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Applying the Transtheoretical Model toCancer Screening BehaviorLeslie Spencer, PhD, CHES; Francie Pagell, EdD, CTRS; Troy Adams, PhD

Objective: To provide a compre-hensive review of published re-search on the application of thetranstheoretical model (TTM) tocancer screening behavior. Meth-ods: Studies were categorized bydesign, given an internal validityrating where appropriate, andrated. Results: Forty-two studieswere reviewed. Stage-matchedmammography interventionswere supported; however, the bodyof literature was of limited size.

Research on the TTM as it appliesto other cancer screenings issparse. Conclusions: Stage-of-change and decisional balanceappear to apply to mammography.More validation research is neededon the application of the TTM toall cancer screening behaviors.

Key words: transtheoreticalmodel, cancer screening, mammog-raphy, sun avoidance, colonoscopy,sigmoidoscopy, PSA

Am J Health Behav. 2005;29(l):36-56

The fundamental concept of thetranstheoretical model (TTM) is thatbehavior change is most successful

when specific behavioral strategies, calledprocesses-of-change, are applied at theright time, or during the appropriate stageof change.' Initially developed as an ap-proach to psychotherapy,^ this model wassoon applied to tobacco cessation and thento other health behaviors, including can-cer screening.-' The focus of this litera-ture review is the application of the TTMto cancer screening behavior.

It is through tobacco-related researchthat the model's primary constructs weredeveloped.'•^•'' Stage-of-change refers to asubject's readiness to either adopt ahealthful behavior or cease an unhealth-

Leslie Spencer, Associate Professor; FranciePagell, Assistant Professor, Department of Healthand Exercise Science, Rowan University,Glassboro, NJ. Troy Adams, Assistant Professor,Department of Exercise and Wellness, ArizonaState Uniuersity, Mesa, AZ.

Address correspondence to Dr Spencer, Depart-ment of Health and Exercise Science, Rowan Uni-versity, 201 MullicaHillRd., Glassboro, NJ 08028.E-mail: [email protected]

ful one.^ Rakowski et al*''' have exploredthe application of the stages of changeconstruct to mammography and identi-fied a unique set of stages, with timeframes that differ from those used in thetobacco studies. These stages are de-fined in Table 1.

Often, researchers refer to subjects inprecontemplation, contemplation, andpreparation as being in "early" stages andthose in action or maintenance as beingin "late" stages. This review did not iden-tify any published research in which thestage-of-change concept was tested for va-lidity for other cancer screening areas.

Processes-of-change refer to 10 behav-ioral strategies used to make a change.People in early stages tend to use theexperiential, or cognitive, processes tohelp them move forward. These includestrategies such as dramatic relief andself-reevaluation. Those in later stagestend to use behavioral processes, such ashelping relationships and stimulus con-trol, more frequently.* Decisional bal-ance is the pros, or benefits, of changingcompared to the cons, or barriers tochange.' Using the experiential pro-cesses-of-change, the cons will decreaseand pros will increase. Research has

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Stage

Table 1Rakowski et al̂ -'' Stage-of-change Definitions

Definition

Precontemplation

Relapse

Contemplation

Relapse Risk

Action

Maintenance

No previous mammogram and no plan to get one within the next "year or 2"

Has had previous mammogram more than 24 months prior, but no plan to get one withinthe next "year or 2"

No previous mammogram or no mammogram within the past 24 months, but plan to getone within the next "year or 2"

Has had previous mammogram within the past 24 months, but no plan to get one withinthe next "year or 2"

Has had first mammogram within the past 24 months and are planning to have anotherone within the next "year or 2"

Has had 2 or more mammograms on schedule (no more than 24 months apart) and areplanning to have another one within the next "year or 2"

Note. The following 2 stages are part of the Rakowski et al' original staging mechanism,but have rarely been used.

Provider'sRecommendation

Inconsistent/Early Action

Has had previous mammogram(s) on schedule, but only plans to have futuremammograms when her physician recommends one

Has had previous mammograms, but not on schedule. Intends to have anothermammogram within the next 24 months

suggested that as a person moves forwardinto preparation, the pros will outweighthe cons, preparing him or her for suc-cessful behavior change.'°

It would be a mistake for practitionersto assume that the TTM can be applied tocancer screening as it does to tobacco.Each TTM construct needs testing andvalidation with specific forms of cancerscreening, as its application to one formmay be different than to another form.Obtaining a cancer screening is a mark-edly different behavior than quitting smok-ing. Rakowski et al" identified the majordifferences as applied to mammography,but they apply to other cancer screeningsas well. Smoking is an addiction and isthe cessation of a continuous behavior.Cancer screening is the initiation of aperiodic, nonaddictive behavior. A smokeris aware of his or her habit daily; however,someone may not think about a cancerscreening for several months betweenscreenings. Smoking is a public behav-ior, whereas cancer screening is private.

A smoker could quit smoking on his orher own or through self-help materialsused in the home, but to have a cancerscreening, a person must use the healthcare system in most cases. One may quitsmoking to decrease the risk of cancer;having regular cancer screenings doesnot decrease the risk of having cancer,but increases the possibility of detectingit sooner.

ObjectiveThe purpose of this paper is to review,

synthesize, and critique the body of peer-reviewed, published research on cancerscreening behavior. A comprehensiveliterature search identified publishedcancer screening studies in the areas ofmammography, cervical cancer (Pap test-ing) , avoidance of and protection from sunexposure to prevent skin cancer, colorectalcancer, and genetic testing for breastcancer. The following research ques-tions are used to guide the analysis of theliterature:

Am J Health Behav.™ 2005;29(l):36-56 37

Cancer Screening Behavior

Table 2Criteria for Rating the Research Design of Individual Studies^

Type Description

Experimental Well designed controlled trial with random selection and assignment of subjects

Quasi-Experimental Well designed controlled trial without randomization

Pre-experimental Well designed cohort or case-control analytic study

Correlation/regression Multiple time series measures taken with or without intervention

Descriptive Expert opinion of individual or committee, case study, cross-sectional survey

a Source: adapted from Harris et al (2001)"

1. What evidence is there to supportthe validity of the stage-of-change, deci-sional balance, and processes-of-changeconstructs as applied to cancer screen-ing? What is the quality of this evidence?

2. To what populations has the TTMbeen applied for cancer screening behav-ior? How do TTM constructs describethese populations?

3. Does the evidence support the use ofstage-based interventions for cancerscreening?

METHODSThis paper is a review of the 42 original

research articles that were published inpeer-reviewed medical and health jour-nals prior to November 1, 2003, in thearea of cancer screening behavior.Medline, Psychlnfo, ERIC, Current Con-tents , Academic Search Premier,GenderWatch, and CINAHL-Allied Healthwere searched using combinations of thekeywords stage of change, readiness tochange, transtheoretical model, deci-sional balance, cancer screening, mam-mography, breast cancer, cervical can-cer. Pap testing, skin cancer, sun expo-sure, sun protection, prostate cancer,colon cancer and genetic testing.

Rating

Table 3Criteria for Rating the Internal Validity of Individual

Intervention Studies*

Description

GoodFairPoor

Meets criteria for internal validity identified belowDoes not meet all identified criteria, but there is no fatal flaw to invalidate resultsOne or more fatal flaws; results may not be valid

Significant threats to internal validity include a lack of any of the following:Initial assembly of comparable groups (elimination of confounding variables, randomization)Maintenance of groups throughout study (attrition, crossovers, adherence, contamination)Loss to follow-up analysis; intention-to-treat analysisReliability and validity of measuresClearly defmed interventionConsideration of all important outcomesAdjustment for confounding variables

a Source: Harris et al (2001)"

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Spencer et al

Table 4Criteria for Rating the Body of Literature^

Rating Description

Conclusive Many well designed experimental and quasi-experimental studies support a cause and effectrelationship between an intervention and outcome. Almost all experts are in agreement regardingthe validity of this relationship.

Acceptable Well designed experimental or quasi-experimental studies support a cause and effect relationshipbetween an intervention and outcome. Most experts support the validity of this relationship.

Indicative Many well designed studies that lack randomized control groups (ie, cohort or case studies)support a cause and effect relationship between an intervention and outcome. Most expertssupport the probability of the relationship, but they recognize the threats to intemal validity inmost of the studies.

Suggestive Several studies support a cause and effect relationship between an intervention and outcome,however they are not well designed and lack randomized control groups. Most experts supportthe probability of a causal relationship based on evidence in other, related areas. Significantintemal validity threats suggest that alternative explanations are possible.

Weak Studies supporting a cause and effect relationship between an intervention and outcome arepoorly designed, nonexperimental and/or lack proper operationalization. Most expertsrecognize that a causal relationship is possible; however, altemative explanations are equallylikely.

a Source: Anderson & O'Donneli (1994)"

Only studies that specifically addressedcancer screening, as opposed to cancertreatment or the primary prevention ofcancer, were included. Exceptions weremade for studies about sun avoidance/protection behavior. These articles wereincluded because the body of literature onthe TTM and skin cancer/sun avoidancewas very small, and they provided infor-mation relevant to this review.

To increase the validity of the findingsof this qualitative review, an attempt wasmade to systematically evaluate eachstudy and the collective body of literatureusing recognized and established criteriain the professional literature. The re-viewed studies were initially grouped ac-cording to their purpose as construct vali-dation, population (descriptive, cross-sec-tional studies), or intervention. The qual-ity of the population studies was assessedusing factors that are important in deter-mining the external validity of a cross-sectional study: sample size, sample se-lection (random vs nonrandom), responserate, use of measures that have beentested for validity, and recognition and

treatment of study limitations. Interven-tion studies were further categorized ac-cording to study design using categoriesdefmed in Table 2.'^

The interventions were also evaluatedand assigned an internal validity ratingby the authors of this study using previ-ously established criteria shown in Table

The body of intervention studies wasthen collectively rated according to thedegree to which they support stage-basedcancer screening interventions usingcriteria shown in Table 4.̂ ^

An additional evaluation was performedon the entire body of mammography lit-erature, as it was the only screening areafor which construct validation, interven-tion, and population studies were pub-lished (other screening areas lacked con-struct validation and/or interventionstudies). For mammography, an evalua-tion of the validity of applying select TTMconstructs was performed using criteriadeveloped by Spencer et al," based on thework of Messick'" and Anastassi,'^ shownin Table 5.



Table 5Criteria for Rating Construct Validity'

Theoretical derivation of the construct:

To what degree is the construct based on an already established theory?

Not at all Somewhat Strongly

Reliability of the construct:What is the test/retest reliability or intemal consistency of the construct?

Poor Fair Good

Analysis of group differences and changes over time:How many cross-sectional and time series studies have demonstrated differences in theoretically appropriatedirections?

None Fewer than 10 10 or more

Generalizability across contextsHow strong is the evidence that the construct can be used across populations and intervention conditions?

Weak Fair Strong

Comparison to rival theories:Do other constructs provide better explanations or results?

No Possibly Yes

a Source: Spencer et al''

RESULTSThe initial database search yielded 81

articles. Forty were excluded becausethey did not measure TTM constructsrelated to cancer screening, and 5 wereexcluded because they were commentar-ies. A manual search of reference listsyielded an additional 6 studies. Thisprocess resulted in 42 studies for inclu-sion in this review, 5 of which addressedmore than one type of cancer screeningbehavior.

Construct Validation StudiesConstruct validity refers to the testing

of a variable, such as stage-of-change ordecisional balance, to determine if it canaccurately and meaningfully be used todescribe a population and differentiateamong individuals. Almost all of the con-struct validation literature is in the areaof mammography.

Table 6 primarily features the researchof Rakowski and his colleagues as theyfirst explored the decisional balance con-

^''^'* briefly examined processes-of-change as they related to decisionalbalance,^ and created the most widelyused staging algorithm for mammogra-phy '̂̂ (Table 1).

Decisional balance has been the pri-mary focus of Rakowski et al's constructvalidation research. A 41-item pros andcons scale, based on the one used fortobacco, was created and tested throughprincipal component analysis and analy-sis of variance (ANOVA)). Using this scale,Rakowski et aP* found that pros increasedand cons decreased for subjects in laterstages. Next, the researchers createdshorter versions of the decisional bal-ance scale that they used with low-in-come, minority women^^ and members ofa health maintenance organization.^ Thiswas followed by the development of a deci-sional balance scale for mammographyand Pap testing combined'* and the ex-pansion of the scale to further exploredifferences among women in the earlystages. This research indicated that de-

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Spencer et al

Author

Rakowski"1992

Rakowski"1993b

Rakowski'1996a

Rakowski'*1997a

Rakowski'1997b

Table 6Construct Validation Studies of the

Purpose

Create adecisionalbalancemeasure forniamnxhgraphy

Determinewhether it ismammographyintention orbehavior thatis related todecisionalbalance amonglow-income,minoritywomen

Relatiotishipbetweendecisionatbalance,processes-of-change andstage of mam-mographyadoption(comparison ol2 algorithms)

Create adecisionalbalancemeasurefor bothscreeningmamnx>-graphy andobtaininga pap test

Mammography (in

Sample

N=142ConveniencesampleAge 40+

N=67677% responserateRandom sampleAvg. age 5760% white

N=1323 HMOmembere74% responserateRandom sampleAge 50-7495% white

N=1864n=1605 (86%)at follow-upConveniencesampleAge 40-74

simultaneously

Developmentof decisionalbalance scaleformammo-graphy thataccounts forgreaterdistinctionamongsubjectsin differentstages

N=8914 HMOmenibers82% responseraleRandom sampleAge 40-7395% white

StudyDesign

Subjects wererecruited at aworksite tocomplete a surveydesigned using asequential methodto achieve contentand internalvalidity.

Telephone surveyof residents in 5low-incotne,minority censustracks inRhode Island

Computer-assistedtelephone survey.

Telephone surveypreceded by coverletter at baselineand one year post-interventiondesigned toincrease regularmamiTW graphy

Computer-assistedtelephone surveywas used.

TTM as Applied tochronological order)

Measures

41-item pros andcons scale (de-cisional balance)Stage-of-change(precontemplation.contemplation.action.maintenance)

12-itemdecisionalbalance scaleIntention-basedstage-of-changescaleBehavior-basedstage-of-changescale usingaltemativecategories

9-item decisionalbalance scaleProcesses-of-change scale (4indices containing4-6 items each)Intention-basedstage-of-changeBehavior-basedstage-of-changescale

Decisionalbalance scalesfor mammo-graphy (13 items).pap testing(14 items), andboth combined(11 items)Frequency ofof obtainingmammogramsand pap tests

19-itemdecisionalbalance scaleStage-of-change(intention andbehaviorcombined)

AnalysisTechniques

PrincipalcomponentsanalysisANOVA

Analysis ofCovariance (co-variates were age.education, healthcare provider.health insurancecoverage, behaviorregarding Pap lest.clinical breastexam and breastself-exam)

ANOVA

ANOVA(Kruskal-Wallistest for nonpara-metric data)

Data set wasrandomly dividedinto 2 subsamples.Sample 1 used fora priori factoranalysis todevelop 2 prosand cons scales.Sample 2 used forstructuralequation modelingto test both scales.

Major Findings

Forward stage progressionled to higher pros scores andlower cons scores. Intentionto have a future mammogramwas more significant thanprevious inammography inrelation pros and consscores.

Both past mammographybehavior and intention tohave a future one predictfuture mammography behavior.Women who have beeninconsistent with previousmammography differed ftomwomen who consistently hadthem in their decisionatbalance scores.

Decisional balance andprocesses-of-change wererelated lo stage membership inIhe expected manner for bothstaging mechanisms. Thelonger staging mechanism wasnx>re sensitive in distinqus-hing between subjects.

Decisional balance appears toapply to Pap testing andmammography screening.Assessing bothsimultaneously is warranted.as compliance with one isrelated to the other.

yielded similar results.Subjects in precontemplationand relapse had the mostnegative decisional balance.subjects in relapse risk andcontemplation weremoderately negative, andthose in action or maintenancehad the most positive ratings.



cisional balance applies to mammogra-phy in an expected manner, with scoresbecoming progressively more positive forwomen in later stages.

Rakowski and his colleagues also stud-ied the stage-of-change construct as ap-plied to mammography. Initially, theyexplored the importance of intention tohave a future mammogram versus priormammography behavior in determiningstage membership.'^ Although intentionto have a future mammogram had aslightly stronger relationship with stagemembership than did prior mammogra-phy,'^ both intention and prior behaviorwere related to the receipt of a subse-quent mammogram,'^ In a second study,Rakowski et al'' evaluated 2 versions of astaging algorithm for mammography, onewith 8 stage categories based on previousbehavior and future intention and onewith 6 stage categories based only onprevious behavior. Although the 8-cat-egory measure was more sensitive indistinguishing among subjects, the au-thors recognized that in some settings,the shorter algorithm might be more con-venient to use. They recommended aprimary emphasis on future intention, asopposed to past behavior, in the algorithmand including the categories "relapserisk," "relapse," and "screening based onprovider's recommendation" (Table 1 fordefinitions).

Rakowski et al'' also addressed the in-ternal consistency (or reliability) of thedecisional balance measure. They re-ported a slightly lower than desiredCronbach's alpha reliability (.60) for thecons scale specifically, indicating thatthe barriers to mammography may bevery specific. Their work overall, though,demonstrated a consistent relationshipbetween the staging algorithms and deci-sional balance, as supported by severalstatistical measures, including principalcomponents analysis, ANOVA, and analy-sis of covariance.

One study examined processes-of-change in relation to stage membership.^As with other health behaviors, experien-tial processes were most often used bywomen in pre-action stages (includingrelapse), and behavioral processes wereused most often by women in action andmaintenance.

Population StudiesTable 7 includes a summary of the 24

cross-sectional studies that describe can-cer screening behavior using TTM con-structs.

Populations included employees, com-munity residents, and members of healthmaintenance organizations (HMO). Allbut 3 studies included only those age 40and older. In addition to white Americanpopulations, subjects were Swiss,^' Aus-tralian,^^ Canadian,^^ Cambodian Ameri-can,3^ and African American.̂ ''•̂ •̂̂ '•̂ ^

Generally, these studies were well de-signed, used random sampling, had largesample sizes and strong response rates,and adequately addressed their limita-tions. An important issue to consider inevaluating the quality of these studies isthe validity of the measures used to as-sess stage-of-change and decisional bal-ance. The measures used in these stud-ies fell into one of 4 categories. Twelvestudies used measures developed andtested by Rakowski et al'̂ '̂ ''̂ ''* to stagesubjects and/or calculate decisional bal-ance. Three studies used a staging algo-rithm based on the early work of Prochaskaet al^* with tobacco. One study used thestaging algorithm developed byDiClemente et aP that was based on re-search in tobacco use. Two studies usedmeasures that did not appear to be basedon prior research.

Two decisional balance studies sug-gested that the barriers to having a mam-mogram (ie, cons) may be much morespecific to women individually than arethe benefits (ie, pros)'''^" and that clini-cians should help patients in the earlystages to identify and overcome theirbarriers rather than just review the ben-efits of screening. The studies relatingthe TTM to the health belief model foundthat the perceived barriers, benefits, andsusceptibility vary among subjects in dif-ferent stages.''••'^ Brenes et al'^ also foundthat precontemplators and contemplatorswere different from relapsers, an impor-tant distinction contradicting the ideathat individuals in these 3 stages aresimilar in attitudes and behavior.

In general, the population studiesshowed that women who were less likelyto have regular mammograms were thosewho perceived themselves to be at lowrisk for breast cancer (even if their actualrisk was high), '̂'̂ '̂̂ '' smoked cigarettes,^^did not receive regular Pap tests or clini-cal breast exams,^^ were not encouragedby family and friends to have a mammo-

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Spencer et al

Population Studies of theAuthor Purpose Sample

Table 7TTM as Applied to Cancer Screening^TTM Measures

Mammo&raDhv and Cervical Cancer ScreenineBrenes"1999

Camp-bell™2000

Chamot^'2001

Cham-pion"1994

Kelaher"1999

Lipkus"1996

Mah"1997

Relationship betweenstage membership,health belief modelconstructs, knowledgeand attitudes formammography

Stage distribution forbreast and cervicalcancer screening andits relationship toliealtli status

Mammography stageof readiness anddecisional balance

Relationship betweenhealth and stageof mammographyadoption

Stage distribution forcervical cancerscreening

Relationship betweenobjective and sub-jective breast cancerrisk assessment andmammography screen-ing; ability of theseand/or decisional bal-ance to predict mammo-graphy stage

Relationship betweenintention to have amammogram, previousmammography behaviorand attitudes andbeliefs about mammo-graphy screening

N=361 urban com-munity members85% response rateRandom sampleAge 40+

N=859 manufact-uring workers70% response rateConveniencesampleAvg. age 3857% African-American

N=909 Swisswomen71% response rateRandom sampleAvg. age 56

N=40441% response rateRandom sampleAge 40+91% white

N=178 AustralianwomenResponse rateundeterminable

Stage-of-change(adaptation ofRakowski et al'with differenttime frame)

Stage-of-change(combinedRakowski et al'and DiClementeet al')

Stage-of-change(Rakowski et al')Decisional Balance(10-items, based onRakowski et al '")

Stage-of-change(Precontemplation,Contemplation,Action/Maintenanceadapted fromRakowski et al')

Stage-of-change(adapted fromRakowski et al')

Convenience sample65% over age 40

N=36457% retained forfollow-up surveyRandom sampleAvg. age 5883% white

N=1211 Canadians78% response rateRandom sampleAge 40-75

Decisional balance(5-items and14-item, based onRakowski et al '")Stage-of-change(Rakowski et al')

Stage-of-change(3 stages: screeners.intenders.nonparticipants)

Conclusions

Health belief model constructs differed among womenaccording to stage, except for perceived seriousness ofbreast cancer. Precontemplators and contemplatorsdiffered from relapsers in many areas, including barriers.knowledge, efficacy and avoidance.

Subjects had poorer health risks than those in the generalpopulation. Women in later stages of mammography weremost interested in quitting smoking and women in laterstages of Pap testing were most interested in dietarychange. Those in earlier stages for both were mostinterested in exercise.

Stage-of-change and decisional balance apply to a Swisspopulation as they do a US population. Low-incomewomen were more often in earlier stages. Cost was citedas a major barrier for contemplators and relapsers.Precontemplators and relapsers were least likely to knowthe benefits of regular mammography.

Subjects in action/maintenance perceived highersusceptibility and seriousness, fewer barTiers and greaterbenefits. Precontemplators were most affected bymammography banners.

Stage was not related to ethnicity, marital status orEnglish proficiency. Stage was positively related to age.decisional balance and knowledge. Women who were incontemplation, action, and maintenance had more prosand fewer cons than those in precontemplation andrelapse/relapse risk.

Subjective risk and objective risk were positivelyassociated, although the relationship between the twowas not strong. Although objective risk, subjective riskand decisional balance all predicted stage membership.subjective risk was most predictive.

Noncompliant women may face barriers that compliantwomen do not face, including support from family/friendsto obtain a mammogram, knowing someone who has hadbreast cancer, encouragement from a physician, receipt ofstage-based educational materials and living near amammography center.

(continued on next 3 pages)



Table 7 (continued)Population Studies of the

Author Purpose Sample

TTM as Applied to Cancer Screening^TTM Measures

MammocraDhv and Cervical Cancer ScreeningPartin-'2003

Pearl-man"1997

Pearl-man-*1996

Pearl-man^'1995

Rakow-ski"1993a

Rimer"1996

Skinner"1998

Identification of stagemembership andbarriers to repealmammography afterinitial screening

Relationship betweendecisional balanceand mammographyover one year

Identification of factorsthat influence mamnw)-graphy stage of adop-tion for white, AfricanAmerican and Hispanicwomen, particularly forthose who are notscreened regularly

Relationship betweensocial influences andstage of readiness formammography

Stage distribution formammographyscreening in a large.national satnplepopulation

Determine predictorsof mammo graphy.clinical breast examand Pap testingamong low-incomewomen

Determine relationshipbetween health beliefmodel constructs(benefits and barriers)and stage-of-change

N=854 low-incomewomen receivingfree federally-funded screening83% response rateRandom sampleage 50+95% white

N=114474% response rateRandom satnpleAge 50-74

N=8965n 1=7163 whiten2=1320 AfricanAniericann3=482 HispanicAge 40-75Secondary analysisof 1990NHIS-HPDP data

N=I324 HMOmembers74% response rateRandom selectionAge 50-74

N=9107Secondaryanalysis of1990 NHIS-HPDP dataAge 40-75

N=926 low-income women71% response rateRandom sampleAge 18-8080% AfncanAmerican

N=1093universityemployees51% response rateconvenience sampleage 40+85% white

Stage-of-change(Rakowski et aF)

Decisional balance(13-items, basedon Rakowskiet al")

Stage-of-change(Rakowski et al')


Stage-of-change(early version ofRakowski et al')

Decisional balance(9-item measure forboth mammographyand Pap testing)

Stage-of-change(adapted fromProchaska et aP')

Conclusions

42% of subjects were in maintenance, 36% were incontemplation, 18% were in action and 4% were inrelapse/relapse risk. PAR analysis revealed that nothaving time, not receiving a reminder, and being unclearon repeat mammography guidehnes had the greatestassociation with not repeating mammography screening.The authors contend that, although staging subjects isuseful, stage-based interventions alone may not lead tosuccessful outcomes.

Subjects who became less favorable toward mammogramsover one year (20%) were more likely to smoke cigarettes.not obtain Pap tests or clinical breast exams, bediscouraged from friends or family members from having amammogram, and have limited social support.

Controlling for SES and other demographic factors, racewas a signiflcant factor in stage membership. Least likelyto receive regular mammograms were Hispanic wotnenwho lived in the south and white women who lived inrural areas, smoked cigarettes or were older than 50. Nobarders were unique to African American women.

Simply receiving information about mammography wasnot signiflcantly predictive of having one; rather, thecombination of receiving information and sharing it withothers predicted mammography stage-ofchange. Under-users were less likely than compliant subjects to valueinformation from friends/family or physicians aboutmammography.

Stage distribution: 29% no intention, 18% relapse risk.24% contemplation, 27% screened/ plan to continueFactors related to earlier stages: African American,Hispanic, irregular clinical breast exams and Pap tests.no established physician, smoking, mobile home/trailerpark, living outside of the western United States, morethan 3 people in home.

A majority of subjects consistently received exams/screenings. Decisional balance related strongly toscreening/exam behavior. Cons included lack ofinsurance, advanced age, lower education level andmisconceptions about the screenings/exams.

Seventy-eight percent of subjects were in action/maintenance; 13% were in relapse. Most common barriersto mammography were physical discomfort (45%), cost(36%) and inconvenience (34%). Barriers tomammography were significantly higher for women inprecontemplation, contemplation and relapse than forwomen in action/maintenance. Beneflts of mammography(such as early detection of a breast lump) weresigniflcantly higher for women in action/maintenance thanfor women in earlier stages.

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Spencer et al


Author Purpose Sample

TTM as Applied to Cancer Screening"TTM Measures

Mammoeraphv and Cervical Cancer ScreenineSkinner"1997

Stod-dard"1998

Tu"2002

Determine stage-of-change, knowledgeand attitudes abouttnamniography

Identify characteristicsof women who donot obtain regularmanmx) grams

Identify stagemembership formammography andclinical breast exam

Sun Avoidance/ProtectionHerrick"1997

Kristjan-sson^'2001

Wein-stock"2000

Differences in self-efficacy and decisionalbalance across thestages of change forsun exposure amonga worksite population

Readiness to changesun protectivebehavior amongbeach-goers andparticipants in amobile cancerscreening

Idenlify factorsassociated with stagemembership for sunprotective behavior

N=253 urban-dwellers85% response rateconvenience sampleAvg. age 7388% AfricanAmerican

N= 11,292 womendrawn from 5breast cancerscreening studies77-90% responseratesRandom sampleAge 50-80

N=413Cambodian-Americans73% response ratecomputer-assistedidentification ofeligible subjectsvia telephonedirectoriesAvg. age 45

N=76052% response rate:nl=186 wellnessparticipantsn2=207comparison groupConvenience sample64% male85% white

N=944 Swedishadults1=742 cancerscreeningparticipantsn2=202 beachgoersResponse rateundeterminableConvenience sample62% female

N=2324 beach-goers in summer83% response rateconvenience sample60% female35% aged16-24 years

Stage-of-change(adapted fromProchaska et aP')


Stage-of-changeforboth mammo-graphy and Paptesting (Prochaskaet aP")

Stage-of-change(DiClemente et al')

Stage of change(adapted fromDiClemente et al')

Stage-of-change(adapted fromDiClemente et aPbut with 12-monthtime frames)

Conclusions

Fifty-one percent of subjects were in action, 32% were inprecontemplation and 17% were in contemplation. Thosein action and contemplation had more positive attitudesand knowledge than those in precontemplation.Contemplators had more fears about mammography thandid those in action.

Subjects in action were more likely than those in earlierstages to be in an HMO, have more education, beetnployed, be white (non-Hispanic), be younger, have apositive decisional balance, and have had a clinical breastexam and/or a recommendation for a mammogram by aphysician.

Mammography stage distribution: 33% precontemplation/contemplation, 26% relapse, 18% action, 23% maintenance.CBE stage distribution: 29% precontemplation/contemplation, 23% relapse, 22% action, 26%maintenance.Subjects with male Asian-American physicians were leastlikely to obtain regular screenings, possibly due toculttiral differences in the way medical care is offered inthe Asian community compared to American practices.

Wellness participants did not differ significantly fromnonparticipants in stage. Pros and self-efficacy increasedas stage increased. Emphasizing pros and building self-efficacy are most important in earlier stages, whereasdecreasing the cons is most helpful in preparation andaction.

Participants in the cancer screening were more likely thanthose on the beach to be in action/maintenance for sunprotective behaviors.

Stage distribution for sun protective behavior: 45%precontemplation, 3% contemplation, 14% preparation, 4%action, 34% maintenance. Stage distribution for use ofsunscreen: 56% precontemplation, 3% contemplation.10% preparation, 5% action, 26% maintenance. Beingolder, female, and sun sensitive (ie, skin type) were moststrongly related to advanced stage membership.

Am J Health Behav.™ 2005;29(l):36-S6 45



Author Purpose

Genetic Testine for BreastJacob- Relationship betweensen-" stage of readiness1997 and decisional balance

concerning genetictesting for breastcancer anwng at-riskwomen

Sample

CancerN=74 females withone or more 1""degree relativeswith breast cancer79% response rate

TTM as Applied to Cancer ScreeningsTTM Measures

Stage-of-change(developed ownstages, no timeflames)Decisional balance

Convenience sample (21 items)Avg. age 4493% white

Colorectal Cancer ScreeningTrauth" Identify stage2003 membership for

colorectal cancerscreening (fecaloccult blood testand flexible sigmoid-oscopy)

Multiple Cancer ScreeningNigg" Stage distribution1999 among older adults as

compared to youngeradults for sunscreenuse, sun avoidanceand cancer screeningbehavior

Prochas Stage distribution and-ka'" relationship to de-1994 cisional balance for

12 behaviors, includ-ing mammography andsunscreen use, amongan adult population

N=1223 adults incommunity45% response rateRandom samplestratified by age.location90% white58% femaleAged 50-79

BehaviorsN=19,266 HMOmembersResponse rate 80%Random sampleAge 18+53-60% female

N=227 sunscreenuse subjects (62%female, 99% white)N=141 mammo-graphy subjectsage 40+Convenience sampl

Stage-of-change(similar toRakowski et al'.addes "unaware"stage)

Stage-of-change(DiClemente et al')

Stage-of-change(DiClemente et al')Decisional balance

Conclusions

Forty-six percent of subjects planned to seek genetictesting as soon as possible, 35% planned to seek it in thefuture, and 19% did not plan to seek it. Pros of testingincluded discussing testing and preventive surgery withrelatives, motivation to perform breast self-exam and havemammograms, and peace of mind. Cons included increasedworry if subject carried the gene.

Stage, fecal occult blood test: 14% unaware, 19%precontemplation, 17% contemplation, 18% relapsed, 14%relapse risk, 18% maintenance. Stage, sigmoid-oscopy:49% unaware, 21% precontemplation, 11%contemplation, 6% relapsed, 8% relapse risk, 5%maintenance. Given the high number of subjects whowere unaware of the tests and/or were unwilling to obtainthem, interventions to increase awareness and overcomebaniers are warranted.

Older subjects (>54 years) tended to be inprecontemplation for sunscreen use, maintenance for safesun behavior, and maintenance for perfonning cancer self-exams.

This study supported the generalizability of both stages ofchange and decisional balance to 12 health behaviors.including mammography screening and sunscreen use.Pros increased and cons decreased in a progressive andpredictable pattern through the stages.

a Where demographic data is not reported, it was not provided in the study under review.

g were not aware of mammogra-phy screening recommendations,^' werenot encouraged by their physician to havea mammogram,^^ did not live near a mam-mography screening site,^^ did not en-courage other women to havemammograms,^^ perceived a lack oftime,^* were not reminded by their healthprovider to schedule a mammogram,^^lacked health insurance,^' or were His-panic or African American.^*

Three studies specifically addressedPap testing.^"'^^'^' One of the Americansamples,^" all blue-collar workers, wasmore likely to be in precontemplation orcontemplation and had multiple healthrisks. In the second American sample,^'

decisional balance and health insurancecoverage were primary predictors of ob-taining a Pap test. Among the Australiansample,2^ those most likely to receiveregular Pap tests had a higher decisionalbalance score and greater knowledgeabout cervical cancer, and they receivedencouragement from their physicians tohave the test.

Five studies addressed the applicationof the TTM to skin cancer. Two specialpopulations surveyed regarding sun be-havior were blue-collar women^^ and olderadults."" Athough older adults were morelikely to protect themselves from the sun,blue-collar women were most often inprecontemplation or contemplation for sun

46

Spencer et al

exposure.Two additional studies, one addressing

the application of the TTM to fecal occultblood screening and one genetic testingfor breast cancer, were also found. Thesummaries of these studies are found inTable 7 and are not repeated here.

Intervention StudiesOf the 13 intervention studies in Table

8, 9 were for mammography and 4 were forsun avoidance/protection. No interven-tions were found in other cancer screen-ing areas.

All mammography interventions usedeither experimental (n=7) or quasi-ex-perimental (n=2) designs with good (n=6)or fair (n=3) internal validity. Four"''"̂ ''"*'5oused stage-of-change and/or decisionalbalance measures developed by Rakowskiet al̂ '̂ ''̂ '̂ ^ specifically for mammography;one"* used the measure developed byDiClemente et ai^ for tobacco use; and theremaining four" '̂"'*'''̂ ''''' used measures notpreviously published.

Of the 9 mammography studies, 8 com-pared stage-matched and standardizedinterventions. Seven of the 8 studiesshowed significantly positive results us-ing stage-matched interventions, particu-larly with underutilizers''^ and AfricanAmerican and low-income women,"* andprecontemplators."^ One well designedexperimental study suggested that thestage-matched intervention was not sig-nificantly more effective than the stan-dard intervention for obtaining a repeatmammography."^ One quasi-experimen-tal study^° comparing 2 levels of an inter-vention with a control group found fewdifferences in mammography screeningrates at follow-up; however, the study hadseveral limitations, including the factthat 70% of subjects were not due for amammogram during the study period.The non-stage-based intervention studyidentified telephone counseling (as com-pared to receipt of print materials) to bemore effective in promoting repeat mam-mography among contemplators.""

Four interventions addressed sun avoid-ance/protection behavior, 2 using ex-perimental designs and 2 usingpreexperimental designs. Two used stag-ing mechanisms adapted from the onedeveloped for tobacco,^ and 2 staged sub-jects using measures that were not previ-ously published^' or defmed.̂ ^ Three werestage-matched interventions.

In a large (n=2324), well designed, ex-perimental study of sunbathers ,Weinstock et aP^ demonstrated signifi-cant positive outcomes using a multi-component, stage-based intervention.Three things were noteworthy from thisstudy. First, the intervention effect wasnot only maintained, but it also increasedfrom the 12-month to the 24-month fol-low-up, with greater numbers of treat-ment subjects moving into the actionstage. Second, the majority (56%) of thepopulation was in precontemplation atbaseline, with only 18% in contempla-tion, preparation, or action. Populationswith such a low readiness to change maybe the hardest to motivate, yet 36% ofthese subjects moved forward in stage.Third, the intervention was most effec-tive with young subjects (age 16-24), anage group that may be considered particu-larly hard to reach. Mermelstein et al̂ ^tested a well designed, experimental stage-matched intervention with 2935 highschool students and did not find supportfor this type of intervention with highschool stuclents. An unexpected resultwas that more students receiving thestandard intervention (20%) than thestage-matched intervention (13%) indi-cated using sunscreen postintervention.Using a preexperimental design (ie, nocomparison group), Robinson et al̂ " pre-sented data on 1042 nonmelanoma skincancer patients who received brief, stage-based counseling and were followed forone year to observe changes in their sunprotection behavior after surgery. Sixty-two percent progressed at least one stagein one year. The greatest barrier tochange was the belief that having a tanenhanced their appearance and feeling ofwell-being.

CONCLUSIONSThe research questions guiding this

review are used to discuss the literature.1. What evidence is there to support

the validity of the stages of change, deci-sional balance, and processes-of-changeconstructs as applied to cancer screen-ing? What is the quality of this evidence?

The criteria in Table 5 were used toevaluate the construct validity of the TTMas applied to mammography. Spencer etal" discussed in depth the first 2 criteria,the founding of a construct on previouslyestablished theory and reliability of theconstruct, in their review of the TTM as it



Table 8Mammography and Sun Avoidance/Protection Interventions

Author/Rating

Based

Purpose

on and/or Evaluated using

Sample

MammoeraDhv InterventionsChampion"2003

ExperimentalGood

Clark"2002

ExperimentalGood

Davis"1997

Experimental

Fair

Comparison of5 theory-basedinterventionson obtaininga mammogram

Effect of stage-matchededucationon obtaininga repeatmammogram

Comparison of3 non-stage-based intervent-ions on stagemembershipand receipt ofmammography

N=773 non-adherent tomammographyguidelinesNl=631 HMOpatients23% AfricanAmericanN2=142 clinicpatients61% AfricanAmerican

Avg. age 61-6430% lost tofollow-up

N=1026 femaleHMO membersN=026at 14-month follow-upAge 50-74

N=395 HMOmembers aged50+, non-adherent tomammographyguidelines

nl=133n2=I31n3=131loss to follow-up specifiedfor n3 only(n3=93)

StudyDesign

Random assignmentto usual care or oneof 5 interventionsbased on the TTMand health beliefmodel. Telephoneor in-person base-line and post-inter-vention interviewswere conducted.Medical recordswere analyzed at 2,4, and 6 months postintervention to determine mammographyresults.

Random assignmentto staged-matchedor control intervent-ion after mammogram.Review ofmedicalrecords at 14 monthsto determine if repeatmammogTam wasobtained.

Random selectionand assignment tousual care or oneof two interventions.Baseline and 6-nwnth follow-uptelephone interviewand medical recordreviews wereconducted.

TIMConstructsMeasured

Stage-of-change{Precontempla-tion, Contemplation. Action -intention only)

Stage-of-change

Stage of Change

Intervention

Five interventionsincluded stage-based phonecounseling, stage-based in-personcounseling, stage-based phonecounseling plusphysician letter.stage-based in-person counselingplus physicianletter, physicianletter. All coun-seling was offeredby trained nurses.Physician letterwas not stagebased.

Subjects were(Rakowski et al') assigned to one

Stage-of-change(Precontenp-lation.Contemplation -no time framesused)

of 3 intervent-ions: standardcare (no educ-cation), standardnontailored)educationalmaterials.tailored educa-tional materials.Educationalmaterials weremailed to thehome aftertelephoneinterview.

Three intervent-ions includedannual birthdaycard reminder(usual care).birthday cardplus a physicianletter and edu-cational mater-ials, and birthdaycard plus tele-phone counselingby trained nurses.None werestage matched.

Conclusions

All 5 interventions weremore effective than usualcare in promoting forwardstage movement. Both in-person and telephonecounseling combined withphysician letter were themost effective intervention.The intervention was moreeffective with the HMOpopulation than withmedical clinic patients. Theinterventions had thegreatest effect onprecontemplators.

Both standard education andstage-matched educationwere more likely than noeducation to result in arepeat mammogram.

Contemplators receiving thephone intervention weresignificantly more likely toreceive a mammogram thanthose receiving the other 2interventions. This wasnot true for precontemp-lators. The phone intervent-ion focused on reduction ofbarriers, which was mosthelpful for conten^ilators.

(continued on next 3 pages)

48

Spencer et al

Table 8 (continued)Mammography and Sun Avoidance/Protection Interventions

Author/Rating

Based on and/or Evaluated using Stage of Change

Purpose Sample

MammoeraDhv InterventionsLipkus"2000

Experimental

Fair

Rakowski"1998

ExperimentalGood

Rimer"2001

ExperimentalGood

Skinner"1994

ExperimentalGood

Comparison ofusual care andtwo stage-matched inter-ventions on re-ceipt of mammo-graphy

Conparison ofstage-matchedand standardmammographyeducation

Comparison ofusual care and2 stage-matchedinterventions onmammographybehavior, know-ledge, attitudes.and satisfactionwith mammo-graphy-relatedchoices

Effect of stage-matched postalletters onmammographystage ofreadiness

N=1099 HMOmen^rs aged50-t-, nonad-herent tomammographyguidelines

nl=362n2=366n3=3715% loss tofollow-up over3 years

N-1864 femaleHMO membersn=1397subjects atfollow-up94% white50% age 50-64

N=1287insurance planmembers aged40+ whocompleted 12-month inter-vention 4%loss tofollow-up85% white

N=497 femalepatients 13%lost tofollow-up84% white53% age 40-49

StudyDesign

Random assign-ment to usualcare or one of2 stage-matchedinterventions last-ing 3 years. Base-line and follow-upinterviews con-ducted at 1, 2, and3 years.

Random selectionand assignment tostage-matched andcontrol interven-tions. Baselineand follow-upsurveys conducted.

Random selection{stratified by ageand mammographyadherence) andassignment to usualcare or one of 2stage-matched inter-ventions.Baseline and 12-month follow-uptelephone interviewwere conducted.

Random selectionand assignnient tostage-matched orcontrol interven-tion. Baseline andfollow-up surveysconducted.


Did not measureStage-of-change;rather, intentionto receive amanmiogramwithin 3 months(yes/no) wasmeasured


Stage-of-change(8 stages - nodefinitionsprovided)

Stage-of-change(6 stages.adapted fromDiClementeet al")

Intervention

Three intervent-ions includedusual care (series)of reminder letters).stage-matchedmailed materials.stage-matchedcomputer-assistedtelephone coun-seling offered bytrained staff (2calls in 2 years)

Subjects dividedinto 3 groups: Noeducational mat-erials, standardmaterials, stage-based materials.Materials weremailed twice tostandard andstage-based groups

Three groups in-cluded usual care(reminder letter.physician re-minders), stage-matched printbooklet, stage-matched printbooklet plustelephone coun-seling (one call).

Stage membershipwas initially de-termined. Oneletter from thephysician wasthen mailed tothe home. Letterscontained eitherstandard adviceor stage-matchedadvice.

Conclusions

Telephone counseling wasmost effective in promotingmammography adherence.followed by print materialsand then usual care.Significant differences werefound, supporting the useof stage-matched telephonecounsehng as the firstchoice amonginterventions.

Support for use of stage-matched interventions.especially with under-screened population.

At baseline, 55% of subjectswere in action ormaintenance. Subjectsreceiving the stage-matchedbooklet and phonecounseling were mostknowledgeable about breastcancer, had the mostaccurate perception ofpersonal risk, and were rrx)stlikely to have received amammogram (69%) at 12months.

Stage-matched, mailedintervention was moreeffective, especially withAfrican American and low-income women.




Author/Rating


Purpose Sample

MammoeraDhv InterventionsCrane"2000

Quasi-experimental

Good

Crane'"1998

Quasi-experimentalFair

Comparison ofstage-matchedsingle and mul-tiple telephonecall intervent-ions on mammo-graphy

Effect of a tele-phone-basedintervention onstage of mammo-graphy adoptionamong low-income women

N=l l l l low-income.minority wo-men receivingmultiple callinterventionn=783 at 6-mo-nth follow-upnc=2212 sin-gle call recipi-ents from pre-vious study80% white

N=3O8O low-income femalesn=2310 at 6-month follow-up n=I878 at2-year follow-up 78% whiteAge 50+

Sun Avoidance/Proteetion InterventionsMemiel-stein"2002

ExperimentalGood

Comparison ofnon-stage-ma-tched and stage-matched inter-vention on sun-screen use

N=2935 highschoolstudents

minimal loss tofollow-up in-ferred (nonre-ported)80% white

StudyDesign

Subjects were soli-cited in person at ashopping center toanswer a baselinesurvey. Subjectsnot in action ormaintenance formammographyreceived up to 5follow-up telephonecalls in which brief.stage-based coun-seling was offered.They were comparedto subjects from aprevious, single-callintervention thatwas offered with andwithout an advancepostcard.

Random assignmentto stage-matched orcontrol intervention.Baseline and follow-up surveys conduct-ed.

Ten high schoolswere randomly ass-igned to either astandard or stage-matched conditiondelivered in healtheducation classes.Baseline and 12-month follow-upsurveys wereadministered.

TTMConstructsMeasured

Stage-of-change(Rakowski et al')Decisionalbalance (13-items, adaptedfrom Rakowskiet al '")

Stage-of-change(Rakowski et al')Decisional bal-ance (14 items.adapted fromRakowskiet al '")

Stage-of-change(Precontemp-lation, Contemplation. Action -no time frames)

Intervention

14- to 18-minutetelephone coun-seling sessionswere offered bytrained educatorsto encourage for-ward stage move-ment and schedul-ing and receipt ofa mammogram.

Subjects receivedone of 3 interven-tions: telephonecall with standardcounseling, tele-phone call withstage-based coun-seling, telephonecall with stage-based counselingpreceded by post-card with stage-based advice.

Schools were ass-igned to one of 2groups: standard-condition (oneclass lesson inskin cancer risksand sun protect-ion) or stage-mat-ched condition(one class lessonplus a personaliz-ed risk assessmentand periodic news-letters). All sub-jects received acoupon for freesunscreen, the re-demption of whichwas used to assesssunscreen use.

Conclusions

Multiple telephone callswere more effective thansingle calls (with andwithout the advancepostcard) in promotingreceipt of mammography.forward stage movement.and a shift toward morepositive decisional balancescores. They were also themost cost-effectiveintervention. Althoughthe authors attempted tocontrol for counfounders.some ofthe differencesbetween interventions maybe due to these.

No suppon for stage-matched intervention;however, study hadlimitations and resultsshould be cautiouslyinterpreted.

20% of subjects in thestandard condition and 13%in the stage-matchedcondition redeemed theircoupons for free sunscreen.Subjects rettuning couponswere significantly morelikely to report usingsunscreen.Postintervention interviewswith a subset of subjectsindicated that studentsliked the intervention andreceiving something for free.yet did not perceivethemselves at risk for skincancer or "forgot" to usesunscreen. Adolescents tiiaynot respond to stage-matchedmatched interventions in thesame way that adults do.

50

Spencer et al


Author/Rating


Purpose Sample

Sun Avoidance/Protection InterventionsWein-stock"2002

ExperimentalGood

Glanz"1998

Pre-experimentalGood

Robinson^*1990

Pre-experimental(N/A)

Effect of stage-matched educa-tion on sunavoidance/protection

Evaluation of anon-stage-basedintervention(SunSmart) onstage-of-changeand related sunprotection beh-aviors for child-ren aged 6-8

Receipt of sunation and use ofsun protectionamong adultswith nonmela-noma skincancer

N=2324beachgoersn=1629 at 12month follow-up n=145O at24 monthfollow-upAge 16-6594% white60% female

Nl=156parentsn=113 atfollow-upN2=45 recrea-tion staffn=41 atfollow-upconveniencesample all sub-jects lived/worked inHawaii

N=1592 adultpatientsn=1042 atfollow-up51% male46% age 51-65Ethnicity notreported

StudyDesign

Sunbathers appro-ached on the beachand volunteered toparticipate. Ratidomassignment to stage-matched interventionor control group.Baseline and follow-up surveys (12 and24 months)conducted.

Subjects fi-om 5 re-creation sites withswimming poolsvolunteered tocomplete a baselineand 4-week, post-intervention follow-up written survey.

Subjects volun-teered to complet-ed consultation,survey, andfollow-up up visitswith the clinician at2 weeks, 6 monthsatid one yearposts urgery.Stage-based educat-tion provided ateach visit.


Stage-of-change(adapted fromDiClementeet al')

Stage-of-change(measure notspecified)

Stage-of-change(adapted fromDiClementeet al')

Intervention

Intervention sub-jects receivedwritten education.brief on-site coun-seling and a perso-nal, on-site sun da-mage photo, foll-owed by mailedtailored materialsat 3 weeks and 12months. Controlsubjects receivedno intervention.

Intervention in-cluded free sun-screen, print ma-terials for childrenand their parents.policy change andon-site trainingfor recreationstaff.

Brief, stage-basedcounseling andprint materialswere provided onday of surgeryand at follow-upoffice visits.

Conclusions

Strong support for stage-matched intervention withlong-term (24 month)impact, especially amongyounger subjects (age 16-24) and those with a lowreadiness to change atbaseline.

A significant number ofchildren, parents and staffreported making positivechanges in sun protectionknowledge and behavior.Forward stage progressionwas evident for all 3 groups.

Sixty-two percent ofsubjects increased their useof sun protection duringthe duration of the study.

applied to tobacco use. They maintainthat the TTM and its constructs are builtupon elements from the health beliefmodel and social/cognitive theory, par-ticularly the concept of self-efficacy. Inaddition, the decision-making model de-veloped by Janis and Mann was the foun-dat±Dn of deaisi3nalbatoioe?'^''° Internalconsistency reliability^ has been exploredfor a decisional balance scale as applied tomammography, with less than desirableresults for the cons index. The third crite-rion, analysis of changes over time or

differences in subjects in an expecteddirection, is supported by the mammogra-phy literature. Although the number ofstudies supporting this is not extensive,they are well designed and offer supportfor TTM-based interventions.Generalizibility of the construct acrosspopulations and intervention types is thefourth criterion. The literature can becharacterized as weak in this area, giventhe small number of studies on nonwhiteAmerican populations (n=3) and popula-tions outside of the tJnited States (n=3).



although a variety of strategies have beenused in the interventions.

The fifth criterion is an evaluation ofalternative theories that might betteraccount for the results of a study. Al-though this idea was not explored in themammography literature, it has been thesubject of debate surrounding the TTM asit applies to tobacco cessation and exer-cise adherence. The debate has centeredprimarily on the concept of staging andwhether discreet, categorical stages ex-ist for a given behavior. Opponents arguethat, in a true stage theory, the stagesmust not overlap, clear differences mustexist between subjects in each stage, andsubjects should progress through eachstage in order.^^ In the areas of tobaccoand exercise, evidence suggests that in-stead of moving from one discrete stage tothe next, individuals move along a con-tinuum of change that allows for greatersensitivity in measuring change as theindividual progresses.^*'^* Norman et al '̂'̂ °have explored the existence of subtypeswithin the pre-action stages and suggestthat further differentiation among indi-viduals in early stages would better de-scribe them and possibly lead to moreeffective stage-matched interventions.Despite these criticisms. Spencer et al''found the TTM constructs to demonstrategood construct validity as applied to to-bacco. It is premature to make this judg-ment about the mammography litera-ture.

Measures of stage membership anddecisional balance have been developedand tested for validity and internal con-sistency reliability in the area of mam-mography, but not in other cancer screen-ing areas. A majority of the mammogra-phy studies have used measures devel-oped and tested by Rakowski et al.^''

The staging of subjects for mammogra-phy screening is quite different than fortobacco cessation. Preparation does notappear to be a discernible stage, but re-lapse and relapse risk are. Women inrelapse, although they have previouslyhad one or more mammograms, may havemore negative attitudes and perceptionsabout having another mammogram thanwomen who are in precontemplation orcontemplation for having their first mam-mogram.*'''

Staging women for mammography hasalso been difficult because of variationsin recommendations from the American

Cancer Society (ACS) and US PreventiveServices Task Force (USPSTF) guidelinesthat are used by the National CancerInstitute.*"'*" Both groups have changedtheir guidelines over the past 2 decadesas more has been learned about mam-mography, and both groups have slightlydifferent guidelines at the present time.Currently, the ACS recommends a mam-mogram each year for women age 40 andolder,*'' whereas the USPSTF recommendsa mammogram once every year or 2 forwomen age 40 and older.*"* An importantaspect of staging is intention to perform abehavior within a specified length of time.Depending on which guidelines one uses,a woman who had a first mammogram 18months prior could either be in action orrelapse.

No formal decisional balance scale hasbeen validated for any cancer screeningother than mammography. Most of themammography studies addressed the con-cept of pros and cons or barriers to screen-ing, either using the Rakowski et aP'^scale or one created by the authors thathad not been tested for construct validity.All of the mammography studies showedan increase in pros and a decrease incons as stage progressed. Prochaska etaP° suggested that the crossover point inwhich the pros are higher than the consoccurs just before the action stage; how-ever, they did not use a staging mecha-nism that was specific to mammography.

Processes-of-change for mammographywere specifically addressed in 2 studiesincluded in this review.*'"** These studiesidentified one behavioral process, "com-mitment to having a mammogram", and 2experiential ones, "thinking beyond one-self and "seeking information/openness/communication with others," for mam-mography screening. The identificationof these concepts as processes-of-changeis questionable, though, as they differfrom Prochaska et al's definition of theprocesses-of-change.* Processes-of-change, as defined by Prochaska and col-leagues, are complex mental and physi-cal activities performed by an individualthat facilitate therapeutic change andcan be used in an intervention. Thosedescribed for mammography appear to beattitudes or actions that might resultfrom an intervention rather than themental and physical activities throughwhich change occurs.

In general, the evidence supporting

52

Spencer et al

the construct validity of the TTM as ap-plied to mammography, as assessed bythe criteria in Table 5, is limited. Cur-rently, there is a small body of high qual-ity research supporting it, but replicationof this work is warranted. TTM con-structs need to be applied to a more di-verse group of subjects, a greater varietyof stage-based interventions need to beevaluated, and the stage-of-change algo-rithm should continue to be refined toimprove the construct validity of the TTMfor mammography.

2. To what populations has the TTMbeen applied for cancer screening behav-ior? How do TTM constructs describethese populations?

The majority of the population studies(n=18) were on mammography, and thefocus in this section will be on thesestudies. Given the small number of stud-ies addressing sun avoidance/protection,cervical cancer, colorectal cancer, andgenetic testing, summative statementsabout these areas are not warranted. It isnotable that all but 6 of the populationstudies used white, middle-class Ameri-can populations.

Almost all of the population mammog-raphy studies focused on decisional bal-ance or related measures that providedfor the identification of barriers and ben-efits to screening. Specific barriers arelisted in the results section of this paperand are not repeated here. It is importantto note, though, that the presence of bar-riers and lack of perceived benefits ofmammography are significant inhibitorsfor many women not in action or mainte-nance for mammography.

In a review of mammography studieswith African Americans, Ashing-Giwa*^offers some useful insights. Compared towhite women, African American womenmay place a greater value on buildingrelationships than on maintaining theirhealth, and they may believe they haveless control. More immediate concerns,such as maintaining an adequate in-come, may outweigh the threat of breastcancer.

Mammography screening amongwomen without health insurance is alsoa significant potential barrier that needsto be addressed.*^ Rimer et al^' found thata lack of health insurance was related tonot having a Pap test or clinical breastexam, but was not related to having amammogram.

3. Does the evidence support the use ofstage-matched interventions for cancerscreening?

Using the criteria identified in Table 4for evaluating the body of literature forcancer screening interventions, supportfor the use of stage-matched mammogra-phy programs is suggestive at this time.The primary reason for this rating is dueto the quantity, not the quality, of thesestudies. Although few in number, theyare well designed in most cases. Supportfor stage-matched sun avoidance/protec-tion interventions is weak, given thelack of quantity and quality of studies.

This paper is limited primarily in thatit is a qualitative review, and the analysisand findings are ultimately subjective;however, a structured and methodicalapproach was used in analyzing both indi-vidual studies and the body of literatureas a whole. This body of literature is toosmall to support a meta-analysis, and awell designed qualitative review offersrelevant insight into the literature thatwould otherwise not be available to re-searchers and practitioners.

Rimer*' suggests that, to be effectivelyapplied to cancer, the TTM must addressthe following concerns. First, the stagesof change need to be clearlyoperationalized. Second, researchersassessing decisional balance and pro-cesses-of-change need to consistently usethe same measures. Third, the focusneeds to expand beyond the individualand their cognitive and behavioral pro-cesses to address the impact of the fam-ily, community, workplace, and environ-ment. Fourth, the impact of race shouldnot be minimized. Finally, Rimer recom-mends collaborative interventions thatinvolve the many disciplines involved incancer screening. These recommenda-tions were made 10 years ago, yet axe stillvalid concerns today.

The data from this literature reviewsupport Rimer's recommendations; how-ever, additional recommendations areoffered. First, more research is neededwith minority populations and non-Ameri-can populations in all cancer screeningareas. Second, although measures ofstage-of-change and decisional balancefor mammography have been tested andare available, those for evaluating theuse of processes-of-change are not. Giventhat the timely and appropriate use ofprocesses is the basis for a stage-matched



intervention, careful definition and mea-surement of the processes is essential.Valid measures for all TTM constructsneed to be developed for other cancerscreening areas; none were evident inthis review. Third, additional well de-signed studies are needed to evaluate theeffectiveness of stage-matched interven-tions for all types of cancer screening. •

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4.Spencer LS, Pagell F, Hallion ME, et al.Applying the transtheoretical model to to-bacco cessation and prevention: a review ofliterature. Am J Health Promot. 2002;17:7-71.

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