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 Application of the transtheoretical model of behavior change to consumption of fruits,

vegetables, and grain products among young adults

by

Susan Nyambura Maina

A dissertation submitted to the graduate faculty

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in partial fulfillment of the requirements for the degree of
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DOCTOR OF PHILOSOPHY
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Major: Family and Consumer Sciences Education

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Major Professor Rosalie J. Amos

Iowa State University

Ames, Iowa

1999

Copyright ® Nyambura Susan Maina, 1999. All rights reserved.

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 DMX Number: 9924743

Copyright: 1999 by

I EW
Maina, Susan Nyambura

All rights reserved.

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UMI Microform 9924743

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 Graduate College
Iowa State University

This is to certify that the Doctoral dissertation of

Susan Nyambura Maina

has met the dissertation requirements o f Iowa State University

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it / ^ ___
Major Professor
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^ortfeSS?
^ P ro g ra m
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the Graduate College

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 ili

TABLE OF CONTENTS

LIST OF FIGURES v

LIST OF TABLES vi

ABSTRACT vii

CHAPTER 1. GENERAL INTRODUCTION 1

Dissertation Organization 1
Need for Study 1
Conceptual Framework 3
Purpose o f the Study 6

CHAPTER 2. LITERATURE REVIEW 8

Introduction 8
Eating Habits of Americans 13

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Young Adults 15
Conceptualization of Food Consumption Behaviors 18
Stage of Change Theory IE 21
Transtheoretical Model of Behavior Change 24
Measurement 28
Validity 31
Reliability 34
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CHAPTER 3. DEVELOPM ENT AND VALIDATION O F AN INSTRUMENT 36

T O MEASURE STAGES O F CONSUMPTION, DECISIONAL BALANCE,
AND SELF-EFFICACY FOR FRUITS, VEGETABLES, AND GRAIN
PRODUCTS
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Abstract 36
Introduction 37
Research Methodology and Design 40
Results 47
Summary and Discussion 57

CHAPTER 4. RELATIONSHIPS AM ONG THE DECISIONAL BALANCE, 62

SELF-EFFICACY, AND STAGES O F CONSUMPTION O F FRUITS,
VEGETABLES, AND GRAIN PRODUCTS
Abstract 62
Introduction 63
Research Design and Methodology 66
Results 67
Summary and Discussion 75

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CHAPTERS. DEMOGRAPHIC PREDICTORS O F DECISIONAL BALANCE 80

AND SELF-EFFICACY FOR CONSUMPTION OF FRUITS, VEGETABLES,
AND GRAIN PRODUCTS AMONG YOUNG ADULTS
Abstract 80
Introduction 81
Research Design and Methodology 85
Results 86
Summary and Discussion 94

CHAPTER 6. SUMMARY, CONCLUSIONS, AND IMPLICATIONS 96

Summary 96
Findings and Conclusions 99
Implications for Nutrition Education 102
Implications for Research 103

APPENDIX A. QUALITATIVE INTERVIEW PROTOCOL 106

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APPENDIX B. SURVEY QUESTIONNAIRE 107

REFERENCES 114
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 LIST O F FIGURES

Figure 1. Theoretical model of hypothesized relationships among decisional balance,

self-efficacy, and stages o f consumption of fruits, vegetables, and grain
products

Figure 2. Food Guide Pyramid

Figure 3. Stages of Change Theory

Figure 4. Placement of the respondents into stages of consumption

Figure 5. Stages of fruit, vegetable, and grain products’ consumption

Figure 6. Pros and cons across the stages of consumption

Figure 7. Decisional balance across the stages of fruit, vegetable, and grain products

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consumption

Figure 8. Self-efficacy across the stages of fruit, vegetable, and grain products
consumption
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 LIST OF TABLES

Table 1. Demographic characteristics of respondents

Table 2. Factor Analysis of self-efficacy scales

Table 3. Factors analysis of the decisional balance scales

Table 4. Goodness of fit indices

Table 5. Internal consistency of the sub-scales

Table 6. Stages of consumption as predictors of pros, cons, and self-efficacy

Table 7. Demographic characteristics of respondents

Table 8. Predictors of decisional balance and self-efficacy for grain products

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consumption

Table 9. Predictors of decisional balance and self-efficacy for vegetable consumption

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Table 10. Predictors of decisional balance and self-efficacy for fruit consumption
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 ABSTRACT

In this study the transtheoretical model for behavior change was applied to the consumption of

fruits, vegetables, and grain products among young adults. The criterion behavior was the

consumption of the recommended number of servings described in the United States

Department of Agriculture Food Guide Pyramid. Three major constructs— stages of

consumption, decisional balance, and self-efficacy—were used. Specific objectives were:

develop and validate an instrument to measure the three constructs; use it to measure

consumption for fruits, vegetables, and grain products among young adults; examine

relationships among the three constructs and among all variables; make recommendations for

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nutrition education and research. Measuring scales were developed for the decisional balance

and self-efficacy portion of the A stage of consumption algorithm was used to

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in s tru m e n t.

assess the stages of consumption. From 800 surveys mailed to a randomly selected sample of
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young adults, 18 to 24 years old, 116 usable (14.5%) questionnaires were returned. Factor and

reliability analyses were conducted to assess the psychometric properties of the instrument.

Decisional balance emerged as two factors— the positive and negative perceptions of increasing
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consumption. Self-efficacy emerged as one general factor. Confirmatory factor analysis indices

indicate the data fit the hypothesized model adequately for the three food groups (AGFI >0.80).

The instrument exhibited moderate to excellent internal consistency for perceived advantages (a

= 0.47 to 0.63), perceived disadvantages (<x> 0.70), and self-efficacy scales (o£> 0.88). T he results

of multivariate analysis of variance indicate that decisional balance and self-efficacy scores differ

as stages of consumption change. The perceived advantages and self-efficacy scores increased

while scores on perceived disadvantages decreased from precontemplation to m a in te n a n c e

stages with the exception of the action stage for fruits and grain products. A t the action stage,

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 the perceived disadvantages increased, with a corresponding decrease in perceived advantages

for grain products. Hispanic origin, gender, race, current relationship status, and living

arrangements were significant predictors of either decisional balance and/or self-efficacy among

young adults. The results have implications for nutrition education and research.

Keywords: transtheoretical model, stages of consumption, decisional balance, self-efficacy,

instrument development, young adults

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CHAPTER 1. INTRODUCTION

Dissertation Organization

This dissertation consists of an abstract, introduction, review of literature, three

individual manuscripts, and conclusions and implications. The introduction includes the

conceptualization of the research problem. The literature review discusses eating habits of

Americans, conceptualization and measurement of food consumption, the transtheoretical

model, the notion of measurement, and attributes of good measuring tools in the social sciences.

The first manuscript is titled “Development and validation of measures of stages of

consumption, decisional balance, and self-efficacy for consumption of fruits, vegetables, and

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grain products among young adults.” The second manuscript is tided “Application of the

transtheoretical model to the measurement of consumption of fruits, vegetables, and grain

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products.” The third manuscript is tided, “Predictors of decisional balance and self-efficacy for
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increasing consumption of fruits, vegetables, and grain products among young adults.” These

manuscripts are suitable for presentation to the Journal o f Health Psychology, Journal c f Family and

Consumer Sciaxes, and American Journal c f Health Promotion. All references are listed in a final
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reference section.

Need for Study

Great emphasis is placed on increasing the consumption of foods of plant origin in the

Dietary Guidelines for Americans established by the United States Department of Agriculture

(USDA) in 1992 These dietary guidelines were designed to help Americans choose diets to

meet nutrient requirements, promote health, support active lives, and reduce the risks of chronic

diseases. The place o f fruits, vegetables, and grain products as the foundation of a healthy diet

also is emphasized in other dietary recommendations such as the Food Guide Pyramid (FGP)

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(USDA, 1995). The FGP, an outline o f foods to eat each day based on the dietary guidelines,

indicates th a t foods from the grain products group, along with vegetables and fruits, are the

basis for a healthy diet. These foods o f plant origin are emphasized in the FGP because they

provide vitam ins, m inerals, complex carbohydrates, and other substances important for good

health (Harris, 1996).

Even though adequate consumption of these foods is associated with a substantially

lowered risk for many chronic diseases such as obesity, high blood pressure, and high blood

cholesterol, national surveys illustrate that, for most Americans o f all ages, the diet includes too

few fruits, vegetables, and grain products (Huang, Song, Schemmel, & Hoerr, 1994; Patterson,

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Block, Rosenberger, Pee, & Kahle, 1990). As such, there is a gap between the recommended

and actual intake of these foods. This suggests that past methods of delivering nutrition
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education messages have not been effective in promoting positive behavior change. Different
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ways of defining, measuring, and monitoring nutrition behavior, and of education, appear

needed.

The need for new approaches becomes even more critical with the increased recognition
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that food choices and good diets can help reduce risk factors for chronic diseases. An

individual’s personal history is identified as the primary source of factors shaping food choice

(Furst, Connors, Bisogni, Sobal, & Falk, 1996). Related to this, factors such as emotional

attachment, habit, resources, and convenience have been identified as important in

understanding and assessing food behaviors of people in general, but especially among young

adults (Georgiou, Betts, Hoerr, Keim, Peters, Stewart, & Voichick, 1997; Keim, Stewart, &

Voichick, 1997). They are making the transition from parental control of their food intake to

being responsible for their own and possibly, that of their children as well (Lau, Quardel, &

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Hartman, 1990; Mitchel, Herzler, & Webb, 1994). The food habits formed by young adults at

this stage also will become a foundation for future practices that will affect their health

throughout life because food behaviors adopted at this stage may become lifelong habits.

C onceptual Fram ework

Nutrition educators have a significant challenge in fin d in g appropriate conceptual

models to use in organizing nutrition curricula and content. Their goal is to teach in ways that

incorporate indicators of good dietary habits and guide their adoption to reduce health risk

factors. One framework that has been applied to education leading to change toward healthier

food choice behavior is the transtheoretical model ( l 'l ’M) (Rossi, Prochaska, & Didemente,

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1988; McDonnell, Achterberg & Clark, & Bagby 1998; Sandoval, Heller, Wiese, & Childs, 1996;

Spomy, & Contento, 1995; Prochaska, DiClemente, & Norcross 1992a). The stage of change is
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the central organizing construct of the T IM (Prochaska, & DiClemente, 1992; Prochaska,
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Redding, & Evers, 1997a; Prochaska, & Velicer 1997b).

The T IM proposes that people pass through a series of five stages in the course of

changing health-related behaviors and also postulates intermediate or dependent variables. In

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this study, the stages of change have been defined as stages of consumption because they have

been applied to food intake:

• precontemplation: consumption is lower than recommended and the person has with no

intent to increase consumption at all.

• contemplation: consumption is lower than recommended and the person has no intent to

increase it within six months.

• preparation: consumption is lower than recommended and the person in te n d s to increase it

within thirty days.

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• action: consumption is equal to or higher than recommended and the person has consumed

at this level for less than six months.

• mamtmanCT; consumption is equal to o r higher than recommended and the person has

been consuming at this level for more than six months.

These stages of consumption can be used to design research techniques to directly observe and

readily measure current behavior and intentions about future behavior (DiClemente &

Prochaska, 1982; Norman, Velicer, Fava, 1998).

The relative significance of psychosocial constituents of behavior such as attitudes, social

influences, self-efficacy, and outcome prospects has been found to differ across the different

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stages of change for most health behaviors (Brug, Glanz, & Kok, 1997; Glanz, 1994). With
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regard to food consumption behavior, researchers have explored the potential of incorporating

these constituents with the I'lM for studying dietary change. Previous studies have only
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attempted to place people into stages of change (Greene, Rossi, & Reed, 1996; McDonnell, et

aL, 1998; Sandoval, et al, 1996; Sporny, & Contento, 1995). However, researchers are urged to

extend the use of the model to include other important constructs, especially decisional balance
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and self-efficacy; hence the term transtheoretical. These two constructs explain movement from

one stage to another and are empirically associated with the stages of consumption (Prochaska &

Velicer, 1997b; Prochaska, 1985; Prochaska & DiClemente 1992; Prochaska, Redding, & Evers,

1997b; Prochaska, 1994; Velicer, DiClemente, Prochaska, & Brandenberg, 1985).

Decisional balance denotes that either positive (pros) or negative (cons) perceptions

about a target behavior, as well as the perception of potential success changing current behavior,

can be held by a person (Jannis & Mann, 1977; Rakowski, Stoddard, Rimer, Fox, Anderson,

Urban, Lane & Costanza, 1997). Results of several studies have suggested that as one progresses

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from a less to a more committed stage o f change, such as precontemplation to m a in te n a n c e ,

decisional balance also changes from more negative (cons) to more positive (pros) perceptions

of change (Rakowski, Fulton, & Feldman, 1993, Rakowski, et aL, 1997). The person weighs the

advantages (pros) and disadvantages (cons) of increasing consumption of grain products,

vegetables, and fruits, for example, perhaps deciding to change the balance Qannis & Mann,

1977).

Self-efficacy is the situation-specific confidence people have that they can cope with

high-risk situations without relapsing to an unhealthy habit (Bandura, 1977). For example,

young adults have a level of confidence related to improved consumption of fruits, vegetables,

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and grain products that varies from one individual to another and that may be changed by
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education and other circumstances. The decisional balance and self efficacy variables are

therefore viable constructs when using the TTM to study behavior with the goal of suggesting
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new interventions for modifying behavior.

Research using the TTM model has focused primarily on unhealthy, addictive behaviors

such as smoking, overeating, alcohol abuse, and drug addiction (Prochaska, 1985; Prochaska &
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DiClemente, 1992; Prochaska & Velicer, 1997a). Few studies have focused on the promotion of

healthy behaviors. However, researchers suggest that because the TTM model has been

successful with the cessation of unhealthy behaviors it also might work for the promotion of

healthy behaviors (Herrick, Stone, & Mettler, 1997; Sigman-Grant, 1996). The acquisition of a

healthy behavior also can be viewed as the cessation of an unhealthy behavior.

Research about the needs of various target audiences for nutrition education and

appropriate delivery methods ranks as a challenge for nutrition educators. Using the stage of

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consumption model and the constructs of decisional balance and self-efficacy in research modes

to study new problems, settings, and populations are needed.

Employing the T IM as a conceptual framework provides a means of assessing young

adults’ readiness and intention to increase consumption of fruits, vegetables, and grain products.

Once the assessment has been made, individuals can be better helped to increase consumption

of fruits, vegetables, and grain products. The appropriate information and support to be

provided at the appropriate stage of change, will be more apparent. Efforts toward behavior

change as a goal of nutrition education will then more effectively reduce the gap between level

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Purpose of th e Study

The purpose of this study was to extend the research on the application of TTM
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constructs to measure consumption behaviors for grain products, vegetables, and fruits among
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young adults ages 18 to 24 years. The criterion behavior was the consumption o f the

recommended number of servings of fruits, vegetables, and grain products as described in the

FGP. The TTM has appeal because it merges key theories o f human behavior to explain why
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and how behavior change occurs.

This study used the three major constructs in the TTM—stage of consumption,

decisional balance, and self-efficacy— to guide the development of an instrument that applies the

TTM to the consumption of fruits, vegetables, and grain products. The dependent variables are

decisional balance and self-efficacy; the independent variables are the stages of change and

demographic variables. Demographic variables were taken as exogenous variables because their

causes lie outside the transtheoretical model and are not influenced by variables in the model

(Figure 1).

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Decisional Balance

Stage of
Consumption

Self efficacy

Figure 1. Hypothesized relationships among stages of consumption o f grain products,

vegetables, and fruits; decisional balance; self-efficacy; and demographic characteristics

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Specific objectives o f the study were to: IE
1. develop and validate an instrument to measure stages of consumption, decisional

balance, and self-efficacy for consumpdon of fruits, vegetables, and grain products.
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2. use the instrument to gather data about stages o f consumpdon for fruits,

vegetables, and grain products, and decisional balance and self-efficacy.

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3. examine the relationships among decisional balance, self-efficacy, and stages of

consumpdon for fruits, vegetables, and grain products in relation to the transtheoretical model

4. determine if demographic characteristics o f young adults are associated with

differences in decisional balance and self-efficacy as they im p a c t stages of consumption for

fruits, vegetables, and grain products.

5. based on fin d in g s m a k e re c o m m e n d a tio n s for c h a n g es and new directions for

nutrition education and n u tritio n education research.

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CHAPTER 2. LITERATURE REVIEW

Introduction

This chapter reviews literature related to the question of what is adequate consumption

of fruits, vegetables, and grain products as defined by the Dietary Guidelines for Americans

(United States Department of Agriculture (USDA), 1992, 1995). Trends related to consumption

of fruits, vegetable, and grain products in general, and among young adults in particular, are

discussed. Further, literature related to stages of change theory and the transtheoretical model

of behavior change is reviewed (Prochaska, Redding, & Evers, 1997a). Finally, literature on

measurement and characteristics o f good measuring tools is presented.

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Research fin d in g s have demonstrated that low consumption of foods from plant origin

is a risk factor for the development of diet-related problems such as cancer, diabetes, obesity,
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and heart diseases (National Research Council, 1997; Frazao, 1995). Obligated to continually
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inform the American public about an adequate diet, the United States Department of

Agriculture developed dietary guidelines (USDA, 1995). The dietary guidelines are an aid to help

Americans choose diets that will meet nutrient requirements, promote health, support active
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lives, and reduce chronic disease risks (USDA, 1992; Kantor, 1996).

To reinforce the dietary guidelines, food recommendations in the Food Guide Pyramid

(FGP) were designed to stress the recommended number of servings per day as a basis for

healthy diets (Welsh, 1994). The FGP uses realistic, typical household measures such as cups

and slices of food to define serving sizes, with the understanding that such measures are easy to

determine and create meaning.

Although the consumption of plant foods is associated with a substantially lower risk for

many chronic diseases, current food consumption patterns are not consistent with these

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 9

guidelines (Breslow, Subar, Patterson, & Block, 1997). Most Americans of all ages eat fewer

than the daily-recommended number of servings o f grain products, vegetables, and fruits

(Harris, 1996, p. 21).

The ultimate goal of nutrition guidance is sustained behavior change, with the intent of

accelerating the shift toward healthful diets. The ability to influence food choices or change

behavior is increasingly h e m m in g a great challenge. Many mediating factors that would make

healthy food choices possible also influence one’s ability to achieve and sustain behavioral

change: cognitive, affective, and behavioral skills; current practices; personal factors such as

behavioral intent; behavioral expectancies; health values; self-efficacy; and environmental

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support (Prochaska, DiClemente, Velicer, & Rossi, 1997; Schwartz, 1996). The gap between
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nutrition knowledge and food choice behavior implies that modes of communicating nutrition

information are not effective in promoting changes in food consumption.

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Understanding how people decide what to eat and the reasons for these decisions are

prerequisites to undertaking any effort to change behavior. N o doubt, the dietary guidelines and

recommendations are an integral part of nutrition policy and education. However, dietary
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guidelines must be behaviorally focused to make a difference (American Dietetics Association,

1996). The key to success in nutrition communication is a clear understanding of the desirable

outcome or impact on the target audience (Schwartz, 1996). That is, the behaviors addressed

through nutrition messages should be drawn from the needs, perceptions, and experiences of

the target audience as well as from national health goals (USDA, 1995).

Although success in dietary change rests on individuals adopting and m a in ta in in g

specific behaviors, few nutrition interventions are grounded in theories of behavior change

(Galavotti et aL, 1995). The development, refinement, and evaluation of such programs are

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severely hampered by the lack o f systematic frameworks for positing which factors are

transformable as a result of intervention, and for measuring program effect. The American

Dietetics Association (1996) emphasized the need to go beyond providing information to

incorporating methods for actually creating behavior change. Can nutrition education make a

difference? This question raises a further question of “make a difference to what?” and draws in

the issue o f how this difference can be measured and attributed to the educational interventions.

A dequate consum pdon

The quesdon of what should one eat to be healthy was addressed in 1980 by nutrition

scientists from the USDA and the Department of Health and Human Services (DHHS). The

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notion of adequate food consumption underlies the concept of achieving adequate nutrition.

Consequently, the concept of adequacy implies a diet that assists the public in achieving and
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maintaining optimal nutritional health. The acknowledgment of the critical role played by diet in
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health promotion and disease prevention prompted the development of dietary guidelines. The

dietary guidelines are supported by a rich history of science-based research. In 1995, the United

States released its fourth set of dietary guidelines since 1980. The audience for these guidelines
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is all Americans. The USDA/DHHS dietary guidelines for Americans are:

1. Eat a variety of foods.

2. Balance the food you ear with physical activity-maintain or improve your weight.

3. Choose a diet with plenty of grain products, vegetables, and fruits.

4. Choose a diet low in fat, saturated fat, and cholesterol.

5. Choose a diet moderate in salt and sodium.

6. If you drink alcoholic beverages, do so in moderation (USDA, 1995).

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As in previous guidelines, the above guidelines emphasize variety, balance, and

moderation in the total diet. The first two focus on variety and weight maintenance. The

remaining four guidelines describe specific characteristics of a good diet.

Researchers have noted the need to go beyond information to provide methods and

strategies that prom ote behavior change (Cullen, Bartholomew, Parcel, & Kok, 1998).

Information from the American Dietetic Association (ADA) further explains that what

consumers want are food guidelines translated into behaviors, directions, and how-tos (ADA,

1996). This is an indication that dietary guidelines, such as consuming plenty of vegetables, grain

products, and fruits, are not directly meaningful to consumers because the information is not

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framed in terms of consumers' actions (ADA, 1996). With this in mind, the United States

Department of Agriculture developed the FGP. In April 1992, USDA officially released
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revisions in the government's nutrition recommendations (Welsh, 1994). The old "four food
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groups" concept was replaced with the new FGP.

Based on current research about diet and disease, these new recommendations place

greater emphasis on fruits, vegetables, and grain products, and less emphasis on animal products
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such as meat and dairy. Forming the base of the pyramid is the bread, cereal, rice, and pasta

group. The second largest layer is for fruits and vegetables. USDA recommends the most (6 to

11) servings from grain products, 3-5 servings from vegetables, and 2-4 servings from the fruits

group each day because foods in these groups are an excellent source of complex carbohydrates

(important for energy, especially in low-fats and sugars).

The FGP is a graphic illustration to help people choose what and how many servings to

eat from each food group (Figure 2). Those who adhere to the general guidelines set forth by

the FGP should get the nutrients they need without too marry calories or too m u rh fat, saturated

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Fate, Oils & Sweats Group

□ Fat (naturaly ocavng and added)
Use Sparingly D Sugars (added)

Milk, Yogurt & Meat, Poultry. Dry Beans,

Cheese Group Eggs & Nuts Group
2-3 Seivings 2-3 Seivings

Vegetable k Fruit Group

Group Jk 2-4 Seivings
3-5
Seivings

k Bread, Cereal

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■Rice & Pasta
k Group
^ 6-11
^Seivings
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Figure 2. Food Guide Pyramid (USDA, 1995).

fat, cholesterol, sugar, sodium, vitamins, minerals, and fiber alcohol (ADA, 1996). At the same
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time, these foods are naturally low in fat, sugar, and sodium. The serving sizes are given only as

a general guideline.

In this study, the FGP was used as a behavioral marker for the criterion of adequate

food consumption for the following reasons:

1. The FGP clearly illustrates that foods from the grain products group, along with

vegetables and fruits, are the basis of healthy diets. Figure 2 depicts these foods as separate and

distinct foods; shape illustrates the relative proportions of each food group in a healthy diet.

These three food groups along with others provide vitamins, minerals, complex carbohydrates,

and other substances that are important for good health.

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2. The FG P emphasizes variety in the diet with grain products, vegetables, and

fruits as key components. The emphasis is not only on the different kinds of food, but also on

the variety within each food group. One can achieve a healthful, nutritious eating pattern by

choosing a variety of foods within and across food groups.

3. The FG P is an easy way to make healthy food choices. The recommended

number of servings range from a low to a high value. This allows for flexibility in the level of

consumption for age, size, and level of activity. Furthermore, the recommended numbers of

servings are in typical and familiar household size measures such as cups, slices of bread, or

whole fruit—measures that are meaningful and realistic to consumers.

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For most people, it is unnecessary to actually measure each serving of food. The familiar
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units facilitate an easy way to self-assess the adequacy of one’s diet. The use of the pyramid as a

dietary behavioral marker eventually should lead individuals closer to meeting the dietary
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guidelines. It would ensure that not only are a variety of foods consumed, but also that a diet

with plenty of vegetables, fruits, and grain products is consumed.

Eating Habits of Americans

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According to the U.S. Surgeon General, the three most important personal habits that

influence health are smoking, alcohol consumption, and diet. For two out of three adults who

do not drink excessively o r smoke, the single most important personal choice in flu e n c in g one’s

long-term health is what one eats. The Surgeon General’s Report on Nutrition and Health

(USDHHS, 1988) establishes the fact that two-thirds o f all d e a th s — in clu d in g coronary heart

disease, stroke, atherosclerosis, diabetes and some types o f cancer— are related to what people

eat.

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