Intervention Summary

Transtheoretical Model (TTM)-Based Stress Management Program

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 Information

Areas of Interest	Mental health promotion
Outcomes	1: Progression to action or maintenance stage of effective stress management 2: Stress management behaviors 3: Perceived stress and coping 4: Level of depression
Outcome Categories	Mental health
Ages	18-25 (Young adult) 26-55 (Adult) 55+ (Older adult)
Genders	Male Female
Races/Ethnicities	Black or African American Hispanic or Latino White Race/ethnicity unspecified
Settings	Home
Geographic Locations	Urban Suburban
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.
NIH Funding/CER Studies	Partially/fully funded by National Institutes of Health: Yes Evaluated in comparative effectiveness research studies: Yes
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 developer.
IOM Prevention Categories	Selective

Quality of Research

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Evers, K. E., Prochaska, J. O., Johnson, J. L., Mauriello, L. M., Padula, J. A., & Prochaska, J. M. A randomized clinical trial of a population- and Transtheoretical Model-based stress-management intervention. Health Psychology, 25(4), 521-529.

Supplementary Materials

Description of Pro-Change Quality Assurance Procedures and Intervention Fidelity

Pro-Change Behavior Systems, Inc. A stress management expert system for cancer prevention: Phase II final report to the National Cancer Institute (Grant #CA81948). West Kingston, RI: Author.

Pro-Change Behavior Systems, Inc.. Transtheoretical Model: Scientific validity [excerpt]. West Kingston, RI: Author.

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 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 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 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 Designs	Experimental
Quality of Research Rating	3.5 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study	Age	Gender	Race/Ethnicity
Study 1	18-25 (Young adult) 26-55 (Adult) 55+ (Older adult)	69% Female 31% Male	85% White 8% Black or African American 6% Hispanic or Latino 1% Race/ethnicity unspecified

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

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

Reliability of measures
Validity of measures
Intervention fidelity
Missing data and attrition
Potential confounding variables
Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome	Reliability of Measures	Validity of Measures	Fidelity	Missing Data/Attrition	Confounding Variables	Data Analysis	Overall Rating
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
2: Stress management behaviors	2.0	3.0	2.5	4.0	2.5	3.5	2.9
3: Perceived stress and coping	4.0	3.5	2.5	4.0	2.5	3.5	3.3
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

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Demonstration of online program

Handouts:

Information for Implementers
Quality Assurance Procedures and Implementation Fidelity

Pro-Change Behavior Systems, Inc. Roadways to healthy living: A guide for effective stress management. West Kingston, RI: Author.

Pro-Change Behavior Systems, Inc. TTMX user manual. West Kingston, RI: Author.

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

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

Availability of implementation materials
Availability of training and support resources
Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation Materials	Training and Support Resources	Quality Assurance Procedures	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.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description	Cost	Required by Developer
Unlimited use of online expert system and materials	$40,000 per year per site	Yes
Individual use of online expert system	$35 per person	Yes
Stress management guide	$20 each	Yes
Basic online training (approximately 4 hours)	$100 per person	No
On-site training for coaches/counselors	$3,000 per day per site	No
Technical assistance and consultation, including on customization	$160 per hour	No
Quality assurance materials	Included with implementation materials	No