RET MTT ope 169 ye Aa Prt ue. The Measure of Stage of Readiness to Change: Some Psychometric Considerations Osvaldo F. Morera, Timothy P, Johnson, Sally Freels, Jennifer Parsons, Kathleen S. Crittenden, Brian R. Flay, and Richard B. Wamecke Univesity of Hlinois at Chicago ‘Previous research in the smoking cessaon lieraure hes shown thatthe key component of the transticoreticl model of change, the stage of readines to change, ist veld independent measure (C.-C. DiClemente& J. 0, Prochaska, 1985; C,C, DiClemeate etl, 1991; W. F Veer J S. Rose, J.0. Prochaska, & C.C. DiClement, 1986). Receny, however, other health service researchers (eg, AI. Farkas fal, 19960) have begun to question the wlty ofthis model; especially ts recive validity (eg, A.J Farkas tal, 199). However, no research to de has examined the reliability and sity ofthe sage of readiness to change mesure. In this toy, the longindinal ‘measurement of stage of readiness to change was weal 2 «quassimples mode! (KG, lreskog, 1970). Bsimates of te stability and reliably for 261 female smokers in 2 general community sample were obcined, Resi indica tha the sage of change measure has dsirsblepeyehomeric proper, Perhaps one of the most influential models in the area of health behavior change within the past 20 years has been the twanstheoretical model of change (TTM; DiClemente et al. 1991; Prochaska & DiClemente, 1983; Prochaska, DiClemeate, Velicer, & Rossi, 1993). The TTM is a model of a stage-based theory of behavioral change, I predicts that individuals system- stically change their readiness to adopt a health behavior on the ‘basis of what they peroeive to be balances between the costs end Denefits of maintaining the behavior and the costs and benefits of ‘change. This balance between costs and benefits ofthe behavior ‘and changing the behavior is generally referred tous ‘“decisional balance” (Velices, DiClomente, Prochaska & Brandenburg, 1985). ‘The TTM is a mulkidimensional model, as it incorporates (a) movement through the stages of change, (b) independent vatiables (eg, processes of change; Prochaske, Velice, DiClemente, & Fava, 1988), (c) dependent variables (2. deci- sional balance and self-efficacy among many others), and (4) Osvaldo F Moers, Timothy P.Johnton Jennifer Persons, and Richard B. Waele, Survey Research Laboratory, Uniresty of nos at Ch cago; Sally Feels, Deparament of Epidemiology end Bionic, Ui versiy of Minos st Chicago: Kathloan 8. Chivenden, Departmen! of Sociology, University of Mlnois at Chicago: Brian R. Flay Health Re- search and Policy Centr, Univerty of Minas a Chicege, ‘This research was funded by Grant CA42760 fom the National Can- cr Instine, We acknowledge Timothy Deller for data management responsibilities in the ever part ofthe smd, Richard Campbell and ‘Albert Maydeu-Olivares for dats-analytie suggestions, esos Chavez for ‘constrecting the figures in this Brief report, Andrea van Proyen snd Marya Ryan for etorisl assistance, and Robin Mermelsiin for com ‘ments on an earlier daft of thie rac. ‘Corzespondence conceming this arcle should be addressed to Os aldo F. Morera, Survey Research Laboratory, University of Minis, #12 South Peoria, Suite 615, Chicago, Minois 60607. Eleczenic mail may bo sent fo omorea@sc.sic.ed, 12 ‘outcome measures. The model is described as transtheoretieal because it incomportes cognitive, motivational, social leaming, ‘and relapse prevention theories. In this model interventions are ‘ypically designed to measure te individual's curent eadiness to accept ideas elated to behavioral change end then © provide information that will help the individual move closer to taking the desied scion ‘The TTM bas been applied in such diverse areas as smoking cessation, weight contol, lcobol consumption, and condom se (Prochaska et al, 1992). However the model has been most thoroughly evaluated inthe smoking cession Merarure (Davidson, 1992), ‘The key feamre of this model states that health behavior change progresses trough a series of spe or sages. Although ihe numberof stages bas been modified (DiClemeate et al, 1991) and refined (Critenden, Manfredi, Lacey, Warnecke, & Parsons, 1994), the stages can generally be devcsbed in the following progression: (a) Precontemplarion involves 30 thought of quiting; (4) contemplavion involves the thought of quitng:(¢) preparation iavolves preparing to qui; (2) action favolves actully quiting; and (e) maintenance involves sbsti- rence. The tage of readiness to change mcasure es been found to be a good predictor of a varity of smpking cessation out- comes (Prochasa etal, 1993; DiClemente et al, 1991; Ceiuen- en, Manfredi, Warnecke, Cho, & Parsons, 1998) owover, the tages of change measure has also come under exitical review within the past few years (Farkas eta, 19962, 19960). Farkas tal. (1996a, 19960) have paid particular att tion tothe predictive validity ofthe readiness of stage to change smeanure. In one ancl, Farkas etal. (19960) compared the original Prochaska and DiClemente (1983) model of sages of change with the revised model of stages of change (DiClemente aly 1991) and found thatthe revised model fared no beter than the original mode in predicting smokin cesttion, In another anle, Farkas etal (1996a) compared the seadi-BRIEF REPORTS 183 ness of stage of change measure with a competing addiction ‘model and found partial support forthe stage of change model (ndividuals in the preparation stage exhibited higher levels of smoking cessation than did individuals in the contemplation stage). Moreover, Farkas et al. (1996a) showed that their adic tion mode! had beter predictive validity than did the single stage of change measure. As Prochaska and Velicer (1996) appropri- aly pointed oat, multiple variables can almost always account for more variation than any single measure, and thus, the com- patison of the two models is not appropriate. ‘Another current shortcoming in research associated with the readiness of stage to change measure is the absence of informa- tion regarding its reliability and stability. method for obtaining ‘estimates of reliability and stability is discussed. Simplex Models and Quasi-Simplex Models ‘One way to obiain estimates of reliability and stability of a single manifest variable is to Ait either a simplex model or a ‘quasi-simplex model to a variable that is longitudinally mea- sured (Jéreskog, 1970). A quasi-simplex model is ¢ covariance structure that considers measurement eror in longitudinal stud jes when the variable is repeatedly measured. Unlike quasi simplex models, simplex models assume that the observed vari- able contains little of no measurement error ‘The estimation of quasi-simplex models for variables that exe longitudinally measured can be beneficial. Change in 2 health behavior measure may be confounded with the unreliability of the health behavior measure in longitudinal data, In other words, the lack of association between measures ofa variable at multi- ple time points may reflect (a) th lack: f stability im the health behavior measure, (b) unreliability ofthe health behavion. or (©) acombination of chese tv points, Theefore, a clear advan- tage for estimating 2 quasi-simplex model over & manifest vati- able approach (e.g., computing measures of linear association) Js that the emor in dhe health behavior measure can be separated from the tue score for the measure. Many researchers (Alvvin & Keosnick, 1989; Heise, 1969: Wiley & Wiley, 1970) have obtained esimates of reliability and stability by estimating 2 three-wave simplex model (2, 8 ‘model in Which the variable of interest hat been measured at three time points). In a quasi-simplex model, reliability is de- fined as the complement of the amount of obterved error inthe ‘manifest variable, Stability, onthe other hand, is defined atthe inverse of the amount of change in the true measure of the manifest variable at each sequential time poiat. Stability can also be interpreted as the test—retsst reliability of the true soore of the manifest variable st each sequential ime point, Following a strategy of Jéreskog and Strbom (1996), we ft an identified six-wave quasi-simplex model (eg., 2 model in ‘which the estimates ofthe path coeficients are unique upto six waves) by equating the errors of measurement between the rst two observed variables and equating the errors of measurement ‘between the lat to observed variables (see Figure 1), In Figure 1, BL Stage refers to stage of readiness to change at baseline; IP Stage refers to stage of readiness to change at immediate postntervention; Stage 6 refers o stage of readiness to change at 6 months postintervention; Stage 12 refers to stage of readiness to change at 12 months postintervention; Sage 18 refers to stage of readiness to change at 18 months postinterven- tion; and Stage 24 refers to stage of readiness to change at 24 ‘months postintervention. Measures of stability are represented by the beta coeffciens ftom each true measure of stage of ‘readiness to change (denoted by the ns in Figure 1) to the next measure. Measures of reliability, the squared multiple correla tions for each of the observed variables, represent how consis- ‘ently the rue measure of stage of readiness to change accounts {or the variation ofthe observed measure of siage of readiness to change. The measure of reliability at each longitudinal time polat is also the complement of the amount of observed error in the manifest variable (denoted by the es in Figure 1) ‘We will estimate the quasi-simplex model in Figure 1 to obtain estimates of reliability and stability ofthe stage of readi- ness to change measure for female smokers inthe general popu- lation. We were interested in determining the relisbility and stability ofthe longinuinal assessments ofthe Critenden etal, (1994, 1998) elaboration of the stage of readiness to change ‘measure over 2 24-month period. Ifthe stage of readiness t0 change measure isa psychometrically sound measure, we would expect to find high measures of reliability and stability. Method Data Collection Dawa were collecid os part of «larger smoking iatrvenion hat stared in 1993. Detals ofthe intervention ean be found in Moers & (1998), All data were collected through pons interviews, and data were frst collected at baseline (prior wo the intrvendon) and agen ‘immediately after te inervention (immediate postaunvention). We ‘ominued io interview respendent at 6, 12,18, nd 24 months following ‘he immedite posiatrvention Inirview. Thi brie repor ie based ob teal of 261 fama eokere fm the grasel population Measure of Stage Partcipanss were clasifed second to the Critenden etal. (1996 1998) elaboradion of th Prochask~DiClement measure into six sages of change: precoatemplatve-1 (aot comtsmplaing quiting or cating dowa): precontemplatve-? (not contemplating iting); prevontemple- tive-3 (contemplating qiting, but not within 6 monks): contemplative: prepared for action nd erin (qultng), Mentures of tage of readiness to change wero collected a the six timepoints inte intervention, of Readiness to Change Statistical Procedure ‘The covariance mtx (calculated between stages and across partic pants) was treated as 2 qusi-simples suctue end analyzed over six iffereat time points by using tbe LISREL & program (Jeeskog & ‘Sosoom, 1995) in order vo obtain estimates of relihlity and suiliy {oc the 261 smokers nthe general population.” Results ‘A quasi-simplex model was ft for the data provided by the 261 smokers inthe population. This model constrained all stabil= ity coefficients to equality. The fit of this constrained model was "Stage of readiness to change, « point variable, was tested 3s contitous, and maximum likelihood etimalion Was sed.184 BRIEF REPORTS & OGGrorg | & | Frscoe] [rice] [cows] fast] ese] owe & & & & & & ay fa san om ine eso = ha omen Mats sgn 20,» 28)» 6p <7, nae tev eae (eta 58 59 ‘goodness of it index of 98. This measure of mode! fit indicates ‘that constraining the stability coeficents to equality provides 1 very good measure of model fit. The unstandardized coefficient estimates and their standard errors are provided in Table 1 ‘The quasi-simplex model provided in Figure 2 shows the completely standardized solution from this model As can be seen from Figure 2, measures of stability ranged from a low of 88 (from BL Stage to TP Stage) to a high of £98 (from Stage 12 Stage 18). In addition, measures of relisbility (she comple- iment of the amount of observable measurement error) ranged from a low of .69 (1.00 ~ 31) at baseline stage to 2 high of [6 (1.00 ~ 24) at Stage 12. These measures of relisbility and Stability suggest thet the stage of readiness to change measure thas sound psychometric qualities. Discussion ‘The debate surrounding the measure of stage of readiness to cchange and the iranstheoretcal model has concemed the pre- ‘ble 1 Maximum Likelihood Path Cosffcients for the Simplex Model of the Population Panei Parameters Path coeficient SE Bas ost 002 Bh os om Bs 097 02 Bre 097 ou Bas 097 oa a 058 oor oa 058 oor os 036 oor “a ost oot De on oor So on oor te 120 ot oe 034 out es 032 010 in 033 0.09 a 007 0.08 a out B ‘The goal of this article was to investigate the roliability and stability ofthe stage of readiness to change measure in a popula tion of female smokers ovee a 2-year period, ‘Tachieve these gools, we analyzed the longitudinal measure- ‘ment of the Crittenden eta. (1994; 1998) stage of readiness to change by using a quasi-simplex model (Toreskog, 1970). The quasi-simplex model makes certain assumptions that have come into question. For example, a quasi-simplex model assumes that change occurs through a Markovian process (i.e, thatthe true measure of stage of readiness to change at time Ty, has no influence on stage of readiness to change at time Ty.1). This sssumption has been questioned by Rogosa (1988) and Batista Fouget, Coenders, and Saris (1996). In addition, the simplex model also assumes tha cere are no correlated measurement ers across the difesent points in e longitudinal panel smdy. If this assumption is violated, low estimates of unreliability would be obtained (Alwin, 1989: Al- win & Krosnick, 1989). Despite these potential shoricomings, Alvin (1989) has indicated cha the simplex model seems viel, suited to obtaining estimates of reliability and stabil. Finally, others argue thet the estimation of quas-simplex models ignores the siahility of particular stagee of readiness to change” With use of stent ansition analysis (Collins & Wis alter, 1992), Velices, Martin, and Collins (1996) and Martin, ‘elicer and Fava (1996) have shown that precontemplation and maintenance are the most sable stages (i.e, the conditional ‘probabilities of being in precontemplation of maintenance at ‘ime Ty, given thatthe individual was in precontemplation or ‘maintenance at time Ty, are the largest conditional probebili- ties). Although latent transition analysis isan appealing statisti- cal methodology, our interest isin determining the stability and reliability ofthe overall measure of stage of redness to change * Consusins on the unsandardized solution do not generate coa- sins onthe standardized solution (se Bole, 1999). Therefore, san- aedized suabiltycooficients are not identical. The standardized esti- tats ofthe unreliability of the manifest measure are sim affected, * We tank en monymou reviewer for resing this point and binging he latent trmsiion analjsis methodology co our ateaon.BRIEF REPORTS. 185 * OAG-G2O2626 j ae say ~ =< ~ a [ fr If 31 27 25 24 2B L Figure 2. Complesly standardized solution for population panel. BL = postin vention (across a set of stages) rather than assessing the stability of an individual stage. ‘The results from our stay indicate thst the measure of stage of readiness to change showed high levels of stability and high levels of reliability for these female smokers. These findings, coupled with the predictive and construct valiity findings of CCeitenden etal. (1998), have shown that the stage of readiness to change measure has desirable psychometric properties. Although previous research efforts have used the stage of readiness to change as a predictor variable to assess smoking cessation outcomes, the sound psychometric properties of this ‘measure indicate tha it may also be useful vo consider the stage of readiness to change as an outcome measure. For example, 8 ‘minimal self-help community intervention that assist in a smok- e's progression through the stage of readiness to change classi- fication would be deemed as an effective intervention, even if quiting vas not achieved. Famhermore, the sound psychometric properties of this measure indicate that precise, tailored inter- vention programs (Morgan ct al., 1996) can be implemented sand based on the measure of readiness of stage to change. In summary, health prectcioners should feel quite comfortable with the stage of readiness to change measure. References ‘Alwia, D.F. (1989) Problems inthe estimation and interpreeion of the relly of survey daz. 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