
be no more effective than simply dedicating more time and resources to individuals. The
perceived riskistic forecast by Velicer and Prochaska (1999) that widespread distribution o f
simply produced stage matched manuals would greatly enhance participation and effectiveness
o f self-help manuals has not been supported in this study.

It is necessary to make a more detailed examination o f the results as a whole. Firstly, process
use across the group in total decreased with the decreases in social support, self liberation and
counter conditioning being significant. This demonstrated that process use may vary significantly
simply over the course o f time. Analysis based on the stages o f change however shows increases
in process use at crucial points. For example, for a precontemplater to move forward to the post
action stages increases in consciousness raising are a vital factor. Also an increase in the pros o f
decisional balance more than a decrease in the cons o f decisional balance is required. Self
reevaluation is also the most widely used process at this point. Also in cross group comparisons
between stable and forward movement pre to post action the use o f dramatic relief, self re
evaluation, self liberation and counter conditioning differed significantly with foiward movers
showing greater use and at follow up significant differences existed in the use o f all processes for
forward movers with the exception o f social support. However, the increase in consciousness
raising and decisional balance pros appear to be the crucial factors.

Once in the action stage the highest scoring processes are consciousness raising, environmental
reevaluation, self reevaluation and self liberation all o f which are cognitive processes. However
when the individual reaches maintenance in order to avoid relapse social support and counter
conditioning need reinforcement. This outlook is supported in the results from the fat
behavioural scores, in which those who moved backward from low fat intake to medium or high
fat intake groups showed decreases in social support and counterconditioning. However in
addition this group also showed a significant decrease in consciousness raising. Therefore
interventions based on this may be more effective than interventions focusing solely on cognitive

197
processes in the pre action stages and solely on behavioural processes in the post action stages
may be.

Overall the results suggest that a model based on the addictions may not be totally transferable to
a dietary habit such as low fat behaviours. Even at the later points in dietary change it may not
be possible to dismiss totally cognitive processes, rather it may be necessary to continually
reinforce them along with behavioural processes to prevent relapse. The following diagram
summarises the application o f the model based on the data from the present study, using the
stage and fat behaviours classifications. The diagram plots an ideal path starting at
precontemplation and moving through the stages to maintenance.

Diagram 5.1 Traiitheoretical process and concept application to dietary change

Precon Contem Prepare Action Maintenanc

1— ► 1r * *” 3 "2 r>

C. R. C. R. C. R. C. R.
Pros Pros S. S. S. S.
C. C. C. C.
Precon = Precontemplation, Contem = Contemplation, Prepare = Preparation, Action = Action,
Maintenanc = Maintenance.
C.R. = Consciousness Raising, Pros = Decisional Balance Pros, S.S. = Social Support,
C.C. = Counter Conditioning

Overall a mix o f cognitive and behavioural processes appears to be the most effective
particularly in the post action stages rather than a reliance on solely cognitive or behavioural
processes particularly in the post action stages, with cognitive processes being emphasised in the
pre action stages. A model similar to this is supported to a degree in early research by Prochaska

198
and DiClemente (1985 p355) which found that people losing weight tend to read more and think
about feedback more than those quitting addictive habits indicating the use o f consciousness
raising.

This may be best demonstrated further with the example o f an imaginary person moving through
the stages o f dietary change. In the pre action stages cognitive processes in particular
consciousness raising are emphasised that is increasing the persons’ awareness o f the dangers o f
high fat foods. Simultaneously the individual could be made aware o f the many benefits of
maintaining low fat behaviours and the disadvantages o f high fat behaviours. This is in contrast
to the stages o f change model, which emphasises separate interventions in the three pre action
stages. Once in action the emphasis changes to preventing relapse, in line with the stages o f
change model behavioural processes are introduced. For example increasing social support may
mean the joining o f a self-help group. With counter conditioning, healthful thoughts and
behaviours are introduced. However, in contrast to the transtheoretical model cognitive
processes are not abandoned at this point. Crucially consciousness raising may still make a
difference, the person may still need to seek out information and increase their knowledge of
dietary fats. This is indicated by the fact that consciousness raising is the highest scoring process
in the action to maintenance group at baseline and the second highest scoring process in the
stable maintainers group. Consciousness raising also shows a significant increase in forward
movers for fat behaviours and a significant decrease in backward movement for fat behaviours.
The use o f a cognitive component at all points with dietary behaviour may be because it is not a
cut o ff behaviour with instant adverse effects with relapse as for example with the majority of
addictive behaviours. These are the core concepts and processes emphasised on the basis o f this
research but additional behavioural and cognitive processes may also be helpful when used as
support to the strategy outlined above.

A major methodological criticism o f the present study must be the small numbers in the groups
due to subject attrition, with 24 participants in the pre to post action groups, 35 in the stable pre
action groups and 19 in the post to pre action groups. With low fat behaviours there were 43
forward movers and 26 backward movers. The question obviously arises as to how valid these

199
scores are in relation to the group in total as many participants simply did not reply to the second
questionnaire.

The small number in some o f the groups perhaps demonstrates how fixed certain categories o f
dietary behaviour may be. The results however do indicate a successful direction o f process and
concept use which participants have taken to initiate and maintain dietaiy change, or in the case
o f relapse the processes and concepts, which significantly decreased. The groups are also similar
in size to initial studies by Prochaska and DiClemente (1985 p356) in which comparisons were
made in process use between smokers and participants losing weight and with a group o f
smokers in the action stage compared with smokers and people coping with distress. Therefore
the results and approach are likely to be o f value to researchers wishing to conduct larger and
lengthier longitudinal studies, perhaps building on the results o f this study.

However a number o f issues regarding the validity o f this study and previous studies in this
dissertation require examination. Therefore an in depth review o f all the studies in this thesis
and the insights and issues raised by them for future research with dietary behaviour and the
transtheoretical model along with stage models in general will now be thoroughly discussed in
the final chapter.

200
Chapter 6: Final Discussion

Overview

The first step in this final discussion is to give a brief overview o f the results from all the studies
in this thesis. To gain a broad insight into the transtheoretical model four studies were conducted,
one a qualitative study consisting o f interviews with 20 participants who had changed their
dietary behaviour, two cross sectional studies focusing on the processes and concepts identified
in the transtheoretical model and a longitudinal study following process use over time and
comparing the effects o f stage matched and general interventions. The conclusions gained from
these studies will be briefly outlined before discussing their limitations and suggestions for
improvement later in this chapter. The first study to be discussed is the qualitative study.

Qualitative study

This was conducted with 20 participants who had changed their dietary habits or were in the
process o f making dietaiy change. The catalyst that finally initiated dietary change with the
majority o f participants was a reaction to a specific event, though participants often had been
aware o f the need for improvement for sometime, this had not resulted in action. The exceptions
to this were students o f health psychology who were studying and receiving intensive health
information on a weekly basis. Once dietary change was established the most successful strategy
was social support, in situations where this was lacking relapse was more likely. With decisional
balance more benefits were associated with dietary change than disadvantages. While the
qualitative study yielded valuable insights into the process o f dietary change an additional aim
was to generate items for inclusion in later quantitative studies and several items were generated
which were included in questionnaires for later studies.

201
Cross sectional studies

Two cross sectional studies were conducted, an exploratory study with a sample o f 150 students
and staff at the University o f Surrey and the main study with a sample o f 955 participants with
type two diabetes at a London hospital. In the exploratory study there was a general effect across
stages for greater use o f processes and concepts but this was mainly between precontemplation
and later stages, the exception to this was self efficacy which showed a significant decrease in
preparation. Analysis based on low fat behavior groups showed significant increases with
increased low fat behaviour- again the exception being self efficacy where no differences were
found.

In the main cross sectional study with 955 participants with type two diabetes, more detailed
questionnaires were used and additional concepts o f perceived risk and dietary knowledge were
examined. There was a general effect across stages, but again this was mainly between the early
pre action and post action. Decisional balance followed the pattern outlined in the
transtheoretical model with the crossover between pros and cons taking place in preparation.
Again use o f processes increased linearly and did not follow the pattern expected o f a stage
model. Again when divided into low fat behaviour groups process use with one exception
followed a linear pattern o f increased use with increased low fat behaviours.

Longitudinal study

228 participants with type two diabetes took part in a six month follow up. In general those
showing forward movement from pre to post action stages showed greater use o f processes at
baseline and follow up, with differences in consciousness raising and the pros o f decisional
balance being significant within the foiward movement group. Participants who relapsed from
post to pre action stages showed a decrease overall in process use with the decreases in social
support and counterconditioning being significant. With the low fat behaviour groups foiward
movement was associated with an increase in consciousness raising and the pros o f decisional
balance while retrograde movement was associated with decreases in consciousness raising,
social support, reinforcement management and counterconditioning.

202
Interventions

In general participants who received interventions were more likely to drop out o f the study, the
response rate o f those receiving matched or general interventions was identical. There was also
no effect for intervention type with processes or concepts. There was however weak evidence
that those who received interventions staged matched or general increased their low fat
behaviours whilst those who received no interventions did not.

Overall the studies gave an interesting insight into the strategies associated with dietary change.
There were however limitations to the studies and these along with suggested improvements will
now be discussed.

General limitations

A necessary step in assessing the validity o f the results contained in this thesis is to look at the
limitations o f the present studies and from there to suggest improvements for future researchers.
Perhaps firstly it is advisable to examine the degree to which these studies have attempted to
answer the criticisms o f previous researchers notably Sutton (1996, 2000 and 2001) in relation to
the applicability o f the transtheoretical model to health behaviours in general and Horwath
(1999) in relation to dietary change in particular. Sutton in particular criticised previous research
on the transtheoretical model as consisting almost entirely o f cross sectional studies. The major
exception to this being one study by Prochaska et al (1991) which looked at five snapshots o f
smokers over 2 years. While the exploratory study and baseline hospital study were both cross
sectional and are both open to the criticisms o f Sutton regarding this type o f study, the follow up
hospital study consisted o f an intervention and six month follow up at least partially answering
this criticism. However while this gives an interesting partial insight, two main problems arose,
firstly there was large subject attrition o f the initial 955 participants at baseline only 228 or 24%
replied at follow up. This was in a relatively short time span and it can only be assumed that a
longer time span would have resulted in greater participant attrition.

203
This raises two issues firstly is the sample in follow up a representative sample o f those in the
initial baseline and are the results a reflection o f what is necessary for example for forward
movement? With the sample that replied it was found that consciousness raising was a crucial
factor in movement from pre to post action stages. However this obviously is based on the
participants who replied and it is possible that many participants who dropped out also showed
foiward movement and could possibly have applied a different but equally effective strategy.
Clearly this is a question that can only be fully answered with close to 100% follow up in the
study which is unlikely to be achieved. However, in support o f the conclusions found in the
study it would be o f considerable practical advantage to practitioners in the field to be aware that
firstly brief interventions may lead to an increase in low fat behaviours with approximately 12%
of their clients. Secondly an emphasis on consciousness raising has an increased chance o f being
effective with clients in the pre action stages o f change attending their clinics, in that it may
move them to either reduce their high fat behaviours or to maintain reductions in high fat
behaviours initiated in the recent past.

A second major criticism may be the actual time elapsing in this study, that is 6 months. A
central feature o f the transtheoretial model is that particular time frames exist between stages.
For instance with participants in contemplation, that is those vaguely considering change, a time
frame o f approximately 6 months is expected, for those in preparation one month may be
required for the planning o f changes, and once in action 6 months o f the changed behaviour is
necessary before maintenance. Therefore even excluding those in precontemplation who have no
intention o f changing a time scale o f just over one year may be necessary in any longitudinal
study to assess fully the differences in process use, transtheoretical concepts and stage
movement. This is supported in previous research, with Prochaska et al (1991) for example
using a two year time frame. Studies related to dietary behaviour have used varying time scales
Beresford et al (1997) collected responses at 3 month intervals over 12 months. Greene and
Rossi (1998) also conducted a 12 month follow up and Glanz et al (1998) reported on a three
year follow up. Therefore while this study provided an interesting snapshot which undeniably
gives an insight into longitudinal changes, ideally this needs to be extended beyond six months.
However in defence o f the present study any information which may establish even a short term

204
change in dietary behaviour will be o f benefit in at least initiating dietary change which in turn
may be built upon further with improved interventions.

Another major criticism o f the research to date regarding the trantheoretical model is the lack of
studies comparing stage and general interventions. Horwath (1999) in particular commented on
the lack o f proper stage matched interventions being tested longitudionally. To date only one
study Campbell et al (1994) has specifically used stage matched interventions to encourage
dietaiy change, specifically low fat intake and higher fruit and vegetable intake. The information
provided was brief and the results found stage matched interventions to be more effective than
standard messages or no messages in reducing fat intake. However the remaining concepts
central to the transtheoretical model, that is stages processes and concepts were not measured.
The present study attempted to address the issue raised by Horwath by introducing stage matched
and general interventions and measuring all the concepts relevant to the transtheoretical model.
Results showed increases in low fat behaviours were significantly higher in both intervention
groups, suggesting that the stage matched interventions were no more effective than standard
which does not support the findings o f Campbell et al (1994).

Two possible conclusions can be made from this, that there are no advantages to stage matched
interventions or that the interventions in this study were not sufficiently detailed or intensive to
fully test the effectiveness o f staged interventions. If the first conclusion is accepted that the
stage matched interventions are indeed no more effective than general interventions, this
questions fundamentally the validity or at least the practical usefulness o f the transtheoretical
model. However before accepting this very strong conclusion the limitations o f the interventions
in this study need to be pointed out. Firstly while the pamphlets in this study fulfilled several o f
the criteria in matching o f interventions to stage with regard to processes and concepts, the
design o f the pamphlet was basic with only one page devoted to each process or concept. This
may not have been sufficient to develop the full use o f a process or concept. The non-tailored
pamphlets were o f similar length and also focused on the processes and concepts central to many
o f the stages o f change. The Campbell et al (1994) study used computer tailored information,
which may have contained more personally relevant information, which in turn may have
motivated participants further. Also in this thesis the same intervention was distributed at both

205
points, participants may have simply responded to the pamphlet in the first instance and found a
second copy o f the same pamphlet uninteresting. A second pamphlet still based on stage or a
general intervention but building on the feedback contained in the questionnaires may have
produced a more productive result. Brug et al (1998) used this approach and found with 800
Dutch participants that iterative feedback (based on responses to questionnaires) was more
effective than standard feedback with dietaiy behaviour when both were distributed twice over 3
months. While the interventions distributed by Brug et al were not tailored to stage o f change, it
still demonstrates the effectiveness o f detailed personalised relevant information. Therefore
before accepting that stage matched interventions are no more effective than general further
investigation with more detailed interventions is necessary.

These issues o f time scale, the sample o f participants, the computer tailoring o f information
based on responses at different time points may all need to be considered in future studies
wishing to provide a more robust test o f interventions based on the transtheoretical model or
indeed dietary interventions in general. The preceding paragraphs have addressed the general
criticisms and suggested improvements for the methodology used the following section will
focus on the structure and design o f the questionnaires used.

Questionnaire design

A critical issue to be addressed is the validity o f the questionnaires used throughout this thesis
and in particular the questionnaires used in the Hammersmith baseline and follow up studies.
Also o f importance are any suggested improvements for fixture studies. Firstly two concepts
perceived risk and dietary knowledge were measured briefly in this thesis, with one item being
used for each concept. In future studies most certainly more detailed assessment will be required
in particular with dietary knowledge. McDonell, Roberts and Lee (1998) measured dietary
knowledge with 11 items and even then failed to find any significant differences across stages.
Future questionnaires examining this concept will need to be revised and made more relevant to
the information used by the average person. With perceived risk also while significant
differences were found between precontemplation and all other groups at baseline it is advised

206
that the concept be explored in more detail, perhaps in a manner similar* to self efficacy with
perceived risk being assessed for different health aspects and situations.

A critical aspect in any study related to the transtheoretical model is the staging algorithm used.
Two algorithms were used in this thesis. The initial one used in the exploratory study used 5
stages matching the five stages o f change. The second in both the Hammersmith hospital studies
contained 7 items with participants in action and maintenance being given an additional option to
state if they intended to reduce their fat intake further. Overall the results showed that this may
be a worthwhile option as a substantial percentage in both post action stages (71% in action and
44.5% in maintenance) indicated they wished to make further dietary changes. This indicates that
many participants who have made dietary changes may wish to make further change in the
future. Another option with low fat behaviour is to give a precise measure o f the required level o f
low fat adherence. For example Reed, Velicer, Prochaska, Rossi and Marcus (1997) in looking
at exercise behaviour included one option which defined exercise as brisk behaviour such as
jogging or aerobic dancing at least 3 times a week. Participants were then given the option to
respond to 5 items matched to the 5 stages o f change. However defining low fat dietary
behaviour is more difficult as it consists o f a wide range o f behaviours much more complex and
varied than exercise behaviour. Therefore the option used in this study o f giving an informed
group, in this instance type two diabetics, the option to' state their intentions and behaviour
regarding low fat dieting and to then measure their behaviour on a dietary behaviour scale may
be the most efficient and practical option. This is supported by the data in relation to the staging
algorithm, which showed significant differences between stages at the level o f low fat behaviour.

The next step is to examine the low fat behaviour questionnaires used. The initial scale in the
exploratory study used 7 items, but this is obviously too few items to measure a behaviour as
diverse as low fat dieting. This is possibly why the scale failed to differentiate between stages
after precontemplation. However the scale used in the baseline and follow up studies contained
14 items and appears to have achieved the necessary sensitivity discriminating between pre and
post action stages in the baseline study and between the early pre and post action stages in the
follow up study. Previous researchers such as Kristal and Shattuck (1990) used 18 items and
Hargreaves, Schlundt, Buchowski and Hardy (1999) used 16 items. Overall it appears a

207
minimum o f 14 items are required and future researchers may wish to add to this number. Also
in situations where dietary habits require investigation for example with cultural differences, a
requirement may be the conducting o f interviews or focus groups to gain detailed insights into
the dietary changes necessary and incorporate these issues into questionnaires. In summary a
short scale consisting o f 14-20 well chosen items is the best option to answer the questions o f
accuracy and practicality.

Processes o f change are a crucial component o f the transtheoretical model and must be measured
accurately. Bowen , Meischke and Tomoyasu (1994) concluded that 60 items from a total o f 121
pilot study items measured the processes associated with dietary change. The current processes
o f change scale for weight loss o f the Cancer Research Center (University o f Rhode Island
http://www.uri.edu/research/cprc/) consists o f 48 items. Based on the results o f this thesis the 42
item scale in the exploratory study did not appear to adequately measure processes o f change as
significant differences were not found with several processes and differences when found were
mainly between precontemplation and post action stages. However a clearer picture emerged
with the inclusion o f additional items in the Hammersmith hospital studies, in that significant
differences were found with all processes and across additional stages. Therefore approximately
60 items may be necessary to measure accurately detailed process use. Future researchers may
wish to include additional items and it is plausible that 1 0 - 2 0 items could be used for
exceptionally detailed measurement o f each individual process. However this may restrict the
number o f processes measured at any one time. Certainly a questionnaire o f over 100 items may
be too cumbersome to be practically useful.

O f the remaining concepts decisional balance and self efficacy, certainly it appeared feasible to
measure decisional balance with 10 items, 5 for pros and 5 for cons. Previous researchers Steptoe
and Ounpouu (1996), Ling and Hoiwath (1999) and O’ Connell and Velicer (1988) used
measures containing 1 0 - 1 2 items. Indeed the evidence in these studies and this present thesis
demonstrates that as expected decisional balance pros increase and decisional balance cons
decrease with stage progression with crossover taking place at approximately preparation. This
hypothesis concerning the increase in pros may now be accepted readily and it may be possible
to measure these concepts with perhaps less items. With self efficacy the initial Clark and

208
Abrams (1991) scale contained 20 items looking at various situations where self efficacy may be
critical. Previous researchers Ounpuu, Woolcott and Rossi (1999) looldng at dietary fat reduction
and Ling and Horwath (1999) used 12 - 20 item scales. The scale used in the exploratory study
in this thesis also consisted o f 20 items and this showed significant differences between
preparation and other stages. Due to practical constraints this was reduced to 10 items in the
Hammersmith studies, and the results were not as clear-cut particularly in the follow up study. It
is possible that the concept o f self efficacy is difficult to measure with perhaps individual’ s
levels varying significantly with circumstances. Future researchers may wish to research this
concept in more detail perhaps using the original Clark and Abrams (1991) scale consisting o f 20
items.

Overall if the present study were to be conducted again, the concepts o f dietary knowledge and
perceived risk would not be investigated, the dietary behaviour scale would contain 14-20 items,
processes could still be measured with approximately 60-65 items, the scale measuring
decisional balance decreased to 2- 4 items and the scale measuring self efficacy increased to 15
to 20 items. Future researchers may wish also to investigate the processes o f change in more
detail, but this may mean less than 9 processes o f change being investigated in any one particular
time frame. Having examined issues such as methodology and item inclusion the final question
which needs to be addressed is how valid overall is the transtheoretical model in relation to
dietary behaviour and in particular in this instance to low fat behaviours.

The validity of the transtheoretical model in relation to low fat behaviour

The final question to be addressed is the one asked initially in this thesis, the issue o f the validity
o f the transtheoretical model in relation to dietary change, in this instance low fat behaviour.
Certainly the results found in the present studies do not support the application o f the established
model to dietaiy change. Reference has previously been made to the initial criticisms by Sutton
(1996) o f the model and at this point the issue may be clarified further by referring to more
recent criticisms by Sutton (2000) and comparing them to the results in the present studies.
Sutton (2000) commented on the expected pattern o f results for true stage and pseudo stage
models to be expected in cross sectional studies. Sutton detailed five possible patterns, but only

209
two most suited to the present studies are summarised below in figure 6.1. Pattern A is that
expected o f a pseudo stage model and pattern B is a true stage model.

Figure 6.1. Pattern of results expected in pseudo stage and true stage models

Pattern A: Pseudo stage model Pattern B True stage model

Sutton commented that the pattern outlined in figure A is typical o f pseudo stage models, with
this there is simply a linear increase or perhaps a linear decrease across stages. Any division at
any point along this line is simply a false one, which may be possibly be useful as a
categorisation tool for practitioners but does not have any sound theoretical basis. Pattern B
represents one option that might be expected with a true stage theory, in that there is no
difference in the scores between the first two points in which a concept is not relevant. This is
followed by a significant increase at point 3 where the concept is crucial to foiward movement
for the participant. This might in turn be followed by a decrease in the process as it was no
longer o f value in movement to later points It is o f interest to compare these expected outlines
with the results obtained in the present studies. Virtually none match the pattern expected o f a
true stage model. The closest to the ideal model is stimulus control, which showed no change
pre action stages followed by a significant increase in action and maintenance. With the concepts
o f change self efficacy showed a significant increase from action to maintenance suggesting that
it may be a crucial factor in establishing long term adherence. Certainly the results on the basis
o f the low fat behaviour grouping match identically that outlined in pattern A with all o f the
processes with the exception o f reinforcement management showing a linear increase. The
increases in concepts also followed a linear pattern with the exception o f the decisional balance

210
cons. Therefore overall there appears to be little evidence to support the conclusion that low fat
behaviours with this sample follows the stage pattern outlined in the transtheoretical model.

There is however evidence as reported earlier in this thesis that processes such as consciousness
raising may play a strong role in foiward movement pre to post action. There is also evidence
that behavioural processes are supportive in the post action stages and there is support for an
increase in the pros o f decisional balance also playing a role in movement from pre to post
action. On that basis practitioners may find stage categorisation o f value, but it is unlikely that
any process or concept can be totally disregarded at any point in dietary behaviour change.
However the transtheoretical model and strategies involved with dietary behaviour change are
certainly worthy o f further investigation and the final contribution in this thesis is an outline o f
the pattern an ideal study for investigating these concepts should follow.

Future studies

The pattern outlined is the model for an ideal study based on the experience gained in this thesis
and on the work o f previous researchers. As previously covered the time scale necessary for a
thorough longitudional study o f the transtheoretical model is one year, with perhaps an ideal time
frame being 2 years provided subject attrition was not extreme. This is the time frame used by
Prochaska , et al (1991) in a study with self changing smokers. O f the longitudinal studies with
diet Campbell et al (1994) used a 4 month timescale but Glanz and Patterson (1998) surpassed
both o f these with a three year longitudional study. Overall however a two year study would
certainly give an adequate time frame to study thoroughly the validity o f the transtheoretical
model.

The next issue to be addressed is the quality and quantity o f interventions to be used. Peyrot
(1999) commented that an ideal test o f a stage model is the inclusion o f four groups, one a
control receiving no intervention, the second a matched group receiving matched interventions,
the third receiving mismatched stage interventions and the fourth receiving comprehensive
interventions. This approach was covered to a degree in the present thesis where the general

211
intervention covered information relevant to all stages. However ideally an additional group
would be included receiving mismatched staged interventions.

In addition the quality and quantity o f interventions needs to be addressed. The model to be used
in this instance is that outlined by Bmg and Glanz (1998) with computer tailored interventions
and iterative feedback. In this instance interventions were based not only on participants initial
responses but also on responses throughout the study. Ideally therefore participant’ s responses in
each group could be monitored for example by the regular completion o f questionnaires every 3-
6 months and interventions tailored to those responses. This detailed diversity o f responses,
groups and interventions will give a hall test to the validity o f the transtheoretical model and to
dietary intervention in general. Lastly also the sample used needs to be as diverse as possible, the
main studies in this thesis focused on the responses o f type two diabetics, whereas ideally several
studies could be conducted including participants with a range o f health problems and
individuals merely wishing to improve their general health. Comprehensive studies such as these
even if they did not support the transtheoretical model would provide invaluable insights into the
processes involved with dietary change.

While studies such as these were beyond the scope and resources available to the present
investigators, it is hoped the information and results in this thesis will provide a direction for
future researchers to take which will lead to improved dietary interventions.

Concluding remarks

The transtheoretical model developed initially with the addictions has since been applied to a
wide range o f non addictive behaviours including dietary change. The main aims o f this thesis
were to examine firstly the validity o f the transtheoretical model to dietaiy change in this
instance low fat behaviour and secondly to gain an insight into the strategies used by successful
changers. The studies conducted have addressed these issues in part. The studies have confirmed
that the processes and constructs outlined in the model are applicable to increasing low fat
behaviours however the pattern o f use does not mirror that outlined in the original model. While
there is weak support for a stage model with for example consciousness raising and decisional

212
balance pros being associated with forward movement from pre to post actions stages, overall the
evidence regarding the pattern o f processes and constructs demonstrates with few exceptions that
these follow a linear rather than stage pattern.

This implies that with regard to low fat behaviour the model developed initially with addictions
requires alteration if it is to be applied effectively. Future studies conducted over a longer time
scale and with more diverse groups using a variety o f qualitative and quantitative methods and to
other areas o f dietary change for example fruit and vegetable intake are necessary to frilly
evaluate the effectiveness o f the model to dietary change. It is hoped that the methods used in
this thesis will be o f value to researchers wishing to explore this model and the entire area o f
improved dietary behaviour change in more detail. Certainly given the high cost in personal and
economic terms o f poor dietary habits further investigation is desirable if not essential.

213
 References

Abrams.D.B., Niaura.R.S. (1987) Social Learning theory. InH.T. Blane and K.E.Leonard
(Eds) Psychological Theories o f Drinldng and Alcoholism (ppl31-178) New York:
Guilford Presss.

Abellanas.L., McLellan,T. (1993) ‘ Stage o f change’ by drug problem in concurrent

opioid cocaine, and cigarette users. Journal o f Psychoactive Drugs, 25. 307 - 313.
[Cited in Sutton.S. (1996) pl94].

Alberti (2000) http://news.bbc.co.uk/hi/en glish/health/newsid

Alexander.F. (1963) The dynamics o f psychotherapy in the light o f learning theoiy.

American journal o f psychiatry, 12 0 , 440 —448.

Applebaum.S.A. (1979) Out in inner space: A psychoanalyst explores the new therapies.
Garden City, N.Y. : Anchor Books.

Ashworth.P. (1997) Breakthrough or bandwagon? Are interventions tailored to the stages

o f change more effective? Health education journal 56, 166 -174

Assema.V.P., Brug.J., Kok.G., Brants.H. (1992) The reliability and validity o f a Dutch
questionnaire on fat consumption as a means to rank subjects according to individual fat
intake. European Journal o f Cancer Prevention. 1 375-380.

Bandura.A. (1977) Self Efficacy: Toward a unifying theory o f behavioural change,

Psychlogical Review, 84, 191-215.

Bandura.A. (1997) The anatomy o f stages o f change. American Journal o f Health

Promotion. 12(1) 9-10.

B.B.C news (2002) Http://news,bbc.co.uk

Bennet.P.H, Rushfort.N.B., Miller.M., LeCompte.P.M. (1976) Rec Progr Horm Res 32:
333-376

Beerman.K., Dittus.K. (1994) Assessment o f a dietary behaviour questionnaire. Health

Values 18(2) 3-6

Beitman.B.D. (1987) The structure o f individual psychotherapy. New York Guildford

Beresford.S.A., Curry.S.J., Kristal.A.R., Lazovich.D., Feng.Z., Wagner.E., (1997) A

Dietary intervention in primary care practice: The eating patterns study. American
Journal o f Public Health. 87 (4) 6 1 0 - 616.

214
Bemier.M., Avard.J. (1986) self efficacy outcome and attrition in a weight reduction
programme. Cognitive Therapy and Research, 10. 319-338.

Bowen.D.J. Meischke.H. Tomoyasu.N. (1994) Preliminary evaluation o f the processes o f

changing to a low fat diet. Health education research 9(1) 85-84

Brownell.K.D. (1982) Obesity: Behavioural treatments for a serious, prevalent and

refractory disorder, hi R.K. Goldstein (Ed.) Eating and weight disorders: Current
developments. New York: Livingstone.

Brownell, K.D., Wadden,T.A. (1983) behaviural self help treatments for obesity. In
M.R.C, greenwood (Ed.) Obesity. New York: Churchill Livingstone.

Brownell.K.D., Marlatt.A.G., Lichtenstein. E., Wilson.T.G. (1986) Understanding and

preventing relapse. American Psychologist 41 (7). 765 -782.

Bmg.J., Assema.V.P, Kolc.G. Lenderink.T. Glanz.IC (1994) Self rated dietary fat intake:
association with objective assessment o f fat, psychosocial factors and intention to change.
Journal o f Nutrition Education, 26(5) 218 - 223.

Bmg.J., Campbell.M., Van Assema.P. (1999) The application and impact o f computer
generated personalised nutrition education: A review o f the literature. Patient Education
and Counselling. 36 145-156.

Bmg.J., Glanz.IC., ICok.G. (1997) The relationship between self efficacy, attitudes, intake
compared to others, consumption and stages o f change related to fruit and vegetables.
Physical Health: Nutrition 12(1) 25-30

Bmg.J., Hospers.J.H., IColc.G. (1997) Differences in psychosocial factors and fat

consumption between stages o f change for fat reduction. Psychology and Health, 12 719-
727.

Bmg.J., Steenhaus,!, Van Assema.P., De Vries.H. (1996) The impact o f computer

tailored nutrition intervention. Preventive Medicine 25. 236-242.

Budd.R.J., Rollnick.S. (1996) The structure o f the readiness o f change questiomiaire: A

test o f Prochaska and DiClemente’s transtheoretical model. British Journal o f Health
Psycholgy. 1. 365-376.

Budd.J.R., Rollnick.S. (1996) The structure o f the readiness to change questionnaire: A

test o f Prochaska and DiClemente's transtheoretical model. British Journal o f Health
Psychology. 1. 365-376.

Burt.IC., Oaksford.M. (1999) Qualitative methods: Beyond beliefs and desires. The
Psychologist. 12(7) 332-335.

215
Campbell.K.M., DeVellis.M.B. Stretcher.J.V. (1994) Improving Dietary Behaviour: The
effectiveness o f tailored messages in primary care settings, American Journal o f Public
Health. 85(5) 783-787.

Clark.M., Abrams.D., Niaura.R (1991) Self efficacy in weight management. Journal o f

consulting and clinical psychology 59 (5) 739 -744.

Clark.C.M (2001) Lifestyle Self-Management Intervention in Patients with Type 2

Diabetes, PhD Manuscript. University o f Surrey. Guildford. England.

Cohen.R.Y., Brownell,K.D., Felix,M.R.(1990) Age and sex differences in health habits

and beliefs o f schoolchildren. Health Psychology 9 , 208 - 224.

Curry.S.J., Kristal.R,A.,Bowen.J,D. (1992) An application o f the stage model o f behavior

change to dietaiy fat reduction. Health Education Research, 7(1) 9 7- 105.

Diclemente.C.C. (1991) Motivational interviewing and the stages o f change in

W.R.Miller and S.Rollnick (eds) Motivational interviewing preparing people fo r change
(pp. 191 - 202) New York: Guilford Press.

DiClemente.C.C., Hughes,S.O (1990) Stages o f change profiles in alcoholism treatment.

Journal o f Substance Abuse, 2. 219 -235

DiClemente.C.C., Prochaska,J.O.(1985) Processes and stages o f chagne : Coping and

competence in smoking behaviour change: P.P. 319-343 hi S.Shifftnan and T.A. Wills
(Eds) Coping and substance abuse San Diego: CA. Academic Press

DiClemente.C.C., Prochaska,J.O., Fairhurst,S., Velicer,W.F., Velasquez,M., Rossi,J.S.

(1991) The process o f smoking cessation : an analysis o f precontemplation,
contemplation and preparation stages o f change. Journal o f Consulting and Clinical
Psychology, 59. 295-305.

Dijlcstra.A., De Vries., Roijackers.J Breukelen.G. (1998) Tailored interventions to

communicate stage matched information to smokers in different motivational stages.
Journal o f Consulting and Clinical Psychology. 66. 549-557.

Egan.G. (1986) The skilled helper. 3rd ed Montiy, CA: Brooks/Cole

Gebhardt. W.A. (1997) Health behaviour goal model. Leiden: University o f Leiden.

Glanz. K., Patterson, R.E., Kristal, A.R. (1994) Stages o f change in adoption healthy
diets: fat,fiber and correlates o f nutrient intake. Health Education Quartley, 21 499-519.

216
Glaser.B.G., Strauss.A.L. (1967) The discovery o f grounded theory: Strategies for
qualitative research. Chicago: Adline

Glasgow.R.E., La Chance.P., Toobert.D., Brown.J., Hampson.S.E., Riddle.M. (1997)

Long term effects and costs of brief behavioural dietary intervention for patients with
diabetes delivered from the medical office. Patient Education and Counseling. 32. 175-
184

Glasgow.E.R., Perry.D.J., Toobert.J.D.,Hollis.F.J. (1996) Brief assessment of dietary

behaviour in field settings. Addictive Behaviours. 21(2) 239- 247.

Graff.C., Gaag.V.M, Kafatos.A., Lennemas.M., Keamey.M.J. (1997) Stages of dietaiy

change among nationally representative samples of adults in the European union.
European Journal o f Clinical Nutrition. 51 s47- s57.

Greene.W.G ., Rossi,S.R ., Richards. G. (1993) The effect of feedback on dietaiy intent to

reduce fat Topics o f Clinical Nutrition 9(1) 20-28

Greene.W.G., Rossi.R.S., Richards.G., Willey.C., Prochaslca.O.J. (1994) Stages of

change for reducing dietaiy fat to 30% of energy or less. Journal o f the American Dietetic
Association. 94. 1105-1110.

Greene.W.G., Rossi.R.S. (1998) Stages of change for reducing dietaiy fat intake over 18
months. Journal o f the American Dietetic Association. 98 (5) 529- 534.

Greene.W.G., Rossi.R.S., Rossi.S.J., Velicer.F.W., FavaX.J., Prochaslca.O.J. (1999)

Dietaiy application of the stages of change model. Journal o f the American Dietetic
Association. 99(6) 673-678.

Goldfried.R.M. (1980) Toward the delineation of therapeutic change principles. American

Psychologist, 35(11) 991- 999

Goldfried.R.M. (1982) Converging themes in psychotherapy. New York. Springer

Hammer.G.P. (1997) Heppatitis B vaccine acceptance among nursing home workers.

Unpublished dissertation, Department of Health Policy and Management. John Hopkins
University. ( Cited in Weinstein.N.D., Rothman.A., Sutton.S. (1998) Stage theories of
health behaviour: Conceptual and methodological issues. Health Psychology 17(3) 290-
299.).

Hansen.B.C. (2000) The Commonsense Guide to Weight Loss fo r People with Diabetes.
American Diabetic Association.

217
Hargreaves.KJVL, Schlundt.G.D., Buchowski.S.M., Hardy.E.R., Rossi.R.S., Rossi.S.J.
(1999) Stages of change and the intake of dietary fat in African American women:
Improving stage assignment using the Eating Styles Questionnaire. Journal o f the
American Dietetic Association. 99(11). 1392- 1399.'

Harris.M.B., Bochner.S. (1982) f a t, four eyed and female: Stereotypes of obesity glasses
and gender. Journal o f Applied and Social Psychology. 7. 101 - 104.

Health in England Report (1998) Investigating the links between social inequalities and
health. London: The Stationery Office

Health of the Nation (1992) Department of Health: A consultative document for health in
England. London: H.M.S.O.

Hesonline nutrition (2000 http://www.hesonline.com/brochures.html).

Hirsch. J. (1973) The psychological consequences of obesity. In G.A. Bray (Ed) Obesity
in perspective Dhew Publications. Washington, DC: U.S. Government Printing Office.

Horwath.C. Gulliver.P. (1998) The challenge of behaviour change. New Zealand Science
Monthly. 9 8-9.

Horwath.C. (1999) Applying the transtheoretical model to eating behaviour change:

Challenges and opportunities. Nutrition Research Reviews. 12. 281- 317.

Janis.LL., Mann,L. (1977) Decision maldng a psychological analysis o f conflict, choice

and commitment. New York: Free Press

Jeffery.W.R., French,A.S., Rothman.J.A. (1999) Stage of change as a predictor of success

in weight control in adult women. Health Psychology. 18(5) 543-546.

Keenan.D., AbuSabha.R., Sigman Grant.M. Achterberg.C., Ruffing.J. (1999) Factors

perceived to influence dietaiy fat reduction behaviors. Journal o f nutrition education 31
134-144

Kristal.A.R., Shattuck.L.A., Henry.J.H., Fowler.S.A. (1989) Rapid assessment of dietary

intake of fat fiber and saturated fat: Validity of an instrument suitable for community
intervention research and nutritional surveillance. American Journal o f Health
Promotion. 4(4) 288 -295.

Kristal.A., White.E., Shattuck.A., Curry.S., Anderson.G., (1992) Long term maintenance

of low fat diet: Durability of fat related dietaiy habits in the women’s health trial.

218
Kristal.A., Andrilla.H., Koepsell.D.T., Diehr.H.P., Cheadle.A. (1998) Dietary assessment
instruments are susceptible to intervention-associated response set bias. Journal o f the
American Dietetic Association. 98(1) 40-43.

Kristal.A., Glanz.K. (1999) How can stages of change be best used in dietary
intervention. Journal o f American Dietetic Association. 99(6). 679-684.

Kristal.A., Hedderson.M., Patterson.E.R., Neuhausler.M. (2001) Predictors of self­

initiated , healthful dietary change. Journal o f the American Dietetic Association. 101(7)
762-766.

Kreuter.M.W., Bull.F., Clark.E., Oswald.L.D. (1999) Understanding how people process

health information: A comparison of tailored and non tailored weight loss materials.
Health Psychology, 18 (5), 487-494.

Laforge.G.R., Velicer .F.W., Richmond.R., Owen.N. (1999) Stage distribution for five
health behaviours in the United States and Australia. Preventive Medicine. 28. 61-74.

Lamb.R., Sissons J. (1996) The stage model and processes of change in dietary fat
reduction. Journal o f human nutrition and dietetics 9 43-63.

Lechner.L., Brug.J., Vries.H., Assema.V.P. Mudde.A. (1998) Stages of change for fruit
vegetable and fat intake consequences of misconception. Health Education Research.
13(1) 1-11.

Lee,C. (1993) Attitudes knowledge and stages of change: A surveyof exercise patterns in
older Australian women. Health Psychology, 12(6) 476-480.

Levy.A.S., Fein.B.S., Stephenson.M. (1993) Nutrition knowledge levels about dietary fats
and cholesterols: 1983-1988. Journal o f Nutrition Education. 25(2) 60-66.

Ling, A.C., Horwath.C, (1999) Self efficacy and consumption of fruit and vegetables:
validation of a summated scale. American Journal o f Health Promotion. 13(5) 290 -298.

Lopez.A., Gonzalez M., Mateos.L.A., Keamey.J., Gibney.M., Martinez J. A. (2000)

Stages of dietary change and nutrition attitudes in the Spanish Population. Public Health.
114.183-189.

Low fat living (2000) Http://wwwl.xe.net-/lowfat/articles)

Marcus.B.H., Rakowski,W., Rossi,J.S. (1992) Assessing motivational readiness and

decision making for exercise. Health Psychology, 11, 257-261.

219
McConnaughy.E.A., Prochaska.J.O., Velicer. W.F.(1983) Stages of change in
psychotherapy: Measurement and sample profiles. Psychotherapy: Theory, Research and
practice. 20, 368 -375.

McConnaughy.E.A., DiClemente,C.C., Prochaska,J.O., Velicer,W. (1989) Stages of

change in psychotherapy: a follow up report. Psychotherapy, 26, 494-503.

McDonnel.G., Roberts.D., Lee. C. (1998) Stages of change and reductin of dietary fat:
Effect of knowledge and attitudes in an Australian university population. Journal o f
nutrition education. 30, (1) 37-46

Medieros.M.,Prochaska, J.O. (1993) Predicting premature termination from

psychotherapy. In press [Cited in Prochaska and Norcross, Systems of Psychotherapy
p500]

Mhurchu. N.C. Margetts,M.B. Speller,M. (1997) Applying the stages of change model to
dietary change, Nutrition Reviews, 55(1) 10-16,

Mija nutrition website (2000 www.cse.iml.edu/~miia/nutrition)

Nationwide Food Consumption Survey. (1988) Journal o f the American Dietetic

Association 92 1352- 1357.

National Food Survey (2000) London Stationery Office.

Nitzke.S., Auld.G., McNulty.J. (1999) Stages of change for reducing fat and increasing
fiber among dietitians and adults with a diet related chronic disease. Journal o f the
American Dietetic Association. 99(6) 728-730.

Novotny.R., Han Sook.J., Biemacke.I.(1999) Motivators and barriers to consuming

calcium rich foods among asian adolescents in Hawaii. Journal o f Nutrition Education.
31(2) 99-104.

O’Connell. K., Velicer,w.R. (1988) A decisional balance measure and the stages of
change model for weight loss. The International Journal o f the Addictions, 23, 729 750.

Orford. J. (1992) Davidson’s Dilemma. British Journal o f Addiction, 88, 832-833

Ounpuu. S., WoolcottD., Rossi.S. (1999) Self efficacy as an intermediate outcome

variable in the transtheoretical model: Validation of a measurement model for application
to dietary fat reduction. Journal o f Nutrition Education. 31(1) 16-22.

Petty.R.E., Cacioppo,J.T. (1981) Attitudes and Persuasion: Classic and Contemporaiy

Approaches. Dubuque, I.A. William C. Brown.

220
Peyrot.M. (1999) Behaviour change in diabetes education. Diabetes Educator.
Supplement (11) 62-73.

Pidgeon.N.(1998) Grounded Theory: Theoretical Background p75-86 in Richardson.J.

(1998) eds Handbook o f qualitative research. Biddles: Derby

Povey.R., Conner.M. (1999) How valid is the application of the transtheoretical model to
dietary behaviour? An investigation of stages of change. Health Psychology. 36. 4-9.

Povey.R., Conner.M., Sparks.P., James.R., Shepherd.R. (1999) A critical examination of

the application of the transtheoretical model’s stages of change to dietary behaviours.
Health Education and Research. 14. 101-111.

Prochaska.J.0. (1979) Systems o f psychotherapy: a transtheoretical analysis. Chicago:

Dorsey Press

Prochaska.J.0., DiClemente,C.C. (1983) Stages and processes of self change of smoking:

Toward an intergrative model of change. Journal o f Consulting and Clinical Psychology,
51(3), 390 - 395.

Prochaska.J.0. (1984) Systems o f psychotherapy a transtheoretical analysis (2nd ed)

Homewood,Dorsey. San Diego: Academic Press.

Prochaska.J.0., DiClemente.C.C (1984) The transtheoretical approach : Crossing the

traditional boundaries o f therapy. Homewood,II: Dow Jones-Irwin.

Prochaska,J.O., DiClemente.C.C. (1985) Common processes of change in smoking

weight control, and psychological distress. P.P. 345 -363 In S.Shiftman , T.Wills (Eds),
Coping and substance abuse

Prochaska.J.0., Velicer,W., Guadagnoli,E., Rossi.J.S. DiClemente.C.C. (1991) Patterns

of change: Dynamic typology applied to smoking cessation. Multivariate Behavioural
Research, 26, 83-103.

Prochaska.J.0., DiClemente.C.C. (1992) The transtheoretical approach. P301-334 in

Norcross,C.J., Goldfried,R.M. Handbook o f psychotherapy integration. New York:
Harper Collins

Prochaska.J.0., DiClemente.C.C. (1992 b) Stages of change in the modification of

problem behaviours. In M.Hersen,R.Meisle,. and P.M.Miller (eds) Progress in behaviour
modifications. Sycamor,IL: Sycamore.

Prochaska .O.J., DiClemente,C.C. Norcross.C.J (1992) In search of how people change.

American Psychologist, 47(9) 1102- 1118.

221
Prochaska.J.O., DiClemente,C.C., Velicer,W., Rossi,J.S. (1993) Standardized ,
individualized, interactive and personalized self help programmes for smoking cessation.
Health Psychology, 12. 399-405.

Prochaska.J.O., Redding,C.A., Harlow,L.L., Rossi,J.S., Velicer,W.F. (1994) The

transtheoretical model of change and HIV prevention - a review. Health education
quartley. 21(4) 471 - 486.

Prochaska.J.O.,Velicer,W.F., Rossi,J.S., Goldstein,M.G. Marcus,B. Rakowski.W. (1994)

Stages of change and decisional balance for 12 problem behaviours. Health Psychology,
13(1) 39 - 46.

Prochaska.J.O., Norcross,C.J.(1999) Systems o f Psychotherapy: A transtheoretical

analysis

Quinlan.K.B., McCaul.K.D. (2000) Matched and mismatched interventions with young

adult smokers: testing a stage theory. Health psychology, 19. 165-171.

Raimy.V. (1976) Changing misconceptions as the therapeutic task. In A.Burton (Ed)

What Makes behaviour change possible? New York: Brunner/Mazel.

Reed.R.G., Velicer.F.W., Prochaska.O.J., Rossi.S.J., MarcusJETB. (1997) What makes a

good staging algorithm: Examples from regular exercise. American Journal o f Health
Promotion. 12(1) 57- 66.

Robson.C. (1996) Real world research. Cambridge. U.S.A.Blackwell

Schachter.S. (1982) Recidivism and self-cure of smoking and obesity. American

Psychologist, 37, 436-444.

Schwarzer.R. (1992) Self Efficacy in the adoption and maintenance of health behaviours:
theoretical approaches and a new model, hi: R.Schwarzer (Ed), Self Efficacy: Thought
control o f action (pp 217 -243) Washington D.C. Hemisphere Publishing Corporation.

Schmid.T.L., Jefffrey,R.W.,Hellerstedt,W.L. (1989) Direct mail recruitment to home -

based smoking and weight control programs: A comparison of strengths. Preventive
Medicine, 18. 503-517.

Simmons.D., Mesui.J. (1999) Decisional balance and stage of change in relation to

weight loss, exercise and dietary fat reduction among Pacific Islands people. Asia Pacific
Journal o f Clinical Nutrition. 8 (1) 39-45.

222
Stafleu.A., Staveren.V.W., Graaf.C., Burema.J. (1996) Nutrition knowledge and attitudes
towards high fat foods and low fat alternatives in three generations of women. European
Journal o f Clinical Nutrition. 50. 33-41.

Stewart. A.L., Brook,R.H. (1983) Effects of being overweight. American journal o f public
health, 73,171-178.

Steptoe.A., Doherty.S., Rinlc.E., Kerry.S., Kendrick.T., Hilton.S. (1999) Behavioural

counseling in general practice for the promotion of healthy behaviour among adults at
increased risk of coronary heart disease: randomised trial. British Medical Journal. 319.
943-946.

Steptoe.A., Wijetunge,S., Sheelagh,D,, Wardle.J. (1996) Stages of change for dietaiy fat
reduction: associations with food intake, decisional balance and motives for food choice
Health Education Journal, 55.108 -122.

Sternberg. B (1998) Relapse in weight control: Definitions, processes and prevention

strategies, P. 521 - 545 in G.A. Marlatt and J.R.Gordon Relapse Prevention:
Maintenance Strategies in the Treatment o f Addictive Behaviours. Guildford Press: New
York.

Suris.M.A., Carmen Trapp.M., DiClemente.C.C., Cousins.J. (1998) Application of the

transtheoretical model of behaviour* change for obesity in Mexican American women.
Addictive Behaviours. 23(5). 655-668.

Sutton.S. (1996) Can ‘stages of change’ provide guidance in the treatment of the
addictions? A critical examination of Prochaska and DiClemente’s model. In G.Edwards
and C.Dare’s Psychotherapy. Psychological treatments and the adictions. P I 89-205.

Sutton.S. (2000) Interpreting cross sectional data on the stages of change. Psychology and
Health. 15 163-171.

Sutton.S. (2001) Recovery and Relapse: Back to the drawing board? A review of the
applications of the transtheoretical model to substance use. Addiction 96. 175-186.

Tiggemann.M., Rothblum,E.D. (1997) Gender differences in internal beliefs about

weight. Psychology o f women Quartley, 21. 581-593

Velicer.W., DiClemente, D., Prochaska,J., Brandenburg,N. (1985) A decisional balance

measure for predicting smoking cessation. Journal o f personality and social psychology,
48. 1279-1289.

Velicer.W., Prochaska.J.0 (1999) www.uri.edu/research/cprc

223
Velicer. W, Prochaska J.O. (1999) An expert intervention for smoking cessation. Patient
education and counselling. 36(2) 119-129.

Velicer,W., Prochaska.1.0., Bellis.J.M. (1993) An expert system for smoking cessation.

Addictive Behaviours. 18. 269-290.

Velicer.W., Prochaska.J.O. Abrams.D.B., Emmons.M.K. (1995) Distribution of smokers

by stage in three representative samples. Preventative Medicine 24. 401-411

Velicer.W., Prochaska,J.O., Beilis,J.M (1993) An expert system intervention for smoking

cessation. Addictive Behaviours, 18, 269 - 290.

Wallston.K.A. (1992) Hocus-Pocus, the focus isn’t strictly on locus: Rotter’s social
learning theory modified for health, Cognitive Therapy and Research, 16, 183-199.

Wardle.J. (1995) The assessment of obesity: Theoretical background and practical advise.
Behaviour Research Therapy, 33, 107-117.

Watkins.P.J. Drury.P.L, Howell.S.L, (1996) Diabetes and its Management Oxford,

Blackwell

Weinstein.N.D., (1988) The precaution adoption process. Health Psychology, 7(4) 355-
386.

Weinstein.N.D. (1982) Unrealistic optimism about susceptibility to health problems:

Journal o f Behavioural Medicine. 5. 441-460.

Weinstein.N.D., Lyon.E.J., Sandman.M.P., Cuite.L.C. (1998) Experimental evidence for

stages of health behaviour change: The precaution adoption process model applied to
Radon testing. Health Psychology, 17 (5) 445- 453.

Weinstein.N.D., Rothman.J.A., Sutton.R.S. (1998) Stage theories of health behaviour:

Conceptual and methodological issues. Health Psychology 17(3) 290 -299.

Whitelaw.S, Baldwin S, Bunton R, Flynn,D. (2000) The status of evidence and outcomes
in stages of change research. Health Education Research 16(6) 707-718

Wolfe.B.E. (1992) Integrative psychotherapy of the anxiety disorders. In J.c. Norcross

and M.R.Goldfried (Eds) Handbook o f psychotherapy integration. New York: Basic
Books.

224
 A p pendix O ne

Exploratory questionnaire and volunteer poster

The following questionnaire is p art o f a
research student’s program m e at the
U niversity o f Su rrey. The purpose of the
questionnaires is to investigate people’s eating
habits. A ll inform ation is confidential and
w ill not be used fo r any other purpose.

The re s e a rc h e r th a n ks y o u in a d va n c e f o r taJdng th e tim e to f i l l o u t th is

q u e s tio n n a ire
Firstly a few details about yourself.

Age

Sex

Occupation (please state your previous occupation if you are a student over 24 years o f
age, or the occupation o f your parents if you a student under 24)

Level of Education
Which of the following qualifications do you have (tick as many boxes as
applicable)

• level or GCSE □
• A level or Scottish highers □
• HN CorHN D □
• BSc/BA/BEd □
• Higher Degree ( eg Masters or PhD) □
• None of the above □

Please read the following question and all the possible answers carefully.
Indicate which answer best describes you by placing a tick on the line
beside it. Do not tick more than one answer.

Do you consistently avoid eating high fat foods?

Yes I have been for more than 6 months — ——

Yes I have been but for less than 6 m onths---------

No but I intend to in the next 30 days ------------

No but I intend to in the next 6 m onths-------------

No and I do not intend to in the next 6 m onths----------

Please indicate on a scale of 1-5 how often you do the following things.

1 = Not at all
2 = Rarely
3 = 50% of the time
4 = Most of the time
5 = Always

I buy low fat foods to help me follow a low fat eating plan.
1.............. 2 .......... 3........... 4 ............5

I limit the amount of salad dressings I use or if I do use them I use low fat
ones.
1.......... ..2 .......... 3 .......... 4 ............5

I substitute low fat dairy foods for high fat dairy foods
1.............2 .......... 3 .......... 4 ............5

I substitute low fat foods for high fat foods

1.............2 .......... 3.......... 4 ............5

I grill or bake instead of hying foods

1............ 2 .......... 3........... 4 ............5

I eat fruit or low calorie desserts instead of high fat desserts

1........... 2 .......... 3 .......... 4 ............5

I count the grams of fat I eat

1......,...2 ............ 3........... 4 ............ 5
Each statement in this questionnaire represents a thought that might occur to
a person who is deciding whether or not to go on a low fat diet. Please
indicate how important each of these statements might be to you if you were
considering a decision to go on a low fat diet. There are five possible
responses to each of the items, that reflect the answer to the question “How
important would this be to you?” Please circle the number that best
describes how important each statement would be to you if you were
deciding whether or not to go on a low fat diet.

1 = Not important at all

2 = Slightly important
3 = Moderately important
4 = Very important
5 - Extremely important

1 Going on a low fat diet would be hard work

1........... 2 ............3 ............4 ............. 5
2 I would feel more optimistic if I was on a low fat diet
1...........2 ............ 3........... 4 ............. 5
3 I would be less productive on a low fat diet
1...........2............ 3........... 4 .............5
4 1 would feel sexier and more attractive on a low fat diet
1...........2 ............ 3 ........... 4 ............. 5
5 In order to stay on a low fat diet I would have to eat less appetizing foods
1...........2 ............ 3 ........... 4 ............5
6 My self respect would be higher on a low fat diet
1...........2 ............ 3 .......... 4 ............ 5
7 A low fat diet would make meal planning more difficult for my family or
housemates
1........... 2 ............3............4 .......... 5
8 My family and friends would be proud of me if I maintained a low fat diet
1.......... 2 ............ 3 ........... 4 ............. 5
9 I would not be able to eat my favourite foods on a low fat diet
1.......... 2 ............ 3 ........... 4 ............. 5
101 would be less self conscious on a low fat diet
1........... 2 ..........3 ......... 4 ............. 5
11 A low fat diet takes the pleasure out of meals
1........... 2 ........... 3......... 4 ............. 5
 12 Others would have more respect for me if I maintained a low fat diet
1........... 2 ............3 ..........4 ............5
13 I would have to cut out some of my favourite foods if I was on a low fat
diet
1...........2 ............ 3........... 4 .......... 5
14 If I was on a low fat diet I could wear more attractive clothing
1...........2 ............ 3 ........... 4 .......... 5
15 Going on a low fat diet would mean avoiding some of my favourite
places or activities
1...........2 ............ 3 ........... 4 .......... 5
16 My health would improve on a low fat diet
1...........2 ............ 3........... 4 .......... 5
17 A low fat diet is expensive when everything is taken into account
1...........2 ............ 3........... 4 .......... 5
181 would feel more energetic on a low fat diet
1...........2 ............ 3 ........... 4 .......... 5
191 would have to cut down on my favourite snacks on a low fat diet
1...........2 ............ 3 ........... 4 .......... 5
20 I would be able to accomplish more on a low fat diet
1.......... 2 ............ 3........... 4 .......... 5
The following experiences affect the fat intake of some people. Think of
similar experiences you may have had in trying to restrict fat intake. Please
rate how FREQUENTLY you use or have used each of these over the past
3 months. There are FIVE possible responses to each item. Please circle the
number that best describes your experience.

1 = Never
2 = Seldom
3 = Occasionally
4 = Often
5 = Always

1 I recall information from articles and advertisements about the benefits of

a low fat diet.
1...........2 ............ 3..........4 ............ 5
2 Society would be better if more people ate low fat diets
1...........2 ............ 3..........4 ............ 5
3 I recall information people have given me about the health problems from
eating a high fat diet.
1...........2 ............ 3..........4 ............ 5
4 I think about infonnation from articles and advertisements on how to
change to a low fat eating plan.
1...........2 ............. 3......... 4 ............5
5 I pay close attention to television programmes about low fat diets
1...........2 ............. 3 ......... 4 ............5
6 I associate with people who are on low fat diets
1...........2 ............. 3......... 4 ............5
7 1 have someone in my life who cares about my diet
1.......... 2 ............. 3......... 4 ............5
8 I have someone who listens when I need to talk about eating low fat foods
1.......... 2 ............. 3......... 4 ............5
9 I can be open with at least one special person about my experience with
low fat dieting
1.......... 2 ............. 3......... 4 ............ 5
101 can expect to be rewarded by others if I eat low fat foods
1.......... 2 ............. 3 ......... 4 ............ 5
11 Warnings about the health hazards of eating high-fat foods move me
emotionally
1............2 ...............3 ...........4 ..............5
12 I have fearful feelings about developing heart trouble from eating too
much high fat food.
1.............2 ........... 3 .......... 4 .......... 5
13 Remembering studies about illnesses caused by high fat foods upsets me
1.............2 ........... 3.......... 4 .......... 5
141 react emotionally to health warnings about high fat foods
1............ 2 ........... 3 .......... 4 .......... 5
15 Dramatic portrayals of the problems of people eating high fat foods
affect me emotionally.
1............ 2 ........... 3 .......... 4 .......... 5
161 notice the difficulty in society because of the high fat foods people eat
1............ 2 ........... 3 .......... 4 .......... 5
171 consider the belief that people consuming low fat diets will improve the
world
1............ 2 ........... 3 .......... 4 ...........5
18 1 think about the need for more people to understand the importance of a
low fat diet
1............ 2 ........... 3 .......... 4 ...........5
19 Overconsumption of high fat foods is responsible for the high death rate
from heart disease and cancer
1........... 2 ...........3...........4 ............ 5
20 Eating low-fat food gives me a feeling of freedom
1........... 2 ...........3.......... 4 ............ 5
21 My consumption of high fat foods makes me feel disappointed in myself
1........... 2 ...........3.......... 4 ............ 5
22 I feel that improving my diet by eating low fat foods is one way to
improve myself
1........... 2 ...........3 .......... 4 ............ 5
23 Choosing low-fat foods gives me a feeling of control
1........... 2 ...........3...........4 ............ 5
24 I get upset when I think about my eating too much high fat food
1........... 2...........3 .......... 4 ............ 5
25 Eating low fat foods is one way to demonstrate my willpower
1...........2 ...........3...........4 ............ 5
26 I am rewarded by others when I keep to low fat foods
1...........2 ...........3 .......... 4 ............ 5
27 Instead of eating high fat foods I do something else
1...........2 ...........3.......... 4 .............5
28 Other people in my daily life make me feel good when I eat low fat foods
1............ 2 ...........3......... 4 .............5
29 When I am tempted to eat high fat foods I think about something else
1............ 2 ...........3......... 4 .............5
301 reward myself when I eat low fat foods
1............ 2 ...........3.........4 .............5
3 IT tell myself I can choose to maintain a low fat diet or not
1............ 2 ...........3......... 4 .............5
32 I tell myself that I am able to lose weight when I want to by maintaining
a low fat diet
1............ 2 ...........3......... 4 .............5

33 I tell myself that if I try hard enough I can keep from eating high fat
foods
1............. 2.......... 3........ 4 ............ 5
3 4 1 make commitments to eat low fat foods
1.............2 .......... 3........ 4 ............. 5
35 When I am tempted to eat a high fat food I try to relax
1.............2 .......... 3 ........ 4 ............. 5
36 Instead of eating high fat foods I engage in physical activity
1.............2 .......... 3........ 4 ............. 5
37 I do something else instead of eating high fat foods when I need to relax
or deal with tension.
1.............2.......... 3 ........ 4 .............5
381 think about something else when I am tempted to eat high fat foods
1............2 .......... 3 ........ 4 ............. 5
391 remove things from my place of work that remind me of eating high fat
foods
1.............2 .......... 3........ 4 ............. 5
40 I keep things around my place of work that remind me not to eat high fat
foods
1 ......... 2............3 .........4 ............ 5
411 put things around the home that remind me not to eat high fat foods
1 ......... 2 ............3.........4 ............ 5
42 I remove things from my home that remind me of eating high fat foods
1 .. . ........ 2 .......... 3........ 4 ............. 5
This form looks at typical eating situations. Everyone has situations which
make it difficult for them not to eat fatty foods. The following are a number
of situations relating to eating patterns and attitudes.
Read each situation carefully and decide how confident you are that you
will be able to resist eating fatty foods in each situation. In other words
pretend you are in the situation now.
On a scale from 0 = not confident to 9 = very confident choose one number
which reflects how confident you feel now about being able to successfully
resist the desire to eat high fat foods.
Write this number down next to each item.
For Example Confidence Number
I am confident I can resist eating at weekends 7

I am confident that
I I can resist eating high fat foods when I am anxious ------

2 1 can control my eating of high fat foods at the weekend ------

3 I can resist eating high fat foods even when I have to

say “no” to others--------------------------------------------------------------- -------
4 I can resist eating high fat foods when I am feeling
physically run down------------------------------------------------------------ -------
5 I can resist eating high fat foods when I am watching t.v. ------

6 I can resist eating high fat foods when I am depressed ------

7 1 can resist eating high fat foods when there are

many different kinds of food available-------------------------------------- ------
8 I can resist eating high fat foods when I feel it is impolite
to refuse a second helping----------------------------------------------------- -------
9 I can resist eating high fat foods when I have a headache ------

101 can resist eating high fat foods when I am reading ------

I I I can resist eating high fat foods when I am angry or irritable ------

121 can resist eating high fat foods when I am at a party —— -

13 1 can resist eating high fat foods when others are
pressuring me to eat them
141 can resist eating high fat foods when I am in pain

15 1 can resist eating high fat foods just before I go to bed

161 can resist eating high fat foods when I have experienced failure

171 can resist eating high fat foods even when high calorie
foods are available
181 can resist eating high fat foods even when I think others
will be upset if I don’t eat them
191 can resist eating high fat foods when I feel uncomfortable

20 I can resist eating high fat foods when I am happy

 Volunteers Needed for Dietary Study

I a m a P h d s t u d e n t a t th e U n i v e r s it y , a n d I n e e d v o l u n t e e r s t o t a k e
p a r t in a s h o r t i n t e r v i e w , l a s t i n g 3 0 - 4 0 m in u te s r e s e a r c h i n g t h e
is s u e s a r o u n d d ie ta r y c h a n g e . I f y o u h a v e s w itc h e d to a h e a lth ie r
d i e t a t a n y s t a g e in t h e p a s t s i x m o n t h s o r a r e t h in k in g o f d o i n g s o
w it h in t h e n e x t s i x m o n th s , p l e a s e c o n t a c t A n d r e w o n

01483 876939
-

OR
[email protected]
 Appendix Two

Ethics and consent forms

 K egistration N o :..................... I

CONFIDENTIAL

HAMMERSMITH, QUEEN CHARLOTTE’S & CHELSEA AND ACTON

HOSPITALS

RESEARCH ETHICS COMMITTEE

APPLICATION FOR ETHICAL APPROVAL OF

PROPOSED CLINICAL RESEARCH
P le a s e note:
• You should read this form and accompanying Guidance Notes
carefully before attempting to complete it.
• Y o u should c o m p le te all s ectio n s o f th e fo rm . W h e re a section is not
re le v a n t to yo u r p ro p o s ed re s e a rc h project, you should w rite “N /A ” in th e
s p a c e provided. In c o m p le te a p p licatio n s will not b e a c c e p te d .
• C ro s s -re fe re n c in g o f a n s w e rs is not a c c e p ta b le , e .g . re s p o n s e s such as
“re fe r to protocol” o r “s e e a b o v e ” m ust b e a v o id e d .
• A void th e u se o f ja rg o n w h e re v e r possible. If te c h n ic a l te rm s a re to be
u s e d , exp lain th e m .
• F o rm s th a t h a v e not b e e n c o m p le te d fully will not b e p a s s e d to th e
C o m m itte e fo r a p p ra is a l.
• Upon completion this form, plus an electronic copy on disk I e-mail
attachment (or an electronic copy alone accompanied or followed by
the declaration and signature pages completed by hand), should be
submitted to the Secretary’s office at least 11 working days before
each Committee meeting, (e-mail applications should be sent to:
[email protected])

F o rm a l closing d a te s a re a v a ila b le from th e S e c re ta ry ’s o ffic e /R E C w e b ­

site: http://www.med.ic.ac.uk/rescon/REC/index.html
(N .B . T h e w e b -s ite a ls o co n tain s inform ation regard in g m e e tin g d a te s ,
g u id a n c e notes fo r co m p le tio n o f th e application fo rm , R E C m e m b e rs h ip
a n d constitution, IC H /G C P an d links to useful re s o u rc e s .)

(N .B . a p p licatio n s will not b e a c c e p te d a fte r th e closing d a te u n d e r a n y

c irc u m s ta n c e s ).

(Revised September 1998)

1
 Registration No: A.

1. T IT L E O F P R O P O S E D R E S i l | O H '.

An investigation of the psychological processes associated with dietary

change in type 11 diabetes____________________________________

2, IN V E S T IG A T O R S

(1) Principal investigator (NB. AH correspondence will be addressed to the

P.l.)
Name and Title: M r A nd rew M oore
Post and Employer: Phd S tud en t University of S urrey
Division and institution: Psychology D epartm ent
Address: University of Surrey, Guildford. G u 2 5 X H

Telephone number: 0 1 4 8 3 -8 7 6 9 3 9
E-Mail: a.m o o re@ su rrey.ac.u k

(2 ) Other investigators (up to four)

Name and Title: Doctor Richard Shepherd
Post and Employer: R eader: University of Surrey
Division and institution: Psychology D epartm ent
City and postcode: Guildford: G U 2 5 X H
Telephone number:
E-Mail: R .S h ep h erd @ su rrey.ac.u k
Name and Title:
Post and Employer:
Division and institution:
City and postcode:
Telephone number:
E-Mail:
Name and Title:
Post and Employer:
Division and institution:
City and postcode:
Telephone number:
E-Mail:
Name and Title:
Post and Employer:
Division and institution:
City and postcode:
Telephone number:
E-Mail:

(3) Head of Section:

(4) Head of Division:
3 . C O M P E N S A T IO N F O R D E A T H O R P E R S O N A L IN J U R Y

2
 Registration No:.

(1) Is the research being commercially sponsored? No

(2) If so, give name of company and a contact name and address (please
note that the company will be charged £750 for the administration of this
application):________________________________________________

N/A

(3) Has the sponsoring company agreed to abide by:

• the ABPI Clinical Trials Compensation Guidelines 1991 (patient
studies)? If so, append a signed copy of the letter of indemnity N/A
(see Appendix Hi).____________________________________
• the ABPI Guidelines for Medical Experiments in non-patient
human volunteers 1988 (healthy volunteer studies)? if so, N/A
append a signed copy of the letter of indemnity (see Appendix
HQ-_______________________________________________________________

(4) if the protocol is not commercially sponsored, give the name and
address of the charity/research council or other sponsoring organization:

N/A

(5) If the research is not sponsored by a pharmaceutical company, state

what arrangements or insurance are/is in place (if any) to compensate a
subject in the event of personal injury or death arising out of
participation in the research, if none, indicate that this is so.________

None

4. THE RESEARCH

3
 Registration No: A.

(1) Background________________________________________________
(i) Purpose & Objectives (including statement of hypothesis):__________
T h e study will e x am in e th e psychological processes associated with dietary
c hange and in particular if th ese m atch the processes outlined in the stages of
chan g e m odel. T h e transtheoretical stages of change m odel proposes that change
is not an all or nothing phenom enon but a process consisting of 5 distinct stages.
T h e s e a re precontem plation, contem plation, preparation, action and m aintenance.
In addition the m odel proposes that that cognitive processes such as
consciousness raising a re em phasised at the earlier stages and behavioural
processes for e x am p le social support are em phasised at the later stages. T h e
theory also proposes that m es sa g e s based on th e stages of change will be m ore
effective than standardised m essag es or no interventions. It is hypothesised firstly
that stages of change will be a predictor of dietary im provem ent and that
interventions based on the stages of change will be m ore effective than
standardised interventions or m ism atched interventions.

(ii) Scientific background (specifically the results of previous studies upon

which your study is based):_______
P rochaska, D iC le m e n te and Norcross (1 9 8 2 ) following 12 years of research
concluded that intentional change involved an individual going through 5 distinct
stages. M uch of the initial research how ever w as conducted with addictive
behaviours. For exam p le P rochaska and D iclem ente (1 9 8 3 ) found support for the
m odel in research with 8 7 2 sm okers. Individuals at the earlier stages w ere found
to use cognitive processes and those in the later stages w ere found to use
behavioural processes. P rochaska V e lic e r and Rossi (1 9 9 2 ) found evidence to
support the m odel across 12 health behaviours including fat reduction, sunscreen
use and addictive behaviours. H ow ever som e researchers h ave criticised the
m odel, Sutton (1 9 9 6 ) doubted if the m odel truly described the processes or tim e
scale individuals go through w hen adapting health behaviours. P ovey, Sparks ,
C on nor and S hepherd (1 9 9 8 ) also criticised the research in support of the m odel
fo r lacking longitudinal studies , particularly in relation to dietary behaviour.

(iii) Value of and need for the research:_____________________________

T h e potential benefit of im proved health behaviours is self evident. Y e t
participation in health im provem ent program m es is often disappointing.
R ecruitm ent and com pletion rates often reaching only 1 0% of those eligible
(P ro ch aska and D iC le m e n te 1 9 9 2 ). Brug C am pbell and V a n A s s e m a (1 9 9 9 ) found
3 criteria to be effective in increasing ad h erence to dietary behaviour. T h e s e w ere
(1 ) Attention to the relevant m otivators and reinforcers (2 ) P ersonalised self
evaluation (3 ) T h e active participation of participants. F a c e to fa c e counselling
provides all of these yet is unlikely to beco m e w idely available to large
populations. H ow ever m essag es tailored to groups with the opportunity to provide
fe e d b a c k h ave the potential to beco m e w idely available. It is hoped in this w a y to
e n h a n c e the results of dietary interventions.

(iv) Has the drug/device/method been used in previous studies? If so,

justify any repetition of previous work;_________________________

4
 Registration No: A.

K ram ish,C am pbell and D e Villis (1 9 9 4 ) found tailored m essag es to be m ore

effective in helping participants to reduce fa t intake and increase fruit and
v e g e ta b le intake in com parison to a control group who received non tailored health
m essag es. T h e m essag es how ever w e re not based on the stages of change
m odel, also to m y know ledge no research has been conducted exam ining the
relationship betw een stages of change, and the dietary behaviour of patients with
type 2 diabetes._____________________________________________________________________

5
 Registration No: A.

(v) Design and methodology (i.e. randomized; explain method of

randomization, placebo-controlled, double-blind etc):
The study focuses on stages of change, in line with the model the following
outcomes will be exam ined,
1 M ovem ent through stages, that is will the person move for exam ple from
precontemplation to contemplation or action
2 Changes in decisional balance, that is will the participants perceptions of the pros
and cons of a different diet change.
3 Change in self efficacy, will the participant believe they can maintain their dietary
change
4 Changes in the processes used, that is will their be changes in for exam ple the
am ount of social support a person needs, will they continue to read about dietary
change, will their self evaluation increase as a consequence of dietary change.
5 On a practical level will levels of blood serum cholesterol show significant
differences across stages and after interventions.

T h e study intends to focus on 2 areas, which are of interest to diabetes research, and
these are fat intake and fruit and vegetable intake.
Sam ple
T he study will consist of an opportunity sam ple of clients with type 2 diabetes at
Ham m ersm ith Hospital. The estim ated sam ple size at baseline is 2 000. These will be
divided into 2 groups of 1000 (groups A and B). Group A will com plete questionnaires
on their attitude to fat intake, and group B on their attitude to fruit and vegetable
intake. The questionnaires will assess their stage of change, level of fat or fruit and
vegetable intake, processes of change, their assessm ent of the pros and cons of
change, their belief in their ability to maintain change and dem ographic data. On
completion of the questionnaires each group will be subdivided in 3 subgroups, A1,
A2, A3, (fat intake) and B 1, B2, B3 (Fruit and vegetable intake) each group will
consist of 333 participants. Interventions tailored to stage of change (Appendix A) will
then be given to groups A la n d B1, Groups A 2 and B2 will receive a general
intervention(Appendix B) and groups A3 and B3 will act as a control group receiving
no intervention other than standard hospital treatm ent (1-1 counseling and a diet
sheet). A flow diagram below indicates the overall plan of the study. This procedure
will be identical for both fat intake and fruit and vegetable intake.
Tim escale
S tage One: Initial questionnaire and intervention
Stage Two: 3 months participants will receive a brief questionnaire assessing their
reaction to the original study and stage of change.
Stage Three: 6 months after the start date participants will repeat the original
questionnaire.
Results
Differences in the processes used, self efficacy, decisional balance and dietary
behaviour will be examined.
Response Rate
A response rate of 6 0 % -7 0% is anticipated, therefore from an initial group of 333 it is
expected to have a final group of approximately 234. Sufficient participants will be
recruited at baseline to allow for a 30% dropout. Also at the 3 months point som e
participants will be given the option of providing minimal feedback, if the drop out rate
at this point is seen to be significantly higher than anticipated it will be possible to
recruit more participants. Participants who drop out at this point (3 months) will not be
contacted further. If however at the end of 6 months participants do not complete the
final questionnaire they will be sent one rem inder letter (copy in appendix).

6
 Registration No: A.

T h e questionnaires consist of items from 2 sources, The primary source is the

University of Rhode Island website. Their research centre has conducted
considerable research regarding the relationship between stages of change and
various health behaviours. Questionnaires have been reviewed in num erous peer
reviewed journals. For exam ple Prochaska, DiClem ente and Norcross,J.C (1992),
O ’Connei and V elicer (1988), Hargreaves et al (1999) and Kristal, Shattuck and
Henry (1990). M any of the items w ere developed in relation to weight control. The
second source is a paper by Bowen and Meischke (1994) which exam ined the
processes associated with dietary change. T h e questionnaires focus on areas
associated with health behaviours that is processes of change, self-efficacy and
decisional balance. The questionnaires broke down into the predicted factors when
tested in a pilot study at the University of Surrey
T h e standard hospital intervention referred to in the study, is 1-1 counselling with a
dietician and standard hospital advice sheets.
References
Bowen.D., Meischke.H., Tomoyasu.N. (1994) Preliminary evaluation of the processes of
changing to a low fat diet. Health Education Research. 9(1) 85-94.
Hargreaves.M., Schlundt.D., Buchowski.M. Hardy.R. Rossi.S., Rossi.J. ( 1999) Stages of
change and the intake of dietary fat in African American women: Improving stage assignment
using the eating styles questionnaire. Journal of the American Dietetic Association. 99(11)
1392- 1399.
 Registration No: A.

Kristal.A., Shattuck.A., Henry.H. (1990) Patterns of dietary behaviour associated with selecting
diets low in fat: Reliability and validity of a behavioural approach to dietary assessment. Journal
of American dietetic association. 90 214-220

O’Connell.D., Velicer,W.F. (1988) A decisional balance measure for weight loss. The
International Journal of the Addictions. 23. 729-750.

Prochaska,J.O., DiClemente.C.C., Norcross.C.J. (1992) In search of how people change.

American Psychologist. 47(2) 1102-1114.

Prochaska,J.O., DiClemente.C.C., Norcross,C.J. (1992) In search of how people change:

Application to the cessation of smoking. Journal of Consulting and Clinical Psychology, 56.
520-528.

(vi) The site(s) where the research will take place (e.g. which hospital(s),
medical school(s), GP clinic(s) etc. - include all UK multi-centre sites):

Flam m ersm ith and Charing Cross Hospitals

(2 ) Is the research multi-centre? (NB. Clinical research studies Y e s /N o

involving five or more LREC's must seek approval from a MREC)____________________

(3 ) Duration of study (approval is normally given for four

years) 2 years_________________________________

(4) How will the data be analysed? Data analysed using S.P.S.S
is this is a pilot study? no
What is the justification for the number of subjects to be studied?
2 ,0 0 0 participants n e e d to b e included to give a w id e ra n g e o f participants, to
allo w fo r e noug h p articipants to b e included in su bgro ups to statistically d e te c t
a n y d iffe re n c e s w hich occur.

What is the smallest clinically relevant difference that the study has
been designed to detect, with the corresponding significance level and
power?_____________________________________________________

The smallest anticipated group of 234 will have a detection rate of 0.3 s.d
this will give it a significance level of .05 and a power of .9.

Outline the statistical methods that will be used to analyse the data.

8
 Registration No: A.

Data will be analysised using analysis of variance tests, correlation

coefficients and if necessary multivariate analysis.

• Who has provided the statistical advice?_________________

University of Surrey, Research Methods Psychology Department

(5 ) Procedures : Administration of questionnaires

(i) Drugs: N/A
(a ) Indicate the dosage and route of administration of the drug (s) used in
the research (indicate which are being researched and which are in standard
practice):______________________________________________________

N /A

(b) Indicate the regulatory status of the study drug(s) by ticking the relevant
box (append copy of relevant certificate or exemption):____________
Product licence (PL) n/a
Clinical Trial Certificate (CTC) n/a
Clinical Trial Certificate exemption (CTX) n/a
Doctors and Dentists exemption (DDX) n/a
(c) State the known pharmacology of the drugs, including possible side-
effects: n/a

9
 Registration No:.................V

(ii) Other substances and/or devices (indicate method of application or

use):_______________________________________________________

N /a

Measurements and samples to be taken: N/A

(a ) Specify the amount and frequency of any samples:
N /A

(b) indicate whether any sample would be taken as part of normal patient
care or specifically for the purposes of the research:_________________

N /A

(c ) Indicate whether if a sample would normally be taken as part of usual

patient care the amount taken would be any greater due to participation
of the subject in the research:____________________________________

N /A

(d) Will any sample be taken for genetic studies (now or in the
future) and stored for this purpose?_____________________ No
(e ) If samples are to be taken for genetic studies, will the
samples be rendered anonymous?__________________ N /A
(iv) Indicate, by ticking the appropriate box, which of the following will be
used in the research (append copies):_________________________________________
• Questionnaires?
• Visual aids?
Psychological tests?
(v ) Specify which research procedures may cause pain, discomfort,
distress or inconvenience to a subject and indicate the likely extent of
such pain, discomfort, distress or inconvenience:_________________

10
 Registration No:................ V

N o distress or discom fort anticipated, if how ever the client feels in anyw ay
uncom fortable with the questionnaire th ey will be advised th at th ey do not have to
com plete it.

(vi) Specify any particular requirements or abstentions which will be

imposed upon the participating subject (e.g. multiple visits, abstention
from alcohol, tobacco etc):_______ _____________________________

N one

(vii) Irradiation
(a ) Will subjects be exposed to additional ionizing radiation in the No
course of this study?_________________________________
(b ) If so, what age groups will be recruited (tick as appropriate)?
• 0-18 years
18-35 years
35 - 65 years /
• > 65 years
(c) Justify your choice (note: the Committee is likely to examine closely
those protocols in which subjects are less than 35 years old):________
D ietary change effects the health of a w ide range of individuals, how ever as type 2
diabetes does not usually e m e rg e until individuals are in th eir late 3 0 ’s it should be
possible to obtain a sufficient sam ple from participants over the a g e of 35.

(d ) Give details of any exposures to x-rays (e.g. conventional plain films, CT

scans, digital subtraction angiography etc):__________________________

N /A

(e ) Give details of the radioisotopes to be administered (including their

activities (MBq) and chemical forms and their frequency of
administration):_____________________________________________

N /A

(f) Has the project been granted an approval by the

Administration of Radioactive Substances Advisory Committee N /A
(append a copy of the appropriate ARSAC certificate)?_______
(g) State the radiation dose (EDE) arising from:
any clinical procedure (a): N/A
all research procedure (b): N/A
• Total (a+b): N/A
(viii) Risks and hazards

11
 Registration No: A.

(a ) Describe the potential hazards or risks, if any, for the subject associated
with participation in the research and the precautions being taken to
minimize and deal with them:

No hazard s or risks anticipated as questionnaires look at th e processes involved

and th e tailored m essag es offer general advice.

(b) Specify the probability and seriousness of the hazard/risk in each case:

N o hazard s or risks anticipated

(ix) Therapeutic research (Note: the Committee will expect the Information
Sheet to make clear that the research is therapeutic or not)
(a) Indicate (by ticking the appropriate box) which of the following
statements applies to this research (Tick ONE only):
• the research may be of general benefit to the subjects
themselves (i.e. therapeutic research):
• the research is intended to be of benefit of patients with the
condition being studied, but not to the subjects themselves (i.e.
non-therapeutic research):
• the research is intended to increase knowledge, but will not
benefit the subjects themselves or patients suffering from a
particular condition (i.e. non-therapeutic research:
(b) For therapeutic research involving patients, describe alternative/standard
treatments (if any), normally given or available to the type(s) of patient(s)
intended to be recruited to the research. Where a subject has been
receiving such alternative and standard treatment prior to enrolment in the
research, or would normally be prescribed such treatment, state whether
such treatment will be temporarily suspended or withheld during the
conduct of the research. State what the implications, if any, of such
withholding or temporary suspension may be for the subject.

12
 Registration no :............ \.

Clients at the hospital will be undergoing the standardised treatm en ts available for
clients with type 2 diabetes. T h e re will be no need to suspend or interfere with any
of these, how ever in addition to this one group will receive tailored m essag es
based on the stages of change, one group will not and another group will a m ixed
intervention.

(x ) Good clinical research practice. Confirm that the research will be

carried out in accordance with recognized standards of good clinical
practice - in particular, the Declaration of Helsinki and ICH/GCP
Guidelines._________________________________________________
T h e research will be carried out in accordance with the recognized standards of
good clinical practice

5. TH E SUBJECTS

(1) Subjects to be studied at this hospital

Patients Male Female Total Volunteers Male Female Total
Number 500 500 600 Number
Upper age limit 65 65 Upper age
limit
Lower age 35 35 Lower age
limit limit

(2) Total number of subjects to be studied in multicentre studies

Patients Male Female Total Volunteers Male Female Total
Number Number
Upper age Upper age
limit limit
Lower age Lower age
limit limit

(3 ) Speciai groups:
(i) Do subjects belong to any of the following groups (tick as appropriate):
• infants (i.e. of age less than 5 years)?
• children (i.e. of ages between 5 and 18 years)?
• pregnant women?
• nursing mothers?
• women of child bearing age (i.e. of ages less than 45 years)?
• the elderly (i.e. of ages greater than 65 years)?
• mentally incompetent?
• emergencies/unconscious patients?
(ii) State what special or additional arrangements, if any, will be applied
particularly in information and consent procedures to safeguard the
interests of such subjects:

13
 Registration No: A.

N o additional arran gem ents are n ecessary for this group as th e questionnaires
focus on th e psychological processes within the person and the interventions can
only lead to increased com pliance with health instructions.

(iii) Explain why it is necessary to conduct the research in such subjects

and whether the required data could be obtained by any other means:

Im proved dietary behaviour is of benefit to w om en of child bearing ag e, the

psychological processes of this group are of interest as they m a y be particularly
concerned about th e prospect of th e adverse effects of poor health on any children
th ey m ay have. Collecting the d ata by the use of questionnaires is also the m ost
effective m ethod of collecting inform ation it also not feasible to g a th er the data in
any other w ay.

(4) Recruitment of subjects______________________________________

(a ) Describe the type/class of subject (e.g. patients with specific diseases)
to be recruited:

Clients with type 2 diabetes

(b) Set-out the inclusion criteria:__________________________________

All clients with type 2 diabetes are expected to im prove their dietary behaviour and
can be included in the study.

(c) Indicate from where/what source will subjects be recruited and describe
the means and methods of recruitment (i.e. by personal contact, by
advertisement within the institution or by public advertisement)?:________

14
 Registration No: A.

S ubjects will be recruited by personal contact, w hen they visit th e hospital or by a

written letter inviting them to ta k e part in th e study

(d) Describe the type of subject and range of conditions which are to be
contraindicated and excluded from the study. What measures will be taken
to identify and exclude subjects who have recently or who are concurrently
taking part in other research projects?_____________________________

All participants will need a fluent know ledge of English to ta k e part in th e study, it
is th erefo re proposed to only include participants either with English as their first
language or if they can dem onstrate a clear com m and of th e English language, for
e x am p le clients who have been educated to G C S E level in English

(e) Will travelling expenses be given?_______________________ No

(f) Indicate whether any payment is intended to be made to research

subjects and, If so, the amounts in question.___________________
Participation will be on a voluntary basis, no p aym ent is anticipated.

(g) State the relationship, if any, which may/will exist between the
investigator(s) and potential subjects: e.g. will any of the subjects be
students, subordinates or colleagues of the investigator, or members of the
Trust or ICSM staff. ___

T h e re will be no relationship betw een the investigator and th e participants

(5 ) Consent
(a ) Will information on the proposed research be provided to the Yes
subjects in written form (if so, please complete Appendix 1)?
(b) If not, justify the provision of verbal information alone:

15
 Registration No:............ .....V

N /A

(c) Confirm the method (oral or written) and manner (i.e. when and by
whom) in which subjects’ consent to participation wiil be obtained, and
where subjects will/may suffer from any difficulties of communication, the
special methods to be employed both as to information and consent
procedures to overcome these difficulties:____________
Subjects will receive a letter describing th e research and th e purpose of the
questionnaire and any further inform ation they will receive. T h e y will be given the
opportunity to ask for clarification or further details by contacting either the
research er or hospital staff.

(d) Indicate how long subjects will be given to consider participation in

the
research:

Participants will be given approxim ately one m onth to consider participation

(e) Will subjects be given the opportunity to consult with third parties,
relatives or their GPs? If so, explain how this will be ensured.

O n receipt of the questionnaire participants will be advised that th ey are fre e to

discuss their participation with anyone they deem necessary.

(f) Where the subject (i.e. a child under 18 years old or mentally
incompetent adult) is not judged able adequately to appreciate the N /a
nature and implications of the research in order to consent in
their own right, will the subject’s assent and co-operation (as
opposed to consent) be sought (append copy of Information
Sheet)?___________________ _ _________________________
(g) Will there be separate Information Sheets for children and their N /A
parents?______________________________________________
(h) Will the consent of the carer (next of kin, parent, legal
guardian) or the order/deciaration of the Court, be sought in N /A
relation to the participation of such subjects in the research
(append copy of the Information Sheet and Statement for
Relatives)?_______________________________________
(i) State the manner in which any apparent objection to participation by a
subject (particularly a child) will be handled:________ __
Participants will be advised that they a re fre e not to ta k e part and th at if they
d ecide not to participate their treatm en t at the hospital will in no w a y be
com prom ised.

16
 Registration No: A.

(6) General Practitioners

(a ) Will the subjects’ GPs be informed of the subjects’
agreement to take part in the research prior to its No
commencement (append copy of appropriate letter)?
(b) If so, will the subjects be asked if this is acceptable to them? Yes
(c) If not, will subjects’ GPs be informed of the subjects’
agreement to take part in the research after completion (append No
copy of appropriate letter):
(d) If you do not intend informing the subjects’ GPs of their patients’
involvement in this project, please give justification:

It will not be necessary to inform participant’s G P s of their patient’s involvem ent

in this project as it does not involve any change in use of m edication and only
involves encouraging participants to a d h ere to guidelines which th ey h ave already
been advised to follow. H ow ever participants will be advised th at if th ey feel it is
necessary to discuss the m atter with their G P or any other m edical practitioner
they should do so.

(7) Confidentiality___________________________________________
(a ) To whom will the data resulting from the study be made available
(e.g. subjects, other researchers, their GPs, the sponsor)?_________

D a ta will b e a v a ila b le only to th e re s e a rc h e r a n d s ta ff a t H a m m e rs m ith

H o sp ital

(b ) State the measures that will be taken to protect the confidentiality of

subjects’ data (i.e. arising out of the research and contained in personal
records). Indicate who will have control of data generated by the
research:____________________________________________________
O n receipt of the initial com pleted questionnaire participants will be allocated an
identification num ber, analysis of data and com parisons will be conducted only on
the basis of this num ber, participants will not be identified by n a m e . Listings of
identification num bers and n am es will be stored at H am m ersm ith hospital.

6. FINANCIAL AND OTHER ARRANGEMENTS

(1) State any financial or other interests the applicant, his Division or
employer has in relation to the conduct of this research.________
17
 Registration No: A.

T h e re s e a rc h e r, his e m p lo y e r o r division h a v e no fin an cial in te re s t in relation

to th e re s ea rc h

(2 ) Confirm that the necessary arrangements have been, or will be,

made to comply with the requirements of the Data Protection Act 1984
with regard to the computer storage and processing of subjects’
personal information and generally, to ensure confidentiality of such
data supplied and generated in the course of the research (note: any
data stored must not be used for any other study other than that
described in this protocol (as approved by the Research Ethics
Committee) without the prior approval of the Research Ethics
Committee.__________________________________________________
All n e c e s s a ry step s will be ta k e n to c o m p ly w ith th e re q u ire m e n ts o f th e d a ta
p rotectio n a c t 1 9 8 4 . A n y d a ta o b ta in e d will not be used fo r a n y p u rp o s e o th e r
th a n th a t d escrib ed in th e protocol w itho ut th e a p p ro val o f th e re s e a rc h ethics
c o m m itte e being o b ta in e d .

7. CURRICULUM VITAE OF INVESTIGATOR(S)

(Additional investigators should provide similar information on a
separate sheet)
Surname Forename(s) Date of birth
Moore Andrew Paul 4-12-55

DEGREES, etc. (subject, class, University and date)

BSc Health Psychology, Thames Valley University 1998: Grade 2.1

MSc Research Methods and Psychological Assessment

University of Surrey 1999. Grade 62%

18
 R egistration no:

POSTS HELD WITH DATES______________________________________

Phd student, University of Surrey: 1999 - Present

Msc student, University of Surrey: 1998-1999

Psychology Undergraduate, Thames Valley University: 1995-1998

Part time care worker, Bournewood Trust: 1996 - Present

RECENT PUBLICATIONS (title and reference)

None

TITLE OF PROPOSED RESEARCH:___________________________

The application of the stages of change model to the dietary behaviour of
patients with Type 2 diabetes._________________________________

8. PRINCIPAL INVESTIGATOR'S DECLARATION

19
 Registration No: A.

I h a v e re a d and u n d ersto o d th e R E C G u id a n c e N o te s a n d all d o c u m e n ts

pertain in g to this re s e a rc h th a t 1 n o w e n c lo s e . T h e info rm atio n th e re in a n d
a b o v e is a c c u ra te to th e b e s t o f m y k n o w le d g e a n d b e lie f a n d I ta k e full
responsibility fo r it.

I u n d ers ta n d it is m y responsibility to obtain m a n a g e m e n t a p p ro v a l w h e re

a p p ro p ria te from th e re le v a n t N H S bod y b e fo re th e p ro ject ta k e s p la c e.

i confirm th a t this re s e a rc h will c o m p ly with all re le v a n t U K legislatio n,

including th e D a ta P ro tectio n A c t a n d th e A c c e s s to M e d ic a l R e c o rd s A ct.

I a g re e to supply interim and final reports to th e R E C a s re q u ire d .

I a g re e to ad v ise th e R E C o f a n y a d v e rs e o r u n e x p e c te d e v e n ts th a t m a y
o c c u r during this project. I also a g re e to a d v ise th e R E C if this is w ith d raw n or
not c o m p le te d .

I a g re e to k e ep th e sig n ed c o n s e n t fo rm s w ith th e re s e a rc h reco rd s a s w ell as

ke e p in g copies in th e p a tie n t’s m e d ic al records fo r th e sta tu to ry life o f th o s e
records.

I a g re e to obtain th e R e s e a rc h E thics C o m m itte e ’s ap p ro v a l fo r a n y c h a n g e s

to th e protocol. T h is includes a n y in c re a s e in th e n u m b e r o f s u b je c ts .

I a g re e to provide d a ta a b o u t th e subjects stud ied and to p ro d u c e th e signed

c o n s e n t form s w h e n re q u e s te d by th e R e s e a rc h E thics C o m m itte e fo r au d it
p u rp o ses.

S ig n e d __________________________________________________ P rin cip al In v e stig a to r

Nam e

D a te d 19

9. S IG N A T U R E S

Signed. C o -in v e s tig a to r 1

D a te d 19

S ig n e d C o -in v e s tig a to r 2
20
 Registration No:................\.... ...............

Dated__________________ 19

S ig n e d C o -in v e s tig a to r 3

D a te d _______________________19

S ig n e d C o -in v e s tig a to r 4

D a te d _______________________19

TO. DIVISIONAL APPROVAL

S ig n e d __________________________________________________ H e a d o f S e c tio n /U n it

D a te d _______________________ 19

S ig n e d __________________________________________________ C h a irm a n , D iv. C o m m .

D a te d _______________________19

S ig n e d 1 H e a d o f D ivisio n/
D e s ig n a te d D ivisional
s ig n a to ry

D a te d _______________________ 19

11. RESEARCH ETHICS COMMITTEE APPROVAL

S ig n e d _________________________________________________________________ C h a irm a n

D a te d _______________________19

THIS PROTOCOL IS VALID UNTIL 20

21
 Registration No: A.

Appendix 1

Information Sheet for Patients and Healthy Volunteers

You will be given a copy of this Information Sheet

A n investigation into th e psychological p ro c e s se s a s s o c ia te d w ith d ie ta ry

Change

D e a r C lie n t

W e w ould like to invite you to particip ate in a re s e a rc h p roject. T h e stu d y is

d e s c rib e d in full on th e a tta c h e d p a g e . Y o u should not ta k e part in th e study if
you do not w ish to do so. If you do d e c id e to ta k e part, p le a s e let us know
b e fo re h a n d if you h a v e b e e n involved in a n y o th e r stud y during th e la st y e a r.
If you d e c id e not to ta k e p a rt yo u r tre a tm e n t will not b e a ffe c te d by y o u r
de c isio n . Y o u a re fre e to w ith d raw a t a n y tim e w ith o u t e x p la n a tio n a n d yo u r
s u b s e q u e n t tre a tm e n t will not be a ffe c te d . Y o u should b e a w a re , h o w e v e r,
th a t it m a y not b e possib le fo r you to co n tin u e to re c e iv e a n y intervention s
b a s e d on this re s e a rc h o n c e yo u r participation in th e trial h as e n d e d .
T h is stud y is being c o n d u cted purely fo r re s e a rc h , a n y m a te ria ls you re c eiv e
will o n ly s u p p le m e n t but not re p la c e a n y tre a tm e n t or m e d ic a tio n you a re
c u rre n tly receiving. T h e re fo re it has not b e e n n e c e s s a ry to c o n ta c t y o u r G P or
a n y m e d ic a l s ta ff reg ard in g yo u r participation. Y o u a re o f c o u rs e fre e to
c o n ta c t th e m if you h a v e a n y doubts regarding y o u r particip atio n .

Y o u rs S in c e re ly
A n d re w M o o re

(V e rs io n D a te : / / )

T h e local R e s e a rc h E thics C o m m itte e has a p p ro v e d th e a b o v e s ta te m e n t:

S ig n e d ..................................................................................... (C h a ir)

D a te ...............................................

T H IS IN F O R M A T IO N S H E E T IS V A L ID F O R U S E U N T I L ..................................
D e a r C lie n t

22
 Registration No:................ \...................

T o intro d u ce m y s e lf I a m a re s e a rc h s tu d en t a t th e psych o lo g y d e p a rtm e n t o f

th e U niversity o f S u rre y and 1 a m currently condu cting re s e a rc h into th e
attitu d es a n d psychological p ro c e s se s a s so ciated w ith d ie ta ry c h a n g e . B elow
a re th e d e tails o f a stud y I a m condu cting, I w ould g re a tly a p p re c ia te it if you
could re a d th ro ugh th e m .
B a c kg ro u n d
R e c e n t re s e a rc h su g g e s ts th a t d ie ta ry c h a n g e follow s a p a rtic u la r s e q u e n c e
an d th a t in tervention s m a tc h e d to this s e q u e n c e will be m o re e ffe c tiv e th an
s ta n d a rd intervention s. T h e opin io ns o f p e o p le w ith ty p e 2 d ia b e te s a re o f
p articu lar in te re s t a s th e m onitoring o f d ie t is an im p o rta n t p a rt o f your
tre a tm e n t; It is h o p ed th a t by gaining an insight into th e p ro c e s s e s and
s tra te g ie s p e o p le like yo u r s e lf u s e , th a t im proved in te rv e n tio n s c an be
d e v e lo p e d fo r o th ers. T h e re fo re I w ould be v e ry g ratefu l if you could help m e
by ta k in g p a rt in a short study, th e plan o f w hich is outlin ed b elo w .
S tu d y P lan
i.Y o u will b e a s k e d to fill o u t an initial q u e s tio n n a ire , w h ich will fo c u s on your
a ttitu d e to e ith e r fa t in ta k e o r fruit a n d v e g e ta b le intake.
2 .0 n co m p letio n o f th e q u e s tio n n a ire you m a y re c eiv e s o m e p a m p h le ts giving
g u id elin e s on h o w to im p ro v e o r m ain tain yo u r a d h e re n c e to y o u r d ietary
p ro g ra m m e .
3 .A p p ro x im a te ly 3 m on ths a fte r this you will be c o n ta c te d a g a in to fo r your
opin io ns o f th e in tervention s a n d q u e s tio n n a ire s .
4 .A t th e e n d o f 6 m on ths you will re c eiv e a seco n d q u e s tio n n a ire w hich will
a g a in e x a m in e y o u r attitude to e ith e r fa t in take o r fruit a n d v e g e ta b le intake.
C o m p letio n o f th e q u e s tio n n a ire s an intervention s should not b e v e ry tim e
c o n su m in g takin g a m a x im u m o f 4 5 m in u tes fo r e a c h o n e . I w o u ld g reatly
a p p re c ia te yo u r h elp if you d e c id e to ta k e part. It is h o p e d th a t th e inform ation
g a in e d will b e o f b e n e fit to in th e desig n o f fu tu re d ie ta ry p ro g ra m m e s .
A n y P ro b le m s
I a s s u re you th a t a n y info rm ation you give m e will be u s e d s o le ly fo r th e
re s e a rc h I h a v e d e s c rib ed . If you h a v e a n y q u eries re g a rd in g th e re s ea rc h , I
a m a v a ila b le to d a y to a n s w e r a n y q u estion s you m a y h a v e , alte rn a tiv ely
p le a s e fe e l fre e to c o n tac t m e a t th e U niversity o f S u rre y on 0 1 4 8 3 -8 7 6 8 8 3 or
on e -m a il a t A .M o o re @ s u rre y .a c .u k . I will b e h a p p y to h elp in a n y w a y I can.

Y o u rs S in c e re ly

23
registration no

24
 Registration No:................ \.................. .

Appendix 2(a)

Participant Consent Form V -

Title of project:

An Investigation into the psychological processes associated with dietary

change in type two diabetes_______________________________________

The participant should complete the whole of this sheet him or herself.

(please tick each statem ent if it applies to you)

I have read the Information Sheet for Patients and ---------

Healthy Volunteers. I

I have been given the opportunity to ask questions and .

discuss this study.

I have received satisfactory answers to all my questions. T

I have received enough information about the study.

The study has been explained to me by:

Prof/Dr/M r/M rs/M s_______________________________________

I understand that I am free to withdraw from

the study at any time, without having to give a reason for
withdrawing and without affecting my future medical care.

1 agree to take part in this study.

Signed...................................................................................................... D a te ...........................................

(N A M E IN BLO CK
C A P IT A L S )................................................................................................................................................

Investigator’s signature..................................................................... D a te :......................................

(N A M E IN BLOCK
C A P IT A L S )..................................................................................................................................................

Appendix 2(b)

25
 Registration No: A.

Statement for Relatives/Carers etc.

Title of project:

Patient’s Name:

The relative/carer should complete the whole of this sheet him or

herself.

I h a v e b e e n fully in fo rm ed o f w h a t th e stud y involves fo r m y re la tiv e /p a rtn e r/

frie n d w h o is n a m e d a b o v e .

T h e stud y has b e e n e x p la in e d to m e by:

P ro f/D r/M r/M rs /M s ...................................... ........................................................................................
(p le a s e tick e a c h s ta te m e n t if it a p p lie s to yo u )

I h a v e re a d th e In fo rm atio n S h e e t fo r P a tie n ts and I---------.

H e a lth y V o lu n te e rs . I

I h a v e b e e n given th e opp ortun ity to a s k qu estio n s and

d iscu ss this study.

I h a v e re c eiv e d s atisfacto ry a n s w e rs to all m y question s.

I h a v e re c eiv e d e n o u g h info rm ation a b o u t th e study.

I u n d e rs ta n d th a t m y re la tiv e /p a rtn e r/frie n d is fre e to w ith d ra w fro m

th e s tu d y a t a n y tim e , w jth o u t having to g ive a re aso n fo r
w ith d raw in g and w ith o u t a ffe c tin g th e ir fu tu re m ed ical c a re .

S ig n e d ......................................................................................... D a te :.......

(N A M E IN BLO CK
C A P IT A L S )..........................................................................................................................

R e la tio n s h ip to
p a tie n t:.................................................................................................................................

In v e s tig a to r’s s ig n a tu re .................................................................... D a te ...............

(N A M E IN BLO CK
C A P IT A L S ).........................................................................................................................

26
 Registration No: A.

Appendix 3
[N.B. if the study is covered by a Sponsoring Company's indemnity this
form must be submitted bearing BOTH institution (Trust or Medical
School as appropriate) and Company signatures. Studies will not be
approved until a signed copy this indemnity form is received.]

Form of Indemnity for Clinical Studies

To: [Name and address of sponsoring company] (“th e S p o n s o r ”)

From: The Hammersmith Hospitals NHS Trust or

The imperial College School of Medicine [delete as appropriate]
(“th e T ru s t/M e d ic a l S c h o o l”)

Re: Project title: ( “th e S tu d y ”)

REC Registration No:

1. It is proposed the Trust/M edical School [d e le te a s a p p ro p ria te ] should agree

to participate in the above sponsored study involving patients of the
Trust/volunteers within the Medical School [d e le te a s a p p ro p ria te ] ("the
Subjects"), to be conducted by Professor/Dr [d e le te a s a p p ro p ria te ]
......................................(“the Investigator”) in accordance with the protocol
annexed, as am ended from time to time with the agreem ent of the Sponsor
and the Investigator (“the Protocol”). The Sponsor confirms that it is a term of
its agreem ent with the investigator that the investigator shall obtain all
necessary approvals of the applicable Local Research Ethics Com m ittee and
shall resolve with the Trust/Medical School any issues of a revenue nature.

2. The Trust/M edical School [d e le te a s a p p ro p ria te ] agrees to participate by

allowing the Study to be undertaken on its premises utilising such facilities,
personnel and equipm ent as the investigator might reasonably need for the
purpose of the Study.

3. In consideration of such participation by the Trust/M edical School [d e le te a s

a p p ro p ria te ], and subject to paragraph 4 below, the Sponsor indemnifies and
holds harmless the Trust/M edical School [d e le te a s a p p ro p ria te ], and its
em ployees and agents against ail claims and proceedings (to include any
settlements or ex-gratia payments m ade with the consent of the parties
hereto and reasonable legal and expert costs and expenses) m ade or
brought (whether successfully or otherwise):

(a) by or on behalf of Subjects taking part in the Study (or their

dependents) against the Trust/Medical School [d e le te a s a p p ro p ria te ]
or any of its em ployees or agents for personal injury (including death)
to subjects arising out of or relating to the administration of the
product(s) under investigation or any clinical intervention or procedure
provided for or required by the Protocol to which the subjects would
not have been exposed but for their participation in the Study.

(b) by the Trust/Medical School [d e le te a s a p p ro p ria te ], its

em ployees or agents by or on behalf of a subject for a declaration
concerning the treatm ent of a Subject who has suffered personal
injury.
27
 Registration No:............ V

4. T he above indemnity by the Sponsor shall not apply to any such claim or
proceeding :
4 .1. to the extent that such personal injury (including death) is caused by
the negligent or wrongful acts or omissions or breach of statutory duty
of the Trust/Medical School [d e le te a s ap p ro p ria te ], its em ployees or
agents;
4 .2 . to the extent that such personal injury (including death) is caused by
the failure of the Trust/M edical School [d e le te a s a p p ro p ria te ], its
em ployees, or agents to conduct the study in accordance with the
Protocol;
4.3. unless as soon as reasonably practicable following receipt of notice of
such claim or proceeding the Trust/Medical School [d e le te a s
a p p ro p ria te ] shall have notified the Sponsor in writing of it and shall,
upon the Sponsor’s request, and at the Sponsor’s cost, have
permitted the Sponsor to have full care and control of the claim or
proceeding using legal representation of its own choosing.
4 .4. if the Trust/Medical School [d e le te a s ap p ro p ria te ], its em ployees or
agents shall have m ade any admission in respect of such claim or
proceeding or taken action relating to such claim or proceeding
prejudicial to the defense of it without the written consent of the
Sponsor such consent not to be unreasonably withheld provided that
this condition shall not be treated as breached by any statem ent
properly m ade by the Trust/M edical School [d e le te a s a p p ro p ria te ], its
em ployees or agents in connection with the operation of the
Trust/Medical School’s [d e le te a s a p p ro p ria te ] internal complaint
procedures, accident reporting procedures or w here such statem ent is
required by law.

5. The Sponsor shall keep the Trust/M edical School [d e le te a s a p p ro p ria te ] and
its legal advisers fully informed of the progress of any such claim or
proceeding, will consult fuily with the Trust/Medical School [d e le te a s
a p p ro p ria te ] in the nature of any defence to be advanced and will not settle
any such claim or proceeding without the written approval of the
Trust/M edical School [d e le te a s a p p ro p ria te ] (such approval not to be
unreasonably withheld).

6. W ithout prejudice to the provisions of paragraph 4 .3 above, the Trust/Medical

School [d e le te a s a p p ro p ria te ] will use its reasonable endeavours to inform
the Sponsor promptly of any circumstances reasonably thought likely to give
rise to any such claim or proceeding of which it is directly aw are and shall
keep the Sponsor reasonably informed of developments in relation to any
such claim or proceeding even w here the Trust/Medical School [d e le te a s
a p p ro p ria te ] decides not to m ake a claim under this indemnity. Likewise, the
Sponsor shall use its reasonable endeavors to inform the Trust/M edical
School [d e le te a s a p p ro p ria te ] of any such circumstances and shall keep the
Trust/M edical School [d e le te a s a p p ro p ria te ] reasonably informed of
developments in relation to any such claim or proceeding m ade or brought
against the Sponsor alone.

7. The Trust/Medical School [d e le te a s a p p ro p ria te ] and the Sponsor will give to

the other such help as m ay be reasonably required for the efficient conduct
and prompt handling of any claim or proceeding by or on behalf of Subjects
(or their dependents) or concerning such a declaration as is referred to in
paragraph 3(b) above.

28
 Registration n o : ....... V

8. W ithout prejudice to the foregoing if injury is suffered by a subject while

participating in the Study, the Sponsor agrees to operate in good faith the
Guidelines published in 1991 by the Association of the British Pharmaceutical
Industry and entitled “Clinical Trial Com pensation Guidelines” (where the
Subject is a patient) and the Guidelines published in 1988 (am ended 1990) by
the sam e Association and entitled “Guidelines for Medical Experim ents in
non-patient Hum an Volunteers” (where the Subject is not a patient) and shall
request the Investigator to m ake clear to the subjects that the Study is being
conducted subject to the applicable Association Guidelines.

9. For the purposes of this indemnity, the expression “agents” shall be deem ed
to include without limitation any nurse or other health professional providing
services to the Trust/M edical School [d e le te a s a p p ro p ria te ] under contract for
services or otherwise and any person carrying out work for the Trust/M edical
School [d e le te a s a p p ro p ria te ] under such a contract connected with such of
the Trust/M edical School [d e le te a s a p p ro p ria te ] facilities and equipm ent as
are m ade available for the Study under paragraph 2 above.

10. This indemnity shall be governed by and construed in accordance with

English law.

S IG N E D on b e h a lf o f th e H a m m e rs m ith H o sp itals N H S T ru s t/th e Im p erial

C o lle g e S ch o o l o f M e d ic in e [d e le t e a s a p p r o p r ia te ]:

N a m e in block cap itals

P o s itio n ................................

D a te d ....................................

S IG N E D on b e h a lf o f th e C o m p a n y

N a m e in block capitals

P o s itio n ...............................

D a te d ....................................

29
 Appendix Three

Final questionnaires and factor analysis exploratory and baseline

L et’s Look at our Attitude to Fat in
our Diet
T he fo llo w in g q u e s tio n n a ire is p a r t o f a re s e a rc h s tu d e n t’s p ro g ra m m e a t
th e U n iv e rs ity o f S u rre y in v e s tig a tin g p e rc e p tio n s a n d a ttitu d e s to d ie t. A ll
in fo rm a tio n w ill be tre a te d as c o n fid e n tia l a n d w ill n o t be u se d f o r a n y
p u rp o s e o th e r th a n re s e a rc h .

P le a s e a n s w e r the q u e s tio n s in s id e a n d re tu rn the c o m p le te d q u e s tio n n a ire

to re c e p tio n .

It should take about 30 minutes of your time

Firstly a few details about yourself.

Age

Sex

Occupation (please state your previous occupation if you are retired, unemployed a
student over 24 years o f age, or the occupation o f your parents if you a student under 24)

Are you mainly responsible for buying preparing and cooking the food you
eat. Circle the appropriate answer

Yes No

Level of Education
Which of the following qualifications do you have (tick as many boxes as
applicable)

• 0 level or GCSE □
• □
A level or Scottish highers
• HNCorHND □
• BSc/BA/BEd □
• Higher Degree ( eg Masters or PhD) □
• None of the above □
This questionnaire examines your eating habits over the last 3 months. Please indicate on
a scale of 1- 7 how often over the last 3 months you have done the following things.

1 = Never 2 = Rarely 3 = Occasionally 4 = Usually

5 = Frequently 6 = Ahnost Always 7 = Always

I buy low fat foods to help me follow a low fat eating plan
1........2 ......... 3 ........ 4 ........ 5.........6 ........ 7

I limit the amount of salad dressings I use or if I do use them I use low fat ones
1......... 2 ........ 3........ 4......... 5.......6......... 7

I substitute low fat dairy foods for high fat dairy foods
( If you do not take daily products, please circle number 8)
1........2 ......... 3 .......4 ........ 5........ 6........ 7......... 8

I substitute low fat foods for high fat foods in general

1......... 2........ 3........ 4......... 5.......6......... 7

I grill or bake instead of hying foods

1......... 2........ 3 ........ 4 ......... 5.......6......... 7

I eat fruit or low calorie desserts instead of high fat desserts

1......... 2........ 3........ 4 ......... 5.......6..........7

I count the number of calories I eat

1......... 2 ........ 3........ 4 ......... 5.......6......... 7

I avoid eating hamburgers and other high fat foods at fast food restaurants
1......... 2........ 3........ 4......... 5.......6 .........7

When I eat at a restaurant I look for low fat foods to order

1.........2........ 3........ 4......... 5.......6..........7

I avoid eating high fat meats ( for example ham, pork, beef, lamb)
( If you do not eat meat circle number 8)
1......... 2........3........4 .......... 5........6......... 7........8

When I eat meats I choose low fat cuts or him off the fat
( If you do not eat meat circle number 8)
1.........2 ........3........4 .......... 5........6......... 7........8

I do not use butter or other high fat products as flavouring on vegetables or potatoes
1........ 2 ..........3 ......... 4 .........5........ 6......... 7
 I avoid eating calces, pastries and processed snacks that are high in calories
1........2..........3........ 4........5........ 6......... 7

I eat breads or rolls without high fat spreads such as butter

1........ 2 ......... 3 ........ 4 ........ 5........ 6.........7

This next section examines your perception of your diet and whether or not you intend
making any changes in your intake of fat over the next few months. Read each statement
and indicate which one best describes you by putting a tick in the box beside it.

Please tick only one box

I have been on a low fat diet for more than 6 months and I do not intend reducing my fat intake any further.
n
I have been on a low fat diet for more than 6 months but I intend to reduce my fat intake further
□
I have been on a low fat diet for less than six months and I do not intend reducing my fat intake any
further. □
I have been on a low fat diet for less than 6 months but I intend reducing my fat intake further □

I am not on a low fat diet but I intend to start one in next month
□
I am not on a low fat diet but I intend to start one in the next 6 Months □

I am not on a low fat diet and I do not intend to start one in the next 6 months □

Please rate on a scale of 1-10 how likely you believe it is that you could develop a
significant health problem because of your intake of fatty foods.

1........2........ 3........ 4 ........ 5.........6.........7........ 8.........9......... 10

Not at all Very Likely

The maximum recommended level of energy derived from fat in the diet is

25% 35% 40% 45% 50%

The following questions look at the experiences which effect the dietary intake of people.
Think of similar experiences you may have had in attempting to improve your diet and
rate how often you have used these over the past 6 months. There are 7 possible responses
to each question. Please circle the number that best describes your experience.

1 = Never 2 = Rarely 3 = Occasionally 4 = Usually 5 = Frequently

6 = Almost Always 7 = Always

1 .1 recall information from articles and advertisements about the benefits of low fat
diets.
1....... 2 .......... 3....... 4 ..........5 ....... 6......... 7

2.Society would be better if more people ate low fat diets

1....... 2 .......... 3....... 4 ......... 5 ....... 6......... 7

3 .1 recall information people have given me about the health problems from eating a high
fat diet.
1....... 2 .......... 3....... 4 ......... 5 ....... 6......... 7

4.1 think about information from articles and advertisements on how to change to a low
fat diet
1....... 2.......... 3....... 4 ..........5 ....... 6......... 7

5 .1 pay close attention to television programmes about low fat diets

1........2 ........3 ........ 4 ........ 5 ........ 6.........7

6 .1 seek out information regarding reducing the fat in my diet

1.......2...........3....... 4 ..........5 ....... 6......... 7

7 .1 talk to people about the systems or tricks they use to stay on low fat diets
1.......2.......... 3....... 4 ..........5....... 6.......7

8 .1 associate with people who are pursuing low fat diets

1... 2 .......... 3....... 4 ..........5 ....... 6......... 7

9 .1 have someone in my life who cares about my diet being low in fat
1.......2 .......... 3....... 4 ......... 5 ....... 6..........7

10.1 have someone who listens when I need to talk about reducing the fat in my diet
1.......2.......... 3....... 4 ......... 5 ....... 6..........7

11.1 can be open with at least one special person about my experience with low fat eating
1.......2.......... 3....... 4 ......... 5 ....... 6..........7

12 J can expect to be rewarded by others if I eat a low fat diet

1........2......... 3.........4........ 5...... ..6.........7
 13. The encouragement of others is a major factor in the lowering of fat in my diet
1........2 ......... 3........ 4........ 5.........6.........7

14.1 make a point of talking to someone regularly about reducing my fat intake
1.........2 ........3......... 4 ........5.........6.........7

15. Warnings about the health hazards of high fat diets move me emotionally
1.........2 ........3......... 4 ........5.........6.........7

16.1 have fearful feelings about developing heart trouble horn eating too much fat
1........ 2 .......... 3 ......... 4 .........5. ......6 ......... 7

17. Remembering studies about illnesses caused by high fat diets upsets me
1.........2 ........ 3.........4........ 5......... 6........ 7

18.1 react emotionally to health warnings about high fat diets

1........ .2........ 3.........4........ 5......... 6........ 7

19. Portrayals of the problems of people eating high fat diets affect me emotionally.
1.........2 ........ 3.........4........ 5......... 6........ 7

20. Discussions about high fat diets affect me emotionally

1.........2........ 3.........4 ........ 5......... 6........ 7

21. News reports and official figures about the dangers of high fat diets upset me
1.........2........ 3.........4........ 5......... 6........ 7

2 2 .1 notice the difficulty in society because of the high fat diets people eat
1........ 2 ........ 3.........4........ 5......... 6........ 7

2 3 .1 consider the belief that people consuming low fat diets will improve the world
1........ 2 ........ 3.........4 ........ 5......... 6........ 7

2 4 .1 think about the need for more people to understand the importance of a low fat diet
1........ 2........ 3.........4........ 5......... 6........ 7

25. High fat diets are responsible for the high death rate from heart disease and cancer
1........ 2........ 3.........4........ 5......... 6........ 7

26. Eating low fat foods gives me a feeling of freedom

1........ 2 ........ 3.........4........ 5......... 6........ 7

2 7 .1 believe that when I am on a low fat diet I get on better with people
1........2......... 3........ 4 ........ 5........ 6.........7
 2 8 .1 believe I could do more for my family and friends if I stayed on a low fat diet
1........2...........3.......4..........5.......6......... 7

29. My consumption of high fat foods makes me feel disappointed in myself

1........2 ...........3.......4..........5.......6..........7

3 0 .1 feel that improving my diet by eating low fat foods is one way to improve myself
1........2 ...........3.......4......... 5.......6..........7

31. Choosing low fat foods gives me a feeling of control

1........2 ...........3.......4..........5.......6..........7

32.1 get upset when I think about my eating too much high fat foods
1........2...........3.......4..........5.......6..........7

33. Eating low fat food is one way to demonstrate my willpower

1........ 2 ..........3.......4..........5........6.........7

34.1 believe that by eating a low fat diet I will become a healthier and happier person
1........ 2 ..........3.......4......... 5........6.........7

35. On an low fat diet I will deal with difficult and stressful situations better
1........ 2 ..........3.......4......... 5........6.........7

36.1 am rewarded by others when I keep to a low fat diet

1........ 2 ..........3.......4......... 5........6......... 7

37. Instead of eating high fat foods I do something else

1........ 2 ..........3.......4 ......... 5........6......... 7

38. Other people in my daily life make me feel good when I eat low fat foods
1........ 2 ..........3.......4......... 5........6......... 7

39 .1 leave situations where there are a lot of high fat foods

1........ 2 ..........3.......4......... 5........6......... 7

4 0 .1 reward myself when I eat low fat foods

1 2..........3.......4..........5........6......... 7

41. Occasionally I reward myself with fatty foods if I have maintained a low fat diet
1........ 2 ..........3.......4 ......... 5........6......... 7

42 .Eating high fat foods is not a problem provided it does not happen too often
1........2 ..........3.......4..........5........6......... 7
 4 3 .1 tell myself I can choose to maintain a low fat diet or not
1........ 2 ..........3........ 4 ....... 5.........6......... 7

4 4 .1 tell myself that I am able to lose weight when I want to by maintaining a low fat diet
1........ 2..........3........ 4 ....... 5.........6......... 7

4 5 .1 tell myself that if I try hard enough I can keep from eating high fat foods
1.........2.......... 3........4 .......5..........6........ 7

4 6 .1.make private commitments to eat low fat foods

1........ 2..........3........4 .......5..........6........ 7

4 7 .1 tell myself I can make the necessary changes to maintain a low fat diet
1........ 2.......... 3........4 .......5..........6........ 7

4 8 .1 tell myself I can dismiss the problems associated with low fat diets
1........ 2.......... 3........4 .......5..........6........ 7

4 9 .1 make public commitments that I will maintain a low fat diet

1........ 2.......... 3........4 .......5..........6........ 7

50. When I am tempted to eat high fat foods I try to relax

1........ 2.......... 3........4.......5..........6........ 7

51. Instead of eating high fat foods I engage in physical activity

1........ 2 ..........3 ........4 .......5..........6........ 7

52.1 do something else instead of eating high fat foods when I need to relax or deal with
tension.
1........2.......... 3........4.......5..........6........ 7

53.1 think about something else when I am tempted to eat high fat foods
1........2 ..........3........4 .......5..........6........ 7

54. When I am tempted to eat high fat foods I eat some favourite health food
1......... 2.........3 .........4 ........ 5........6.........7

55.1 find keeping myself busy is a good way to avoid eating high fat foods
1.........2.........3.........4........ 5........6.........7

56. Telling others about the benefits of a low fat diet helps me maintain a low fat diet
1........2 .........3 .........4 ........ 5........ 6.........7
57 .1 remove things from my place of work that remind me of eating high fat foods
1........ 2.........3 ........ 4 .........5........ 6......... 7

58.1 keep things around my place of work that remind me not to eat high fat foods
1........ 2 ..........3 ........ 4.........5.........6........ 7

59.1 put things around the home that remind me not to eat high fat foods
1........ 2 ..........3 ......... 4... 5.........6........ 7

6 0 .1 remove things from my home that remind me of eating high fat foods
1........ 2..........3......... 4 ........5 .........6........ 7

6 1 .1 avoid occasions where there are a lot of high fat foods

1........ 2 ..........3......... 4 ........5.........6........ 7

6 2 .1 make sure there are plenty of low fat foods in my home

1........ 2..........3......... 4... 5.... 6 ........ 7

63. When I shop I avoid areas where there are a lot of high fat foods
1........2 ..........3......... 4 ........5.........6........ 7

The following questions look at the decisions people make when they decide whether or
not to improve their diet. Please indicate how important each of the following statements
would be to you if you were deciding to go on an improved diet. There are 7 possible
responses to each of the items. Circle the number that best describes how important each
statement would be to you if you were deciding whether or not to go on an improved diet.

1 = No importance at all 2 = Very little importance 3 = Slight importance

4 = Moderate importance 5 = Significantly important 6 = Veiy important
7 = Extremely important

1 Going on a low fat diet would be hard work

1......... 2 ........3 ..........4 .........5...... 6..........7

2 1 would feel sexier and more attractive on a low fat diet

1......... 2........3..........4 .........5...... 6..........7

3 My self respect would be higher on a low fat diet

1......... 2........3..........4 .........5...... 6..........7

4 A low fat diet would make meal planning more difficult for my family or house mates
1......... 2........3..........4 .........5...... 6..........7

5 My family and friends would be proud of me if I maintained a low fat diet

1........ .2........3..........4...... ..5...... 6..........7

6 Others would have more respect for me if I maintained a low fat diet
1......... 2........3..........4 ........ 5...... 6..........7

7 I would have to cut out some of my favourite foods if I was on a low fat diet
1......... 2........3..........4........ 5...... 6.......... 7

8 Going on a low fat diet would mean avoiding some of my favourite places or activities
1......... 2........3..........4 ........ 5...... 6.......... 7

9 I would feel better all round on a low fat diet

1......... 2........3..........4 ........ 5...... 6.......... 7

10..A low fat diet takes the pleasure out of meals

1.........2 ........3..........4........ 5...... 6.......... 7
The next questions look at typical eating situations. Everyone has situations which make
it difficult for them not to eat fatty foods. The following are a number of situations
relating to eating patterns and attitudes.
Read each situation carefully and decide how confident you are that you will be able to
resist eating fatty foods in each situation. In other words pretend you are in the situation
now.
On a scale from 1 = not confident to 7 = very confident circle the number which reflects
how confident you feel now about being able to successfully resist the desire to eat high
fat foods.

For Example
I am confident Confidence Number .
I can resist eating high fat foods at weekends................... 1......2..... 3..... 4 ..... 5 ..... 6..

I am confident that
I I can resist eating high fat foods when I am anxious 1.....2......3..... 4..... 5..... 6......7

at the weekend 1.... 2 ... 3....... 4... 5.....6......7

when I am watching T.V 1.... 2 ... 3....... 4 ... 5 ...... 6......7

when I am depressed 1.... 2... 3........4... 5......6......7

when I feel it is impolite to refuse a second helping 1.....2 ..... 3..... 4 ..... 5..... 6......7

when Ihave a headache 1 ? 3 4 5 6 7

when I am at a party 1 ?. 3 4 5 6 7

when others are pressuring m e to eat them 1 ?. 3 4 5 6 ...7

when I am in pain 1, 2 ,3, 4 5 ,,,7

just before I go to bed 1.. 2.. 3.. 4.. 5...6.....7

Dear Participant
Approximately 6 months ago you completed a questionnaire and were given a brochure
with some information and exercises, three months later you were again sent a copy o f the
brochure. It would greatly assist me if you could complete the following brief
questionnaire giving your opinion o f the brochure you received Please circle the
appropriate response.

Did you read the brochure ? Yes No

Have you saved the brochure? Yes No

Did you find the brochure helpful? Yes No

Did you discuss the brochure with others? Yes No

Did you complete all the exercises Yes No

Did you complete some o f the exercises Yes No

 Factors processes of change exploratory study

Item 1 2 3 4 5 6 7 8 9
1 .604
2 .195 .48
3 .69
4 .62
5 .53
6 .56
7 .75
8 .74
9 .68
10 .64
11 .72
12 .81
13 .80
14 .74
15 .77
16 .59
17 .80
18 .47
19 .52
20 .42 .39
21 .75
21 .54
23 .70
24 .74
25 .78
26 .52
27 .34
28 .37
29 .54
30
31 .72
32 .68
33 .61
34 .371
35 .68
36 .82
37 .60
38 .60
39 .76
40 .80
41 .80
42 .90
Variance 36.4 7.2 5.9 5.0 4.5 3.6 3.0 2.7 2.5
%
Factors decisional balance exploratory
study

Item 1 2
1 .45
2 .68
3 .44
4 .79
5 .69
6 .84
7 .62
8 .69
9 .84
10 .76
11 .85
12 .69
13 .85
14 .72
15 .54
16 .43
17 .30 .36
18 .63
19 .87
20 .67
Variance 31.2 18.1
%
 Factors Processes of change Hospital baseline

Item 1 2 3 4 5 6 7 8 9
1 .75
2 .31 .61
3 .54
4 .75
5 .66
6 .58
7 .54
8 .54 .17
9 .90
10 .91
11 .85
12 .55 .26
13 .40
14 .35
15 .71
16 .67
17 .86
18 .92
19 .86
20 .86
21 .83
22 .42
23 .54
24 .42
25 .69
26 .36 .28
27 .51 .17
28 .41 .24
29 .37
30 .32
31 .32
32 .31
33 .38
34 .20
35 .44
36 .51
37 .44
38 .44
39 .42
40 .38
41 .60
42 .73
43 .58
44 .65
45 .77
46 .59
47 .69
 48 .42
Item 1 2 3 4 5 6 7 8 9
49 .24
50 .46
51 .72
52 .89
53 .74
54 .56
55 .67
56 .35 .15
57 .69
58 .74
59 .76
60 .73
61 .64
62 .18
63 .604
Variance 42.5 5,1 3.9 3.3 3.2 2.3 2.0 1.9 1.7
%

Factors decisional balance hospital baseline

Item 1 2
1 .48
2 .80
3 .87
4 .77
5 .76
6 .75
7 .68
8 .66
9 .77
10 .88
Variance % 47 13
 Appendix Four

Intervention pamphlets and letters

Thank you for recently completing my
questionnaire on attitudes to nutrition and diet.
According to your questionnaire results you may
be eating above the recommended level o f fat in
your diet and you are not currently thinking o f
reducing it. On the following pages is some
information, which you might find helpful.
Please take the time to read it
Firstly there are some issues I would like you to consider
Being overweight has been likened to a domino effect, in that it could be the
first step to numerous health problems. Imagine a row of dominoes, you
knock over the first one, this in turn knocks over the second which in turn
knocks over the third which in turn knocks over the fourth and so on. A
simple example of this is that excess weight can raise the level of unwanted
fats in your blood, these in turn can clog your arteries which makes you
more vulnerable to heart attacks and strokes. Excess fat has also been linked
with increased risk of cancer, arthritis and of course diabetes. However the
good news is that if you can stop this chain reaction by eating more
healthfully, you may not develop these health problems. In fact you will
most likely live longer and you will certainly live more comfortably and
enjoyably.
Sadly it is estimated that the majority of the British population consume too
much fat in their diet. Perhaps many people are ill informed regarding the
damage caused by excess dietary fat, perhaps they feel it is not worth their
while or practical to reduce their fat intake, they may have tried in the past
and failed and just feel too frustrated with the whole issue of dietary change.
Yet making a few simple changes can have tremendous long-term health
benefits.
A certain amount of dietary fat is good for your health, supplying energy,
essential fatty acids and promoting the absorption of some vitamins.
However the consumption of too much fat, has many health disadvantages.
Fats are a high calorie food. The average person requires in the region of
2,000-3, 000 calories a day to maintain their body weight. Too much fat
means too many calories, which in turn are stored in the form of excess
weight. This can restrict the enjoyment of many everyday activities, from
going for a walk with friends to partaking in sport events. It could also
result in a general feeling of fatigue and constant breathlessness. The long
term effects however can be much more devastating and undoubtedly many
people die early as a result of high fat intake. Below are some examples of
how excess fat can effect your health.

L Breathing: excess fat can press on the lungs making it harder to breath.
2. Arthritis: Excess pounds can weigh heavy on thejoints.
3 High blood pressure: Excess weight causes 30% to 50% o f cases o f high
blood pressure.
Take the time to think about some o f the following statements for a few
minutes

Poor diet alone may contribute to 35% o f the total cancers in the population and to
lessen the probability o f cancer one o f the most highly recommended dietary changes is
to reduce the percentage o f calories provided by fats particularly saturated fats fo r
example butter or lard.

Throughout the United Kingdom the average person gets 42%> o f their energy intake from
fat, while the recommended level is 35%. The majority o f people therefore need to reduce
their fat intake. This means it is more probable than not that you eat too much fat.

Remember however reducing fat does not mean eliminating your favourite foods but
controlling them.

Having read the previous statements you may feel fine that is all true, but it
is my life and I am free to eat and live as I choose and so what if I lose a few
years off my life at least I will be happy while I am alive. However consider
the long-term effects your high fat intake may have on the family and
friends around you. In the short term you may not be able to partake fully in
many activities with them, in the long term premature ill health can be a
serious burden to your nearest and dearest and they can be robbed of many
years of worthwhile contribution from you. Spend a few minutes thinking
about the many benefits you could bring to the people close to you by
maintaining your health. Perhaps some of the following short statements
may help you realise just how much of a difference you maintaining your
health could mean to you and to the quality of the relationship you have
with those close to you in the short term and the long term.

A woman o f 51 describing her Another woman aged 79 talking

mother o f 77 had this to say, about herself commented
" To be well in health means 1
“ She goes around looldng after feel I can do others a good turn ij
friends and shopping fo r them. She they need help ”
is active her mind’s alive. She paints Another woman o f 74 said
and sh e’s a member o f the theatre “ Youfeel as though everyone is
club and a lot o f other groups your friend, I can enjoy life more
and I can work and help other
people ”_______________________
A 22 year old shop manager 29 year old mother said o f herself
commented “ When I am healthy 1 “ I clean the window and rush
am very talkative. I f I am feeling around like a mad thing. When I am
low I keep myself to m yself-1 am not healthy is when I want to sit in
very outgoing when I am well and front o f the box
not moody.

An old saying is that a picture is worth a thousand words, and perhaps it can
be a thousand times more effective, in promoting change. So picture
yourself as a happier healthier more energetic person. Perhaps if there is
someone you know who has improved themselves by reducing their fat
intake, realise how much better they must feel and how much better you
would feel. In the future spend a few minutes whenever you can imagining
the benefits of a healthier more energetic you. Think of the person you
could be and how much a better person that would be. Here are some short
statements from people who have reduced the fat in their diet some from
situations where they were extremely overweight. Take the time to read
them remember if others can do it so can you.

One middle aged woman described it like Another participant summed it up in a

this sentence
I can do a lot more things now than 1
“It was exciting, every week being would have been able to do before. 1
weighed in and dropping and dropping think when I was that overweight it was
and some weeks not dropping at all and a bit like being in a trance as well.
other weeks going down. It was exciting, it
was proving to myself I could do it and
you Imow when the first stone went o ff it
was just wonderful That was just such an
achievement and then getting more o ff ”

Another girl summed it up like this

OH much better, and that’s a really cheesy thing to say but I do feel a lot better, I have got
much more energy, going out shopping is a brilliant experience, I can fit into, sizes 1
haven’tfitted into since I was much younger, and I do feel better.
Thank you fo r recently completing my questionnaire on
attitudes to nutrition and diet. Your results show that while
you may be eating above the recommended level o f fa t in
your diet, you are thinking about reducing your fa t intake
but not however in the immediate future. The following is
some information which, you might find helpful. Please
take the time to read it.

C
Well done you are taking the first step in making a positive change, that is
you are thinking about improving your diet, even if you do not intend taking
any action in the immediate future. Controlling your fat intake could be the
first step to a healthier and happier life. You may have many reasons for
wanting to reduce your fat intake, from protection against long term health
problems, to having more energy to simply looking better. Whatever your
reason there are some issues and steps I would like you to consider which
hopefully will make it easier for you to take action.
Any dietary> change requires a certain amount o f sacrifice and alteration to on e’s
lifestyle. Many people feel there are more disadvantages than advantages to improving
their diet, particularly as the benefits o f improved diet are not immediately apparent.
However the long term benefits are undeniable, improved diet leads to increased energy
and less risk o f heart disease, cancer and obesity. However before you change this is
something you must see fo r yourself Research has shown that a hey factor in bringing
about change in any area is seeing that the advantages o f change outweigh the
disadvantages. There follows a simple 10 minute exercise that could help you greatly
improve your life. On the following sheet in the left hand box list all the advantages you
can think o f that will come about by reducing your fat intake, in the right hand box list all
the disadvantages you can think o f associated with a high fat diet. When you have
completed the sheet focus on the benefits that can come about hold them strongly in your
mind, let them be the motivation that will bring you closer to change. When you think o f a
high fat intake see all the disadvantages associated with it and remember the advantages
o f a low fat diet fa r outweigh the disadvantages associated with a few changes. Firstly
however let us look at some statements by others regarding the advantages o f low fat
dieting.

One woman commented Another participant summed it up

like this
“ I feel so much better, much
better, because I am much more In terms o f feeling more alert, I am
mobile, I can get about now feeling much better, this morning I
and I have so much more felt quite well even though I went to
energy ” bed late and I Imow that if I had had
a few beers or not eaten properly I
would have not have felt so good.

A participant 6 weeks into a low fat diet said

“My quality o f life, I guess it is improving I feel more positive because I Imow my goal is
achievable which I never thought before, and I Imow it is not easy, and I Imow it is going to
get harder later on but that it is achievable but so fat as my quality o f life Ifeel better Ifeel
healthier............. I feel happy enough in myself in that I Imow that I am eating so much
flkfegdtitages of a Low Fat Diet__________ Disadvantages of a high Fat Diet
Good you have completed the exercise, now focus on the many benefits
you will have both health wise and emotionally as a result o f improving
your diet, Let them increase your motivation to move forward', Ideally
once a week take some time to repeat this exercise. There is another
similar exercise on the following page. Please take a few minutes to
complete it.
Research has shown that an important factor in stimulating change are the evaluations we
have o f ourselves. Firstly consider how you would rate yourself if you keep eating a high
fat diet, particularly now that you have taken the first step by thinking about making a
change. Now take a few moments and consider how you will feel when you make the
changes and start on a diet low in fat. Imagine what an improved life you will have, you
may feel more in control o f your life believing that you have taken an important step in
improving yourself and that you are a more capable person overall. You may also be able
to cope with difficult and stressful situations better when you are a healthier and happier
person. So as a second exercise in the left hand box list how you will feel about yourself
if you reduce your fat intake and in the right hand box list how you will feel about
yourself if you do not reduce your fat intake. Again for example people have reported
feeling more in control o f their life or having a sense o f improving themselves if they
improve their diet. Others have said that they feel disappointed or frustrated with
themselves if they do not.

How I will feel on a low fat diet How I will feel on a high fat diet

Finally thanks for taking the time to read this, keep it safe somewhere and
once a week for the nextfew weeks take 10 minutes to repeat the exercises
Remember any step forward will be a help.
The information in this pamphlet is for general knowledge only it is not
intended to replace information given by a health practitioner

Rational behind contemplation brochure

In line with the stages o f change m odel, an increase in the pros and a decrease in the cons
is necessaiy before participants will move from contemplation to action ( Prochaska 1999
 Thank you fo r recently completing my questionnaire on
attitudes to nutrition and diet. According to your
questionnaire results you are eating above the
recommended level o f fat in your diet, but you are however
seriously thinking o f reducing your intake in the near
future. On the following pages is some information which
you might find helpful. Please take the time to read it.
Congratulations you have made a definite commitment to change. You have become
aware o f the problems o f too much fat in the diet and you feel it is worth your while
making a significant change. However before you start your dietary change there are
some techniques 1 would like you to become aware o f which may help you to initiate
and maintain your action plan.

Changing your diet will involve a lot o f changes to your lifestyle some o f which may not
be easy, however with the proper plan and belief in yourself it is something you can
achieve. Many people about to make changes are not sure o f their ability to follow them
through. Research has shown that if you have a strong belief in your ability to make a
change, then your chances o f success are much higher. Therefore one o f the first steps is
to build up a belief in yourself that you can and will maintain change. To help you to do
this a simple plan follows. In the first box below are a list o f situations which have
proved difficult for people on a low fat diet. Read through them and consider if you
would also find it difficult in similar situations.

Box One: Problem Situations

Social Events, Festive Occasions, When I am feeling depressed, When I am feeling

anxious, When I am feeling bored, When I am feeling angiy, When I am feeling
happy, When I am relaxing, When things do not work out, When low fat foods are
not available, When it its impolite to refuse high fat foods,
When I am overworked or under stress

As you can see this covers a wide range o f situations, which people have mentioned these
as times when they tend to break their diet. The next box contains strategies which they
feel helped them cope.

Coping Strategies

I simply avoid situations, I tell people that I am on a low fat diet,

I plan ahead to avoid situations where only high fat food is available,
I distract myself with another activity, I reward m yselfwith something other than
high fa t foods, I Remind myself taking high fat foods will not help,
I Remind myself o f the benefit o f low fat foods,
I try to relax, I tell others clearly why I am on a low fat diet,
I take up exercise, I talk to a close friend, I Occasionally break the diet.
Again these are the suggestions people have made for situations where they had found it
difficult to maintain a low fat diet, spend a few minutes thinking about strategies you will
use to help you cope in situations where you find it difficult to maintain your diet. Write
them down in the box below, it does not matter if you repeat some o f the suggestions
already made. Just be clear that you have plans in place for coping with difficult
situations. If necessary continue on a separate sheet o f paper. Remember research has
shown that if you are prepared and have a strong belief in your ability to succeed then
your chances o f success are much higher.

The next step is to make a definite commitment to change. However the first
commitment you must make is to yourself. So set a start date and prevare for it.
Remember to make it easier for yourself, have a plan also. Be certain you have a variety
o f foods available to you, plan for the first few days once the momentum starts you will
find it easier to maintain it.
Aside from the commitment to yourself also make commitments to other people. At first
this might seem a risky strategy but it has a number o f advantages, in telling the people
close to you that you are prepared to make a change the commitment to yourself is
reinforced. Secondly it will give those close to you the opportunity to provide support.
Changing a diet can be stressful at times and having the support o f those close to you will
be a tremendous help. If you really believe you can change you have nothing to lose and
everything to gain by making a strong commitment. So make sure you have at least one
person who you can talk to and is fiilly supportive o f your effort to change your diet. If
possible encourage them to help you by giving some active support. It could be going to
an exercise class with you, or perhaps sharing some recipes with you. A loose plan is
outlined on the next page, please add to it with some suggestions o f your own.
You have made a serious commitment to change your diet, you know this will bring
an improvement in your life both short term and long term. Here are some
suggestions you might find helpful.

Firstly on the next line set out a date when you intend to start your improved diet and in
the box underneath it write down why you are making these changes

Start Date

Why I am improving mv diet

In the next box write down the steps you intend to take, it could for example be cutting
out high fat spreads or cutting out grilling foods. Tiy and put down 10- 12 steps you
intend to take.

In the next box write down the names o f some people who you will tell about your
commitment to change your diet for the better. Also write down some ways which you
feel they might help you. Try to include one special person who you feel will be
particularly supportive. Remember you stand a greater chance o f success if you are
committed to yourself and other people.
 Finally thank you for taking the time to read this, keep it safe
somewhere and once a week for the next few weeks take 10
minutes to repeat the exercises. You have made a strong
commitment to change your diet for the better plan ahead and
you will achieve the maximum. Good luck.
The information in this pamphlet is for general knowledge only,
it is not intended as medical advice or to replace information
given to you by your health practitioner.
Thank you fo r recently completing my questionnaire on attitudes to
nutrition and diet. According to your questionnaire results you
have reduced the amount o f fat in your diet within the last 6
months. On the following pages is some information which you
mightfind helpful Please take the time to read it
Firstly congratulations you have made a big step in improving your health. You are
possibly already feeling the benefits of improving your diet. Now that yon have
made the first step it is just a question of gaining momentum and making sure you
take to steps to maintain your progress. In this brochure there are some steps which
it is recommended you take to help you along the way.

The first step is to see that you are properly rewarded for the efforts you have made.
While it is helpful if others recognise your achievements and comment on your results
this may not always happen. In fact others may take your progress for granted, not
appreciating the work you have put in. It is essential therefore that you positively reward
yourself, become your own best suvvorter and give yourself the recognition you deserve.
In the first box below you will see a list o f the rewards people give themselves when they
have maintained their diet. In the second box make a list o f the things you would like to
reward yourself with when you have maintained your low fat diet an in the third box put
in a rewards timetable. It is important to focus on rewarding yourself if you make the
occasional slip do not feel disappointed or guilty with yourself. Simply feel good about
the positive steps you have already taken

hi the box below are a list o f the rewards people give themselves for staying on low fat
diets.

I buy myself some flowers or a new plant, I buy myself some new clothes,

I buy some o f my favourite music, I go an see a show or film , I have a nice day out,

I read a cook book and experiment with some new recipes, I have a massage

I remind myself o f the progress I have made

In the next box list some o f the rewards you would like to give yourself. They can be the
same as the ones above or include some o f your own. Remember improving your diet is
meant to be enjoyable. Make sure it is something you enjoy.
Now you have seen a list o f the rewards other people have given themselves and you have
thought o f some o f your own. Now in the next box make a timetable o f how you intend to
reward yourself. For example after two weeks on my diet I will buy myself some c.d.’ s

An important factor in maintaining your dietaiy change is to have some friendly people
on your side. Ideally it should be someone you can trust be open with and who is
accepting o f your need to change. In the next box list the names o f someone or possibly
a few people who you feel can help. If necessary consider self help groups but have some
friends who can help you.

Now that you have identified a few people who you can help you with your programme in
the next box list some specific ways in which they can help you. It could be that they
might spend half an hour a week to talk with you, they might be willing to go to an
exercise class with you or simply spend some time on the phone talking to you. It will
however be a huge help to you if you can get some people in your comer.
At times it may be particularly difficult to stay on your low fat diet, it will be a
tremendous help to have some techniques or strategies to fall back on which will assist
you to maintain your diet. Research has shown that in particular individuals at your stage
benefit from having enjoyable alternatives to high fat foods. Below are a list o f activities
other people have used perhaps you can add some o f your own. Try some o f the activities
out and develop your own favourite few. Having a healthier alternative will pay big
dividends in the long term.

When I feel like eating high fat foods I talk things over with a friend
I listen to my favourite music,
I look at television
I read a favourite book
I eat a health food,
I think about the benefits o f healthy eating
I keep myself busy
I take up exercise,
I work in the garden,
I have some fruit as a snack
I think about the damage high fat foods do
I talk to people about the benefits o f a low fat diet

Above were some o f the strategies other people use, some o f these may suit you and some
may not, however in the box below put down some o f the activities you would partake in
rather than eating high fat foods.
Good you have found yourself some alternatives to eating high fat foods, these may be
activities you have not had time for in the past, already you can see how improving your
diet is improving your whole life, take this opportunity to develop new interests and make
your life more interesting. Now is the time to get started in the box below list some times
when you will start your new interests. Perhaps fit them in at times when you feel you are
most likely to break your diet.

The final step in helping you to maintain your healthier diet is to surround yourself with
information that reminds you o f the benefits o f your new health programme. Make
certain you have plenty o f the right foods available to you. Have magazine articles or
posters on the benefits o f proper nutrition close to you. Also remove anything associated
with high fat diets. In the box on the left hand side are some o f the strategies other people
use. Keeping a positive image o f the benefits o f your dietary programme will help you
maintain it. It is all too easy to get downhearted and forget the benefits o f what you are
doing. Keep these clear in your mind and staying on your programme will become more
fun. Once you have read through the suggestions in the left hand box take some time and
fill in the right hand box with some new strategies o f your own.

I keep a picture o f myself

when I was slim on the refrigerator
door,
I put lists o f the benefits o f low fat
foods where I can see them.

I put lists o f the damage done by

high fat foods around the house.

I keep pictures o f role models

around the house.
I put pictures o f people I would not
like to look like around the house.

I put lists o f my goals where I can

see them.
The main aim o f this exercise is to constantly remind yourself o f the benefits o f your new
eating pattern and the disadvantages o f your old one while these axe all interesting
exercises they are o f no benefit unless you put them into action. In the box below list
some o f the first steps you intend to take to remind yourself o f the benefits o f low fat
foods. Make a definite commitment to get started.

For example: I intend to make a list o f the benefits o f a low fat diet next week

Finally thank you for taking the time to read this, keep it safe and once a
week for the next few weeks take 10 minutes to repeat the exercises.
Congratulations again on your change to a healthier lifestyle.
The information in this pamphlet is for general knowledge only, it is not
intended as medical advice or to replace information given by your health
practitioner.
Thank you for recently completing my questionnaire on
attitudes to nutrition and diet. According to your
questionnaire results you have reduced the amount of fat in
your diet for more than six months and you are considering
reducing even further in the future. On the following pages is
some information which you might find helpful. Please take
the time to read it.
Firstly congratulations you have not only made a big step in improving
your health but you have also maintained it for some time and you are
considering making more improvements in the future. You have obviously
managed to cope with many of the problems associated with staying on
your improved diet However this brochure contains a few suggestions
which Ihope you will find helpful.
A n im p o rtan t s tep in helping you to m a in ta in and im prove y o u r h e a lth ie r diet is to
surroun d y o u rs e lf w ith inform ation th a t rem inds you o f th e b e n e fits o f yo u r n ew
h e alth p ro g ra m m e . In th e box on th e left hand side a re s o m e o f th e strategies
o th e r p e o p le u se. K e e p in g a positive im a g e o f th e b en efits o f yo u r d ie ta ry
p ro g ra m m e will help you m ain tain it. It is all to o e a s y to g e t d o w n h e a rte d and
fo rg e t th e b en efits o f w h a t you a re doing. K e e p th e s e c le a r in y o u r m ind and
staying on yo u r p ro g ra m m e will b e c o m e m o re fun. O n c e you h a v e re a d through
th e s u g g estio n s in th e left h an d box ta k e s o m e tim e and fill in th e right hand box
w ith n e w s tra te g ie s o f yo u r ow n.

I k e e p a picture o f m y s e lf
w h e n I w a s o v e rw e ig h t on th e
re frig e ra to r door.

I put lists o f th e b en efits 1 h a v e

o b ta in e d fro m low fa t fo ods w h e re I
c a n s e e th em .

I p u t lists o f th e d a m a g e d o n e by m y
high fa t d ie t in th e p a s t a round th e
ho u se.

I k e e p pictures o f role m od els

aro u n d th e house.

I put pictures o f p e o p le I w ould not

like to look like aro u n d th e hou se.

I put lists o f m y a c h ie v e m e n ts and

g o a ls w h e re I c an s e e th e m .

In th e box b e lo w list s o m e o f th e first step s you will ta k e to rem ind y o u rs e lf o f th e

b e n e fits o f low fa t fo o d s. M a k e a d e fin ite c o m m itm e n t to g e t s ta rte d , th a t is by a
ce rta in d a te or tim e.

F o r e x a m p le : I intend to m a k e a list o f m y a c h ie v e m e n ts and o r g o a ls a n d put

th e m w h e re 1 can s e e th e m in th e n ext 2 w e e k s .
A n im p o rtan t fa c to r in m a in tain in g and im proving y o u r d ie t is to h a v e s o m e
frie n d ly p e o p le on y o u r side. Id e a lly it should be s o m e o n e you c an trust, be o p en
w ith a n d w h o is a c cep tin g o f y o u r p ro g ra m m e . Y o u h a v e b e e n m a in tain in g yo u r
d ie t fo r s o m e tim e and m a y a lre a d y h a v e frien d s you c o n fid e in. In th e next box
list th e n a m e s o f all th e p e o p le you fe e l h a v e h e lp ed you a n d a n y you fe e l m a y
h elp you in th e fu tu re . If n e c e s s a ry c o n s id e r s e lf help g rou ps but h a v e s o m e
frie n d s w h o will e n c o u ra g e you w ith y o u r diet.

N o w th a t you h a v e identified a fe w p e o p le w h o you c a n ta lk to a b o u t y o u r

p ro g ra m m e in th e n ext box list s o m e specific w a y s in w hich th e y c an help you
m a in ta in o r im p ro v e y o u r d ie t It could b e th a t th e y m ight s p e n d h a lf an hou r a
w e e k to ta lk w ith you, th e y m ight b e w illing to go to an e x e rc is e c las s w ith you or
sim p ly s p e n d s o m e tim e on th e p h o n e talking to you. P e rh a p s you c an sp en d
s o m e tim e talking to oth ers a b o u t diet. It will h o w e v e r be a tre m e n d o u s help to
re in fo rc e yo u r im proved d iet in this w a y . R e m e m b e r th e m o re p e o p le you h a v e in
y o u r c o rn e r th e m o re likely you a re to m ain tain a n d im prove y o u r diet.
Y o u h a v e m a in ta in e d y o u r d ie t fo r s o m e tim e h o w e v e r a t tim e s it m a y b e
p articularly difficult to s ta y on y o u r low fa t diet. In such situation s it can be a
tre m e n d o u s h elp to h a v e s o m e te c h n iq u e s o r s tra te g ie s to fall b a c k on w hich will
help you m ain tain yo u r diet. A t yo u r p re s e n t s ta g e you obvio u sly h a v e m a n y
s tra te g ie s w h ich you h a v e a lre a d y u sed . R e s e a rc h h as show n th a t in individuals
a t y o u r s ta g e b e n e fit fro m having e n jo y a b le a lte rn a tiv es to high fa t fo o d s. B elo w
a re a list o f activities o th e r p e o p le h a v e used p e rh a p s you c an a d d s o m e o f yo u r
o w n. T ry s o m e o f th e activities o u t and d e v e lo p yo u r ow n fa v o u rite fe w . T h e
m o re a lte rn a tiv e s a n d s tra te g ie s you h a v e th e b e tte r in th e long run.

W h e n I fe e l like ea tin g high fa t fo ods I ta lk things o v e r w ith a friend

I listen to m y fa v o u rite m usic,
I look a t television
I read a fa v o u rite book
I e a t a health food,
I think a b o u t th e b enefits o f h e a lth y eating
I k e e p m y s e lf busy
I ta k e up e x e rc is e ,
I w o rk in th e g a rd e n ,
I h a v e s o m e fruit a s a s n a c k
I th in k a b o u t th e d a m a g e high fa t fo ods do
I ta lk to p e o p le a b o u t th e benefits o f a low fa t diet

A b o v e a re s o m e o f th e s tra te g ie s and te c h n iq u e s o th e r p e o p le h a v e used to

m a in ta in th e ir low fa t d iets o r health p ro g ra m m e s . S o m e o f th e s e you m a y
a lre a d y u s e o r you m a y h a v e s o m e stra te g ie s o f yo u r o w n. In th e box b e lo w put
d o w n s o m e o f th e activities you b e lie v e will h elp you to m a in ta in a n d reinforce
y o u r h e a lth p ro g ra m m e .
G o o d you h a v e fo u n d y o u rs e lf s o m e a lte rn a tiv e s , n ow in th e n ext b o x put d ow n
s o m e d e fin ite c o m m itm e n ts a s to w h e n you Intend to add th e s e activities to yo u r
h ealth p ro g ram m e .

In th e box b e lo w a re a list o f th e re w a rd s p e o p le give th e m s e lv e s fo r staying on

low fa t diets. In th e n e x t b o x list s o m e o f th e rew ard s you w ould like to give
y o u rs e lf. M a k e out a realistic plan. Y o u h a v e m a in ta in e d y o u r low fa t d iet fo r
s o m e tim e now . T h e re m a y h o w e v e r be c e rtain a n n iv e rs a rie s fo r e x a m p le you
m a y h a v e m a in ta in e d a p a rtic u la r w e ig h t lose fo r s o m e tim e w h e n you w ould like
to re w a rd yourself. It is so e a s y fo r a d ie t to b e c o m e m o n o to n o u s and a strong
fa c to r in m aintaining a d iet is to m a k e it a s e n jo y a b le a s possible.

I buy m y s e lf s o m e flo w e rs o r a n e w plant, I buy m y s e lf s o m e n e w clothes,

I b u y s o m e o f m y fa v o u rite m usic, I go a n s e e a s how o r film , I h a v e a nice d a y

out,

I re a d a co o k bo o k a n d e x p e rim e n t with s o m e n e w re cip es, I h a v e a m a s s a g e

I rem ind m y s e lf o f th e p rog ress I h a v e m a d e

In th e n ext box list s o m e re w a rd s you in particu lar w ould like to g ive yourself.
T h e y c an be th e s a m e a s th e o n e s a b o v e or include s o m e o f y o u r o w n . T a k e a
fe w m in u tes and s e e w h a t you c o m e up w ith.
N o w you h a v e s e e n a list o f th e re w a rd s o th e r p e o p le h a v e given th e m s e lv e s and
you h a v e th o u g h t o f s o m e o f yo u r ow n. N o w in th e n e x t b o x m a k e a realistic
tim e ta b le o f h o w you intend to rew ard yo u rself. F o r e x a m p le I will ta k e a holiday
w h e n I h a v e m a in ta in e d m y p ro g ra m m e fo r a y e a r.

Slips
Y o u h a v e m a in ta in e d yo u r d ie t fo r s o m e tim e now . H o w e v e r th e re m a y b e tim e s
w h e n you fa lte r o r slip. R e m e m b e r this is nothing to be c o n c e rn e d abo u t. It is
o n ly if a slip b e c o m e s e x te n d e d fo r e x a m p le if you s ta y on a high fa t d iet fo r a
w e e k ra th e r th an ju st b reakin g it fo r a social o ccasio n , th a t it b e c o m e s a c a u s e
fo r c o n c e rn . A g a in c o n g ratu latio n s on having m a in ta in e d y o u r d ie t a n d finally
m a k e su re to ta k e th e tim e to rem ind y o u rs e lf o f th e benefits you h a v e a c h ie v e d .
M a k e a list o f th e m and p e rh a p s add a fe w n e w go als. In th e n e x t b o x m a k e a list
o f w h a t you h a v e a c h ie v e d a n d h ow it will b e n e fit you in th e fu tu re .

F o r e x a m p le : by m aintaining m y low fa t d ie t I h a v e d e c re a s e d m y risk o f h e a rt

d is e a s e
Congratulations again on your change to a healthier
lifestyle and thank you for taking the time to read this
brochure, keep it safe and once a week for the next few
weeks take the ten minutes necessary to repeat the
exercises.
The information in this pamphlet is for general
knowledge only, it is not intended as medical advice or
to replace jnfomiation given by your health practitioner.
Thank you for recently completing my questionnaire on attitudes to
nutrition and diet. According to your questionnaire results you
have reduced the amount o f fat in your diet and you have been
doing so fo r more than six months. On the following pages is some
information which you might find helpful Please take the time to
read it.
Firstly congratulations you have not only made a big step in improving your health but
you have also maintained it for some time. You have obviously managed to cope with
many o f the problems associated with staying on your improved diet. However this
brochure contains afew suggestions which I hope you willfind helpful.
An important step in helping you to maintain your healthier diet is to surround yourself
with information that reminds you o f the benefits o f your new health programme. In the
box on the left hand side are some o f the strategies other people use. Keeping a positive
image o f the benefits o f your dietary programme will help you maintain it. It is all too
easy to get downhearted and forget the benefits o f what you are doing. Keep these clear in
your mind and staying on your programme will become more fun. Once you have read
through the suggestions in the left hand box take some time and fill in the right hand box
with new strategies o f your own.

I keep a picture o f myself

when I was overweight on the
refrigerator door.

I put lists o f the benefits I have

obtained from low fat foods where I
can see them.

I put lists o f the damage done by my

high fat diet in the past around the
house.

I keep pictures o f role models

around the house.

I put pictures o f people I would not

like to look like around the house.

I put lists o f my achievements and

goals where I can see them.

hi the box below list some o f the first steps you will take to remind yourself o f the
benefits o f low fat foods. Make a definite commitment to get started, that is by a certain
date or time.

For example: I intend to make a list o f my achievements and or goals and put them where
I can see them in the next 2 weeks.
An important factor in maintaining your dietary change is to have some friendly people
on your side. Ideally it should be someone you can trust, be open with and who is
accepting o f your programme. You have been maintaining your diet for sometime and
may already have friends you confide in. In the next box list the names o f all the people
you feel have helped you and any you feel may help you in the future. If necessary
consider self help groups but have some friends who will encourage you with your diet.

Now that you have identified a few people who you can talk to about your programme in
the next box list some specific ways in which they can help you maintain or improve your
diet. It could be that they might spend half an horn* a week to talk with you, they might be
willing to go to an exercise class with you or simply spend some time on the phone
talking to you. Perhaps you can spend sometime talking to others about diet. It will
however be a tremendous help to reinforce your improved diet in this way. Remember the
more people you have in your comer the more likely you are to maintain and improve
your diet.
You have maintained your diet for sometime however at times it may be particularly
difficult to stay on your low fat diet. In such situations it can be a tremendous help to
have some techniques or strategies to fall back on which will help you maintain your diet.
At your present stage you obviously have many strategies which you have already used.
Research has shown that in individuals at your stage benefit from having enjoyable
alternatives to high fat foods. Below are a list o f activities other people have used perhaps
you can add some o f your own. Tiy some o f the activities out and develop your own
favourite few. The more alternatives and strategies you have the better in the long run.

When I feel like eating high fat foods I talk things over with a friend
I listen to my favourite music,
I look at television
I read a favourite book
I eat a health food,
I think about the benefits o f healthy eating
I keep myself busy
I take up exercise,
I work in the garden,
I 'have some fruit as a snack
I think about the damage high fat foods do
I talk to people about the benefits o f a low fat diet

Above are some o f the strategies and techniques other people have used to maintain their
low fat diets or health programmes. Some o f these you may already use or you may have
some strategies o f your own. In the box below put down some o f the activities you
believe will help you to maintain and reinforce your health programme.
Good you have found yourself some alternatives, now in the next box put down some
definite commitments as to when you intend to add these activities to your health
programme.

In the box below are a list o f the rewards people give themselves for staying on low fat
diets. In the next box list some o f the rewards you would like to give yourself. Make out a
realistic plan. You have maintained your low fat diet for sometime now. There may
however be certain anniversaries for example you may have maintained a particular
weight lose for sometime when you would like to reward yourself. It is so easy for a diet
to become monotonous and a strong factor in maintaining a diet is to make it as enjoyable
as possible.

I buy myself some flowers or a new plant, I buy myself some new clothes,

I buy some o f my favourite music, I go an see a show or film , I have a nice day out,

I read a cook book and experiment with some new recipes, I have a massage

I remind myself o f the progress I have made

In the next box list some rewards you in particular would like to give yourself. They can
be the same as the ones above or include some o f your own. Take a few minutes and see
what you come up with.
Now you have seen a list o f the rewards other people have given themselves and you have
thought o f some o f your own. Now in the next box make a realistic timetable o f how you
intend to reward yourself. For example I will take a holiday when I have maintained my
programme for a year.

Slips
You have maintained your diet for sometime now. However there may be times when you
falter or slip. Remember this is nothing to be concerned about. It is only if a slip becomes
extended for example if you stay on a high fat diet for a week rather than just breaking it
for a social occasion, that it becomes a cause for concern. Again congratulations on
having maintained your diet and finally make sure to take the time to remind yourself o f
the benefits you have achieved. Make a list o f them and perhaps add a few new goals. In
the next box make a list o f what you have achieved and how it will benefit you in the
future.

For example: by maintaining my low fat diet I have decreased my risk o f heart disease
Congratulations again on your change to a healthier lifestyle and
thank you for taking the time to read this brochure, keep it safe
and once a week for the next few weeks take the ten minutes
necessary to repeat the exercises.
The information in this pamphlet is for general knowledge only,
it is not intended as medical advice or to replace information
given by your health practitioner.
 P s y c h o lo g y D e p a rtm e n t
U n iv e rs ity o f S u rre y
G uildford
S u rre y
3/6/01
D e a r P a rtic ip an t

T h a n k you fo r recently filling o u t th e d ie ta ry q u e s tio n n a ire a t H a m m e rs m ith o r C h arin g

C ro s s hospitals. E n clo sed is a b ro ch u re I h o p e you will find b e n e fic ia l.

Y o u rs S in c e re ly
A n d re w M o o re
 P s y c h o lo g y D e p a rtm e n t
U n iversity o f S u rre y
G uildford
S u rre y
G U27XH
10/1/02
D e a r P a rtic ip an t

Firstly th a n k you v e ry m uch fo r com pleting m y q u e s tio n n a ire a t e ith e r H a m m e rs m ith o r

C h a rin g C ro s s hospitals 6 m on ths a g o . A s I m a y h a v e e x p la in e d a t th e tim e a central
aim o f th e stud y is to s e arc h fo r a n y c h a n g e s , w hich ta k e p la c e in p a rtic ip a n t’s opinions
a fte r 6 m on ths. W ith this in m ind I h a v e e n c lo s e d a seco nd co p y o f th e q u e s tio n n a ire fo r
you to c o m p le te a n d return in th e en c lo s ed pre paid e n v e lo p e . A g a in I w ould like to
th a n k you in a d v a n c e fo r takin g th e tim e to do this, yo u r help is a p p re c ia te d .

Y o u rs S in c e re ly
A n d re w M o o re
 P s yc h o lo g y D e p a rtm e n t
U niversity o f S u rre y
G uildford
S u rre y
G U27XH
10/ 1/02
D e a r P articip an t

Firstly th a n k you ve ry m uch fo r com pleting m y q u e s tio n n a ire a t e ith e r H a m m e rs m ith or

C h a rin g C ro ss hospitals 6 m on ths ago. A s I m a y h a v e e x p la in e d a t th e tim e a central
aim o f th e study is to se arc h fo r a n y c h a n g e s , w hich ta k e p la c e in p a rtic ip a n t’s opinions
a fte r 6 m onths. W ith this in m ind I h a v e en c lo s ed a seco nd copy o f th e q u e s tio n n a ire for
you to c o m p le te and a short q u e s tio n n a ire looking at yo u r opin io ns o f th e brochu re you
re c eiv e d . P le a s e return both in th e e n clo sed pre paid e n v e lo p e . A g a in I w ould like to
th a n k you in a d v a n c e fo r taking th e tim e to do this, yo u r help is a p p re c ia te d .

Y o u rs S in c e re ly
A n d re w M o o re

r-oryU
 P s yc h o lo g y D e p a rtm e n t
U n iv e rs ity o f S u rre y
G uildford
S u rre y
25-11-01
D e a r P a rtic ip an t

T h a n k you fo r re c en tly co m p letin g m y q u e s tio n n a ire a t H a m m e rs m ith o r C h arin g C ross

hospital, I e n c lo s e a co p y o f th e broch u re you re c eiv e d w h e n you c o m p le te d th e
q u e s tio n n a ire . I h o p e you will h a v e th e tim e to c o m p le te s o m e o f th e e x e rc is e s ag a in
an d th a t you will find th e m helpful.

Y o u rs S in c e re ly
A n d re w M o o re