Readiness to Change Among a Group of Heavy-Drinking College Students: Correlates of Readiness and a Comparison of Measures

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  • This article was downloaded by: [The UC Irvine Libraries]On: 07 November 2014, At: 20:13Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41Mortimer Street, London W1T 3JH, UK

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    Readiness to Change Among a Group of Heavy-DrinkingCollege Students: Correlates of Readiness and a Comparisonof MeasuresT. Robert Harris PhD a , Scott T. Walters PhD b & Matthew M. Leahy MA ca The University of Texas School of Public Health, Dallasb Health Promotion and Behavioral Sciences, The University of Texas School of Public Healthc Department of Psychology, Southern Methodist University, Dedman College, DallasPublished online: 06 Aug 2010.

    To cite this article: T. Robert Harris PhD , Scott T. Walters PhD & Matthew M. Leahy MA (2008) Readiness to Change Among a Group ofHeavy-Drinking College Students: Correlates of Readiness and a Comparison of Measures, Journal of American College Health, 57:3,325-330, DOI: 10.3200/JACH.57.3.325-330

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  • 325

    Abstract. Objective: Although several multi-item scales assess readiness to change alcohol consumption, some researchers have proposed that a small number of single-item rulers may assess readiness nearly as well. Participants: In fall 2006 and spring 2007, the authors assessed 279 participants who reported at least 1 heavy drinking episode in the 2 weeks prior to the survey. Methods: The authors compared answers from the Readiness to Change Questionnaire with rulers measuring importance and confidence regarding change. Results: Importance correlated strongly with readiness to change, whereas confidence correlated negatively and less strongly with readiness. The validity of the importance ruler as a proxy for readiness was supported by its correlations with several measures of patterns of alcohol use, as well as its precur-sors and consequences. Conclusions: Given the strong correlation between the importance ruler and the Readiness to Change score, this method may have practical utility as a brief assessment tool. Adding confidence as a second dimension slightly improved the ability to predict readiness.

    Keywords: alcohol, college, drinking, motivation

    eavy drinking has become a familiar feature of college life. Approximately 75% of college stu-dents drink alcohol, and depending on the metric,

    between 47% and 76% of college men and 30% and 55% of college women engage in heavy drinking episodes.1,2 More-over, researchers have estimated that nearly 1 in 3 college students meet the definition of alcohol abuse and that 1 in 17 could be diagnosed as alcohol dependent.3 Heavy alco-

    H

    Readiness to Change Among a Group of Heavy-Drinking College Students: Correlates of

    Readiness and a Comparison of Measures

    T. Robert Harris, PhD; Scott T. Walters, PhD; Matthew M. Leahy, MA

    hol consumption among college students is associated with a number of social, academic, and legal consequences.4,5

    The concept of readiness to change has gained popular-ity in recent years as a way to understand how and why drinkers change behavior.6 Most researchers have used readiness to change measures based on Prochaska et als transtheoretical model,7 which suggests that individuals move through stages when thinking about change. Stages range from precontemplation about changing, to contem-plation, to preparation, to action and maintenance. Because it specifies cognitive tasks associated with each stage, the model lends itself to stage-specific interventions. Research suggests that interventions tailored to a persons stage of change are generally more effective than those that are not stage matched.8,9

    At the college level, students who drink more and have more problems tend to report greater levels of readiness to change.10 This is consistent with the idea that negative con-sequences may lead to realization of the need to cut back on alcohol consumption10,11; however, researchers have also found that negative consequences often are not enough to influence motivation.10,12 For example, two-thirds of heavy- drinking college students are in the precontemplation stage of change, even though most report some negative conse-quences as a result of drinking.10

    A reliable method of assessing readiness to change would identify and address student drinking in the most prudent manner possible. Researchers have developed sev-eral measures of motivation to change, including the 12-item Readiness to Change Questionnaire (RTCQ),13 the 19-item Stage of Change Readiness and Treatment Eager-ness Scale (SOCRATES),14 and the 32-item University of Rhode Island Change Assessment (URICA).15 Research-ers designed the SOCRATES and RTCQ specifically to examine motivation to change alcohol use, whereas the

    Dr Harris is an associate professor of biostatistics at the University of Texas School of Public Health, Dallas. Dr Walters is an associate professor of Health Promotion and Behavioral Sciences at the University of Texas School of Public Health. Mr Leahy is a clinical psychology doctoral student at Southern Methodist University, Dedman College, Department of Psychology, Dallas.

    Copyright 2008 Heldref Publications

    JOURNAL OF AMERICAN COLLEGE HEALTH, VOL. 57, NO. 3

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    Harris et al

    URICA can be adapted to assess other problem behaviors. All have demonstrated adequate reliability and validity in previous studies.16

    When dealing with college students in everyday practice, clinicians may benefit from a quicker way of assessing motivation to change. One method, the use of readiness rulers, typically assesses how ready participants are to change or how confident they are in their ability to change, on a scale ranging from 1 to 10. Investigators developed the rulers to assess smoking cessation during brief medical consultations,17 and others have used them in studies on smoking, alcohol use, HIV risk, and other health behav-iors18,19 and have found them to be associated with ques-tionnaires that assess readiness to change. Some research has differentiated between 2 rulersimportance of change and confidence in the ability to change ones behaviorthat may independently predict change and thus be useful for tailoring interventions.20

    In the present study, we built on the assumption that readiness to change rulers are as reliable and valid as are more lengthy questionnaires. We hypothesized that 2 readi-ness rulersimportance and confidencewould be associ-ated with a longer questionnaire that assesses readiness to change and that the rulers would also be associated with students reports of background factors and current behav-iors indicating alcohol-related risk. We used data from a study of heavy-drinking college students,21,22 an important at-risk population for which readiness to change and its measurement are important issues.

    METHODS

    ParticipantsWe used data from a clinical trial in which researchers

    are investigating the effects of motivational interviewing -(MI) and personalized feedback on heavy drinking college students. For the current analyses, we used participants baseline information.

    The researchers recruited participants from a private university in the southern United States during the fall of 2006 and spring of 2007. Participants were aged at least 18 years and reported at least 1 heavy drinking (binge) episode in the past 2 weeks. A heavy drinking episode was defined as 5 or more drinks in a single episode for men and 4 or more drinks in a single episode for women.23 In the parent trial, investigators used a variety of methods to inform stu-dents of the opportunity to participate, including invitation e-mails to undergraduate psychology students, brief pre-sentations in undergraduate health and psychology courses, and flyers posted across campus. All participants provided informed consent, and the Institutional Review Boards of the University of Texas Health Science Center at Houston and the university from which participants were recruited approved the study.

    MeasuresWe assessed alcohol use via a modified version of the

    Daily Drinking Questionnaire.24 To calculate estimated

    past-month peak blood alcohol concentration (BAC), we used participants self-reported weight and sex, along with the number of drinks and hours spent drinking during the participants heaviest drinking episode. Participants also indicated the number of times they had engaged in heavy drinking episodes during the past 2 weeks and past month.

    Genetic risk of alcoholism, a potential correlate of readi-ness, was determined by the number of blood relatives that participants indicated were or had been problem drinkers or alcoholics. We modified the specific procedures for estimat-ing genetic risk from Project MATCH.25

    We determined participants protective behaviors via the 15-item Protective Behavioral Strategies Survey (PBSS).26 Participants indicated the extent to which they had used a range of protective behaviors in the past 3 months while drinking. The PBSS has shown adequate reliability in previous studies.26,27 In the present study, = .86 for the total scale.

    We measured drinking-related consequences via the 23-item Rutgers Alcohol Problem Index (RAPI).28 The RAPI consists of questions that tap physical, social, and legal consequences of drinking and has shown adequate reliabil-ity and validity in previous studies.29,30 In the present study, = .87 for the scale.

    We measured drinking severity via the 10-question Alcohol Use Disorders Identification Test (AUDIT).31

    The AUDIT has shown acceptable internal consistency and validity among college students.2734 In the present study, =.77.

    We measured readiness to change in 2 ways. First, participants completed the 12-item RTCQ.13 The RTCQ contains three 4-item scales that assess levels of precon-templation, contemplation, and action. The RTCQ has demonstrated adequate internal consistency and testretest reliability13 and strong predictive validity.14,35 In the present sample, reliability (Cronbach alpha) for the precontem-plation, contemplation, and action subscales was .64, .79, and .80, respectively. We calculated the total RTCQ score by subtracting the precontemplation subscore from the sum of contemplation and action subscores. Reliability for the RTCQ total score was .86. As a second measure of readi-ness to change, participants answered 2 scaled questions (How important is it to make a change in your drinking? and How confident are you that you could make a change in your drinking if you wanted to?) on a 10-point Likert scale ranging from 1 (not important/confident at all) and 10 (the most important/confident). Previous researchers have used similar procedures and generally reported adequate reliability and validity.16

    RESULTSThe sample consisted of 279 participants. Sixty-five per-

    cent of participants were female, the majority (86%) were of white ethnicity, and the mean age was 19.8 (SD = 2.0) years. In terms of stage of change, 162 (58.1%) were in the precontemplation stage, 50 (17.9%) were in the contempla-tion stage, and 67 (24.0%) were in the action stage. For the

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  • VOL 57, NOVEMBER/DECEMBER 2008 327

    Readiness to Change

    total sample, the mean score for importance of change was 3.45 (SD = 2.35) and mean score for confidence in being able to change was 8.78 (SD = 1.83; on a 110 scale). As shown in Table 1, importance was lowest for students in the precontemplation stage and highest for those in the contemplation stage, with the reverse pattern for confidence (F[2, 276] = 76.1 for importance and F[2, 276] = 12.0 for confidence; for both, p < .01). Using a BonferroniHolm adjustment, we found that pairwise differences were signifi-cant at the .05 level, except contemplation versus action for the importance ruler.

    Table 2 shows correlations between the rulers, RTCQ subscale scores, and total score. Students expressing great-er importance of change had less confidence in the ability to do so (r = .20). The total Readiness to Change score was correlated with importance (r = .70) and confidence (r = .34). Using linear regression to predict the total readiness score, we found that the adjusted R2 when using importance alone as a predictor was .484; this increased to .523 with the addition of confidence as a predictor. Table 3 shows coefficients for the latter regression. An analysis of residuals suggested a curvilinear relationship between the Readiness to Change score and importance, and adding a quadratic term in importance to the regression increased adjusted R2 to .541. Each additional predictor was highly significant (p < .01), although the increase in variance explained may not justify the increased model complexity. In a multinomial logistic regression analysis, importance and confidence were predictive of stage of change in 186 of the 279 cases.

    Like the correlation of importance with the total readi-ness score, its correlations with RTCQ subscores were positive (except for precontemplation, which is scored in the opposite direction). Confidence was negatively corre-lated with the total readiness score and subscores (except precontemplation). Importance was correlated with precon-templation (r = .60) and contemplation (r = .62), and less strongly with action (r = .51). The same general pattern held for confidence, although the correlations were much lowerbetween .3 and .4 for the total score and all sub-scores except action.

    The rulers validity and utility may also be inferred from their correlations with other potentially related variables: genetic risk of alcohol abuse, drinking pat-tern (eg, drinks per week, heavy drinking episodes, peak BAC, protective behaviors), and indications of problem-atic drinking (eg, scores on the RAPI, AUDIT). Table 4 shows correlations of the rulers and readiness score with these variables. The strongest correlates of readiness and the rulers were RAPI and AUDIT scores. Readiness was not significantly correlated with protective behaviors. The other variables correlated in the same direction, although less strongly, with importance and with readi-ness. Confidence was more highly correlated than was importance with family risk, peak BAC, and RAPI and AUDIT scores, despite the fact that importance was more strongly correlated with readiness. Interestingly, confi-

    dence was more highly correlated with peak BAC than was readiness and was the only significant correlate of protective behaviors.

    COMMENTWe found that participants importance estimates cor-

    related strongly with readiness to change, whereas confi-dence estimates were negatively and less strongly corre-lated with readiness. The validity of the importance ruler as a proxy for readiness was also supported by its correlations with several measures of patterns of alcohol use, as well as its precursors and consequences. Given the strong cor-relation between the importance ruler and the readiness to change score, and the substantially smaller burden on sur-vey administrators, this method may have practical use as an assessment instrument. Adding confidence as a second dimension of assessment slightly improved the ability to predict readiness.

    It is interesting that both rulers correlated less strongly with the action subscore than with the other subscores. It may be that, for students who have already made changes in their drinking, the rulers are difficult to interpret because they ask about making future changes in drinking. This may indicate that the rulers are less appropriate for the relatively small number of students who have already made changes. Further evidence for a complex rulerstage-of-change rela-tionship comes from the significant quadratic effect of importance in predicting readiness and also from the cur-vilinear relationship of mean importance and confidence with stage of change (see Table 2). Although the contempla-tionaction difference in importance was not significant in our sample, Williams et al20 reported the same pattern. By definition, people in the precontemplation stage see little importance or need for change. However, compared with students in the contemplation stage, those in the action stage may see less urgency in making further change. The curvilinear pattern for confidence also seems reasonable. Perceived risk of alcohol dependence may be one important factor leading to students contemplating change, account-ing partially for the lower levels of confidence among those in the contemplation compared with those in the precon-templation stage. Furthermore, change may appear more difficult once a person sets a timeline for change or begins to consider the steps he or she will need to make to achieve change. An increase in the level of confidence as people move from contemplation into action may be the result of experiencing some early successes.

    Consistent with previous findings,8,10,14,36 we found strong correlations between readiness to change and both the RAPI and AUDIT scores. This finding suggests that experiencing drinking-related consequences may lead to a students readiness to change. Readiness was also correlat-ed with genetic risk and drinking pattern (drinks per week, number of bingeing episodes, peak BAC). Importance was similarly correlated with most of these variables, which is consistent with the idea that importance is an approximate measure of readiness. Confidence tended to be correlated at

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    Harris et al

    TABLE 1. Mean Importance and Confidence Ruler Scores for the Total Sample and Readiness to Change Stages

    Importancea Confidencea

    Stage of change M SD M SD

    Precontemplation 2.27 1.58 9.17 1.48Contemplation 5.42 2.53 7.82 2.48Action 4.82 2.02 8.55 1.76Total 3.45 2.35 8.78 1.83

    aAnchor points: 1 (not at all important/confident) to 10 (very important/confident).

    TABLE 2. Correlations of Importance and Confidence Rulers, Readiness to Change Subscores, and Total Score (N = 279)

    Variable 1 2 3 4 5 6

    1. Importance 2. Confidence .197** 3. Precontemplation .603** .352** 4. Contemplation .623** .377** .735** 5. Action .506** .126* .368** .470** 6. Total readiness .697** .336** .819** .883** .773**

    *p < .05. **p < .01.

    TABLE 4. Correlation of Importance and Confidence Rulers and Readiness to Change Score With Genetic Risk, Drinking Patterns, and Drinking-Related Behaviors (N = 279)

    Variable Importance Confidence RTCQ Total

    Genetic risk .068 .176** .155*Drinks per week .141* .137* .231**Heavy episodes .161** .126* .262**Peak BAC .094 .216** .151*Protective behaviors .096 .161** .034RAPI .255** .317** .391**AUDIT .238** .396** .436**

    Note. AUDIT = Alcohol Use Disorders Identification Test; BAC = blood alcohol content; RAPI = Rut-gers Alcohol Problem Index; RTCQ = Readiness to Change Questionnaire.*p < .05. **p < .01.

    TABLE 3. Regression of Total Readiness to Change Score on Importance and Confidence Rulers

    Variable B SE t p

    Intercept 4.118 1.808 2.278 .024Importance 2.223 0.143 .656 15.524 < .001Confidence 0.898 0.184 .207 4.887 < .001

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  • VOL 57, NOVEMBER/DECEMBER 2008 329

    Readiness to Change

    least as highly as importance with these variables, and, in some cases, confidence was more strongly correlated with variables than was readiness itself. This occurred despite the fact that the importance ruler was better correlated with readiness. Confidence may tap important information not contained in the RTCQ. For example, it may reflect a gen-eralized sense of self-efficacy not specific to alcohol use. Furthermore, high levels of family risk could erode such efficacy, as could alcohol-related consequences. However, heavy drinking could be, in part, a consequence of low efficacy; for example, an alternative method of reducing the pain of unpleasant life circumstances for those who do not envision other instrumental actions to change them. In this scenario, the positive correlation of level of confidence with protective behaviors is reasonable. Confidence may be partly an internal psychological state and partly a reflection of social support from family, peers, or others.

    Our study is limited in several ways. First, our findings might be partially a function of the study population, which was self-selected from undergraduate students at a private, southern US university. Furthermore, the way in which the investigators administered the rulers may have influenced the results. Other researchers have posed the ruler questions in slightly different language or used a different numerical range. For example, Williams et al20 asked How ready are you to change your drinking habits? and LaBrie et al19 used verbal cues at 5 locations on a scale of 1 to 10. A final limitation is the cross-sectional nature of the data. The relationships we propose may be better elucidated by longitudinal data that link importance and confidence with readiness over time. The work cited earlier by Etter and Perneger8 and Prochaska et al36 suggests that motivational profile may vary as people progress through the stages of change. Longitudinal data would provide useful evidence about relationships of readiness measuresincluding the rulersand changes in risky or problematic behaviors such as high BAC, frequent binge drinking, or associated behav-iors as assessed in the RAPI or AUDIT. In later waves of the parent study, readiness may mediate or moderate the experimental interventions.

    Our results may have important implications for preven-tion efforts. First, our findings suggest that the importance ruler, in particular, may be a valid way to quickly assess motivation to make changes in drinking; this simple 1-item measure correlated highly with a longer questionnaire. This finding may be important to busy clinicians who would not otherwise have time to assess patients motivation to make changes in drinking. Furthermore, Walters and Baer37 used the importance and confidence rulers to structure a brief motivational intervention focused on drinking, and our results support their utility in a clinical context. Second, the modal pattern of low importance and high confidence argues that college-drinking interventions should center on raising the levels of motivation (importance) rather than efficacy (confidence). Walters and Baer37 argued that college drinkers are largely precontemplators who benefit more from approaches like motivational interviewing that

    attempt to reduce drinking by raising levels of discrepancy and the feeling of needing or wanting to change. Although skill-building activities may be of some use, our data sup-port the idea that most heavy-drinking students perceive themselves as able to make changes in their drinking; at the same time, however, the data suggest that as students increase their readiness for change (ie, move from precon-templation into contemplation), level of confidence may decrease. From this finding, one might infer that students high confidence estimates are partially a feature of believ-ing that they do not need to change. There might also be an optimal sequence to interventions; one such example would be beginning an intervention by focusing on raising levels of motivation and later providing information and assis-tance in making changes.

    ACKNOWLEDGMENTThis project was supported by Grant R01 AA016005-01

    from the National Institute of Alcohol Abuse and Alcohol-ism. The authors thank Amanda M. Vader, MPH, for contri-butions to the interpretation of the data and for assistance in preparing the manuscript.

    NOTE

    For comments and further information, address cor-respondence to T. Robert Harris, University of Texas School of Public Health, 5323 Harry Hines Blvd., V-8, Room 112, Dallas, TX 75390-9128, USA (e-mail: trobert .harris@utsouthwestern.edu).

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