the readiness to change questionnaire: reliability and validity of a swedish version and a...

The Readiness to Change Questionnaire:Reliability and validity of a Swedish versionand a comparison of scoring methods

Lars Forsberg1*, Soren Ekman2, Jan Halldin3 and Sten Ronnberg4

1Department of Clinical Neuroscience, Section of Dependency Disorders,Karolinska Institutet, Sweden

2Department of Surgery at Danderyd Hospital, Sweden3Department of Public Health Sciences, Division of Social Medicine,Karolinska Institutet, Sweden

4Department of Social Work at Stockholm University, Sweden

Objectives. The aim of this study was to investigate the relative merits of threemethods of scoring the Swedish version of the Readiness to Change Questionnaire(RTCQ), either by assigning a stage in the Prochaska and DiClemente (1986) Stages ofChange Model or by treating the scores as a continuous readiness to change variable.Assigning a stage of change was achieved with both the quick method and the refinedmethod.

Design and methods. Out of 563 patients screened at an emergency surgical wardfor risky alcohol consumption, 165 met risk criteria and responded to the RTCQ. Thethree scoring methods were examined with regard to internal consistency, test–retestreliability, construct and predictive validity.

Results. All three methods of treating the RTCQ scores had satisfactory reliability.Since stages of change (quick method) were significantly but modestly correlated toalcohol consumption and to change-related behaviours at intervention, and moderatelycorrelated to alcohol problems, the quick method had reasonable construct validity.The refined method had higher construct validity; however, this method left 32% of thepatients without a stage assignment. The continuous readiness scale had higherconstruct validity than the quick method, but was not in par with the refined method.No scoring method was found to have predictive validity.

Conclusions. The RTCQ scores treated as a continuous readiness scale were a viablealternative to the original ways of assigning a stage of change to a patient. The SwedishRTCQ is reliable and has reasonable construct validity, but its predictive validity needsfurther investigation.

* Correspondence should be addressed to Lars Forsberg, Karolinska lnstitutet, Department of Clinical Neuroscience,Section of Dependency Disorders, Magnus Huss Clinic M4:02, Karolinska Hospital, 171 76 Stockholm, Sweden(e-mail: [email protected]).

335

British Journal of Health Psychology (2004), 9, 335–346

q 2004 The British Psychological Society

www.bps.org.uk

During the last 15–20 years the Stages of Change Model (Prochaska & DiClemente,

1986), conceptualizing motivational processes in behaviour change, has received

increasing attention (Miller & Heather, 1998, pp. 49–60). Clinicians and researchers in

health care and social services have found the model helpful when applied to risky

lifestyle behaviours such as eating disorders, smoking and excessive alcohol

consumption. It is believed that treatment outcome can be improved when there is amatch between the patient’s stage of change and the type of treatment offered

(Prochaska & DiClemente, 1986). The model (Prochaska & DiClemente, 1986) has five

stages of change: precontemplation, characterized by lack of problem recognition;

contemplation, characterized by uncertainty; preparation, when a decision to change is

taken, goals are set and plans are made on how to succeed; action, when the individual

experiments with alternative behaviours; and maintenance, along-term reinforcement

of the individual’s new healthier behaviours, so that they stabilize.

There are several tests assessing stages of readiness to change. In the alcoholtreatment field there is the short Readiness to Change Questionnaire (RTCQ; Rollnick,

Heather, Gold, & Hall, 1992), designed for clients with alcohol problems who do not

seek alcohol treatment. It provides scores for three scales representing three of the

stages of change, omitting the preparation and maintenance stages. Several methods of

allocating a patient to a stage of change in RTCQ were examined. Rollnick et al. reported

that the quick method has satisfactory reliability for all three scales in male excessive

alcohol consumers with low alcohol dependence who have sought health care but not

alcohol treatment. Using the quick method, the test has both concurrent (Rollnick et al.,1992) and predictive (Heather, Rollnick, & Bell, 1993) validity. However, the refined

method of stage allocation was shown to have higher validity in terms of prediction of

drinking behaviour as compared to the quick method. Furthermore, the refined method

could also allocate patients to the preparation stage. When testing the matching

hypothesis derived from the Stages of Change Model, only the refined method was

successful in matching risk drinkers to either brief motivational or skill-based

intervention (Heather, Rollnick, Bell, & Richmond, 1996). Patients not ready to change

were more successful with brief motivational intervention than with skill-basedintervention. Thus, this scoring method seems superior to the quick method and could

be used for treatment matching.

The psychometric properties of the RTCQ, when using the quick method, have been

examined by a number of researchers. In a US study, low internal consistency reliability

was reported for the precontemplation and contemplation subscales of the RTCQ,

possibly due to the sample used; it was composed of alcohol-dependent patients seeking

alcohol care (Gavin, Sobell, & Sobell, 1998). In contrast, in a Dutch study (Defuentes-

Merillas, Dejong, & Schippers, 2002) of patients seeking alcohol treatment, the internalconsistency of the three scales was reported to be acceptable and having both

discriminant and concurrent validity. In both a Spanish (Rodriguez-Martos et al., 2000)

and German (Hannover et al., 2002) study, the internal consistency of the three scales

was found to be satisfactory. The German study found construct validity, but the Spanish

study found unsatisfactory concurrent validity. Unfortunately, none of the studies

examined the predictive validity of the RTCQ.

Budd and Rollnick (1996) found theoretical weaknesses in the model of discrete

stages of change and a re-analysis of the original data in the Rollnick et al. (1992) studyfavoured a continuous ‘readiness to change’ variable instead. Budd and Rollnick

proposed that the two alternative models should be examined further with regard to

reliability and validity, contrasting their relative merits. However, to our knowledge such

Lars Forsberg et al.336

studies have not been carried out. In a comprehensive review (Carey, Purmine, Maisto, &

Carey, 1999) of the psychometric properties of tests assessing stages of change, including

the RTCQ, Carey et al. are in favour of a continuous readiness to change construct.

Scores from a valid test assessing stages of change should correlate with change-

related behaviours such as quit attempts, thoughts about quitting, and decisions to

reduce or cut drinking (construct validity; Nunnally, 1967). Moreover, alcohol problemseverity and alcohol consumption have been related to motivation to change. Hence,

patients report more reasons to change drinking with more advanced stages of change

and stage of change is positively associated with alcohol problem severity (Kahler,

2001). Internal motivation for alcohol treatment has been found to be greater in patients

with more severe alcohol problems than in patients with fewer problems (DiClemente,

Bellino, & Neavins, 1999). Vik, Culbertson, and Sellers (2000) report that heavy drinking

students in the contemplation stage drank more and had more negative consequences

than students in the precontemplation and action stages. Thus, a valid readiness tochange test should also correlate with level of severity of alcohol problems. The Stages

of Change Model predicts that patients in the action stage would more likely reduce

alcohol consumption than patients in the contemplation stage and those in the

contemplation stage more likely than patients in the precontemplation stage. In the

Project Match study (Project Match Research Group, 1998), motivation to change was

the most potential predictor of drinking outcome throughout the three-year post-

treatment period. Thus, predictive validity is also important in considering the merits of

a test assessing motivation.The aim of the present study was to investigate the reliability in terms of test–retest

and internal consistency as well as construct (Nunnally, 1967) and predictive validity of

the RTCQ scores, treated either according to the Stages of Change Model or as one

continuous readiness variable (Likert scale). Assigning a stage of change was in its turn

achieved with both the quick method and the refined method. Construct validity was

examined by relating RTCQ scores to severity of alcohol problems, amount of alcohol

consumed, and whether or not the patients would set a goal and form a strategy to

reduce drinking at intervention. Predictive validity was examined by relating RTCQscores to changes in alcohol intake as assessed six months later.

Method

ParticipantsThe study was carried out as part of a randomized controlled study about brief

interventions (Forsberg, Ekman, Halldin and Ronnberg, 2000) approved by the Research

Ethical Committee at Karolinska Hospital (No. 92-327). Patients admitted consecutively

for emergency care in a surgical ward at Danderyd Hospital in Stockholm were asked to

participate in a study regarding, ‘alcohol and well-being’. Data were collected on l6 to

73-year-old patients, excluding those who were terminally ill, did not speak or

understand Swedish, or used drugs illicitly. Patients were informed that their results

would not be registered in their hospital records, that they would receive feedback andwere at liberty to withdraw from the study whenever they wished. Out of 697 patients

approached, 563 (81%) participated in the study. There were no differences in gender

and age between participants and non-participants.

The participants were interviewed using the screening questionnaires Mm-MAST

(Kristenson & Trell, 1982), CAGE (Ewing, 1984), and the Trauma Scale (Skinner, Holt,

Schuller, Roy, & Israel, 1984). The cut-off limit for alcohol problems was two affirmative

Swedish RTCQ: Reliability and validity 337

answers in any of the questionnaires. Positive cases were further assessed with regard to

alcohol consumption, and those having risk consumption according to either of two

criteria were subject to further analysis. The first criterion of risk consumption was

regularly drinking $162 grams of absolute alcohol per week on average for men and

$82 grams for women (Ashley, Ferrence, Room, Rankin, & Single, 1994). The second

criterion was peak consumption during the last 12-month period, for males $1.05

grams of absolute alcohol per kg body weight, and for females $0.90 grams (Babor &

Grant, 1991). Of the patients, 165 (29%) were classified as risk consumers (See Table 1)

and randomized to either extended alcohol counselling (modified Drinkers Check Up;

Forsberg et al., 2000) or a brief assessment and feedback. Both groups were followed

up. The baseline and follow-up assessments consisted of the Time Line Follow Back

Table 1. Descriptive data for the sample

Males(n ¼ 118)

Females(n ¼ 47)

Age16–30 yrs 35% (41) 51% (24)31–59 yrs 53% (62) 45% (21)$60 13% (15) 4% (2)

Civil status: Married/as couple 66% (78) 64% (30)Working status

Employed/studying 78% (92) 74% (37)Retired 12% (14) 11% (5)Unemployed 9% (11) 9% (4)Missing data 1% (1) 1% (1)

Alcohol diagnosis during the last 5 yrs 9% (11) 6% (3)No. of affirmative answers in CAGE

2 19% (23) 15% (7)3–4 22% (25) 13% (6)

No. of affirmative answers in Mm MAST2–3 50% (59) 64% (30)$4 40% (47) 26% (12)

Frequency of binge drinking(men, corresponding to 2 bottles of wine;women, 1 bottle of wine)Never 0% (0) 4% (2)#once per mth 7% (8) 7% (3)2–4 times per mth 53% (63) 49% (23)1–2 times per wk 29% (34) 32% (15)$3 times per wk 11% (13) 9% (4)

IQR1 Median IQR3 IQR1 Median IQR3

Weekly consumption in grams alcohol 39 103 184 28 66 102Peak amount in grams

alcohol/kg body weight1.50 1.95 2.88 1.26 1.67 2.59

Typical amount in gramsalcohol/kg body Weight

0.65 0.95 1.70 0.49 0.85 1.42

Number of sober days in a month 16 23 27 20 25 27


(TLFB; Sobell & Sobell, 1995) for a 14-day period and frequency and amounts of alcohol

consumed during the past 12-month period (six months at follow-up) and the RTCQ.

The preliminary somatic diagnoses of the risk consumers (N ¼ 165) were classified

in 11 categories: suspicion of appendicitis (27.3%; n ¼ 45), acute abdomene (22.4%;

n ¼ 37), trauma (20.6%; n ¼ 34), GI-bleeding (7.3%; n ¼ 12), proctological ailments

(4.8%; n ¼ 8), ulcer/vomiting (4.8%; n ¼ 8), diverticulitis (3.0%; n ¼ 5), pancreatitis(1.8%; n ¼ 3), gallstone disease/jaundice (1.2%; n ¼ 2), intestinal obstruction (1.2%;

n ¼ 2), and others (5.5%; n ¼ 9).

RTCQThe second and first author of this article translated the RTCQ into Swedish. The

understanding of each item was tested on staff and patients. The first negatively

formulated item in RTCQ was positively reformulated following comments on the first

version. Slightly different wordings of the items were tested repeatedly on staff and

patients until the understanding of the items was clear (see the Appendix).

Since many patients were exhausted, RTCQ was administered as an interview. The

interviewer and the patient had a copy each of the RTCQ and the interviewer read theitems, marking the alternatives that best suited the patient. Each of the three subscales

of the questionnaire measuring precontemplation, contemplation and action contained

four statements each to which the patients responded with one of the following five

alternatives: totally agree/þ2, agree partly/þ1, unsure/0, partly disagree/–1, totally

disagree/–2. Thus, the patients’ score on each scale ranged from 28 to þ8.

The quick method of allocating stage of change was based on the highest score

obtained either on the precontemplation, contemplation or action scales. In the event of

a tie between two scale scores, the most advanced stage was chosen (Heather et al.,1993, Rollnick et al., 1992).

In the refined method of allocating stage of change, only stage score profiles that are

logically consistent with the stages of change model are used. Hence, this method

discards participants with a stage profile with:

. positive scores on precontemplation and action and a negative score on

contemplation;

. positive as well as negative scores in all three scales;

. positive scores on both precontemplation and contemplation; and

. negative scores in precontemplation and contemplation and positive scores in action.

Participants who scored 0 or negatively on precontemplation and positively on

contemplation and action were defined as reflecting the preparation stage of change if

the contemplation score was higher than the action score. If the action score was as

high or higher than the contemplation score, participants were allocated to the action

stage (Heather et al., 1993).All 12 items of the readiness score were combined to form a continuous Likert scale.

The signs of the precontemplation items were changed to represent readiness to

change, which formed a scale ranging from 224 to þ24.

Reliability and validity testsTo investigate the test–retest reliability of the RTCQ, 18 patients responded to the

questionnaire twice. These patients were chosen simply because they were in-patients

and available for the second interview one or two days after the first. Another


interviewer most often performed the second interview. Cronbach’s alpha coefficients

were calculated to estimate the internal consistency reliability of the scales. However,

the internal consistency was not possible to calculate for the refined method, since this

method uses stage score profiles instead of scale scores to allocate patients to a stage.

The session protocols of one of the randomized groups (n ¼ 85), the modified

Drinkers Check Up, with motivational interviewing and feedback about risk

consumption, were examined regarding notes about patient considerations to reduce

drinking. To estimate the construct validity (Nunnally, l967), the RTCQ results were

correlated with the patients’ self-reports to reduce or cut drinking (‘goal to change’) and

a strategy to do so (‘strategy to change’); both variables were dichotomous. Construct

validity was also estimated by correlating RTCQ results to amount of alcohol consumed,

severity of alcohol problems and alcohol diagnoses. The five measures of alcohol

consumption were:

(1) weekly consumption in grams of pure alcohol estimated by the TLFB;

(2) typical amount in grams of pure alcohol per kg body weight (‘On a typical day

when you drink alcohol, how much do you drink?’);

(3) peak amount in grams of pure alcohol per kg body weight (‘On the occasion youdrank the most, what and how much did you drink?);

(4) frequency of binge drinking (‘How often have you on one and the same occasion

drunk the equivalent or more of [for males] two bottles/[for females] one bottle of

wine?’);and

(5) sober days (‘In an average month, on how many days do you abstain from alcohol?’).

Indices of alcohol problems were the number of affirmative answers in CAGE and in

Mm-MAST at intervention and a DSM-diagnosis of alcohol dependence or alcohol abusein the last five-year period. The diagnoses were taken from a medical-care register,

where all in-patient care within Stockholm County is recorded. The construct validity

was estimated by calculating Kendall tau correlation coefficients with discrete two or

three level variables, while Spearman rank correlation coefficients were calculated with

continuous data. One-tailed testing at 5% significance level was chosen because of the

hypothesized direction of the correlation.

The predictive validity (Nunnally, 1967) of the three methods to treat RTCQ scores

was also examined. Stages of change and readiness scores were each correlated with the

differences in alcohol intake between baseline and a six-month follow-up with regard to

four measures of alcohol consumption. This change score was calculated as a ratio of the

difference in alcohol intake and the mean of consumption at baseline and at follow-up,

thus compensating for regression towards the mean. Frequency of binge drinking was

coded as ‘increasing–equal–decreasing’ between baseline and follow-up, thus making it

possible to calculate a correlation with RTCQ scores. Follow-up data was available for

122 out of 165 patients (74%).

Results

Quick methodUsing the quick method of stage allocation, out of 165 patients, 92 (56%) were

classified to the precontemplation stage, 40 (24%) to the contemplation stage and 33

(20%) to the action stage. The median score was 3.00 for the precontemplation

scale (IQR1 ¼ 23:00; IOR3 ¼ 6:50), 22.00 for the contemplation scale

(IQR1 ¼ 25:00; IQR3 ¼ 4:00) and 24.00 for the action scale (IQR1 ¼ 28:00;


IQR3 ¼ 4:00), where IQR ¼ integrative range: The internal consistency reliability was

estimated to be .78 for the precontemplation scale,.80 for the contemplation scale and

.80 for the contemplation scale and .74 for the action scale. Of 18 patient, 16 were

allocated to the same stage of change both times.

There were significant relationships between stage of change and indices of alcohol

problems (yes responses in CAGE and Mm-MAST; see Table 2). However, the

correlations were low between stages of changes and indices of alcohol consumption

measures, an alcohol diagnosis, ‘goal to change’ and ‘strategy to change’ (see Table 2).

Thus, the method had modest construct validity. There was no significant correlation

between stage of change and changes in any of the measures of alcohol consumption at

the six-month follow-up. There was a tendency that patients in the contemplation stage

reduced weekly consumption (t test, p , :07) more often than patients in the action and

precontemplation stages. Thus, the evidence of predictive validity was weak and needs

to be further established.

Refined methodUsing the refined method of stage allocation, out of 165 patients, 70 (42%) were

classified to the precontemplation stage, 16 (10%) to the contemplation stage, 13 (8%)

to the preparation stage, and 13 (8%) to the action stage. However, 53 (32%)

patients were not classifiable. The test–retest reliability was satisfactory, since of the 18

patients the same four patients were unclassified both times and of the remaining

Table 2. Correlations (tau) between assigned stage of change versus continuous readiness score in

relation to alcohol consumption, severity of alcohol problems and patient intentions to reduce drinking

at intervention (N ¼ 165)

Stage of change Readiness score

Quick method Refined methodb Trichotomized Continuousa

Weekly consumption in gramsalcohol

.19** .32** .23** .22**

Peak amount in gramsalcohol/kg body weight

.12* .22** .15** .14**

Typical amount in gramsalcohol/kg body weight

.13* .20** .18** .15**

Frequency of binge drinking(for men corresponding to2 bottles of wine,for women 1 bottle

.22** .27** .23** .21**

Alcohol diagnosis during thelast 5 years

.21** .33** .26** .25**

Affirmative answers in CAGE .47** .61** .56** .54**Affirmative answers in Mm-MAST .34** .47** .46** .40**Setting a goal to

reduce drinking.24*c .49**e .23*c .25**c

Forming a strategy toreduce drinking

.26**d .62**f .36**d .38**d

**Correlation significant , .01 level (1-tailed); *Correlation significant , .05 level (1-tailed).aSpearman rank correlation; bN ¼ 12; cN ¼ 81; dN ¼ 82; eN ¼ 55; fN ¼ 56:


14 patients, 13 were allocated to the same stage of Change both times. The refined

method resulted in higher correlations between stages of change on the one hand and

indices of alcohol problems, measures of alcohol consumption, goal to change and

strategy to change on the other (see Table 2). Thus, construct validity was found.

However, there was no significant correlation between stage of change and changes in

any of the measures of alcohol consumption at the six-month follow-up. Thus, nopredictive validity could be found.

The Kendall tau correlation (Spearman rank correlation in parentheses) between the

quick method and the refined method was .97 (.99). Thus, the refined method did not

have unique information as compared to the quick method.

Continuous modelUsing the continuous readiness score, the median readiness score was 27.00

(IQR1 ¼ 216:00; IQR3 ¼ 6:00). The test–retest reliability was .82 (Kendall tau) and the

Spearman rank correlation was .86. The internal consistency reliability of thecontinuous scale was .88 Items deleted from the scale did not increase the reliability.

The average inter-item correlation was .38. The corresponding inter-item correlation in

the quick method was .47 for the precontemplation scale, .51 for the contemplation

scale and .50 for the action scale.

When the continuous readiness score was treated as a trichotomous discrete variable

to be comparable to the analyses of stage of change, 15 of the 18 patients were in the

same third range of the variable both times. Thus, the continuous model had test–retest

reliability. The trichotomized continuous variable was significantly correlated (tau) with

indices of alcohol problems and strategy to change (see Table 2). However, the

significant correlations to alcohol consumption and goal to change were low. The

correlations were of about the same size when using the continuous variable without

trichotomizing it (see Table 2). Thus, reasonable construct validity was found. The

continuous readiness score was weakly but significantly correlated (Spearman rank

correlation) with reduced weekly alcohol consumption (r ¼ 0:15; p , :05) at the six-

month follow-up. This relationship disappeared when using the trichotomized variable.

Thus, only weak predictive validity was found.The tau correlation (Spearman rank correlation in parentheses) between the

continuous readiness score and the quick method was .63 (.80), and between the

continuous method and refined method was .71 (.84).

Discussion

Both the quick method of stage allocation and scoring of RTCQ as a continuous

readiness scale showed satisfactory test–retest reliability. Compared to the quick

method with three stages of change, the internal consistency reliability was higher in the

continuous scale due to more items in the scale despite somewhat lower average inter-item correlations. The quick method showed lower construct validity than the

continuous scale model. Using the trichotomized continuous variable did not lower the

validity. Stage of change using the quick method did predict drinking behaviour after a

six-month period of time, albeit weakly. Thus, patients in the contemplation stage

reduced their weekly consumption more often than patients in the precontemplation


and action stages. There might be weak predictive validity even for the continuous

variable, but it has to be investigate further.

The cut-off points of the trichotomous division of the variable varied depending on

the sample used. However, the trichotomous division of the continuous variable made

the comparisons between the scoring methods more accurate in the present study. An

objection to the continuous readiness variable model is that more research is needed todevelop norms, to give meaning to the scale scores. In contrast, a stage allocation

immediately informs the clinician of what kind of predictive relations according to the

stages of change model that the client has attained to.

The refined method of stage allocation had satisfactory test–retest reliability and

showed construct validity. However, the high correlations indicating construct validity

might be an artifact as a result of the selection of only 68% of the patients with consistent

response pattern. Thus, no less than 32% of the patients had responded to the RTCQ in a

way that was not consistent with the refined Stages of Change Model. In the original

study (Heather et al., l993) only 22% of the patients had response patterns, which did

not conform to the model. In another sample of alcohol-dependent patients seekingalcohol treatment, 32% could not be classified according to the refined method

(McMahon & Jones, 1996). In contrast, only 16% of the patients attending a

detoxification programme could not be classified to the Stages of Change Model; in the

same study, 28.1% in a sample of offenders with alcohol-related crimes were

unclassifiable (Defuentes-Merillas et al., 2002). Hence, scoring the RTCQ according to a

strictly interpreted Stage of Change Model often seems to leave a significant proportion

of patients without a stage assignment, which suggests that the refined method has

doubtful clinical value. However, in a revised version of the RTCQ (Heather, Luce, Peck,

Dunbar, & James, 1999), no less than 95% of the patients had score profiles that werelogically consistent.

In contrast to earlier findings, the refined method in the present study did not show

predictive validity (Heather et al., 1993). Thus, the refined method did not seem to be of

greater clinical use than the other two methods of treating the RTCQ scores.

The weak predictive validity of the Swedish RTCQ might be due to small changes in

alcohol consumption between baseline and the six-month follow-up. Reported weekly

alcohol consumption was reduced by 28% (37 grams of alcohol), the typical amount by

only 13% (0.15 grams of alcohol/kg body weight) and the peak amount of alcohol by

16% (0.37 grams of alcohol/kg body weight). Thus, improved criteria variables areneeded in future RTCQ validation research.

In another study of the Swedish RTCQ (Forsberg, Halldin, & Wennberg, 2003) a

confirmatory factor analysis found slightly better fit for a three-factor model than for one

continuous variable. However, it seems justifiable from a psychometric point of view to

score the Swedish RTCQ either as a stage of change using the quick method or as a

continuous readiness score.

The questionnaire was a clinically useful basis for discussing risk consumption and

readiness to change a patient’s alcohol use in a non-confronting way. Another potential

use is to examine difficult populations with regard to stage of change as a foundation ofhow to raise the often difficult to approach alcohol issue. In the present sample, 80% of

the patients with hazardous or harmful alcohol use were not ready to change and the

outcome in screening as well as in interventions might be improved if the screening

tests, the administration of the tests and the interventions were adapted to the initially

low awareness of own alcohol problems and readiness to change. Future research

should establish whether the outcome of alcohol screening and brief intervention is


improved by adapting the tests, test administration and interventions to patients not

ready to change.

More work should be carried out to improve the reliability and validity of tests of

motivation to change. Hence, there are findings that indicate that the assessed readiness

to change does not represent all of the constructs of patient motivation (McMahon &

Jones, l996). Thus, motivation to change might be a wider construct than what is assessedby the tests. McMahon and Jones (1996) found that negative alcohol expectancies

predicted days to relapse, as did readiness to change, but that the two tests were

uncorrelated. The expectancy test and the readiness to change test each seem to have

their own strengths and to reflect different aspects of patient motivation. A revised

expectancy/motivation hypothesis has been proposed, which states preconditions for a

successful outcome of treatment (McMahon & Jones, 1992, 1996). Recently,

precontemplation has been differentiated in reluctance, rebellion, resignation and

rationalization (DiClemente & Velasquez, 2002), where each type might call for adifferent intervention strategy. Thus, precontemplation might rather be split into four

aspects to be appropiately assessed. The Readiness to Change and the Stages of Change

Models are complex constructs and each needs further study as well as tests measuring

the constructs.

Conclusion

The RTCQ scores treated as a continuous readiness scale are a viable alternative to the

original quick method of assigning a stage of change to a patient. The refined method of

stage allocation seems to be of limited clinical value, leaving a significant proportion of

the patients without a stage assignment. The Swedish RTCQ is reliable and hasreasonable construct validity, but needs further investigation to establish its predictive

validity.

Acknowledgements

The National Institute of Public Health provided this project with financial support. Professor

Hans Bergman has contributed with valuable points of view. Ulf Brodin Ph.D. has acted as

statistical consultant. We are also indebted to the staff of the surgical admission ward (Ward 61 at

Danderyd Hospital) under the leadership of Chief Nurse Mildred Rutstrom as well as to the staff on

the surgical unit and surgical wards.

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Received 1 June 2002; revised version received 2 April 2003

Appendix: Items in the Swedish Readiness to Change Questionnaire showing thehypothesized three stages of change: precontemplation (P), contemplation (C) and action (A)

Items

1.P Jag tycker att jag dricker lagom mycket.I don’t think I drink too much.

2.A Jag forsoker dricka mindre nu an jag gjorde forr.I am trying to drink less than I used to.

3.C Jag tycker om att dricka men ibland dricker jag for mycket.I enjoy my drinking but sometimes

I drink too much.4.C Ibland tycker jag att jag borde minska mitt drickande.

Sometimes I think I should cut down on my drinking.5.P Det ar ingen mening med att tanka pa mina alkoholvanor.

It is a waste of time thinking about drinking.6.A Jag har nyligen minskat min alkoholkonsumtion.

I have just recently changed my drinking habits.7.A Vem som helst kan tala om att gora nagot at sitt drickande, men jag gor faktiskt

nagonting at det.Anyone can talk about wanting to do something about drinking, but I am actually

doing something about it.8.C Jag ar i den situationen att jag borde tanka pa att dricka mindre alkoholhaltiga

drycker.I am at the stage where I should think about drinking less alcohol

9.C Ibland tycker jag att min alkoholkonsumtion blir ett problem.My drinking is a problem sometimes.

10.P Jag behover inte andra mina alkoholvanor.There is no need for me to think about changing my drinking.

11.A Jag, haller faktiskt pa att andra mina dryckesvanor nu.I am actually changing my drinking habits right now.

12.P Det finns ingen anledning for mig att dricka mindre alkohol.Drinking less alcohol would be pointless for me.


the readiness to change questionnaire: reliability and validity of a swedish version and a...

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