As the effectiveness of tailored information continues to be tested, an important issue that remains to be addressed is whether the identified constructs associated with the stages of change also hold in socioeconomically disadvantaged groups of people. The term medically underserved is used to describe people with a low socioeconomic status who have reduced access to health care and a higher prevalence and worse prognosis of disease, including preventable diseases.21 Smoking within this population occurs within a framework of social inequalities that may affect morbidity and mortality more directly and may lead to problems that are more immediate or require more complex management22,23; however, the presence of these medical problems should not preclude the provision of preventive health care, including smoking cessation advice. If the transtheoretical model is increasingly used as the basis for developing smoking cessation guidelines for use with all smokers, then it should first be determined whether the processes of change that are characteristic of smokers in the general population are also characteristic of smokers who are medically underserved.
Materials And Methods
Subjects
People older than 18 years were interviewed at 4 clinics providing care for the medically underserved in Northeast Ohio over a 6-week period. Medicaid covered 20% of the patients at 1 clinic and 8% of the patients at another clinic; 1 clinic did not accept payment of any kind and the other 3 accepted fees on a sliding scale. Approximately 20% of the funding in 1 clinic was from private insurance. Two of the clinics excluded patients with income exceeding 200% of the Federal Poverty Guideline. Two female, Caucasian medical students employed for a summer fellowship conducted one-on-one interviews in English. Eligible subjects included patients and those accompanying patients in the waiting rooms of these clinics. None of the people approached appeared acutely ill to the medical students. This study was approved by the Institutional Review Board of the Northeastern Ohio Universities College of Medicine and informed consent was obtained.
Questionnaires
Subjects were asked demographic questions, questions about their smoking histories, current smoking habits, whether they lived with people who smoked, and whether their health care provider had ever advised them to quit smoking. Measures based on the transtheoretical model (short form versions) that have been widely used and validated were used to assess subjects’ stages of change,12,24 processes of change,25 decisional balance (pros and cons of smoking),26 and level of temptation and efficacy about smoking cessation.27 The decisional balance questions were not designed to assess which pros and cons of smoking were most important to patients, but whether cons of smoking were rated as more important than pros of smoking by patients stating their willingness to quit smoking and whether the reverse was true in patients who stated they would not quit smoking in the near future. A detailed overview of the transtheoretical model, development of the questionnaires, and the questionnaires themselves are available at the University of Rhode Island’s Cancer Prevention Research Center Web site.28
Analysis
Data were recorded by the interviewers on Trans-Optic forms and then scanned into an ASCII database. Data analysis was performed with SAS software (SAS Institute, Cary, NC). Ten experiential processes questions, 10 behavioral processes questions, 6 decisional balance questions, and 9 self-efficacy/temptation questions were asked. Subscale scores were generated for the processes of change (5 subgroups each for experiential and behavioral processes), decisional balance (2 subgroups, pros and cons), and self-efficacy/temptation (3 subgroups: social situations, negative situations, and habit). Individual item scores ranged from 1 to 5, with increasing numbers indicating that the process was of greater importance. A 2-way analysis of variance was conducted to measure differences among smokers in the precontemplation, contemplation, and preparation stages and how those responses differed between those who smoked a pack or more each day and those who smoked less than a pack a day. The interaction effect between stages of change and amount smoked was also included in the model. Post hoc analyses were conducted with the Tukey-Student range test.
Results
Subjects
A total of 523 people were approached by the interviewers. Sixty-six (13%) refused to participate (66% were female). Of the remaining 457 people, 173 (38%) had never smoked, 39 (9%) quit smoking more than 5 years previously, and 245 (54%) were current smokers or had quit within the past 5 years. Four cases were lost due to incomplete collection of information. The percentages of patients in each stage of change are presented in the Figure.
The final study sample consisted of 200 current smokers: 16% were in the preparation stage, 47% were in the contemplation stage, and 38% were in the precontemplation stage.