Volume 13 Number 3, 2000, Page 125
Helping People With Diabetes Change Behavior: From Theory to Practice
Laurie Ruggiero, PhD
As we move forward with the goal of helping people best self-manage diabetes, it is important to follow the lead of those providing the medical management of diabetes. We need to look to the best evidence to guide our intervention development. The Diabetes Control and Complications Trial (DCCT), the United Kingdom Prospective Diabetes Study (UKPDS), and other recent clinical trials have provided us with essential guidelines for medically managing diabetes. Unfortunately, such studies tend to attract participants who are most motivated to self-manage diabetes. Therefore, they may not offer much insight into the best practices for helping people who are less motivated.
In the recent joint Diabetes Educational and Behavioral Research Summit, opinion leaders in diabetes education emphasized the importance of using theory (along with vision) to drive research and intervention development efforts.1-3 This article will focus on one theory, the Transtheoretical Model (TTM), because it applies to people at all stages of readiness for change and has been developed and studied for nearly 20 years.
The TTM focuses on both enhancing motivation in those not ready to optimally self-manage and changing behavior and maintaining behavior change for those who are motivated. Its application in diabetes care was first introduced in this journal in 1993.4 This article will provide a general overview of the TTM with an emphasis on its practical application in medical nutrition therapy (MNT) for diabetes, along with updates on the relevant research on the model.
THE TRANSTHEORETICAL MODEL: HELP FOR EVERYONE
The Stages of Change
Precontemplationnot intending to change to the goal level of a behavior (e.g., reduce fat intake to <30% of total) in the foreseeable future;
Contemplationintending to change to the goal level in the foreseeable future (next 6 months), but not the immediate future (next 30 days);
Preparationintending to change to the goal behavior in the immediate future and taking behavioral steps in the direction of change;
Actionhas made a change to the goal level of the behavior in the recent past (6 months);
Maintenancehas been at the goal level of the behavior for 6 months or longer.
In addition, the addictive behavior literature using this model suggests that there may be a stage in which people feel fully confident across all situations that they can continue the goal behaviorthis has been referred to as the termination stage.6 For example, a former smoker who has not smoked for 7 years and has not experienced a temptation to have a cigarette in several years would be in the termination stage on smoking cessation. Research is beginning to examine this stage with other types of behaviors.
RecyclingAn Important Part of
the Process of Change
Stage of Change Is Not a LabelIt Is the Roadmap
In order to use stage of change to its fullest as the roadmap to change, it is necessary to be familiar with the other important components of this model: decisional balance, situational self-efficacy/temptations, and the processes of change. Knowledge and integrated application of all of these components can help health care providers best tailor behavior change interventions to maximize successful outcome for individuals.
Decisional BalanceWeighing the Pros and Cons of
When matching intervention approaches with stage of change, it is important to help people focus on the benefits of the goal behavior in the early stages and help them reduce the cons or costs of engaging in the goal behavior. For example, when trying to help an obese woman with type 2 diabetes increase her activity or exercise level, it may help to ask her to generate a list of benefits of this behavior that are relevant for her. So, instead of just focusing on the health benefits of exercise in general or even for diabetes, it may help to encourage her to think of the benefits for her family when she maintains good health.
She may be able to generate a list of benefits that may be more meaningful to her, such as "my family will worry less about my health"; "I will have more energy to take my grandchild for a walk in the park"; or "I can get my overweight husband to try to exercise by going for walks with him." It will also help if she writes down this list to remind herself of the benefits when she experiences the challenges of making and maintaining this positive health behavior change.
Situational Self-EfficacyGaining the Confidence
Needed to Be Successful
Research has shown a specific pattern of changes in self-confidence and temptations across the stages of change. Specifically, people report greater temptations and less confidence in the early stages, and this pattern reverses itself in the later stages where people feel less temptation and more confidence.12 So, when matching intervention to a person's stage of change, it is also important to be aware of their self-confidence and temptations across important situations. For example, when individuals are trying to reduce their dietary fat intake, they may be tempted to eat high-fat foods in a number of situations, such as when at a party, during a coffee break at work, when dining out, or when feeling stressed or depressed. To help people move through the stages, it is important to help them identify and manage their situational temptations or to build their confidence in following their plan across situations.
Processes of ChangeUsing the Right Tools at the
There are two global categories of processes of change, that is, the experiential processes and the behavioral processes. The experiential processes include consciousness raising, dramatic relief, self-reevaluation, social liberation, and environmental reevaluation. The behavioral processes include self-liberation, stimulus control, counterconditioning, helping relationships, and reinforcement management.5 Research has suggested that change is best achieved by appropriate matching of processes with the stage of change.13
Consciousness raising involves increasing awareness and information about the behavior, such as its benefits and consequences and the person's current patterns. For example, keeping a diary of daily eating habits would help increase the person's awareness of the current patterns and where changes would be beneficial. In addition, providing educational materials regarding changing dietary patterns or carbohydrate counting would be an example of the use of this process in MNT for diabetes.
Dramatic relief involves arousing emotional responding with a follow-up reduction in affect, such as through provision of information indicating how appropriate action can help reduce or avoid potential negative consequences of the undesirable behavior pattern. For example, dramatic relief would be the process employed by media campaigns portraying individuals who had diabetes-related complications, such as blindness or amputations, which may have been delayed or avoided with better control of glucose levels through optimal self-management.
Environmental reevaluation involves having individuals reflect (i.e., cognitive and affective dimensions) on how their behavior affects the environment, especially the social environment. An example of using this process includes helping an elderly woman with diabetes reflect on the fact that her children may worry less about her living alone if she works toward tight glucose control through optimal self-care.
Self-reevaluation involves having individuals reflect (i.e., cognitive and affective dimensions) on their self-image as it relates to the target behavior. Helping an obese man with type 2 diabetes see that he can be a positive role model for his obese wife if he reduces his dietary fat intake and increases his activity level is an example of this process.
Social liberation involves increased societal changes or opportunities that help promote the healthier behavior. An example of this process is the inclusion of labeling on food products indicating the specific nutritional and caloric content of the item. Such labeling can help promote many goals of MNT, such as carbohydrate counting and reduction of calorie, salt, or fat intake. Another example includes the development of government-funded community walking and cycling paths to help promote regular exercise.
Self-liberation involves making a choice and commitment to change a behavior. Making a New Year's resolution or telling others of a decision to make dietary changes and exercise to lose weight are examples of the use of this process.
Stimulus control involves changing the environment to promote the healthier behavior and/or avoid the undesirable behavior. An example would be removing high-fat snacks from the house to reduce cues to eat unhealthy snacks. Another example would be keeping walking shoes in the car as a prompt to take a walk during the coffee break at work.
Counterconditioning involves learning new, healthier substitutes for the undesirable behavior, such as chewing gum instead smoking for a smoker trying to quit. Another example is learning to substitute lower-fat snacks for high-fat snacks.
Helping relationships involves getting and using support to help with positive behavior change. For example, participation in a diabetes support group or a weight-loss group will offer individuals support in making healthy changes in diabetes care behaviors. In addition, diabetes educators can be valuable support people in the change process.
Reinforcement management involves using rewards, both tangible and intangible, for positive changes. It is important to keep in mind that rewards do not need to cost money; for example, praise from a health care professional is a powerful reward.
Assessment of Stage of Change
The goal behavior is generally determined based on the available scientific evidence and/or expert opinion on the level of the behavior necessary to obtain optimum health benefits. For example, the DCCT supported the use of an action criteria of four self-tests per day (at a minimum) to achieve tight control of blood glucose for people with type 1 diabetes.
When conducting MNT, it is important to determine the specific dietary intake goals before attempting to determine a person's stage of change. Once the action criteria are determined, assessment of stage involves questions focused on identifying the person's current behavior pattern (e.g., action vs. maintenance) or intention to pursue the desired goal behavior (e.g., precontemplation, contemplation, preparation). Being clear about the action criteria or outcome goal for a behavior will also help diabetes educators develop specific goals for the intervention plan.
Assessing stage of change for specific dietary behaviors can be complex. Fortunately, researchers have begun to develop questionnaires and staging algorithms to help with this process. The TTM has been applied in a general population for a number of dietary areas, such as dietary fat reduction,15-18 weight control,19-21 and consumption of fruits and vegetables.18,22,23
Readers are encouraged to review the research in their area of interest to learn specific guidelines for assessing stage of change or applying the TTM. Since most of the work applying the TTM in the dietary area has been focused on reduction of dietary fat intake, this area will be used to highlight important points about assessing stage of change.
Research on dietary fat has underscored the complexity of assessing stage of change for dietary behaviors. Studies assessing stage of change based solely on participants' global perception of fat intake without including a behavioral measure to estimate fat intake indicated that the majority (6163%) perceive themselves to be reducing fat intake.15 Research on three large samples (N = 9,582)15 assessing stage of change for dietary fat reduction using a behavioral measure (criterion of <30% of calories from fat) to estimate fat intake revealed the following patterns for stage distributions:
These stage distributions, compared with those based solely on perceived stage of change, emphasize the importance of clearly defining your action criteria and carefully assessing stage of change, especially including a behavioral estimate in the dietary area.
Assess each target behavior. Clearly defining and carefully assessing stage of change for each target behavior is particularly important. This is especially true for eating habits, since people may be at different stages for different aspects of dietary intake, such as fat intake, caloric intake, salt intake, or carbohydrate intake. For example, someone may be in the preparation stage for reducing caloric intake because of weight-loss goals. In contrast, the same person may be in the precontemplation stage on carbohydrate counting, since the value of this behavior in managing diabetes has not been made clear to the individual.
Even within a particular behavioral domain, such as maintaining low-fat dietary intake, a thorough assessment of behavior patterns (versus global questions) are critical for determining stage of change. For example, many people will confidently say that they could avoid drinking whole milk for good, but few would say the same about eating regular ice cream.
Assessing stage of change for each target behavior will give us more useful information to guide and evaluate our interventions. Therefore, when assessing eating habits for MNT, it is important to assess a person's stage of change for each targeted behavior.
Gina: a case example. Gina has been referred to you by her endocrinologist, Dr. Johnson, for a consult ation on MNT to help her better manage her diabetes. Dr. Johnson requested that you focus on helping her lose weight and more closely follow her daily self-care plan.
Before you meet with Gina, you followup with Dr. Johnson to determine the recommended self-care goals. You learn that last week she was started on insulin 70/30 since her blood glucose levels have been consistently high for a while. Gina also has hypertension and is obese, with a body mass index of 30. Dr. Johnson has reportedly been trying to get her to lose weight for many years without luck. In fact, Gina has gained weight since she retired. You ask about exercise, and Dr. Johnson indicates that it is safe for Gina to engage in regular walking based on her recent physical exam and lab values.
Her self-testing recommendation was twice a day, but this was increased to four times a day when she was started on insulin last week. Dr. Johnson informs you that Gina had regularly been testing twice a day based on her memory meter results. She agreed to gradually work up to four times a day, and set a goal with Dr. Johnson to start with three times a day next week and increase to four times a day in 2 weeks.
In your interview, you discover that Gina is a 65-year-old woman diagnosed with type 2 diabetes 6 years ago. She retired from teaching school 9 months ago. She lives at home with her 70-year-old husband, Tony. Tony is also retired but still works occasionally as a part-time consultant for an engineering firm. Although retired, Gina is constantly busy babysitting her 5-year-old grandson and participating in community activities, such as serving as the president of her local retired teacher's association. She and Tony also travel frequently.
When you meet with Gina, you discover that she is not clear about the specific recommendations for losing weight, so you clarify these for her. You discuss the importance of consuming <30% of calories from fat, reducing her caloric intake, and increasing her physical activity with a goal of walking at least three times a week for 30 minutes or more.
You ask about her current exercise or activity patterns. She says she realizes she has not been as physically active since she retired. She used to stand up all day while teaching and chase 5-year-olds around the playground each day. She notes that she knows exercise would be good for her diabetes and her weight, but she has not been able to find the time to exercise lately. If she is not babysitting or doing community work, she and Tony are traveling.
You ask if she intends to start walking three times per week in the foreseeable future. She says she will think about taking walks after dinner, but she cannot promise that they will do it three times a week since she is usually exhausted by that time of day.
You begin to assess her eating habits and readiness to change her caloric and fat intake. She comments that she has a calorie counting book and is ready to start to reduce her caloric intake but is not sure how to best do so. You continue to assess her eating habits by asking if she generally avoids eating high-fat foods. She says no, so you ask if she intends to do so. She comments that she does not see how she could do this since she has to feed her grandson and usually eats at least two meals a day with him. She also notes that she invites her daughter and son-in-law for dinner at least twice a week, and she jokingly says that his favorite meal is steak and her homemade pasta. She adds that it would not be fair to deprive them of their favorite foods, and she probably wouldn't see them as often if she didn't cook for them. In the end, she says, "there is only so much I can do. I have been doing so well taking my insulin just as the doctor ordered and testing every day; I'm even working up to testing four times a day."
Based on your initial visit with Gina and the information provided by her endocrinologist, you assess Gina to be in the following stages of change for her diabetes care and weight management behaviors:
Putting It All Together: Individualized Stage-Matched
Research has indicated that interventions tailored for the individual's stage of change work better than generic approaches.6 Interventions based on the TTM are tailored for individuals based on their stage at the highest level and then on the other variables of the model to maximize effectiveness. General guidelines for which processes and principles of change to emphasize at a particular stage are shown in Figure 2. These are designed to be general stage-matched guidelines, and readers should refer to the most recent literature regarding a particular behavior to obtain specific guidelines.
A number of interventions have been developed based on this model. Stage-matched interventions based on the TTM have included written stage-based self-help materials, such as handbooks, manuals, and newsletters. Interventions that are further individualized include stage-matched counseling approaches and expert system-generated individualized feedback (e.g., written reports, interactive computer). (See Ruggiero et al., 1997,25 or Velicer et al., 1994,26 for detailed descriptions of stage-matched approaches.)
Expert system approaches use sophisticated staging algorithms and computer-based decision rules to mimic the decision making of experts to generate behavior change feedback tailored to the current patterns of an individual. This approach allows both consistent delivery of best practice approaches and individualization to optimally assist a particular person.
Tailoring your intervention for Gina. At the end of the session with Gina, you work with her to set realistic and attainable goals. Since you are using the TTM to guide your interventions with Gina, you set your own goals to be "movement one stage forward for each behavior." Since Gina is in the preparation stage on two behaviors (self-testing and reducing caloric intake), you ask her preferences regarding which behavior she would like to work on first. She says that she has already made progress toward increased self-testing and would like to reach her goal before worrying about anything else.
She still asks for help on learning about counting calories to get ready to reduce caloric intake after reaching her self-testing goal. Since she mentioned an interest in using the Internet, you show her a free Internet site to help her easily track her daily caloric intake, so you can focus on cutting calories as her next action goal when you meet again in 2 weeks.
You help Gina best prepare for achieving her self-testing goal by providing specific behavioral strategies to help her self-test four times per day. For example, you suggest that she keep a monitor and test-strips in her handbag when she leaves home, put out testing supplies ahead of time where she will need them during the day, and link self-testing to other routine behaviors, such as preparing meals. Because you know the importance of rewards in promoting behavior change, you put a note in her chart to remind yourself to ask about her progress in self-testing at your next visit and compliment her on any positive changes.
Knowing the importance of increasing the perceived benefits of change for people in the precontemplation stage on a behavior, you decide to work with Gina on this today as well. Because she also has many barriers to reducing her fat intake, especially her concerns about its impact on her family interactions, you decide that this may be the place to start. In discussing her family, you realize that Tony is obese and has had a heart attack; her daughter is also obese and has hypertension; and her son-in-law has been gaining weight and has a family history of diabetes. So, in addition to noting the benefits of reduced fat intake for her own health, such as better controlling her diabetes, blood pressure, and weight, you focus on the positive impact on her family as well. You note that her son-in-law is at high risk of developing diabetes, so reducing fat consumption would help him reduce his risk as well. You encourage her to think of other benefits for herself and her family.
Gina sets a goal of creating a list of the benefits of reducing fat intake for herself and her family before your next visit. You encourage her to get her family to help with this activity.
In discussing exercise, you ask how her family would feel if she suggested a walk after meals when they are visiting. She says that they are always complaining about being overweight, and she might be able to inspire them to take a walk if she says it would help her with her diabetes. You note that she would be setting a good example for everyone else if she were walking regularly. Gina mentions that she could also take occasional walks in the local park with her grandson. When setting goals at the end of the session, Gina suggests an exercise goal of trying to take at least one walk a week by the next visit.
You also check on her insulin use and compliment her on carefully following her insulin regimen. You schedule a return visit in 2 weeks to follow up on her progress with each behavior. If she has reached her self-testing goal, you will talk with her about specific strategies to help her reduce caloric intake. You will also reassess her stage for each behavior and tailor your intervention accordingly.
Moving From the General to the Specific
Regarding the area of MNT in particular, extensive work has been conducted on the application of this model in dietary fat reduction. Specific assessment measures have been developed and validated for each of the constructs of the model.29-33 Unique applications of this model with dietary fat reduction have also emerged, such as an additional process of change, called interpersonal systems control.15 Interpersonal systems control involves avoiding other people who encourage consumption of high-fat foods or create barriers to low-fat eating.
Research Support for the Effectiveness of
A more recent large-scale (N = 4,653) intervention trial35 compared interactive and noninteractive stage-matched smoking cessation interventions in a managed care population. The noninteractive intervention included only self-help manuals, while the interactive intervention included the same stage-matched manuals plus stage-matched expert system-generated individualized feedback reports. The results indicated that the interactive intervention outperformed the noninteractive intervention at 6-month, 12-month, and 18-month follow-up points. This supports the effectiveness of interactive stage-matched intervention approaches.
Other clinical trials examining further enhancements of the interactive intervention for smoking cessation are currently underway. In addition, several intervention trials are underway examining various stage-matched interventions across a variety of behaviors (e.g., healthy eating, exercise, smoking); populations (e.g., adolescents, the elderly, managed care subscribers, low-income pregnant women); and settings (e.g., schools, health clinics, doctor's offices).
Diabetes-related research and clinical trials. A large-scale (N = 2,056) cross-sectional study of the stages of change applied to diabetes care behaviors has been conducted.36 This study focused on validating the use of the TTM in diabetes and developing psychometrically sound measurement tools. A number of publications based on this project are underway.
One published study from this project focused on the stages of change for smokers in this sample of people with either type 1 or type 2 diabetes.37 This study found the following overall distribution of stages: 15.8% in the precontemplation stage, 9.6% in the contemplation stage, 2% in the preparation stage, 3.2% in the action stage, and 69.4% in the maintenance stage. The results indicated significant differences in smoking status across type of diabetes. Specifically, of those who ever smoked, more people with type 2 diabetes were in the maintenance stage (72.5% vs. 44.5%). There were no differences in stage across type of diabetes for those who were current smokers. Across groups, 57.8% of current smokers were in the precontemplation stage, 35.1% were in the contemplation stage, and 7.1% were in the preparation stage.
These results suggest that people with diabetes who smoke are less ready to change than the general population, for which the distribution of stages has been 40% precontemplation, 40% contemplation, and 20% preparation.38 In addition, individuals who reported that they had received provider advice (provider broadly defined, e.g., doctor, nurse, dietitian) regarding quitting smoking were further along on the stages of change. More than 85% of those who reportedly had not received provider advice about smoking were in the precontemplation stage. This emphasizes the importance of provider advice in promoting smoking cessation (as well as other healthy behaviors) and underscores the necessity for tailoring advice and interventions to the person's stage of change.
Although little has been published on the application of this model in diabetes, large-scale trials examining stage-matched intervention approaches in people with diabetes are in progress. The trials examine stage-matched intervention programs for multiple diabetes and related health behaviors compared with usual care approaches. Stage-matched interventions for diabetes based on this model include written stage-based self-help materials, such as handbooks and newsletters; stage-matched telephone counseling approaches; and expert system-generated individualized feedback reports. Individuals in these trials will be followed for 1 year following the initiation of the intervention, and progress across the stages will be assessed, along with a variety of health and psychosocial outcomes. The trials will be completed in the near future.
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Laurie Ruggiero, PhD, is a professor of psychology at the University of Rhode Island in Kingston.
Copyright © 2000 American Diabetes Association
Last updated: 9/00