Research and Theory for Nursing Practice: An International Journal, Vol. 22, No.

2, 2008
148 2008 Springer Publishing Company
DOI: 10.1891/0889-7182.22.2.148
Commitment to Health Theory
Cynthia W. Kelly, PhD, RN
Xavier University, Cincinnati, Ohio
This article introduces commitment to health as a middle-range. Commitment to health
(CTH) is derived from Prochaska and DiClementes (1983) Transtheoretical Model
of Behavior Change. CTH theory is designed to predict the likelihood of behavior
change between the action and maintenance stages of change. Commitment is
defined as a freely chosen internal resolve to perform health behaviors, even when
encumbered or inconvenienced by difficulties. Health is defined as the optimal level
of well-being. Commitment is an independent continuous variable, but it can be
categorized into three time-oriented categories: (1) low-level, (2) middle-level, and
(3) high-level commitment. The higher the level of commitment, the more likely the
individual will adopt long-term behavior change. This article presents the definitions,
assumptions, and relational statements of CTH.
Keywo rds: health promotion; behavior change; middle range theory;
commitment to health
P
romoting health often means providing behavioral health interventions to
encourage healthy eating, participation in daily physical activity, and the
elimination of tobacco smoking (Centers for Disease Control [CDC], 1996).
Yet unless the patient actively engages in health-behavior change, success may
be limited (Bellg, 2003). Therefore, the health behavior choices of our patients
continue to present many clinical challenges. This article presents a new middle-
range theory, commitment to health (CTH), which may be crucial to understanding
how early health-behavior activities become lifelong behavior change. CTH is an
extension of the Transtheoretical Model (TTM) of Behavior Change (Velicer, Rossi,
Prochaska, & DiClemente, 1996).
CTH theory grew out of efforts over the past decade to understand why people
make healthy decisions and how they continue to perform those behaviors that
are considered healthy. During October 1996, a literature search utilizing National
Institutes of Health periodical index and Ohio Link index databases was performed.
Key search words were used to identify theoretical and supporting empirical research
studies (quasi-experimental and experimental designs) related to how people who
have unhealthy behavior(s) change those behaviors. Behaviors of interest included
smoking, diet, and exercise.
Commitment to Health 149
The findings indicated a long history of theory development and testing con-
cerning health-behavior change. Of the many theoretical models in the literature,
the TTM appeared to be popular with clinicians and researchers and was selected
based on this finding, and because its major concepts, assumptions, and statements
are easily understood.
THE TRANSTHEORETICAL MODEL
OF BEHAVIOR CHANGE
TTM, developed by Prochaska and DiClemente (1983) in the early 1980s, evolved
from early work on smoking cessation behavior. The major constructs of TTM are
(1) the stages of change, (2) the decisional balance scale, (3) the strong and weak
principle, (4) self-efficacy, and (5) the processes of change (Prochaska & Velicer,
1994; Velicer et al., 1996; Velicer, Prochaska, Fava, Norman, & Redding. 1998).
STAGES OF CHANGE
TTM proposes five stages of change. The first three stages are precontemplation,
contemplation, and preparation. Precontemplation is the stage at which the person
is not thinking about making a health behavior change. Contemplation and prepara-
tion are stages that signal the patients early thinking about change. Contemplation
occurs when the person is thinking about behavior change within the next 6 months.
A person in the contemplation stage may say to a clinician, I was thinking about
starting an exercise program in the spring. The preparation stage is reached when
the person plans to change behavior within the next month. A clinician may hear
a patient discuss specifics about planning for change, such as joining a health club
within the next month.
Following preparation are the action and maintenance stages. Action is defined
as the first 6 months of active behavior change. A patient in the action phase
has stopped smoking or has begun a behavior change involving, for example,
exercise or healthy eating, and is actively working to continue to perform the
new behavior. The patient might report, I walk a mile every other day, and I am
starting to see my energy improve. Maintenance is the final stage. Depending on
the behavior, it ends in permanent behavior change or at the point when the new
behavior is fully integrated into daily activities (Velicer et al., 1996). The person
in maintenance no longer feels the temptation to revert to old behaviors. The
triggers that initiated the behavior in the past no longer have the same effect. For
example, a patient who stopped smoking 6 months ago may report, Historically
I had a cigarette after dinner, and recently I realized that I dont even think about
smoking anymore.
Movement between the stages of change occurs as the benefits (pros) of a new
behavior outweigh the costs (cons) of a behavior. These related concepts of pros
and cons are combined to define the decisional balance scale. The decisional bal-
ance scale is theorized as a continuous variable with pros and cons as polar ends.
150 Kelly
When the pros of change are greater than the cons of a behavior, stage change
occurs based on what Prochaska called the strong and weak principle (Prochaska
& Velicer, 1994). Applying the strong and weak principle, the clinician would expect
the patient to begin to recognize behavior change as a very positive activity and the
unhealthy behavior as a negative activity. The last concepts, self-efficacy and the
processes of change, further enhance behavior change. Self-efficacy supports change
as ones belief or confidence in the ability to overcome the temptation to revert to
old behavioral patterns grows.
PROCESSES OF CHANGE
The processes of change are a set of 10 cognitive processes that are related to
adjacent stages of change (see Table 1). These processes are used by clients and
their clinicians to advance the clients decision making (decisional balance scale)
relative to their stage of change (continue to move forward, or prevent relapse).
A clinician can promote behavior change (stage movement) by knowing the clients
stage of change as well as by using the corresponding processes of change. For
example, the client who has been exercising for 2 weeks (action stage) could benefit
from clinical strategies related to the processes of change from action to mainte-
nance. The processes of change from action to maintenance are stimulus control,
counter-conditioning, helping relationships, and reinforcement (see Table 1). In our
example, the client has identified that exercise performance is hampered by his/her
long work hours. The clinician might spend the therapeutic time to help the client
identify strategies to restructure the daily routine to help eliminate long work hours
as a reason for relapse into nonexercise behaviors. Restructuring daily routine as
an intervention strategy falls within the processes of change category identified as
stimulus control (Table 1) (Velicer et al., 1998).
The aforementioned example demonstrates the strong clinical relevance of TTM.
It is this clinical orientation that explains the adaptation of TTM to many clinical
settings, patient demographics, and health behaviors (Prochaska & Velicer, 1994).
Yet, opinions about the robustness and usefulness of the model vary. Concerns
about the model are best illustrated by social learning theorist Albert Bandura
(1997), who identified three main areas of concern: (1) the stages of change con-
cept is too restrictive to explain human functioning; (2) the TTM model ignores a
substantial body of intervention research; and (3) the TTM model is not integrative
but instead adopts concepts from divergent philosophical perspectives. In response
to Banduras comments, Prochask a and Velicer (1997a) indicate that the stages
of change construct is not a theory but a variable, and therefore not intended to
explain or predict change. They also take exception to Banduras other assertions,
as demonstrated by the large number of research and clinical papers utilizing the
model. Whether Bandura is correct or not, the main strength of TTM is the models
impact on clinical practice. Clinicians find that TTM is readily adaptable to practice
regardless of the professional discipline, largely due to the simplicity and clarity of
the model (Jeffery, 2004; Littell & Girvin, 2002; Samuelson, 1997, Siegal, Li, Rapp,
and Saha, 2001).
Commitment to Health 151
TABLE 1. Stages of Change, Processes of Change, and Related Definitions
and Interventions
Processes of Change Definition/Interventions
Stage change: Precontemplation to contemplation
Consciousness raising Efforts by the individual to seek
new information and to gain
understanding and feedback about
the problem behavior/Observations,
confrontations, interpretations,
bibliotherapy
Dramatic relief Experiencing and expressing feelings
about the problem behavior and
potential solutions/Psychodrama,
grieving losses, role playing
Environmental reevaluation Consideration and assessment of how
the problem behavior affects the
physical and social environment/
Empathy training, documentaries
Stage change: Contemplation to preparation
Self-reevaluation Emotional and cognitive reappraisal of
values by the individual with respect
to the problem behavior/Value
clarification, imagery, corrective
emotional experience
Stage change: Preparation to action
Self-liberation Choice and commitment to change the
problem behavior, including belief in
the ability to change/Decision-making
therapy, New Years resolutions,
bibliotherapy techniques, commitment-
enhancing techniques
Stage change: Action to maintenance
Counter-conditioning Substitution of alternatives for the
problem behavior/Relaxation,
desensitization, assertion, positive
self-statements
Helping relationships Trusting, accepting, and utilizing the
support obtained by caring for others
during attempts to change the problem
behavior
Reinforcement management Rewarding oneself or being rewarded
by others for making changes/
Contingency contracts, overt and
covert reinforcement, self-reward
(continued)
152 Kelly
TABLE 1. (continued )
Processes of Change Definition/Interventions
Social liberation Awareness, availability, and acceptance
by the individual of alternative,
problem-free lifestyles in society/
Empowering, policy interventions
Stimulus control Control of situations and other factors
that trigger the problem behavior/
Adding stimuli that encourage
alternative behaviors, restructuring the
environment, avoiding high-risk cues,
fading techniques
Note. The clinician can facilitate stage movement by using the corresponding
process of change. This table provides the stage of change range, the corre-
sponding processes of change, and the definition of each process of change
(Prochaska & Velicer, 1997b).
COMMITMENT TO HEALTH AS
A MIDDLE-RANGE THEORY
Using established criteria for theory and research evaluation (Walker & Avant, 1995,
Polit & Hungler, 1995), the present author reviewed and evaluated all existing TTM
theory, research, and commentary articles covering the period 1982 through 1996.
The focus of the review was to evaluate the adequacy of TTM to explain health
behavior change. Review of empirical support for TTM included evaluation of research
designs, validity and reliability of measurement (instrumentation) (Table 2), reliability
of findings, and usefulness for practice.
This review resulted in the conclusion that the primary strength of TTM is the
parsimonious nature and the clarity of definition of concepts, assumptions, and
statements. These attributes of TTM have led to its acceptance and adoption
as a framework for clinical practice. However, the primary theoretical limita-
tions of TTM were identified as follows: (1) TTM is applicable to only a single
unhealthy behavior and does not consider the impact of other confounding
health behaviors; (2) it is applicable only as an enhancement for thinking about
change; (3) it does not address the biological, environmental, or social issues
related to change in health behaviors; and (4) it does not differentiate between
patients who are able to make lifelong change and those who are not (Kelly,
2001). The last limitation is a most critical theoretical gap, since achieving life-
long behavior change is the goal of all health behavior change intervention. This
limitation became the catalyst for the research that led to the development of
the CTH theory (Kelly, 2001).
Commitment to Health 153
COMMITMENT TO HEALTH THEORETICAL DEVELOPMENT
This article presents the process by which the CTH theory was developed and its
resulting theoretical propositions, which are intended to explain the transition from
action to maintenance stages. This work was undertaken in an effort to answer
the question, Does the TTM decisional balance scales strong and weak principle
predict stage movement from the action to the maintenance stage for smoking,
exercise, and/or dietary behavior change?
Determining the Psychometric Properties of TTM Constructs. Very little evi-
dence of psychometric validation for TTMs stages of change or for the decisional
balance scale construct, and nothing regarding movement between action and
maintenance stages, was found in the literature review (Kelly, 2001). For example,
the literature for the stages of change did not provide a consistent format, validity
and reliability information, or even a description of how to consider the concept of
stages of change in relationship to decisional balance.
Between 1983 and 1996, the only published (and often cited) psychometric esti-
mates found for the stages of change variable were from a 1992 study (Marcus,
Rakowski, & Rossi, 1992). This study did not assess validity. Also interesting, the
stage of change instrument, usually a 5-item agree/disagree format categorical
variable, used in Marcus and colleagues (1992) study was an 11-item continuous
measure, testing only 20 subjects to assess 2-week test-retest reliability using the
Kappa index (.78) (see Table 2).
Similarly for the decisional balance scale, also a key component of application of
the TTM, reports are limited and conflicting regarding internal consistency reliabil-
ity for pros and cons subscales and contain very little validity testing (see Table 2).
Depending on the behavior under investigation, internal consistency reliabilities for
pros ranged from .69 (smoking) to .95 (exercise), and cons ranged from .56 (exercise)
to .90 (smoking).
Examining Empirical Evidence. Given the paucity of psychometric testing, as
well as the theoretical gap surrounding the way in which stage movement occurs,
separate studies were performed (Kelly, 2001) to provide psychometric evaluation
of the stage of change instruments and the decisional balance scale for smoking,
diet and/or exercise, as well as to evaluate how well each instrument correlated
to the reported health behaviors (Kelly, 2001). The subjects represented a range of
ages, races, economic/educational levels, geographic locations, and genders.
The study findings revealed that decisional balance and stages of change were
not correlated when applied to smoking ( r = .03), exercise ( r = .04), or dietary
health behaviors ( r = .19). Factor analyses for these instruments generated mixed
results that were difficult to interpret within the perspective of the TTM for either
construct. However, for the decisional balance scales, four factors accounted
for approximately 64% of variance. The pros items, which constituted Factor 1,
accounted for the majority of the explained variance (27%). Cons were distributed
between Factors 2 and 4, together accounting for another 25% of the explained
variance. However, Factor 3, with an eigenvalue of 2.5 and accounting for 11% of
the explained variance, represented neither pros or cons, as theoretically defined
T
A
B
L
E

2
.

S
t
a
g
e
s

o
f

C
h
a
n
g
e

a
n
d

D
e
c
i
s
i
o
n
a
l

B
a
l
a
n
c
e

S
c
a
l
e

P
r
o
p
e
r
t
i
e
s

f
o
r

M
e
a
s
u
r
e
d

H
e
a
l
t
h

B
e
h
a
v
i
o
r
s
S
t
a
g
e
s

o
f

C
h
a
n
g
e
D
e
c
i
s
i
o
n
a
l

B
a
l
a
n
c
e

S
c
a
l
e
S
t
u
d
y
N
B
e
h
a
v
i
o
r
V
a
l
i
d
i
t
y
R
e
l
i
a
b
i
l
i
t
y
V
a
l
i
d
i
t
y
a
P
r
o
s
b
C
o
n
s
b
P
r
o
c
h
a
s
k
a

&

D
i
C
l
e
m
e
n
t
e

(
1
9
8
3
)
8
4
3
S
m
o
k
i
n
g
N
A
N
A
4
6
%
0
.
8
7
0
.
9
0
P
r
o
c
h
a
s
k
a
,

R
o
s
s
i
,

e
t

a
l
.

(
1
9
9
3
)
1
8
0
D
i
e
t
N
A
N
A
A
m
b
i
g
u
o
u
s

r
e
s
u
l
t
s
0
.
9
0
0
.
8
1
O

C
o
n
n
e
l
l

&

V
e
l
i
c
e
r

(
1
9
8
8
)
2
6
4
D
i
e
t
N
A
N
A
5
0
%
0
.
9
1
0
.
8
4
E
m
m
o
n
s
,

M
a
r
c
u
s
,

L
i
n
n
a
n
,

R
o
s
s
i
,

&

A
b
r
a
m
s

(
1
9
9
4
)
1
5
5
9
S
m
o
k
i
n
g
D
i
e
t
a
r
y
E
x
e
r
c
i
s
e
N
A
N
A
N
A
8
0

9
0
b
N
A
N
A
N
A
N
A
N
A
0
.
8
0
N
A
0
.
9
5
0
.
9
0
N
A
0
.
7
5
M
a
r
c
u
s
,

R
a
k
o
w
s
k
i
,

&

R
o
s
s
i

(
1
9
9
2
)
7
7
0
c
E
x
e
r
c
i
s
e
N
A
0
.
7
8
c
6
0
.
4
%
0
.
9
5
0
.
7
9
K
i
n
g
,

M
a
r
c
u
s
,

P
i
n
t
o
,

E
m
m
o
n
s
,

&

A
b
r
a
m
s

(
1
9
9
6
)
3
3
2
S
m
o
k
i
n
g
E
x
e
r
c
i
s
e
N
A
N
A
N
A
N
A
N
A
N
A
0
.
6
3
0
.
7
0
0
.
8
5
0
.
5
6
H
e
r
r
i
c
k
,

S
t
o
n
e
,

&

M
e
t
t
l
e
r

(
1
9
9
7
)
3
9
3
S
m
o
k
i
n
g
N
A
N
A
N
A
0
.
6
9
0
.
7
2
D
i
e
t
N
A
N
A
N
A
0
.
8
6
0
.
8
4
E
x
e
r
c
i
s
e
N
A
N
A
N
A
0
.
7
0
0
.
5
6
S
u
n

p
r
o
t
e
c
t
i
o
n

u
s
e
N
A
N
A
N
A
0
.
7
8
0
.
7
1
N
o
t
e
.

N
A

=

n
o
t

a
s
s
e
s
s
e
d
.
a
P
r
i
n
c
i
p
a
l

C
o
m
p
o
n
e
n
t
s

A
n
a
l
y
s
i
s

u
s
e
d

t
o

a
s
s
e
s
s

e
x
p
l
a
i
n
e
d

v
a
r
i
a
n
c
e
.

b
C
r
o
n
b
a
c
h

s

a
l
p
h
a
.

c
T
e
s
t
-
r
e
t
e
s
t

f
o
r

a

2
-
w
e
e
k

p
e
r
i
o
d
.
Commitment to Health 155
in the TTM. The wording for 6 of 22 items or 27% of the total number of items
with a loading on factor 3 of .50 or greater was examined closely and appeared
to represent a new concept.
EVOLVING THE COMMITMENT TO HEALTH CONSTRUCT
Using Walker and Avants (1995) theory synthesis method, the findings from research
were organized and interpreted in a process that resulted in the CTH theory. First,
the content of the items comprising Factor 3 were examined in relationship to the
theoretical definition of pros and cons. The items were judged as not true to the
definition, which is focused on weighing the benefits or costs of performing a health
behavior as a decision-making process (Proch aska & Velicer, 1997b). Rather, the
items were more suggestive of a new concept that appeared to reflect a commit-
ment to perform a health behavior consistently and over long periods of time (Kelly,
2001). For example, the items I resist unhealthy behaviors in order to achieve a
healthy lifestyle and Maintaining a healthy lifestyle is a priority for me indicate
behaviorally specific actions, as well as an internal resolve to perform behaviors
that promote a healthy lifestyle.
Second, the literature pertaining to the TTM and health promotion was searched
for terms representative of the items on Factor 3. The TTM literature did not reveal
any recognition of a third variable within the decisional balance scale or any other
TTM construct representative of the items. With the exception of one article, the
health promotion literature similarly did not yield a construct that could incorporate
the items. The only seemingly related concept was that of will (referred to as belief,
confidence, prior action, and desire) as a factor in health promotion but not within
any given theory or as part of the TTM (Anderson et al., 2004).
Third, lacking published terms with theoretical or empirically based definitions
that could encompass the Factor 3 items, a term to label them as a construct was
selected: commitment to health. To define the new construct, several dictionaries
were consulted and found to define commitment in a way similar to that of Merriam-
Websters Collegiate Dictionary (1984, p. 265): committed: the state of being bound
emotionally or intellectually to a course of action. Based on the nature of the items,
to fully define the term (commitment to health), a definition would also need to
include the concepts of free choice (I strive daily to achieve a healthy lifestyle) and
internal resolve (I resist unhealthy behaviors in order to achieve a healthy lifestyle),
concepts also represented in Merriam-Websters Dictionary (1984). Free choice means
that the performance of a behavior is selected voluntarily and not determined by
anything beyond their own nature or being ( pp. 490, 237). Internal resolve is defined
as fixity of purpose and existing within the mind (pp. 632, 1004).
Health as a variable is not defined in the TTM literature, so health was defined
according to the common understanding of health, using the World Health Organization
g uidelines provided by stn & Jakob (2005), as a complete state of physical,
mental and social well-being, and not merely the absence of disease or infirmity.
According to Chinn and Kramer (1995), health is a goal, and optimal health is the
desired goal. Optimal health is conceptualized as the superior or maximal end of
156 Kelly
a health-illness continuum, not merely the absence of disease. Nursings purpose
then is to assist patients to achieve the highest degree of health possible (Chinn &
Kramer, 1995, p. 44).
Commitment to health is therefore defined as a freely chosen internal resolve to
perform health behaviors. When considering all the commitment items, it appears
that in order for the patient to continue to perform healthy behaviors, the commit-
ment must be such that, even when faced with obstacles, the patient will continue
to perform the behaviors.
FITTING COMMITMENT TO HEALTH WITHIN THE TTM
Because commitment to health (CTH) emerged from research on TTM, it assumes
TTMs constructs and their relationships. There are three main assumptions to CHT.
First, behaviors are observable activities that promote health. Examples of observ-
able behaviors include such varied activities as vigorous daily exercise, adherence
to healthful eating, and the absence of cigarette smoking. Second, performing
healthy behaviors is the outward expression of commitment to health. And, third,
commitment and health are measurable and observable; they are time oriented
and exist as continuous variables.
CHT relates to TTM as described in the following five relational statements:
1. Commitment to health is measurable in the contemplation through maintenance
stages of change.
2. Commitment to health is supported by the pros of behavior change.
3. Commitment to health is supported by self-efficacy.
4. Commitment to health is needed to overcome temptation.
5. Commitment to health is supported by the processes of change.
Pulling the CHT components together are the following propositions:
1. Commitment to health is an independent variable.
2. The degree of internal resolve to perform health behaviors is measurable and
is referred to as level of commitment.
3. Level of commitment is a continuous variable, which can be categorized into
three levels (low, middle, and high).
The person with a low level of commitment may or may not consciously intend to
perform health behaviors but is not able to follow through with a behavior change
for more than a month. A person with a middle level of commitment intends to
perform health behaviors but is either inconsistent or is unable to sustain health
behavior performance for more than 6 months. A person with a high level of com-
mitment is able to perform health behaviors consistently and across a wide range
of behaviors for more than 6 months. As commitment to health was generated
from the TTM but is phenomena-specific, applicable to practice, and can be used
to explain long-term adoption and maintenance of new health behaviors, CTH fits
the definition of a middle-range theory (Fawcett, 2000; McKenna, 1997; Meleis,
1997; Walker & Avant, 1995).
Commitment to Health 157
COMMITMENT TO HEALTH THEORY TESTING
A third pilot study was conducted using the commitment to health (CTH) items.
Subjects ( n = 158) were obtained from community health centers and employers in
a middle-sized midwestern city. Analysis of the subjects indicated a fairly homoge-
neous sample of essentially healthy individuals with a broad range of health behav-
iors. Scale items were assessed by classical and Rasch measurement methods. The
internal consistency reliability of the scale was .94 (Cronbach s alpha).
Further theory testing was performed using the Rasch rating scale method. The
Rasch method is used to test whether predicted items structures would replicate
subjects patterns of responses. As predicted, the theoretical ordering of item struc-
ture was equivalent to the observed ordering of items. Standardized scale scores
were then used to determine if the scale scores would predict self-reported health
behaviors (Kelly, 2006). Stepwise polytomous logistic regression analysis (Wald chi-
square at p = .05) resulted in a model whereby the score predicted single reported
behaviors. The results are as follows: (1) for healthy exercise behavior ( n = 63), df = 1,
r
2
= 12.97, p = .0003; (2) for healthy diet ( n = 91), df = 1, r
2
= 12.03, p = .0005; (3) for
former smoking ( n = 22), df = 1, r
2
= 2.92, p = .087; (4) for never smoked ( n = 96),
df = 1, r
2
= 11.77, p = .0006. The small number of former smokers may have resulted
in the low r
2
and p values. While the former smoker category was nonsignificant, the
never-smoked subjects did exhibit a significant correlation between their CTH score
and their smoking behavior.
To further demonstrate the relationship between subject scores and subjects
level of commitment, the subject scores were plotted against CTH item weights
(low- to high-level commitment items). What was expected and then observed was
that subjects with higher scores would endorse those items that represented higher
levels of commitment. This would also apply to those whose scores indicated a
lower level of commitment and were expected to endorse items that represented
a lower level of commitment. Subjects with high-level commitment were expected
to have scores in the 1+ and above range, those with low-level commitment in the
1 or lower range, and those with medium-level commitment between 1 and +1.
Figure 1 demonstrates that relationship as well as its linear nature.
Based on these findings, commitment to health appears to function as a predictor
variable for those who are currently in the action stage of health behavior change.
The limitations of adopting this theory are based on the methodological limita-
tions and the pilot nature of the studies leading to the development of the theory.
Additional research is needed to determine if CTH is a viable theory over extended
timeframes (longer than 6 months), as well as for those with chronic diseases.
Research is needed to identify therapeutic nursing modalities that increase com-
mitment to health, leading to the maintenance stage of health behavior change.
The potential uses of CTH include the development of a health promotion frame-
work of evidence-based practice based on regular measurement of stage of change
and level of commitment for patients in the action stage of behavior change. The
nurse can use TTM processes of change (Table 1) to support continuing performance
158 Kelly
Subject Scores Compared to Item Weights
2.5
2
1.5
1
0.5
0
0.5
1
1.5
2
2.5
3
Subject Scores Rasch (Logits)
Item Weights
Note. Those with high-level commitment would endorse those items with values greater than 1.
Those with low-level commitment would have scores less than 1. Those with medium-level
commitment would have scores between 1 and +1.
Figure 1. Comparing commitment to health scale item weights and subject scores
computed and presented as Rasch logits.
of the new behavior and to take extra steps for the patient at risk of relapse into
old patterns of unhealthy behaviors. Nurses who are short on resources (especially
time) may find that they can tailor the amount of time as well as the direction of
the intervention to more closely target patients who will receive the most benefit
from a nursing intervention. This is not to exclude those who have low levels of
commitment, but to better serve those who are moving toward higher levels of
commitment to health. Additionally, by using CTH for specific health behaviors, the
nurse can monitor how well nursing interventions increase commitment to perform
healthy behaviors. Finally, CTH and the CTH scale could serve as quality indicators
or nursing effectiveness indicators. For example, if the goal of the health-promotion
nurse is to increase the level of commitment to diet management in a diabetic clinic,
the CTH could act as an intermediate cognitive variable to explain improvements
or relapses in adherence to treatment recommendations.
REFERENCES
Anderson, D., Plotnikoff, R. C., Raine, K., Cook, K., Smith, C., & Barrett, L. (2004). Towards the
development of scales to measure will to promote heart health within health organiza-
tions in Canada. Health Promotion International, 19 (4), 471481.
Commitment to Health 159
Bandura, A. (1997). The anatomy of stages of change. Science of Health Promotion, 12 (1),
810.
Bellg, A. J. (2003). Maintenance of health behavior change in preventive cardiology.
Internalization and self-regulation of new behaviors. Behavior Modification, 27 (1),
103131.
Centers for Disease Control. (1996). Guide to clinica l preventative services. Atlanta, GA:
Author.
Chinn, P. L., & Kramer, M. K. (1995). Theory and nursing: A systematic approach (4th ed.).
St. Louis, MO: Mosby.
Emmons, K. M., Marcus, B. H., Linnan, L., Rossi, J. S., & Abrams, D. B. (1994). Mechanisms
in multiple risk factor interventions: Smoking, physical activity, and dietary fat intake
among manufacturing workers. Preventive Medicine, 23, 481489.
Herrick, A. B., Stone, W. J., & Mettler, M. M. (1997). Stages of change, decisional balance, and
self-efficacy across four health behaviors in a worksite environment. Science of Health
Promotion, 12 (1), 4956.
Jeffery, R. W. (2004). How can health behavior theory be made more useful for intervention
research? International Journal of Nutrition and Physical Activity, 1 (1), 10.
Kelly, C. W. (2001). Measuring health behavior change. Doctoral dissertation, University of
Cincinnati, 2001. ProQuest ( UMI No. 3038948). Abstract retrieved from http://www.
ohiolink.edu/etd/view.cgi?ucin1006199575
King, T. K., Marcus, B. H., Pinto, B. M., Emmons, K. M., & Abrams, D. B. (1996). Cognitive-
behavioral mediators of changing multiple behaviors: Smoking and a sedentary lifestyle.
Preventative Medicine, 25 (6), 684691.
Littell, J. H., & Girvin, H. (2002). Stages of change: A critique. Behavior Modification, 26 (2),
223273.
Marcus, B. H., Rakowski, W., & Rossi, J. S. (1992). Assessing readiness, self-efficacy and
decision-making for exercise. Journal of Applied Social Psychology, 22 (1), 316.
Merriam-Websters collegiate dictionary (9th ed.). (1984). Springfield, MA: Merriam-Webster.
OConnell, D., & Velicer, W. F. (1988). A decisional balance measure for weight loss. International
Journal of Addictions, 23, 729750.
Peterson, S. J., & Bredow, T. S. (2004). Middle range theories: Application to nursing research.
Philadelphia: Lippincott Williams & Wilkins.
Polite, D. F., & H ungler, B. P.(1995). Nursing research: Principles and methods (5th ed.).
Philadelphia: Lippincott.
Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking:
Toward an integrative model of change. Journal of Consulting and Clinical Psychology,
51 (3), 390395.
Prochaska, J. O., Rossi, J. S., et al. (1993). Measurement structure of a decisional balance ques-
tionnaire for dietary fat reduction. Toronto, Ontario, Canada: American Psychological
Association.
Prochaska, J. O., & Velicer, W. F. (1994). Stages of change and decisional balance for 12 prob-
lem behaviors. Health Psychology, 13, 3946.
Prochaska, J. O., & Velicer, W. F. (1997a). Misinterpretations and misapplications of the trans-
theoretical model. American Journal of Health Promotion, 12 (1), 1112.
Prochaska, J. O., & Velicer, W. F. (1997b). The transtheoretical model of behavior change.
American Journal of Health Promotion, 12 (1), 3848.
Samuelson, M. (1997). Changing unhealthy lifestyle: Whos ready . . . whos not? Argument
in support of the stages of change component of the transtheoretical model. American
Journal of Health Promotion, 12 (1), 1314.
Siegal, H. A., Li, L., Rapp, R. C., & Saha, P. (2001). Measuring readiness for change among crack
cocaine users: A descriptive analysis. Substance Use & Misuse, 36 (67), 687700.
160 Kelly
stn & Jakob. ( 2005) Re-defining health. World Health Organization. Retrieved August 2007,
from http://www.who.int/bulletin/bulletin_board/83/ustun11051/en/
Velicer, W. F., Fava, J. L., Prochaska, J. O., Abrams, D. B., Emmons, K. M., & Pierce, J. P. (1995).
Distribution of smokers by stage in three representative samples. Preventative Medicine,
24 , 401411.
Velicer, W. F., Prochaska, J. O., Fava, J. L., Norman, G. J., & Redding, C. A. (1998). Detailed
overview of the transtheoretical model. Retrieved August 2001, from University of Rhode
Island CPRC website, http://uri.edu/research/cprc/TTM/detailedoverview.htm
Velicer, W. F., Rossi, J. S., Prochaska, J. O., & DiClemente, C. C. (1996). A criterion measurement
model for health behavior change. Additive Behaviors, 21 (5), 555584.
Walker, L., & Avant, K. (1995). Strategies for theory construction in nursing (3rd ed.). Norwalk,
CT: Appleton and Lange.
Acknowledgments. This research study was partially supported by NIOSH Pilot Research Project
Training Program Grant #T42/CCT510420 through the University of Cincinnati Education and
Research Center (UC/ERC).
Correspondence regarding this article should be directed to Cynthia W. Kelly, PhD, RN, Xavier
University, Department of Nursing, 3800 Victory Parkway, Cincinnati, OH 45207. E-mail:
kellyc3@xavier.edu