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Using the multi-theory model of health behavior change to identify correlates of change in substance use behavior in a mental health clinic-based sample

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Using the multi-theory model of health behavior change to identify correlates of change in substance use behavior in a mental health clinic-based sample

Abstract

Background: Substance use is a chronic disorder that requires lifelong multimodal management. This study utilized the Multi-Theory Model (MTM) of Health Behavior Change to identify correlates of change in substance use behavior. Methods: Data were collected, using a cross-sectional design, from 93 participants who completed treatment at a substance use treatment facility. Participants completed a 40-item, newly developed, self-administered questionnaire, grounded on relevant substance use, treatment, and health-related behavior. Cronbach’s alpha of all subscales were over 0.70 and deemed acceptable. Results: The majority of the participants were Caucasian (72.7%). Males comprised 60% of the sample. A stepwise multiple regression predicting initiation and sustenance of intentional substance use cessation showed a total of 34.2% of the variance. The initiation for the intentional substance use cessation was accounted for by participatory dialogue, advantages minus disadvantages (p = .001) and behavioral confidence (p = < 0.001). The sustenance for intentional substance use cessation was accounted for a total of 33% of the variance by practice for change (p = .004) and changes in the social environment (p = < 0.003). Conclusions: The MTM could be a useful model for predicting substance use behavior change. Clinicians and patients can gain insight and discuss behavioral changes necessary for recovery.
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Journal of Substance Use
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Using the multi-theory model of health behavior
change to identify correlates of change in
substance use behavior in a mental health clinic-
based sample
Edith Claros, Vinayak K. Nahar, Milad Mafi, Carol Eliadi, Sherief Abu-
Moustafa & Manoj Sharma
To cite this article: Edith Claros, Vinayak K. Nahar, Milad Mafi, Carol Eliadi, Sherief Abu-Moustafa
& Manoj Sharma (2020): Using the multi-theory model of health behavior change to identify
correlates of change in substance use behavior in a mental health clinic-based sample, Journal of
Substance Use, DOI: 10.1080/14659891.2020.1745309
To link to this article: https://doi.org/10.1080/14659891.2020.1745309
Published online: 01 Apr 2020.
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Using the multi-theory model of health behavior change to identify correlates of
change in substance use behavior in a mental health clinic-based sample
Edith Claros
a
, Vinayak K. Nahar
b,c
, Milad Mafi
d
, Carol Eliadi
e
, Sherief Abu-Moustafa
f
, and Manoj Sharma
g,h,i
a
School of Nursing, MCPHS University, Worcester, MA, USA;
b
Department of Dermatology, School of Medicine, University of Mississippi Medical
Center, Jackson, MS, USA;
c
Department of Preventive Medicine, School of Medicine, University of Mississippi Medical Center, Jackson, MS, USA;
d
DeBusk College of Osteopathic Medicine, Lincoln Memorial University, Harrogate, TN, USA;
e
Behavioral Health Department, Harrington Memorial
Hospital, Southbridge, MA, USA;
f
The Florida House Experience Health, Deerfield Beach, FL, USA;
g
Department of Behavioral & Environmental
Health, School of Public Health, Jackson State University, Jackson, MS, USA;
h
School of Health Sciences, Walden University, Minneapolis, MN, USA;
i
Health for All, Omaha, NE, USA
ABSTRACT
Background: Substance use is a chronic disorder that requires lifelong multimodal management. This
study utilized the Multi-Theory Model (MTM) of Health Behavior Change to identify correlates of change
in substance use behavior.
Methods: Data were collected, using a cross-sectional design, from 93 participants who completed
treatment at a substance use treatment facility. Participants completed a 40-item, newly developed, self-
administered questionnaire, grounded on relevant substance use, treatment, and health-related beha-
vior. Cronbachs alpha of all subscales were over 0.70 and deemed acceptable.
Results: The majority of the participants were Caucasian (72.7%). Males comprised 60% of the sample.
A stepwise multiple regression predicting initiation and sustenance of intentional substance use cessa-
tion showed a total of 34.2% of the variance. The initiation for the intentional substance use cessation
was accounted for by participatory dialogue, advantages minus disadvantages (p= .001) and behavioral
confidence (p= < 0.001). The sustenance for intentional substance use cessation was accounted for
a total of 33% of the variance by practice for change (p= .004) and changes in the social environment
(p= < 0.003).
Conclusions: The MTM could be a useful model for predicting substance use behavior change. Clinicians
and patients can gain insight and discuss behavioral changes necessary for recovery.
ARTICLE HISTORY
Received 23 September 2019
Revised 2 March 2020
Accepted 12 March 2020
KEYWORDS
Substance use; cessation;
multi-theory model;
behavior; correlates
Introduction
Substance Use Disorders (SUD) take a significant toll on the
healthcare system regarding cost, loss of life, productivity, crime,
and family disruption (Lander et al., 2013). SUD are a chronic
disorder with behavior patterns reflective of addictive substance
use despite adverse consequences (American Psychiatric
Association, 2013). Similar to chronic illnesses, SUD have cumu-
lative effects requiring lifelong multimodal management.
Treatment often consists of self-management, adherence, hospi-
talization, medication, behavioral therapy, relapse prevention,
harm reduction, and ongoing support (U.S. Department of
Health and Human Services, 2016). Despite empirical evidence
of SUD as a brain disease with complex biological and environ-
mental risk factors, treatment becomes episodic in a rather short
time. Many individuals who complete treatment relapse within
the first year, most often before 6 months (Scott et al., 2005).
Simoneau et al. (2018) conducted a systematic review of the
efficacy of interventions for SUD for persons cycling in and
out of treatment. They did not find evidence regarding the
optimal duration of treatment, length of continuity of care, and
sustained recovery.
We utilized the Multi-Theory Model of Health Behavior
Change (Sharma, 2015) to identify correlates of change in
substance use behavior. The MTM model has been empirically
tested for leading behavior change, is exclusive for health educa-
tion, uses modifiable constructs, is parsimonious, may guide
long-term or one-time behavior change, and is widely applicable
across a variety of settings and cultures (Hayes et al., 2018;
Knowlden et al., 2017;Sharma,2015).
The MTM has two main components, the initiation of beha-
vior change and the sustenance of the behavior change (Sharma,
2015). Within the first stage of the MTM, initiation, three main
constructs are determined. First is participatory dialogue,
a form of adult education wherein the facilitator facilitates
a discussion to explain that the advantages of changing the
behavior outweigh the disadvantages. Second is behavioral con-
fidenceand it relates to the way individuals project a positive
future for them in their effort to make a change. Third, relates to
changes in the physical environmentin which the individual
makes changes regarding availability, convenience, and access to
resources (Sharma, 2015,2017). For example, staying away from
smoke shops if trying to quit smoking.
The second stage is maintenance or continuation of
a behavior change and it is composed of three discrete con-
structs, emotional transformation, practice for change, and
changes in the social environment. Emotional transformation
CONTACT Edith Claros edith.claros@mcphs.edu School of Nursing, MCPHS University, Worcester, MA, USA
JOURNAL OF SUBSTANCE USE
https://doi.org/10.1080/14659891.2020.1745309
© 2020 Taylor & Francis Group, LLC
is the ability of a person to gather upall of ones feelings about
a goal and then using them to direct a goal. This mustering is
done in spite of self-doubt, inertia and impulsivenessand thus
constitutes a sort of emotional transformation (Sharma, 2015,
2017).
The practice for change construct involves consistently
thinking of health behavior change to overcome barriers by
making adjustments as necessary. Staying focused can be
achieved through daily journaling or using an app to track
the progress of behavior toward onesgoals or through pre-
paration behaviors that increase the likelihood of following
through with the behavior change, i.e. constantly being vigi-
lant about the behavior change (Sharma, 2015,2017).
The changes in the social environment construct are
derived from the related concepts of helping relationships,
social support, and minimizing adversarial influences to help
solidify the behavior as ones social reality becomes grounded
in the behavior change thus significantly reducing the possi-
bility of abandoning the behavior change or reverting to
another one (Sharma, 2015,2017).
Research evidence points to the MTM as a reliable model
for producing health-behavior changes. Knowlden et al.
(2017) found that the MTM constructs of behavioral confi-
dence, changes in the social environment, emotional transfor-
mation, and practice for change were significant factors in the
initiation or continuation of improved sleep patterns. The
MTM model was found to be predictive of initiation and
maintenance of physical activity in college students (Nahar
et al., 2016); and offered promising results in African
American women on physical activity change (Hayes et al.,
2018). Additionally, the model was predictive in initiating and
sustaining the consumption of healthier food portions, in the
prediction of water consumption in lieu of sugar-sweetened
beverages, and as a predictor of responsible drinking among
college students (Sharma et al., 2018,2016,2017). Hayes et al.
(2019) demonstrated the usefulness of MTM in increasing
minutes of physical activity to recommended levels and
decreasing waist circumference among African American
women. It is in this backdrop that the purpose of this study
was to use MTM to identify correlates of change in substance
use behavior in a mental health clinic-based sample.
Methods
This study utilized a cross-sectional design. For a priori sam-
ple size calculation, G*Power was utilized (Faul et al., 2009,
2007). For estimating sample size the power was set at 0.80,
α= 0.05, medium effect size as 0.15, the number of indepen-
dent variables in each model was three which yielded a sample
size of 77. This was inflated by 15% for any missing values to
arrive at a sample size close to 99 participants. A self-
administered, paper-and-pencil questionnaire was adminis-
tered to patients in a residential and outpatient substance
use treatment program. The requirements to participate in
the study were (1) completion of treatment in the inpatient
program and readiness for discharge at the time of the survey;
(2) above 18 years of age; (3) no court-mandated treatment;
(4) and willingness to provide informed consent to partici-
pate. The questionnaire took 15 to 20 min to complete. There
was no identifiable information in the surveys. Of the 110
questionnaires administered, 93 were completed (93%). The
Institutional Review Board, IRB protocol # IRB022818 C, at
MCPHS University approved all study procedures.
Measures and instrument
A 40-item questionnaire was developed. Item # 1 of the
questionnaire assessed the type of substances used in the
past 30 days before receiving treatment. Items 2 to 6 assessed
patterns of use. Items 7 to 12 assessed patient demographics
including gender, race, ethnicity, education, and income.
Items 13 through 40 pertained to the MTM model.
MTM construct of initiation of the behavior change
Four items assessed the advantages of participatory dialogue
using a 5-point Likert scale. For example, if you quit the above-
marked substance(s), after finishing your treatment, you will be
healthier.Each item response ranged from strongly disagree (0)
to strongly agree (4). The items were summed toderive the score
of advantages that ranged from 0 to 16units. Fouritems assessed
the disadvantages of participatory dialogue. For example, if you
quit the above-marked substance(s), after finishing your treat-
ment, you will not be able to relax as well.Each item response
ranged from strongly disagree (0) to strongly agree (4). The
items were summed to derive the score of disadvantages that
ranged from 0 to 16 units. The number of items in the advan-
tages scale and disadvantages scale was kept as equivalent to
avoid any bias. The score of participatory dialogue was obtained
by subtracting the score of disadvantages from advantages. Five
items assessed behavioral confidence. For example, how sure
are you that you will be able to quit the above-named substance-
(s) after finishing your treatment?Each item response ranged
from not sure at all (0) to completely sure (4). These items were
summed to obtain a score in the possible range of 020 units.
Three items assessed changes in the physical environment. For
example,how sure areyou that you will be able to stay away from
triggers and not buy any quantity of this substance(s)?Each
item response ranged from not sure at all (0) to completely sure
(4). These items were summed to obtain a score in the possible
range of 012 units. To assess the initiation of behavior change,
participants were asked: how likely is it that you will stay off the
substance in the upcoming week after treatment?The response
ranged from not at all likely (0) to completely likely (4).
MTM construct of sustenance of the behavior change
Three items assessed emotional transformation. For example,
how sure are you that you can motivate yourself to stay off the
substance(s) every day?Each item response ranged from not
sure at all (0) to completely sure (4). These items were summed
to obtain a score in the possible range of 012 units. Three items
assessed practice for change. For example, how sure are you
that you can come up with a strategy to stay off this substance(s)
every day if you encounter barriers?Each item response ranged
from not sure at all (0) to completely sure (4). These items were
summed to obtain a score in the possible range of 012 units.
Three items assessed changes in the social environment. For
2E. CLAROS ET AL.
example, how sure are you that you can get help from family so
that you can stay off the substance(s) every day?Each item
response ranged from not sure at all (0) to completely sure (4).
These items were summed to obtain a score in the possible
range of 012 units. Behavior sustenance was assessed by asking
the participant how likely is that you will stay of the substance-
(s) every day for the rest of your life after completing treat-
ment?The response ranged from not at all likely (0) to
completely likely (4).
Face and content validity
To establish face and content validity, seven experts in areas
of health behavior, substance use disorders and treatment
provided a qualitative evaluation of all items in the question-
naire. The instrument was revised over three-rounds based on
recommendations from the experts. The FleschKincaid
Grade level of the instrument was 4.2 (at or less than 5
th
grade). The FleschKincaid Reading Ease was 76.7.
Construct validity
Construct validity was determined using confirmatory factor
analysis (CFA) and supported one-factor solutions for all
subscales. The criteria of Eigenvalues over 1.0 and factor
loadings over 0.32 were met for all subscales (Sharma &
Petosa, 2014). The Cronbachs alphas of all subscales were
over 0.70 indicating satisfactory internal consistency reliabil-
ity. However, the entire scale of initiation had a Cronbachs
alpha of 0.65 which is minimally acceptable but since the
subscales had satisfactory alphas and this was a new scale it
was considered appropriate to use (Sharma & Petosa, 2014).
Data analyses
Descriptive statistics were performed to describe the study vari-
ables. We conducted stepwise multiple regressions to determine
correlates of change in substance use behavior (i.e. initiation and
sustenance). To assess demographic covariates (i.e. age, gender,
race/ethnicity, education, work status, and yearly household
income), Pearson product-moment correlations, independent
t-tests, and analysis of variance were performed, as appropriate.
Only age was found to be statistically significantly related with the
intent for initiation (r= 0.209; p= .045); hence, it was included as
a covariate in the stepwise multiple regression analysis for initia-
tion model. For stepwise multiple regressions, we chose 0.05 as
a criterion of the probability of Fto enter the independent variable
in the model and we chose 0.10 as a criterion of the probability of
Fto remove the independent variable from the model. Listwise
deletion for missing values was used for the regression analysis. All
statistics were conducted using IBM SPSS (Version 23.0).
Results
The mean±sd age of the respondents was 33.31 (±10.58) years.
Males comprised 60% of the sample. A majority of the respon-
dents were Caucasian (72.7%). Over one-fourth (28.2%) were
educated to a collegiate level while 22.7% had completed high
school or obtained a GED. With regard to work status, 46.4% of
the respondents stated they were currently working at the time
of the study. A total of 29.1% of the respondents reported
earning less than 50,000. USD Table 1 provides the socio-
demographic characteristics of the participants.
Table 2 provides the descriptive statistics of the constructs of
MTM. The mean (±sd) for intent for initiation was 3.63 (±0.62).
Advantages, disadvantages, behavioral confidence, and changes
in the physical environment had mean (±sd) scores of 14.32
(±3.39), 4.80 (±3.58), 15.78 (±3.19), and 9.44 (±2.49) units,
respectively. The mean (±sd) for intent for sustenance was
2.83 ± 0.95 units. Emotional transformation, practice for change,
and changes in the social environment had mean (±sd) values of
9.16 (±2.32), 9.14 (±2.07), and 9.64 (±3.32) units, respectively.
Tables 3 and 4provide results of stepwise multiple regres-
sion predicting initiation and sustenance for intentional sub-
stance use cessation, respectively. A total of 34.2% of the total
variance in the initiation for intentional substance use cessa-
tion was accounted for by advantages minus disadvantages
(unstandardized coefficient = 0.033, p= .001) and behavioral
confidence (unstandardized coefficient = 0.085, p< .001). For
the sustenance model, 33.0% of the total variance in the
sustenance for intentional substance use cessation was
accounted for by practice for change (unstandardized coeffi-
cient = 0.145, p= .004) and changes in the social environment
(unstandardized coefficient = 0.134, p< .003).
Discussion
The purpose of this study was to identify correlates of beha-
vioral change in individuals diagnosed with Substance Use
Disorder (SUD) using the Multi-Theory Model of Health
Behavior Change (Sharma, 2015). Using a quota sample of
participants, we replicated and expanded upon the prior work
related to MTM with several health behaviors (Hayes et al.,
2018,2019; Knowlden et al., 2017; Nahar et al., 2016; Sharma
et al., 2018,2016,2017).
Table 1. Socio-demographic Characteristics of the Participants (n= 93).
Mean (SD) n (%)
Age (years) 33.31 (10.58)
Gender
Male 66 (60.0%)
Female 27 (24.5%)
Race/Ethnicity
White or Caucasian American 80 (72.7%)
Black or African American 7 (6.4%)
Hispanic American 6 (5.5%)
Education
Some schooling but not completed high school 4 (3.6%)
Completed high school or GED 25 (22.7%)
Some college 31 (28.2%)
Completed college/graduate degree 24 (21.8%)
Postgraduate degree 5 (4.5%)
Professional degree 3 (2.7%)
Work Status
Yes 51 (46.4%)
No 42 (38.2%)
Yearly Household Income
Less than $ 50,000 32 (29.1%)
$ 50,000 to $ 100,000 22 (20.0%)
$100,001 to $150,000 12 (10.9%)
More than $150,000 7 (6.4%)
Due to missing data, the percentage of participants in each category of socio-
demographic characteristics do not sum to 100%
JOURNAL OF SUBSTANCE USE 3
The results of this study indicate that for the initiation or
cessation of substance use, participatory dialogue, advantages
over disadvantages, were significant predictors in the initiation
of the intentional cessation of substance use. A total of 34.2% of
the total variance was accounted for by the advantages versus
the disadvantages (p< .001). This finding was consistent with
previous studies (Knowlden et al., 2017; Sharma 2016; Sharma
et al., 2017). Behavioral confidence was significant (p< .001).
Participatory dialogue and behavioral confidence were predic-
tors of initiating behavior changes in portion size consumption
(Sharma et al., 2016) as well as initiating and maintaining
physical activity (Nahar et al., 2016), and in initiating and
completing the series of HPV vaccinations (Asare et al.,
2020). Additionally, we found age to be a predictor of the intent
of initiating behavior change that is consistent with previous
research (Asare et al., 2020).
This study revealed that the sustenance of behavior change
for the intentional cessation of substance, the construct of
practice for change (p< .004) and changes in the social
environment (p< .003) were accounted for a total of 33.0%
of the variance. Practice for change included keeping track of
the urge to use, coming up with strategies to stay focused and
off the substance when encountering barriers. Practice for
change and changes in the social environment have been
supported in previous studies (Asare et al., 2020; Nahar
et al., 2016; Sharma et al., 2016). Changes in the social envir-
onment include concepts of the helping relationship and
social support such as obtaining support from family, friends
and seeking help from help professionals.
Our findings highlight the significance of participatory dialo-
gue, behavioral confidence, changes in social environment, and
practice for change. These findings point to the importance for
clinicians to promote discussion and for individuals to reflect on
the benefits of substance use cessation such as feeling healthier and
more productive, saving money, being able to relax, socialize,
overcome the urge to use, and possibly reframe or form new
relationships. Finding self-worth and building confidence is
often a necessary step in regaining sobriety. Clinicians can max-
imize interactions with individuals to help them build and boost
confidence that supports their recovery and to overcome barriers,
such as being able to finish treatment and fulfill obligations.
Individuals with SUD often struggle to recognize their use patterns
or are ambivalent regarding treatment. Lack of confidence can
prevent an individual from seizing opportunities to make the
change that can present as risk-taking to the individual.
Behavioral change maintenance requires an understanding of the
surrounding context that can either facilitate or impede behavior
change.
Many individuals with SUD cycle through periods of remis-
sion, relapse and treatment reentry and intervention models
targeting this population are scarce. Studies conducted between
2000 and 2015 identified intervention models designed within
the pretense of addiction as a chronic illness or focused on
individuals with SUD who cycle in and out of treatment
Table 2. Descriptive Statistics of the Constructs of MTM (n= 93).
Constructs Possible range Observed range Mean (SD) Cronbachs alpha
Intent for Initiation 0 424 3.63 (0.62)
Participatory dialogue: advantages 0 16 0 16 14.32 (3.39) 0.92
Participatory dialogue: disadvantages 0 16 0 16 4.80 (3.58) 0.74
Participatory dialogue: advantages disadvantages score 16 +16 8+16 9.65 (5.58)
Behavioral confidence 0 20 6 20 15.78 (3.19) 0.85
Changes in physical environment 0 12 1 12 9.44 (2.49) 0.78
Entire initiation scale ––0.65
Intent for Sustenance 0 404 2.83 (0.95)
Emotional transformation 0 12 3 12 9.16 (2.32) 0.91
Practice for change 0 12 3 12 9.14 (2.07) 0.83
Changes in social environment 0 12 3 12 9.64 (3.32) 0.74
Entire sustenance scale ––0.90
Entire scale ––0.85
Table 3. Stepwise Multiple Regression Predicting Initiation for Intentional Substance Use Cessation (n= 93).
Variables BSE
B
βp-value 95% CI sr
2
Participatory dialogue: advantages disadvantages score 0.033 0.010 0.293 0.001 0.013, 0.053 0.080
Behavioral Confidence 0.085 0.017 0.434 < 0.001 0.050, 0.119 0.175
F(2, 89) = 23.079, p< 0.001, R
2
= 0.342, Adjusted R
2
= 0.327
Dependent variable: initiation for intentional substance use cessation; Independent variables in the model: age, participatory dialogue, behavioral confidence, and changes in
physical environment; Excluded variables: age and changes in physical environment; B= unstandardized coefficient; SE
B
= standard error of thecoefficient; β=standardized
coefficient; p= level of significance; CI = confidence interval; sr
2
= squared semipartial correlation.
Table 4. Stepwise Multiple Regression Predicting Sustenance for Intentional Substance Use Cessation (n= 93).
Variables BSE
B
βp-value 95% CI sr
2
Practice for Change 0.145 0.049 0.316 0.004 0.047, 0.243 0.064
Changes in Social Environment 0.134 0.044 0.327 0.003 0.047, 0.222 0.069
F(2, 90) = 22.175, p< 0.001, R
2
= 0.330, Adjusted R
2
= 0.315. Dependent variable: sustenance for intentional substance use cessation; Independent variables in the
model: emotional transformation, practice for change, and changes in social environment; Excluded variables: emotional transformation; B= unstandardized
coefficient; SE
B
= standard error of the coefficient; β= standardized coefficient; p= level of significance; CI = confidence interval; sr
2
= squared semipartial
correlation.
4E. CLAROS ET AL.
(Simoneau et al., 2018). Individuals with SUD represent
a challenging population for longitudinal study due to the socio-
demographic characteristics of individuals affected with the dis-
order. Questions regarding the length of optimal treatment and
the efficacy of rehabilitative care, until the relapse rate stabilizes
(5 years), needs to be studied (Simoneau et al., 2018). The overall
question regarding the optimal duration of continuation of
behavior change requires further research.
Limitations
Our cross-sectional design provides a snapshot of the variables
at one point in time, thus limiting the ability to judge any
temporal association between the variables. We cannot argue
that the MTM constructs precede the behavior change in SUD.
Empirical interventional research with the MTM suggests that
the constructs precede the behavior change (Hayes et al., 2018).
Additionally, we utilized a self-report questionnaire, which is
subject to self-favoring by the participants. The study included
a relatively small sample size and a set of participants who were
relatively homogenous, with the majority being Caucasian
males receiving treatment at a private treatment facility. It
would be important to expand this study to other levels of
care including public treatment centers. Due to the transient
nature of individuals in terms of a revolving door of episodic
treatment within multiple treatment centers, the outcomes of
those subjects who participated in the study remain unknown.
Longitudinal studies to address the efficacy of the MTM as well
as answering many other fundamental questions regarding
SUD treatment and recovery are necessary.
Conclusion
Evidence suggests that people with SUD suffer from
a chronic condition whereby they experience periods of
relapse, treatment reentry, recovery, and even incarceration.
Similar strategies used for other chronic diseases must
replace the current system of disconnected episodic care
(McLellan et al., 2000). An estimated 4060% of those with
addiction relapse, which is consistent with well-understood
chronic disorders. Relapse does not mean treatment failure;
rather, it is an indicator of the need for treatment readjust-
ment. Current studies demonstrate that MTM is a useful and
viable model in predicting behavior change in substance use
and provide insight for designing interventions that promote
substance use cessation.
Data Availability Statement
Thedatathatsupportthefindingsofthisstudyareavailablefromthe
corresponding author, EC, upon reasonable request (edith.claros@mcphs.
edu).
References
American Psychiatric Association. (2013). Diagnostic and statistical man-
ual of mental health disorders (5th ed.). Author.
Asare, M., Agyei-Baffour, P., Lanning, B. A., Barimah Owusu, A.,
Commeh, M. E., Boozier, K., Koranteng, A., Spies, L. A.,
Montealegre, J. R., & Paskett, E. D. (2020). Multi-theory model and
predictors of likelihood of accepting the series of HPV vaccination:
A cross sectional study among Ghanaian adolescents. International
Journal of Environmental Research and Public Health,17(2), 571584.
https://doi.org/10.3390/ijerph17020571
Faul, F., Erdfelder, E., Buchner, A., & Lang, A.-G. (2009). Statistical
power analyses using G*Power 3.1: Tests for correlation and regres-
sion analyses. Behavior Research Methods,41, 11491160. https://doi.
org/10.3758/BRM.41.4.1149
Faul, F., Erdfelder, E., Lang, A.-G., & Buchner, A. (2007). G*Power 3:
A flexible statistical power analysis program for the social, behavioral,
and biomedical sciences. Behavior Research Methods,39, 175191.
https://doi.org/10.3758/BF03193146
Hayes, T., Nahar, V. K., & Sharma, M. (2018). Predicting physical activity
behavior in African American females: Using multi theory model.
Journal of Research in Health Sciences,18(2), e00410. http://jrhs.
umsha.ac.ir/index.php/JRHS/article/view/3812/pdf
Hayes, T., Sharma, M., Shahbazi, M., Sung, J. H., Bennett, R., & Reese-
Smith, J. (2019). The evaluation of a fourth-generation multi-theory
model (MTM) based intervention to initiate and sustain physical
activity in African American women. Health Promotion Perspectives,
9(1), 1323. https://doi.org/10.15171/hpp.2019.02
Knowlden, A. P., Sharma, M., & Nahar, V. K. (2017). Using multi Theory
model of health behavior change to predict adequate sleep behavior.
Family & Community Health,40(1), 5661. https://doi.org/10.1097/
FCH.0000000000000124
Lander, L., Howsare, J., & Byme, M. (2013). The impact of substance use
disorders on families and children: From theory to practice. Social
Work in Public Health,28(34), 194205. https://doi.org/10.1080/
19371918.2013.759005
McLellan,A.T.,Lewis,D.C.,OBrien,C.P.,&Kleber,H.D.(2000). Drug
dependence, a chronic medical illness: Implications for treatment, insur-
ance, and outcomes evaluation. Journal of the American Medical
Association,284(13), 16891695. https://doi.org/10.1001/jama.284.13.1689
Nahar,V.K.,Sharma,M.,Catalano,H.P.,Ickes,M.J.,Johnson,P.,&
Ford,M.A.(2016). Testing multi-theory model (MTM) in predicting
initiation and sustenance of physical activity behavior among college
students. Health Promotion Perspectives,6(2), 5865. https://doi.org/10.
15171/hpp.2016.11
Scott, C. K., Foss, M. A., & Dennis, M. L. (2005). Pathways in the relapse
treatmentrecovery cycle over 3 years. Journal of Substance Abuse
Treatment,28(2), S63S72. https://doi.org/10.1016/j.jsat.2004.09.006
Sharma, M. (2015). Multi-theory model (MTM) for health behavior
change. Webmed Central Behaviour,6(9), WMC004982. https://
www.webmedcentral.com/article_view/4982
Sharma, M. (2017). Theoretical foundations of health education and
health promotion (3rd ed.). Jones and Bartlett Learning.
Sharma, M., Anyimukwu, C., Kim, R. W., Nahar, V. K., & Ford, M. A.
(2018). Predictors of responsible drinking or abstinence among col-
lege students who binge drink: A multitheory model approach. The
Journal of the American Osteopathic Association,118(8), 519530.
https://doi.org/10.7556/jaoa.2018.120
Sharma,M.,Catalano,H.P.,Nahar,V.K.,Lingam,V.,Johnson,P.,&
Ford,M.A.(2016). Using multi theory model to predict initiation and
sustenance of small portion size consumption among college students.
Health Promotion Perspectives,6(3), 137144. https://doi.org/10.15171/
hpp.2016.22
Sharma,M.,Catalano,H.P.,Nahar,V.K.,Lingam,V.C.,Johnson,P.,&
Ford,M.A.(2017). Applying multi-theory model (MTM) of health beha-
vior change to predict water consumption instead of sugar-sweetened
beverages. Journal of Research in Health Sciences,17(1), e00370. file:///
Users/edithclaros/Downloads/129720170102.pdf
Sharma, M., & Petosa, R. L. (2014). Measurement and evaluation for
health educators. Jones & Bartlett Publishers.
Simoneau, H., Kamgang, E., Tremblay, J., Bertrand, K., Brochu, S., &
Fleury, M.-J. (2018,April). Efficacy of extensive intervention models for
JOURNAL OF SUBSTANCE USE 5
substance use disorders: A systematic review. Drug and Alcohol Review,37
(Suppl. 1), S246S262. https://doi.org/10.1111/dar.2018.37.issue-S1
U.S. Department of Health and Human Services. (2016,November).
Facing addiction in America: The surgeon generalsreporton
alcohol, drugs, and health [Internet]. Substance Abuse and Mental
Health Services Administration (US); Office of the Surgeon General
(US). Available from: https://www.ncbi.nlm.nih.gov/books/
NBK424857/
6E. CLAROS ET AL.
... A study conducted in the USA showed the MTM has effectiveness for predicting initiation and sustenance of SC behavior [16]. Another study from a mental health clinic in the USA also revealed participatory dialogue, behavioral confidence, practice for change, and social environment are predictors for intension for substance cessation [17]. Such a study has not been yet conducted in low-income countries where the burden of tobacco and deaths is heaviest [1]. ...
... This theory has been applied in different areas to change health behavior such as to predict: SC, water drinking instead of sugar-sweetened beverages, adequate sleep, physical activities, and dietary patterns. The findings of these studies revealed MTM theory significantly predict for both initiation and sustenance of behavior changes [12,14,16,17,[22][23][24][25][26]. The reliability coefficient of each construct in this study is ≥ 0.7 indicates constructs are acceptable which Table 3. Parameter estimates based on stepwise regression analysis to predict the initiationand sustenance of smoking cessation (n = 132). ...
... Our study reveals that changes in the physical environment played a significant role in SC. This means the ability to get rid of all cigarettes from the environment, the ability to refrain from buying cigarettes, and the ability to substitute smoking time with something else which is derived from Bandura's social cognitive theory [12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28]. Previous studies on SC shows a change in the physical environment is not statistically significant but found significant in physical activities and drinking water instead of sugar-sweetened beverage [12,22,24]. ...
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Introduction: Smoking and use of other tobacco products are a global public health threat. The objective of the study was to predict the initiation and sustenance of smoking cessation (SC) by applying the multi-theory model (MTM) of health behavior change. Methods: In a cross-sectional study, the face-to-face interview was conducted by visiting different public places and coffee shops in Kathmandu Metropolitan, Nepal. A 30-item valid and reliable MTM-based survey instrument was administered to the participants who smoked cigarettes. Stepwise multiple regressions were conducted to explain SC behavior. The entire value of the Cronbach alpha coefficient (α) of the subscales and the scale was 0.91 which is excellent internal consistency. Results: A total of 132 participants completed the study (93.6%). The median age of participants was 35.53 years and 75% of them were males. The median number of cigarettes smoked per day was 7. Behavioral confidence (β = 0.06, P = 0.02) and changes in the physical environment (β = 0.11, P = 0.01) were significant predictors for the initiation of SC. Next, emotional transformation (β = 0.25, P < 0.001) was a significant predictor for sustenance for SC. Conclusion: MTM has the usefulness to assess both the initiation and sustenance behavior of SC. Potential solutions using MTM constructs should be developed in future interventions to change behavior of SC.
... The MTM has demonstrated efficacy in its ability to conceptualize behaviors, including, physical activity, dietary behaviors, vaccination practices, substance use, relaxation practices, intentional outdoor behaviors, and COVID-related handwashing, among others. [16][17][18][19][20][21][22][23] Initiation of behavior change is predicted by; participatory dialogue, behavioral confidence, and changes in the physical environment. Participatory dialogue considers the advantages and disadvantages of changing behavior. ...
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Background: Recommendations and policies, regarding the use of face coverings, have been instituted to control transmission of coronavirus disease 2019 (COVID-19). Understanding of psychosocial factors related to the use of face coverings within the context of COVID-19 is needed. This study aimed to conceptualize mask-wearing behavior among students using the Multi-theory Model (MTM) of behavior change. Methods: In October 2020, students (n = 595) enrolled in a large public southeastern US university were recruited to participate in a cross-sectional survey, using a valid and reliable instrument. Univariate, bivariate, and multivariate techniques described mask-wearing behavior and differentiated theoretical drivers of mask-wearing between individuals compliant and non-compliant with guidelines. Results: Compliant individuals reported significantly higher scores (P <0.05) for initiation and sustenance of mask-wearing, participatory dialogue, behavioral confidence, emotional transformation, practice for change, changes in the social environment, and significantly lower scores for disadvantage. Among multivariable models, all theoretical predictors exhibited significant relationships to their respective outcomes (initiation and sustenance). Specifically, MTM constructs explained approximately 35% of variance in initiation (R2 = 0.346, F(3,526) = 94.32, P <0.001) and 33% of variance in sustenance of mask wearing (R2 = 0.328, F(3,529) = 87.71, P <0.001) for compliant individuals. Behavioral confidence and emotional transformation exhibited the strongest relationships to initiation (ß = 0.403, P <0.001) and sustenance (ß = 0.450, P <0.001), respectively. Conclusion: Findings suggest a need to design educational programming based on the MTM to promote mask-wearing behavior among laggards who defy face mask guidelines, recommendations, and mandates.
... The MTM has demonstrated efficacy in its ability to conceptualize behaviors, including, physical activity, dietary behaviors, vaccination practices, substance use, relaxation practices, intentional outdoor behaviors, and COVID-related handwashing, among others. [16][17][18][19][20][21][22][23] Initiation of behavior change is predicted by; participatory dialogue, behavioral confidence, and changes in the physical environment. Participatory dialogue considers the advantages and disadvantages of changing behavior. ...
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HPV vaccines are efficacious in preventing HPV related cancers. However, the vaccination uptake in Ghana is very low. Studies that utilize theoretical frameworks to identify contributory factors to HPV vaccination uptake in Ghana are understudied. We used multi-theory model (MTM) constructs to predict initiation and completion of HPV vaccination series in Ghanaian adolescents. Adolescents (n = 285) between the ages of 12 and 17 years old were recruited from four selected schools in Ghana to participate in the cross-sectional study. Linear regressions were used to analyze the data. Most participants were female (91.2%) and senior high school students (60.0%). Many of the participants had neither heard about HPV (92.3%) nor HPV vaccinations (95.4%). Significant predictors of adolescents’ likelihood of getting the first dose of HPV vaccination were perceived beliefs and change in a physical environment (p < 0.001), with each variable accounting for 6.1%and 8.8% of the variance respectively. Significant predictors of adolescents’ likelihood of completing HPV vaccination recommended series were perceived beliefs, practice for change, and emotional transformation (p < 0.001), with each variable accounting for 7.8%, 8.1%, and 1.1% of the variance respectively. Findings underscore important opportunities for developing educational interventions for adolescents in Ghana to increase the HPV vaccination uptake.
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Background: The United States Department of Health and Human Services (USDHHS)recommends that adults achieve 150 minutes per week of moderate-intensity aerobic activity.Most African American women do not meet these guidelines. The purpose of this study was to determine the efficacy of an intervention based on the fourth generation, multi-theory model (MTM) of health behavior change for initiating and sustaining physical activity among African American women when compared to a first generation, knowledge-based intervention. Methods: The randomized controlled trial (RCT) utilized a pre-test, post-test and 6-week followup evaluation with an experimental (n=25) group and a comparison group (n=23). Process evaluation for satisfaction and program fidelity was conducted along with impact evaluation for changes in MTM constructs, intent to initiate and sustain physical activity, minutes of physical activity, body mass index (BMI), waist circumference and blood pressure in hypertensives. Results:The MTM-based intervention proved significantly efficacious in increasing the minutes of physical activity from pre-test mean of 37 minutes to 172 minutes at follow-up (mean difference135.08 minutes, 95% CI: 106.04 to 164.13, P<0.0001), reducing waist circumference from pretest mean of 39 inches to 38 inches at follow-up (mean difference -1.12 inches, 95% CI: -1.70 to-0.545, P<0.001) and modifying the MTM construct of changes in physical environment from a mean of 7 units at pre-test to 9 units at follow-up (mean difference 2.08 units, 95% CI: 0.73 to 3.43, P<0.004) when compared to the knowledge-based intervention over time. Conclusion: There were directional improvements in the mean scores for most of the study variables over time for the MTM intervention group and statistically significant improvement in minutes of physical activity and waist circumference.
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Context: Binge drinking is a salient problem on college campuses, with estimates as high as 40% of students engaging in it. Binge drinking is associated with numerous negative consequences among college students, such as suicide attempts, unsafe sex practices, property damage, and driving under the influence. Several behavioral approaches in this regard have had modest impact and only short-term effects, however. Objective: To use the multitheory model (MTM) of health behavior change to predict initiation and sustenance of responsible drinking or abstinence among binge-drinking college students in a sample drawn from a large southern public university. Methods: This cross-sectional survey study included a sample of college students who binge drank in the past 30 days. A 39-item face- and content-valid instrument was used. In addition, construct validity using confirmatory factor analysis and internal consistency reliability using the Cronbach α were established. Hierarchical regression modeling was used to build models. Results: A total of 289 students participated. The Cronbach α for the scale and all subscales ranged from 0.81 to 0.94 and demonstrated acceptable internal consistency reliability. Construct validity using confirmatory factor analysis yielded 1-factor solutions for each of the subscales. On hierarchical regression modeling, gender (P=.05), race/ethnicity (P=.004), behavioral confidence (P=.029), and changes in physical environment (P=.001) were associated with intended initiation for drinking responsibly/abstinence behavior change. The addition of MTM constructs led to a significant increase in R2 of 0.20 (F3,194=18.1; P<.001). The sustenance constructs yielded a significant increase in R2 of 0.20 (F3,193=19.4; P<.001). Conclusion: This study provides empirical justification for MTM constructs that can be used to inculcate the intention to drink responsibly or abstain among college students who binge drink. This predictive model may prove valuable in the design of interventions aiming to improve responsible drinking behavior in this population.
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Background: Despite physical activity having several benefits, a considerable number of Americans do not engage in sufficient exercise. Among the high-risk groups are African American women. A recent theory, multi theory model (MTM) for health behavior change can be used to develop effective interventions. The objective of this research was to test MTM in its ability to predict physical activity behavior in African American women. Study design: A cross-sectional study. Methods: African American women aged 18 yr and older were recruited at various locations (primarily churches) of Jackson, a large city in southern Mississippi to participate in this cross-sectional study in 2016. The valid and reliable survey was administered to a G*Power calculated quota sample of 156 women either in person or via a Qualtrics link sent through an e-mail. Results: The regression analysis revealed that 32.7% of the variance in initiating physical activity behavior was predicted by participatory dialogue, behavioral confidence, and changes in physical environment. Sustenance of physical activity behavior was predicted up to 38.8% by emotional transformation and changes in social environment. Conclusions: MTM appears to be a robust theory in its application for changing physical activity behavior in African American women. This theory must be reified and empirically tested with this population.
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Background: A substantial proportion of college students to not drink enough water and consume sugar-sweetened beverages (SSBs). Consumption of SSBs is associated with weight gain, obesity, type 2 diabetes mellitus, dental carries, and increased risk for cardiovascular disease. Hence, the purpose of this study was to use the multi-theory model (MTM) in predicting initiation and sustenance of plain water consumption instead of sugar-sweetened beverages among college students. Study design: A cross-sectional study. Methods: In this cross-sectional study, a 37-item valid and reliable MTM-based survey was administered to college students in 2016 via Qualtrics at a large public university in the Southeastern United States. Overall, 410 students responded to the survey; of those, 174 were eligible for the study and completed it. Results: Stepwise multiple regression analysis revealed that 61.8% of the variance in the initiation of drinking plain water instead of SSBs was explained by behavioral confidence (P<0.001) and changes in the physical environment (P<0.001). Further, 58.3% of the variance in the sustenance of drinking plain water instead of SSBs was explained by emotional transformation (P<0.001) and practice for change (P=0.001). Conclusions: Multi-theory model of health behavior change is a robust theory for predicting plain water consumption instead of SSBs in college students. Interventions should be developed based on this theory for this target population.
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Background: Consumption of large portion sizes is contributing to overweight and obesity.College students are a vulnerable group in this regard. The purpose of this study was to use multi-theory model (MTM) to predict initiation and sustenance of small portion size consumption in college students. Methods: A total of 135 students at a large Southern US University completed a 35-item valid (face, content, and construct) and reliable (internally consistent) survey electronically in a cross-sectional design. The main outcome measures were intention to start eating small portion sizes and continuing to eat small portion sizes. Only those students who ate large portion sizes during the past 24 hours were included. Results: Step wise multiple regression showed that initiation of small portion size consumption was explained by participatory dialogue (advantages outweighing disadvantages), behavioral confidence, age, and gender (adjusted R(2) = 0.37, P < 0.001). Males were less likely to initiate small portion size consumption than females (β = -0.185, 95% CI = -0.71- -0.11). Regarding sustenance, emotional transformation, changes in social environment, and race were the significant predictors (adjusted R(2) = 0.20, P < 0.001). Whites were less likely to sustain small portion size change than other races (β = -0.269, 95% CI = -0.97 - -0.26). Conclusion: Based on this study's findings, MTM appears to be a robust theoretical framework for predicting small portion size consumption behavior change. Interventions in this regard need to be designed.
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Background: Most college students do not adequately participate in enough physical activity(PA) to attain health benefits. A theory-based approach is critical in developing effective interventions to promote PA. The purpose of this study was to examine the utility of the newly proposed multi-theory model (MTM) of health behavior change in predicting initiation and sustenance of PA among college students. Methods: Using a cross-sectional design, a valid and reliable survey was administered in October 2015 electronically to students enrolled at a large Southern US University. The internal consistency Cronbach alphas of the sub-scales were acceptable (0.65-0.92). Only those who did not engage in more than 150 minutes of moderate to vigorous intensity aerobic PA during the past week were included in this study. Results: Of the 495 respondents, 190 met the inclusion criteria of which 141 completed the survey. The majority of participants were females (72.3%) and Caucasians (70.9%). Findings of the confirmatory factor analysis (CFA) confirmed construct validity of sub-scales (initiation model: χ2 = 253.92 [df = 143], P < 0.001, CFI = 0.91, RMSEA = 0.07, SRMR = 0.07; sustenance model: χ2= 19.40 [df = 22], P < 0.001, CFI = 1.00, RMSEA = 0.00, SRMR = 0.03). Multivariate regression analysis showed that 26% of the variance in the PA initiation was explained by advantages outweighing disadvantages, behavioral confidence, work status, and changes in physical environment. Additionally, 29.7% of the variance in PA sustenance was explained by emotional transformation, practice for change, and changes in social environment. Conclusion: Based on this study’s findings, MTM appears to be a robust theoretical framework for predicting PA behavior change. Future research directions and development of suitable intervention strategies are discussed.
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In health education and health promotion an ideal theory is one that is exclusive to health behaviors, predicts health behavior change, is based on empirical evidence with health behavior changes, provides enough predictive power, is parsimonious, has constructs that are malleable, caters to both one-time and long-term health behavior change, works at individual, group and community levels, and is applicable across cultures. This commentary discusses the limitations of commonly used theories such as health belief model, transtheoretical model, PRECEDE-PROCEED and ecological models and proposes a framework for a new theory exclusive for health behavior change. Such a new theory will address both initiation and sustenance of health behavior change, will incorporate cognitive, conative, and environmental empirically tested components from existing theories, will be parsimonious, applicable at individual, group and community levels, will be culturally robust and useful for resource-scarce settings. http://www.webmedcentral.com/article_view/4982
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Issues: Despite a growing trend towards considering addiction as a chronic disease, the development of intervention models addressing the chronicity of substance use disorder is relatively new, and no literature review on this topic is available. The aim of this systematic review is to evaluate the efficacy of intervention models designed within the perspective of addiction as a chronic disease and those tailored to persons with substance use disorder who revolve in and out of treatment. Approach: Electronic databases were searched to identify articles published between 2000 and 2015 reporting an empirical study of an intervention model with data on its effectiveness. Study selection, data extraction and quality appraisal were performed independently by two reviewers. Key findings: The selection process yielded 16 studies meeting all the inclusion criteria. The intervention models were classified into four groups according to the duration, frequency and components of the interventions. In general, the models showed potential therapeutic effects. The outcomes tended to be positive immediately after the end of the treatment. However, months after, the benefits obtained during treatment did not persist. Implications and conclusion: The review highlights that models designed specifically for persons with multiple treatment re-entries are scarce, but promising. Further research is needed to determine the best match between the clinical profile of persons with substance use disorder and a model's components, intensity and duration. [Simoneau H, Kamgang E, Tremblay J, Bertrand K, Brochu S, FleuryM-J. Efficacy of extensive interventionmodels for substance use disorders: A systematic review. Drug Alcohol Rev 2017;00:000-000].
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The purpose of this article was to use the multitheory model of health behavior change in predicting adequate sleep behavior in college students. A valid and reliable survey was administered in a cross-sectional design (n = 151). For initiation of adequate sleep behavior, the construct of behavioral confidence (P <.001) was found to be significant and accounted for 24.4% of the variance. For sustenance of adequate sleep behavior, changes in social environment (P <.02), emotional transformation (P <.001), and practice for change (P <.001) were significant and accounted for 34.2% of the variance.