Addictive Behaviors, Vol. 23, No. 5, pp.

655–668, 1998
Copyright © 1998 Elsevier Science Ltd
Pergamon Printed in the USA. All rights reserved
0306-4603/98 $19.00 1 .00
PII S0306-4603(98)00012-4

APPLICATION OF THE TRANSTHEORETICAL MODEL OF

BEHAVIOR CHANGE FOR OBESITY IN MEXICAN
AMERICAN WOMEN
ALINA M. SURÍS,* MARIA DEL CARMEN TRAPP,†
CARLO C. DICLEMENTE,‡ and JENNIFER COUSINS§
*Department of Veteran Affairs, North Texas Health Care System, and The University of Texas
Southwestern Medical School; †The University of Oklahoma;
‡The University of Maryland; and §Baylor College of Medicine

Abstract — The prevalence, consequences, and resistance to treatment of obesity make it

one of the most difficult psychological and medical problems in society today. The incidence
of obesity is greater in Mexican Americans than in Caucasians. The purpose of this study was
to apply the Transtheoretical Model of Behavior Change on a sample of Mexican American
women in weight-loss study. Questionnaires assessing the stages and processes of change were
shortened, translated, and administered to subjects. Cluster analyses were conducted to deter-
mine the stage of change profiles, with five distinct profiles emerging. These profiles are con-
sistent with those reported in previous research on smoking, psychotherapy, alcoholism, and
overeating. Relationships among stages, processes, and profiles of change were examined and
found to be consistent with previous research. This study supports the use of the Transtheo-
retical Model with Mexican American women who were enrolled in a behaviorally oriented
weight-loss program. Results of the study are limited owing to a small sample size; however, it
does provide a foundation to incorporate Hispanic populations in future studies pertaining to
stages and processes of behavior change. © 1998 Elsevier Science Ltd

The seriousness, prevalence, and resistance to treatment of obesity make it one of the
most difficult psychological and medical problems in society today (Brownell, 1982).
The third National Health and Nutrition Examination Survey (NHANES III) found
that more than one-third of adults in the United States are 20% or more overweight
(Kuczmarski, Flegal, Campbell, & Johnson, 1994). There are differences in weight de-
pending on sex, age, race, and socioeconomic status, with more women than men be-
ing overweight: 27% of women compared to 24% of men (Kuczmarski, 1992). How-
ever, the tendency to become overweight increases in both sexes with age (Wadden &
VanItallie, 1992) and the incidence of obesity is greater in Mexican Americans, both
women and men, than in Caucasians (Villareal, 1986).
Obesity has been associated with several health risks that increase morbidity and
mortality. Stewart and Brook (1983) reviewed 21 studies and concluded that being se-
verely overweight is associated with premature mortality. Research has also consis-
tently demonstrated an association between obesity and hypertension, hyperlipi-
demia, diabetes mellitus, carbohydrate intolerance, cardiovascular disease, surgical
risk, risk with anesthesia, pulmonary and renal problems, sleep apnea, gall bladder
problems, and complications during pregnancy (Pi-Sunyer, 1991, 1993; Grunstein &
Wilcox, 1994). Other less serious complications also associated with obesity include
hernias due to stretching and thinning of the abdominal musculature, osteoarthritis
due to increase wear on joints, and menstrual disturbances (Agras, 1987).

Requests for reprints should be sent to Alina Surís, PhD, Veterans Affairs North Texas Health Care
System (116A), 4500 South Lancaster Rd., Dallas, TX 75216.

655
656 A. M. SURÍS et al.

According to Brownell and Wadden (1983), the psychological and social hazards of
obesity are more important to dieters than are the medical hazards. The psychological
consequences do not affect all obese people, but in many individuals, the long-term
consequences can be disabling and permanent (Brownell, 1982). According to Hirsch
(1973), the effects range from mild feelings of inferiority to very serious incapacities
that can occur when obesity acts as an impediment to normal socializing and sexual ac-
tivity, which may encompass all areas of a person’s life including marriage, education,
and employment. In addition to the physical and emotional hazards of being over-
weight, in the United States there is a stigma associated with obesity (Wardle, 1995).
Mexican Americans have been shown to be at increased risk for obesity and for many
of its associated risk factors, highlighting the disadvantages of obesity for this popula-
tion. Thus, these psychological and social disadvantages may be of particular relevance
to Mexican Americans as they are more likely to be obese and have unique cultural
characteristics that may interact with the disadvantages of obesity. Several investigations
have concluded that the prevalence of obesity among Mexican American adults is 30%
or higher by age 30 (e.g., Mueller, Joos, Hanis, Zavaleta, Eichner, & Schull, 1984).
There is a large variability in treatment outcomes in obesity programs (Brownell,
1982). Consequently, the search for predictors of successes or failures in obesity re-
search has led scientists to assess the viability of using the Transtheoretical Stages of
Change Model (Prochaska & DiClemente, 1983; Velicer, Prochaska, Rossi, & Snow,
1992). In this model, behavior change is conceptualized as a complex procedure in-
volving the application of 10 processes of change across 5 stages of change at 5 differ-
ent levels of change (Prochaska, 1984; Prochaska & DiClemente, 1986). The Transthe-
oretical Model is based on an analysis of the 24 most popular theories of
psychotherapy, including affective, behavioral, cognitive, dynamic, experiential, rela-
tionship, and systems approaches to therapy (Prochaska, 1984). The focus of the trans-
theoretical approach is on change, and it uses the structure of intentional change as
the foundation of its integrative efforts (Prochaska, 1984). Interacting with these 10
processes of change are 4 stages of change through which individuals proceed when at-
tempting to change. They are defined as follows:
1. Precontemplation: Individuals are entering a change situation, but they do not be-
lieve they have a problem or know they do not want to change. They may feel pres-
sured or coerced into being there by a significant other. They do not intend to
change themselves and may focus on changing others in the environment.
2. Contemplation: Individuals in this stage are beginning to be aware that the problem
exists or that they are bothered by something about themselves. They are strug-
gling to understand the problem (i.e., cause, solution) and are seeking more infor-
mation. They are considering change but have not made a commitment to change.
3. Preparation: Individuals in this stage intend to take action within the next month
and have been unsuccessful in taking action within the last year. They have made
some reductions in their problem behaviors, but they have not yet reached a crite-
rion for effective action.
4. Action: In the action stage, people have decided to change and have actively started
to work on changing, often seeking help to do so more effectively.
5. Maintenance: Here, individuals work to prevent relapse and consolidate gains ac-
complished during the action stage.
Adjacent stages are more highly correlated than are nonadjacent stages, with some in-
dividuals moving smoothly from contemplation to action to maintenance without
 Behavior change for obesity 657

complications. However, most people follow a more complicated course of change

(Prochaska, 1984). Individuals can begin to contemplate change, then decide not to
change and exit the cycle at that point (DiClemente & Hughes, 1990). Similarly, action
or maintenance is often interrupted by relapse, with the person returning to the prob-
lematic behavior. Individuals who are attempting to alter addictive behaviors such as
smoking, alcoholism, or obesity often make several revolutions through the cycle be-
fore achieving successful behavior change (Schachter, 1982; Prochaska & DiClemente,
1986; Norcross & Vangarelli, 1989; Prochaska, DiClemente, & Norcross, 1992a). Thus,
movement through the stages is not linear but cyclical in nature, with a person enter-
ing and exiting at different stages.
Individual profile patterns (cluster analysis) across all four stages reveal that indi-
viduals can simultaneously be engaged in tasks associated with more than one stage at
the same time, with people showing differential involvement in each of the stages (Mc-
Connaughy, DiClemente, Prochaska, & Velicer, 1989; McConnaughy, Prochaska, &
Velicer, 1983). These cluster-analytic techniques have yielded several distinct stages of
change profiles, which are consistent across different populations including individuals
in psychotherapy and alcoholics (DiClemente & Hughes, 1990; McConnaughy et al.,
1989; McConnaughy et al., 1983):

1. Participation cluster: Has below-average scores in precontemplation and above-

average scores in contemplation, action, and maintenance. These individuals report
involvement in changing.
2. Precontemplation cluster: Has scores well above average on precontemplation and
well below average on the other three stages, indicating a reluctance to change.
3. Uninvolved/discouraged cluster: Characterized by having average scores on all the
stages, showing minimal involvement in any of the stages.
4. Ambivalent cluster: Characterized by well-below-average scores on maintenance
and average scores on the other three stages. These individuals are about average
relative to others in terms of denying, thinking about, taking action, or changing,
and they are not maintaining the changes that they have made previously.
5. Contemplation cluster: Characterized by average scores on contemplation, below-
average scores on precontemplation, well-below-average on action, and about-
average on maintenance. These individuals are thinking about changing, but they
have not begun to take action.

Stages and processes of the Transtheoretical Model have been applied to smokers
(Fava, Velicer, & Prochaska, 1995), psychotherapy clinic populations (McConnaughy
et al., 1983, 1989), and alcoholics (DiClemente & Hughes, 1990). It is conceptually
suited to research with weight loss as well (Rossi, Rossi, Rossi-DelPrete, Prochaska,
Banspach, & Carleton, 1994; O’Connell & Velicer, 1988), but there have been rela-
tively few studies that have applied constructs from the transtheoretical approach to
the study of obesity (Prochaska, Norcross, Fowler, Follick, & Abrams, 1992b). To
date, only one study in the literature assesses the applicability of the Transtheoretical
Model to Mexican Americans (Gottleib, Galavotti, McCuan, & McAlister, 1990). Spe-
cifically, the study examined the self-change processes of smoking cessation, including
intentions to quit smoking and self-change perceptions, in a large sample of Mexican
Americans.
The Transtheoretical Model is a promising approach to conceptualizing and treating
eating patterns (Glanz, Patterson, Kristal, DiClemente, Heimendinger, Linnan, &
658 A. M. SURÍS et al.

McLarren, 1994). It attempts to isolate and describe basic elements in the process of
behavior change. The model is eclectic and comprehensive enough to incorporate
multidimensional issues such as obesity.
There is very little research assessing the appropriateness of applying the Transthe-
oretical Model to specific cultures. It is possible that various cultures may use different
processes of change more than others and use additional ones that are not yet incorpo-
rated into the model. Some processes may be more readily accepted by cultures while
others are more problematic.
The purpose of the present study was to apply the Transtheoretical Model to an
obesity-intervention program for Mexican American women. It focused on whether
aspects of the Transtheoretical Model can usefully be applied to understanding obe-
sity treatment among Mexican American women. More specifically, can the usefulness
and results of the Transtheoretical Model, which have been demonstrated with indi-
viduals with smoking, psychological, and alcohol problems, be replicated in a cultur-
ally sensitive obesity-treatment program?

M E T H O D

Participants
Eighty-one families were recruited from a larger study, Cuidando el Corazón
(CEC). The larger investigation was conducted to evaluate the effectiveness of pro-
moting weight loss in young Mexican American families by modifying their dietary
and physical activity patterns. The CEC was designed to take into account several rel-
evant cultural issues, including language, traditional Mexican American nutrition, fa-
milismo, personalismo, and machismo. CEC integrated the elements of several ap-
proaches to obesity treatment involving behavior modification, information about
nutrition and exercise, lifestyle change, and inclusion of the family. Family involve-
ment was a factor because of its cultural relevance and because of research indicating
the importance of family in modifying health behaviors. However, the women were
the focus of the intervention.
An initial screening was conducted to ensure the families met the inclusion criteria.
These criteria were as follows: (1) the participant was of Mexican origin; (2) the partic-
ipant was at least 20% over ideal body weight; (3) the participant was married and had
at least one child 3 to 6 years of age; (4) the participant was between 18 and 45 years of
age; and (5) the participant and her family were residents of Fort Bend County, Texas.
Potential subjects were excluded from the study if they met one or more of the fol-
lowing exclusion criteria: (1) having a chronic illness that had dietary and/or exercise
recommendations different from those proposed in the program; (2) being greater
than 100% over ideal body weight; (3) having diastolic blood pressure measurements
of 115 or greater; or (4) being diagnosed diabetic or having a fasting plasma glucose
value greater than or equal to 140 mg/dl.

Instruments
University of Rhode Island Change Assessment Scale (URICA). The University of
Rhode Island Change Assessment Scale (URICA) is a 32-item questionnaire that
measures involvement in the tasks of various stages of change: precontemplation, con-
templation, action, and maintenance (McConnaughy et al., 1983). There are eight
items measuring each of the stage subscales. Internal consistency and reliability coeffi-
cients have been calculated for each of the four, 8-item scales. Coefficient alphas for
 Behavior change for obesity 659

each scale are: precontemplation, .88; contemplation, .88; action, .89; and mainte-
nance, .88. Responses are given on a 5-point Likert format (strong disagreement 5 1,
to strong agreement 5 5). Subscale scores are summed, and scores on each of the four
stages are obtained for each subject.
Because of the time constraints of the larger study, Cuidando el Corazón, a short
version of the URICA was generated using the four highest loading items for each
stage subscale. The questionnaire was then translated into Spanish, back into English,
and compared for significant differences. No significant differences emerged between
the Spanish and English modified versions.

Weight Processes of Change Scale (WPCS). The original Processes of Change Scale
is a Likert-type instrument that uses 4-item scales to measure 10 cognitive and behav-
ioral coping processes for smoking behavior (DiClemente & Prochaska, 1985). A
weight-loss-specific version was developed based on the items and loading factors
from the original Processes of Change Scale (PCS). The WPCA on weight-control
items yielded 11 components accounting for 70.2% of the total variance. Forty-five of
the 50 items loaded .40 or greater on a single component. Coefficient alphas ranged
from .68 to .96, with a mean alpha of .81.
Because of time constraints in the larger study, a short version of the WPCS instru-
ment was created using the two highest loading items for each process. One process,
environmental reevaluation, was omitted and two questions about satisfaction with
appearance were added. The questions were then translated into Spanish, back into
English, and then also compared for differences. No significant differences were de-
tected.

Procedures
Participants for the study were drawn from year 3 of the aforementioned 7-year
study, CEC. The current study used the following measures: Body Mass Index (BMI),
the modified URICA (McConnaughy et al., 1983), and the modified WPCS (Di-
Clemente & Prochaska, 1985). The BMI is a means of measuring body weight that has
the highest correlation with body fat (Bray, 1976), and was obtained at baseline. The
modified URICA, and WPCS questionnaires were also administered at baseline. The
questionnaires were administered by bilingual interviewers in Spanish or English, de-
pending on the subject’s preference.

R E S U L T S

Overall, participants were young (M 5 33.0, SD 5 6.3), had low levels of education
(M 5 9.6, SD 5 3.9), and low family incomes (22% making less than $10,000, 50%
making between $10,000 and $30,000, and 27% making over $30,000). Forty-three per-
cent of the sample was employed outside the home, while the rest classified them-
selves as homemakers. The majority of the sample was classified as “truly bicultural”
(M 5 2.63, SD 5 .84) by the Acculturation Rating Scale of Mexican Americans (Cuel-
lar, Harris, & Jasso, 1980).

Psychometric analyses
University of Rhode Island Change Assessment Scale (URICA). Cronbach’s Alpha re-
liability coefficients were calculated for each subscale of the URICA-Short form to as-
660 A. M. SURÍS et al.

sess their degree of internal consistency. Considering the substituted shortened version
of the scale, the coefficients were fairly high for the precontemplation (.78), contem-
plation (.74), action (.78), and maintenance (.63) subscales.
Participant’s scores were then characterized by averaging subscale scores within
each stage. The means and standard deviations were: precontemplation: M 5 1.97 (SD 5
.75); contemplation: M 5 4.35 (SD 5 .40); action: M 5 3.88 (SD 5 .71); and mainte-
nance: M 5 3.78 (SD 5 .66). For comparability, subject’s scores were then standard-
ized with a mean of 50 and a standard deviation of 10.

Weight Processes of Change Scale (WPCS). Cronbach’s Alpha reliability coefficients

were calculated for each process-of-change subscale to assess their degree of internal
consistency. Because the process subscales were reduced from original versions and
consisted of only two questions each (with the exception of dramatic relief, which has
three questions), the coefficients were not expected to be very high. The coefficients
were as follows: consciousness raising (.36), self-liberation (.57), social liberation (.44),
counter-conditioning (.69), stimulus control (.41), contingency control (.52), dramatic
relief (.73), helping relationships (.91), substance use (.91), and appearance satisfac-
tion (.50).
Participant’s scores on each process of change were then calculated by averaging
scores within each process subscale. The means and standard deviations are presented
in Table 1. Overall, the subjects reported an average amount of process usage as indi-
cated by the means on each of the processes, with a few (consciousness raising and so-
cial liberation) being more highly endorsed at baseline. Results of this analysis are in
the predicted direction, with significant correlations being found especially among the
behaviorally based process.
The correlations among the processes of change at baseline are found in Table 2.
Previous research indicates that the processes are relatively independent techniques;
hence, a high degree of intercorrelation among all the processes of change would not
be expected. However, the experientially based processes would be expected to be
more correlated with each other as would the behaviorally oriented processes be ex-
pected to correlate more highly with each other. The results of this analysis are in the
predicted direction, with significant correlations being found especially among the be-
haviorally based process.

Table 1. Means and standard deviations of the

processes of change

Process M SD

Behavioral
Self-Liberation 3.34 .84
Counter-Conditioning 2.58 .84
Stimulus Control 2.53 .88
Contingency Control 2.45 .93
Cognitive
Consiousness Raising 3.74 .73
Social Liberation 3.88 .86
Dramatic Relief 3.61 .84
Other
Substance Use 1.50 .84
Appearance Satisfaction 3.12 .87
 Behavior change for obesity 661

Table 2. Correlations among the ten processes of change at baseline

Processes of Change CR SL CC SC HR DR SOL AS SU

Consciousness Raising
Self-Liberation .16
Counter-Conditioning 2.11 .13
Stimulus Control 2.07 .19 .35**
Helping Relationships .12 .29* .07 .18
Dramatic Relief .29* .23 .11 .03 .14
Social Liberation .38** .16 .28 .33* .14 .06
Appearance Satisfaction 2.02 .28* 2.06 2.03 .05 .29* .18
Substance Use .05 .16 2.13 .05 .01 .07 .05 .12
Contingency Control .19 .41** .28* .10 .44** .17 .17 .06 .16

*p , .01.
**p , .001.

Stage of change profiles. To determine the presence of distinct stage of change pro-
files, a cluster analysis was done using the standardized URICA short-form scores and
a hierarchical agglomerative method (minimum variance) with Squared Euclidean dis-
tance as the distance measure. The minimum variance method was used because re-
search has demonstrated that it is the best technique for clustering psychological data
(Punj & Stewart, 1983). Both the hierarchical tree and the clustering coefficients were
used to determine the number of clusters. Complete data was available on 79 of the
original 81 participants. Five clusters adequately differentiated the groups of partici-
pants (Fig. 1a–e). The within-cluster patterns are consistent with the five clusters that
were found in an outpatient alcohol treatment study by DiClemente and Hughes
(1990) as well as in previous research (McConnaughy et al., 1983, 1989). These clusters
are labeled and described as follows:
1. Precontemplation Profile: The three subjects in this cluster (Fig. 1a) are character-
ized by the above-average scores on precontemplation (M 5 80.7), particularly low
scores on contemplation (M 5 40.8), below-average scores on action (M 5 44.4),
and barely above-average scores on maintenance (53.3). These subjects are not
contemplating or engaging in change.
2. Discouraged Profile. The 18 subjects in this cluster (Fig. 1b) are characterized by
below-average scores for all the stages (M 5 42.9 for contemplation, M 5 47.6 for
action, and M 5 38.4 for maintenance) except precontemplation, which is slightly
above average (M 5 53.4). These subjects have a moderately low level of endorse-
ment and seem somewhat listless in their attitudes to change the problem behavior.
They appear to be barely uninvolved in altering their behaviors and may represent
a group of subjects who are close to giving up on change.
3. Ambivalent Profile: The 25 subjects in this cluster (Fig. 1c) are characterized by
slightly above-average scores on precontemplation (M 5 52.7), action (M 5 52.6),
and maintenance (M 5 55.1). Contemplation (M 5 45.4) is the only subscale with
below-average scores. Subjects seem to have no peak scale score. This may reflect
their ambivalence or reluctance about changing their eating style; thus, they can en-
dorse conflicting statements.
4. Contemplation Profile: The 14 subjects in this cluster (Fig. 1d) are characterized by
below-average scores on all but the contemplation scale (53.6), with very low scores
on action (M 5 35.5). These subjects are interested in changing their problem be-
havior, but have not yet taken action.
662 A. M. SURÍS et al.

5. Participation Profile: The 19 subjects in this cluster (Fig. 1e) are characterized by a
low score on precontemplation (M 5 44.2) and above-average scores on contem-
plation (M 5 61.0), action (M 5 60.0), and maintenance (M 5 55.73). These sub-
jects seem to be reporting both a high interest and involvement about changing
problem behavior based on their attitudes.
Several additional analyses were conducted to determine whether differences ex-
isted among the five clusters on education, income, acculturation, and baseline BMI
and weight. Chi-square analyses by cluster (N 5 5) for education and income were
computed. Originally, education was reported as number of years of school. To make
the analysis more meaningful, this variable was divided up into four categories: ele-
mentary school only, some high school, high school graduate, and some college. The
chi-square analysis was not significant (x2(12, N 5 79) 5 11.09, p 5 .52). Educational
level was distributed fairly evenly across all the clusters. Because greater than 20% of
the cells had an expected frequency of less than five (84%), income level was recoded
into two categories (less than $20,000 a year and greater than or equal to $20,000 a
year). This analysis was nonsignificant (x2(4, N 5 78) 5 4.23, p 5 .38), with none of
the clusters differing significantly in the amount of income they earn.
To assess possible cluster differences with acculturation score, a one-way ANOVA
was computed. The results of this analysis were nonsignificant (F(4, 73) 5 2.37, p 5
.06). The Precontemplation Cluster members had a lower level of acculturation com-
pared to the other clusters.
A final analysis was computed to see if clusters groups differed on initial body mass
index (BMI). The one-way ANOVA for initial BMI and cluster membership was non-
significant (F (4, 74) 5 1.57, p 5 .19). Thus, at baseline, there was not a significant dif-
ference among the clusters in BMI.
To examine differential use of processes of change among clusters, ten individual
one-way ANOVAs were computed for each process of change and each cluster. Indi-
vidual ANOVAs were calculated because of the small sample size and the unequal
distribution of subjects across the clusters. The F values, p values, means, and standard
deviations are reported in Table 3. There were two processes that varied significantly
across clusters, counter-conditioning (F(4, 74) 5 4.5, p 5 .002) and contingency control
(F(4, 74) 5 2.9, p 5 .03). A post hoc Scheffe comparison test on counter-conditioning
indicated that clusters 1 (precontemplation) and 3 (ambivalent) differed significantly
from each other at the 0.05 level, with the precontemplation cluster having the lower
scores. The post hoc Scheffe comparison test on contingency control indicated there
were significant differences among clusters 3 (ambivalent) and 4 (contemplation) on
this process at the .05 level. Overall, when looking across clusters, the participation
cluster usually had the highest scores, with the precontemplation cluster having the
lowest scores on the 10 processes of change.

D I S C U S S I O N

This study supports the use of the Transtheoretical Model with Mexican American
women who were enrolled in a behaviorally oriented weight-loss treatment program.
Despite being shortened and translated, the questionnaires were able to discriminate
significantly different clusters of change among participants.
The shortening of the WCPC questionnaire resulted in a wide range of reliability
quotients. These coefficients were not expected to be very high, as there are only two
 Behavior change for obesity 663

Fig. 1. (a) Precontemplation cluster; (b) Discouraged cluster; (c) Ambivalent cluster; (d)
Contemplation cluster; and (e) Participation cluster.
664 A. M. SURÍS et al.

Fig. 1. Continued.
 Behavior change for obesity 665

Fig. 1. Continued.

questions per process of change (with the exception of dramatic relief, which had
three questions). However, they still averaged out to have reliability coefficients of
greater than 60%. Future studies should consider using the longer form to assure that
the quality of the concept being measured is preserved. If this is not possible, as with
this study, a Principal Components Analysis of the questionnaire may help clarify ex-
actly which processes are being assessed by the shortened form. It is possible that the
behavioral processes and cognitive processes will group together and subsequent anal-
ysis can use these as process variables instead of the individual subscales.
Results indicate that the modified URICA can be used to classify Mexican Ameri-
can women participating in a weight-loss treatment program into five distinct stage-
related profiles: Precontemplation, Discouraged, Ambivalent, Contemplation, and Par-
ticipation. These profiles are remarkably similar to those found with subjects entering
treatment for alcohol addiction and general psychiatric problems in predominantly
Caucasian populations.
Even though analyses indicated no significant differences on several demographic
characteristics, an interesting pattern emerged when looking at the means of these
variables across the profiles. The Precontemplation cluster seemed to be less edu-
cated, less acculturated, and had a lower income. It is possible that as people become
more acculturated, they may be more likely to agree with the Anglo American ideal of
thinness, which would increase their likelihood of changing behavior. It is plausible,
that if the sample had been larger there would have been more participants classified
as Precontemplators, which would increase the chances of finding significant differ-
ences among these descriptive variables.
666 A. M. SURÍS et al.

Table 3. F-Values, p-values, means, and standard deviations for processes of change by cluster profiles

Clustera

Process of change 1 2 3 4 5 F p

Consciousness Raising 3.3 3.4 3.8 3.8 3.8 1.4 .26

.58 .73 .60 .75 .84
Self-Liberation 3.3 2.8 3.5 3.3 3.6 2.0 .10
1. .81 .6 .97 .85
Counter-Conditioning 1.3 2.6 3.0 2.3 2.4 4.5 .002
.58 .93 .68 .61 .88
Stimulus Control 2.5 2.1 2.7 2.6 2.7 1.2 .30
1.5 .68 .94 .82 .91
Helping Relationship 1.7 2.3 2.8 2.3 2.7 1.2 .32
.58 1.2 1.0 1.1 1.3
Dramatic Relief 3.7 3.2 3.8 3.9 3.4 1.9 .13
.66 1.0 .80 .66 .84
Social Liberation 2.8 3.7 3.9 4.0 4.0 1.7 .17
1.0 .93 .81 .63 .94
Appearance Satisfaction 3.5 2.9 2.9 3.5 3.2 1.7 .17
.70 .95 .82 .82 .87
Substance Use 1.2 1.2 1.8 1.7 1.3 1.6 .20
.29 .73 .95 .91 .76
Contingency Control 2.3 2.3 2.8 1.8 2.5 2.9 .03
.28 .83 .90 .53 1.1

Note. Standard deviations are in italics.

aCluster definitions: 1, Precontemplation; 2, Discouraged; 3, Ambivalent; 4, Contemplation; 5, Participation.

With regard to the acculturation variable, it is interesting to note that the Contem-
plation and Participation profiles were the most acculturated of all the stage of change
clusters (even though they were not statistically significantly different). It is possible
that the URICA is picking up on an acculturation component, with the more accultur-
ated subjects reporting greater readiness to change. These are the Mexican American
women who are more likely to have incorporated the Anglo American ideals of thin-
ness and health and therefore may be more motivated to do something about their
weight. Again, a larger sample will provide more power to verify this hypothesis.
Even though there were few significant differences, the Participation profile mem-
bers reported frequent use of action-oriented processes of change, while the Precon-
templation cluster members endorsed the lowest levels of process activity. This pat-
tern is similar to what has been found in previous research on process and stage
interaction.
The processes of change provide useful clinical information about participants in
this study. In general, at baseline, participants were using experientially oriented tech-
niques (e.g., dramatic relief) much more often than behavioral techniques (e.g., stimu-
lus control). Research has shown that Mexican Americans are less knowledgeable
about cardiovascular risks and are less likely to control their weight through diet and
exercise when compared to Anglo Americans (Stern, Pugh, Gaskill, & Hazuda, 1982).
Consequently, it makes sense that they would not be using behaviorally oriented pro-
cesses at the beginning of treatment, as they usually require formal training and/or
previous knowledge. It would be informative to assess the fluctuations in the processes
of change usage during treatment. The expected patterns of process usage were also
found with the action-oriented stages using more processes more frequently than the
non-action-oriented cluster members.
 Behavior change for obesity 667

A limitation is the small subject sample. Because of the small number (N) of the
study, some analyses had less power to detect differences. The small N is especially
problematic for cluster analyses because the sample has to be divided into even
smaller subgroups. Cluster analyses are typically performed on much larger Ns, mak-
ing relatively equitable participant distribution among the clusters more likely. In the
current study, there were large differences in size among the five stage of change clus-
ter profiles, which could have accounted for lack of significant differences. Replication
with larger sample will not only increase the chances of significant results but also
strengthen the conclusions of the study.
Another limitation of the study is a heavy reliance on self-report data. As in all stud-
ies that rely on self-report data, accuracy may be in question, even with the attempts
to incorporate cultural differences and characteristics such as language barriers. Relat-
edly, participants’ understanding of questions on measures may also be problematic—
especially because they are probably foreign concepts—especially to the less accultur-
ated participants.
The results of this study assist in laying a foundation for research to incorporate mi-
nority populations in future studies pertaining to the processes of change. It appears
from this initial endeavor that both Hispanic and Anglo American populations with
regards to the stages of change may be defined by the Transtheoretical Model of Be-
havioral Change, which can assist the facilitation of modification through understand-
ing and meeting participants at the level at which they begin intervention as opposed
to generic programs.

R E F E R E N C E S

Agras, W. S. (1987). Eating disorders: Management of obesity, bulimia and anorexia nervosa. New York:
Pergamon Press.
Bray, G.A. (1976). The obese patient. Philadelphia, PA: W.B. Saunders.
Brownell, K. D. (1982). Obesity: Behavioral treatments for a serious, prevalent and refractory disorder. In
R. K. Goldstein (Ed.), Eating and weight disorders: Current developments. New York: Springer.
Brownell, K. D., & Wadden, T. A. (1983). Behavioral self-help treatments for obesity. In M. R. C. Green-
wood (Ed.), Obesity. New York: Churchill Livingstone.
Cuellar, I., Harris, L., & Jasso, R. (1980). An acculturation scale for Mexican American normal and clinical
populations. Hispanic Journal of Behavioral Sciences, 2, 199–217.
DiClemente, C. C., & Hughes, S. O. (1990). Stages of change profiles in outpatient alcoholism treatment.
Journal of Substance Abuse, 2, 217–235.
DiClemente, C. C., & Prochaska, J. O. (1985). Processes and stages of change: Coping and competence in
smoking behavior change. In S. Shiffman & T. A. Wills (Eds.), Coping and substance abuse. New York:
Academic Press.
Fava, J. L., Velicer, W. F., & Prochaska, J. O. (1995). Applying the Transtheoretical Model to a representa-
tive sample of smokers. Addictive Behaviors, 20(2), 189–203.
Glanz, K., Patterson, R. E., Kristal, A. R., DiClemente, C. C., Heimendinger, J., Linnan, L., & McLarran, D.
F. (1994). Stages of change in adopting healthy diets: Fat, fiber and correlates of nutrient intake. Health
education Quarterly, 21(4), 499–519.
Gottleib, N. H., Galavotti, C., McCuan, R. A., & McAlister, A. L. (1990). Specification of a social-cognitive
model predicting smoking cessation in a Mexican-American population: A prospective study. Cognitive
Therapy & Research, 14(6), 529–542.
Grunstein, R. R., & Wilcox, I. (1994). Sleep disordered breathing and obesity. Ballieres Clinical Endocrinol-
ogy and Metabolism, 8(3), 601–628.
Hirsch, J. (1973). The psychological consequences of obesity. In G. A. Bray (Ed.), Obesity in perspective
(DHEW Publication No. NIH 75-708). Washington, DC: U.S. Government Printing Office.
Kuczmarski, R. J. (1992). Prevalence of overweight and weight gain in the United States. American Journal
of Clinical Nutrition, 55(suppl), 495S–502S.
Kuczmarski, R. J., Flegal, K. M., Campbell, S. M., & Johnson, C. L. (1994). Increasing prevalence of over-
weight among United States adults: The National Health and Nutrition Examination Surveys, 1960–
1991. Journal of the American Medical Association, 272, 205–211.
668 A. M. SURÍS et al.

McConnaughy, B. A., DiClemente, C. C., Prochaska, J. O., & Velicer, W. F. (1989). Stages of change in psy-
chotherapy: A follow-up report. Psychotherapy: Theory, Research, and Practice, 4, 494–503.
McConnaughy, B. A., Prochaska, J. O., & Velicer, W. F. (1983). Stages of change in psychotherapy: Mea-
surement and sample profiles. Psychotherapy: Theory, Research, and Practice, 20, 368–375.
Mueller, W. H., Joos, S. K., Hanis, C. L., Zavaleta, A., Eichner, N., & Schull, W. J. (1984). The diabetes alert
study: Growth, fatness, and fat patterning. Adolescence through adulthood in Mexican Americans.
American Journal of Physical Anthropology, 64, 389–399.
Norcross, J. C., & Vangarelli, D. J. (1989). The resolution solution: Longitudinal examination of New Year’s
change attempts. Journal of Substance Abuse, 1, 127–134.
O’Connell, D. O., & Velicer, W. F. (1988). A decisional balance measure of the stages of change model for
weight loss. International Journal of the Addictions, 23, 729–840.
Pi-Sunyer, F. X. (1991). Health implications of obesity. American Journal of Clinical Nutrition, 53, 404–413.
Pi-Sunyer, F. X. (1993). Medical hazards of obesity. Annals of Internal Medicine, 119, 655–700.
Prochaska, J. O. (1984). Systems of psychotherapy: A transtheoretical analysis (2nd ed.). Chicago: Dorsey
Press.
Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: Toward an
integrative model of change. Journal of Consulting and Clinical Psychology, 5, 390–395.
Prochaska, J. O., & DiClemente, C. C. (1986). The transtheoretical approach. In J. C. Norcross (Ed.), Hand-
book of eclectic psychotherapy. New York: Brunner/Mazel.
Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992a). In search of how people change: Applica-
tions to addictive behaviors. American Psychologist, 47, 1102–1114.
Prochaska, J. O., Norcross, J. C., Fowler, J. L., Follick, M. J., & Abrams, D. B. (1992b). Attendance and out-
come in a work site weight control program: Processes and stages of change as process and predictor
variables. Addictive Behaviors, 17, 35–45.
Punj, G., & Stewart, D. (1983). Cluster analysis in marketing research: Review & suggestions for applica-
tion. Journal of Marketing Research, 20, 134–148.
Rossi, S. R., Rossi, J. S., Rossi-DelPrete, L. M., Prochaska, J. O., Banspach, S. W., & Carleton, R. A. (1994).
A processes of change model for weight control for participants in community-based weight loss pro-
grams. International Journal of the Addictions, 29(2), 161–177.
Schachter, S. (1982). Recidivism and self-cure of smoking and obesity. American Psychologist, 37, 436–444.
Stern, M. P., Pugh, J. A., Gaskill, S. P., & Hazuda, H. P. (1982). Knowledge, attitudes, and behaviors related
to obesity and dieting in Mexican Americans and Anglos: The San Antonio Heart Study. American
Journal of Epidemiology, 115, 917–928.
Stewart, A. L., & Brook, R. H. (1983). Effects of being overweight. American Journal of Public Health, 73,
171–178.
Velicer, W. F., Prochaska, J. O., Rossi, J. S., & Snow, M. G. (1992). Assessing outcome in smoking cessation
studies. Psychological Bulletin, 111, 23–41.
Villareal, S. E. (1986). Current issues in Hispanic health. U.S. Department of Health and Human Services,
Report of the Secretary’s Task Force on black and minority health: Volume VIII. Washington, DC: U.S.
Government Printing Office.
Wadden, T.A., & VanItallie, J.B. (1992). Treatment of the seriously obese patient. New York: Guilford
Press.
Wardle, J. (1995). The assessment of obesity: Theoretical background and practical advise. Behavior
Research Therapy, 33, 107–117.