Search Interventions

Search Interventions

Home About Find Interventions Review Process Submissions Resources  Help Contact

Home About Find Interventions Review Process Submissions Resources  Help Contact

Transtheoretical Model (TTM)-Based Stress Management Program
Date of Review: October 2007

The Transtheoretical Model (TTM)-Based Stress Management Program targets adults who have not been practicing effective stress management for 6 months or longer. TTM is a theory of behavior change that can be applied to single, multiple, and complex behavioral targets. TTM's premise is that behavior change is a process and that as a person attempts to change a behavior, he or she moves through five stages: precontemplation (not intending to begin in the next 6 months), contemplation (intending to begin in the next 6 months), preparation (intending to begin in the next 30 days), action (practicing the behavior for less than 6 months), and maintenance (practicing the behavior for at least 6 months). This application of TTM to stress management focuses on increased regular relaxation, exercise, and social support activities. The intervention helps participants develop new strategies that can promote progress to the next stage of change in the adoption of effective stress management practices. The program uses a computerized expert system to provide individualized feedback reports on stress management behaviors at the beginning of the intervention and 3 and 6 months afterward. Participants receive feedback about themselves compared with their peers that includes stage of change, processes of change, self-efficacy, decisional balance responses, and their use of stress management behaviors. Because the intervention uses a self-directed computer program, no training is needed for implementation. A user manual provides answers to frequently asked questions, instructions on how to extract data, and technical support.

Descriptive Info Outcomes Ratings Study Populations Studies/Materials Replications Contacts

Descriptive Information

Topics	Mental health promotion
Outcomes	Outcome 1: Progression to action or maintenance stage of effective stress management Outcome 2: Stress management behaviors Outcome 3: Perceived stress and coping Outcome 4: Level of depression
Study Populations	Age: 18-25 (Young adult), 26-55 (Adult), 55+ (Older adult) Gender: Female, Male Race: Black or African American, Hispanic or Latino, White, Race/ethnicity unspecified (See Study Populations section below for percentages by study)
Settings	Home, Suburban, Urban
Implementation History	It is estimated that 6,000 individuals have received the intervention. The program has been implemented with the employees and students of several academic institutions and with the employees and customers of various businesses.
Replications	This intervention has been replicated. (See Replications section below)
Adaptations	The program has been adapted to be delivered over the telephone by health coaches. The coaches use the program to direct their telephone sessions with participants.
Adverse Effects	No adverse effects, concerns, or unintended consequences were identified by the applicant.
Public or Proprietary Domain	Proprietary
Costs	An annual fee of $40,000 allows an organization unlimited use of the online expert system and materials. An individual user may pay $35 to use the online program. Offline versions are also available; an individual can purchase the printed stress management guide alone ($20) or in combination with an offline version of the system that provides feedback at three time points ($80).
Institute of Medicine Category	Selective

back to top

Outcomes

Outcome 1: Progression to action or maintenance stage of effective stress management

Description of Measures	Participants were given a brief description of stress management (e.g., regular relaxation, physical activity, social activities) and were asked, "Do you effectively practice stress management in your daily life?" The five response categories placed participants in one of five stages of change for effective stress management: precontemplation, contemplation, preparation, action, and maintenance.
Key Findings	More than 60% of individuals in the treatment group who completed the study began practicing effective stress management within 6 months and maintained the behavior up to the 18-month follow-up, compared with about 40% of control group participants, who received assessments only (p < .01).
Studies Measuring Outcome	Study 1 (Study numbers correspond to the numbered citations in the Studies and Materials Reviewed section below)
Study Designs	Experimental
Quality of Research Rating	2.9 (0.0-4.0 scale)

Outcome 2: Stress management behaviors

Description of Measures	Stress management behaviors were assessed using the Stress Management Behaviors Inventory (SMBI). This 24-item measure uses a 5-point scale from 1 (never) to 5 (repeatedly) to determine the behaviors individuals use most often to manage their stress. The tool has six subscales: Setting Limits, Planning, Help From Others, Professional Help, Reframing, and Unhealthy Activities.
Key Findings	Participants from the treatment group showed significant improvement in both the Planning and Professional Help subscales at 6-, 12-, and 18-month follow-ups compared with control group participants, who received assessments only (p = .001 to p < .01). In addition, the treatment group showed an improvement in the Help From Others subscale at 18 months (p < .001) and the Unhealthy Behaviors subscale at 6 months (p < .001) compared with the control group. There were no significant differences between the two groups on the Setting Limits and Reframing subscales.
Studies Measuring Outcome	Study 1 (Study numbers correspond to the numbered citations in the Studies and Materials Reviewed section below)
Study Designs	Experimental
Quality of Research Rating	2.9 (0.0-4.0 scale)

Outcome 3: Perceived stress and coping

Description of Measures	Perceived stress and coping were assessed using the 10-item Rhode Island Stress and Coping Inventory (RISCI). Using a scale from 1 (never) to 5 (repeatedly), participants reported how frequently they felt stressed or were able to cope in specific situations.
Key Findings	Participants from the treatment group showed a significant reduction in their perceived stress at 6-, 12-, and 18-month follow-ups compared with control group participants, who received assessments only (p < .001 to p < .01). There were no significant differences between the two groups on their perceived coping.
Studies Measuring Outcome	Study 1 (Study numbers correspond to the numbered citations in the Studies and Materials Reviewed section below)
Study Designs	Experimental
Quality of Research Rating	3.3 (0.0-4.0 scale)

Outcome 4: Level of depression

Description of Measures	Level of depression was assessed using the 11-item Center for Epidemiological Studies Depression Scale (CES-D), which asks how often in the past week an individual felt each of nine negative and two positive feelings. Responses are based on a 3-point Likert scale from 0 (hardly ever or never) to 2 (much or most of the time).
Key Findings	Participants in the treatment group reported significantly less frequent depression at the 6- and 18-month follow-ups compared with control group participants, who received assessments only (p < .001 and p < .01, respectively).
Studies Measuring Outcome	Study 1 (Study numbers correspond to the numbered citations in the Studies and Materials Reviewed section below)
Study Designs	Experimental
Quality of Research Rating	3.5 (0.0-4.0 scale)

back to top

Ratings

Quality of Research Ratings by Criteria (0.0-4.0 scale)

Outcome	Reliability of Measures	Validity of Measures	Fidelity	Missing Data/Attrition	Confounding Variables	Data Analysis	Overall Rating
Outcome 1: Progression to action or maintenance stage of effective stress management	2.0	3.0	2.5	4.0	2.5	3.5	2.9
Outcome 2: Stress management behaviors	2.0	3.0	2.5	4.0	2.5	3.5	2.9
Outcome 3: Perceived stress and coping	4.0	3.5	2.5	4.0	2.5	3.5	3.3
Outcome 4: Level of depression	4.0	4.0	2.5	4.0	3.0	3.5	3.5

Study Strengths: The study used a rigorous design, a relatively long-term follow-up (18 months), two well-recognized measures (RISCI and CES-D), assessors blind to the experimental condition, and appropriate statistical analyses.

Study Weaknesses: There was a high attrition rate within the intervention group. Adequate information was not provided about the reliability of the stage of change algorithm or the treatment of intervention fidelity. Although computerization likely ensured fidelity, no fidelity checks or quality assurance procedures were presented that would ensure the program was implemented correctly.

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

Implementation Materials	Training and Support	Quality Assurance	Overall Rating
3.5	3.8	4.0	3.8

Dissemination Strengths: Both online and offline versions of materials are available for implementation. The program is completely self-directed, so no training is required. Technical assistance is available to support users before and during implementation. The computerized nature of the program ensures implementation fidelity, and the interactive computer application allows administrators to monitor program use and progress.

Dissemination Weaknesses: No information is provided for integrating this program into the existing mental health system. The user manual provides minimal discussion of how clinicians can help clients interpret their stress management needs.

back to top

Contact Information

Web site(s):

http://www.prochange.com

For information about implementation:

Janice M. Prochaska, Ph.D.
President and Chief Executive Officer
Pro-Change Behavior Systems, Inc.
P.O. Box 755
West Kingston, RI 02892
Phone: (401) 874-4109
Fax: (401) 874-4103
E-mail: jmprochaska@prochange.com

Kerry E. Evers, Ph.D.
Director of Health Behavior Change Projects
Pro-Change Behavior Systems, Inc.
P.O. Box 755
West Kingston, RI 02892
Phone: (401) 874-4118
Fax: (401) 874-4103
E-mail: kevers@prochange.com

For information about studies:

Kerry E. Evers, Ph.D.
Director of Health Behavior Change Projects
Pro-Change Behavior Systems, Inc.
P.O. Box 755
West Kingston, RI 02892
Phone: (401) 874-4118
Fax: (401) 874-4103
E-mail: kevers@prochange.com

back to top

The NREPP review of this intervention was funded by the Center for Mental Health Services (CMHS).