Relationships between stage of change for stress management behavior and perceived stress and coping

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1 Japanese Psychological Research 2010, Volume 52, No. 4, doi: /j x Short Report Relationships between stage of change for stress management behavior and perceived stress and coping SATOSHI HORIUCHI*, AKIRA TSUDA, and EUIYOEN KIM Kurume University KWANG-SHIK HONG Jeonju National University of Educationjpr_ YOUNG-SHIN PARK and UICHOL KIM Inha University Abstract: The main aim of this study was to examine the relationships between stage of change, which was guided by the transtheoretical model, for stress management behavior and perceived stress and coping. First, we developed the Korean version of the Rhode Island Stress and Coping Inventory (RISCI). Second, we related stage of change for stress management behavior to perceived stress and coping. Based on two surveys that we conducted (n = 530 for survey 1 and n = 299 for survey 2), we developed the Korean version of the RISCI with acceptable internal consistency and criterion-related validity against the depressive level measured using the Korean Beck Depression Inventory II. The stress score of the Korean version of the RISCI was significantly lower in maintenance than in the other stages, while the coping score was significantly higher in action and maintenance than in the first three stages (n = 804), irrespective of sex. These results provided further empirical evidence to validate stage classification in the field of stress management behavior. Key words: the Korean version of the Rhode Island Stress and Coping Inventory, stress management behavior, coping, stress, stage of change. Stress has adverse effects on the economy as well as on people s mental and physical health (Prochaska, Prochaska, & Evers, 2005), and it is important for people to practice stress management behaviors to manage stress effectively in everyday life. We have previously reported that, despite the adverse effects of stress, approximately 60% of Korean college students do not practice stress management behavior (Kim, Tsuda, Horiuchi, Park, Kim, & Hong, 2009). Takenaka (2005) suggested that undertaking any type of activity to control stress in everyday life is important for reducing stressrelated problems. Therefore, there is a need to help these students practice stress management behavior which is aimed at preventing stress-related problems. Behavioral science models of behavior change provide theoretical frameworks by which to formulate proper interventions. The transtheoretical model (TTM) of behavior change (Prochaska & DiClemente, 1983) is one of the leading frameworks in this field. The TTM consists of four constructs: stage of *Correspondence concerning this article should be sent to: Satoshi Horiuchi, Research Fellow of Japan Society of the Promotion of Science, Kurume University, Mii-machi, Kurume , Japan. ( satosato.007@nifty.com) 2010 Japanese Psychological Association. Published by Blackwell Publishing Ltd.

2 292 S. Horiuchi, A. Tsuda, E. Kim, K.-S. Hong, Y.-S. Park, and U. Kim change, processes of change, self-efficacy, and decisional balance. The TTM can be applied not only to single, but also to complex behavioral targets such as a high-fat diet and stress management behavior (Evers, Prochaska, Johnson, Mauriello, Padula, & Prochaska, 2006; Prochaska & DiClemente, 1986). Stage of change refers to current behavioral practices and the intention to perform the targeted behavior. The TTM differentiates people into five stages (precontemplation, contemplation, preparation, action, and maintenance). Processes of change refer to the overt and covert activities that individuals use to facilitate a forward stage transition. Self-efficacy represents situation-specific confidence to practice the targeted behavior. Decisional balance involves the balance of perceptions of gain (pros) and loss (cons) resulting from performing the behavior. Application of the TTM to stress management is a relatively new field (Evers et al., 2006); therefore, the applicability of the model should be further tested. It is essential to validate stage classification for stress management behavior, that is, to confirm whether there is a match between stage of change for stress management behavior and actual stress management activity. The validity of stage classification for stress management behavior has been examined in two ways (Nakamura, 2005). One method is to examine directly the relationships between stage of change for stress management behavior and frequency of stress management behavior. This approach is based on the hypothesis that the stage is related to the frequency of particular behaviors. Only one study, by Riley and Fava (2003) in HIV-positive women, has reported that stress management practice is significantly, but to a weak extent, related to stage of change for stress management behavior (r =.251, p =.001). This approach requires measurements of stress management behavior, but this measurement is difficult for the following reasons (Nakamura, 2005). First, stress management behavior is highly variable between individuals, and it is difficult to specify and list particular behaviors. In addition, psychological stress is a subjective phenomenon, and it is difficult to determine objectively whether a healthy activity effectively manages stress. Thus, such an approach may not be suitable for effective stress management behavior, defined as healthy activities for managing stress. The other method is to confirm the relation between stage of change for stress management behavior and stress responses. This approach is based on the hypothesis that individuals in later stages tend to exhibit better mental health status (Nakamura, 2005). Individuals in the last two stages are expected to carry out effective stress management behavior, resulting in better mental health status. Previous studies have confirmed that stress responses, measured by depressive levels (Horiuchi, Tsuda, Tanaka, Okamura, Yajima, & Tsuda, 2009; Kim et al., 2009; Nakamura, Oka, Matsuo, Takenaka, & Agari, 2002) and a number of other symptoms (Padlina, Aubert, Gehring, Martin-Diener, & Somaini, 2001), are lowest in the maintenance stage, thereby partially supporting the validity of stage classification. In this study, the authors attempt to validate stage classification further by confirming a predicted relationship between stage of change and the perceived ability to cope with stressful situations. We expect such a perception to correlate tightly with successful practice of stress management behaviors. This perception is not only independent of what kind of activity subjects perform to manage stress, but can also exclude the effects of activities that are not beneficial in reducing stress responses. In line with this, Padlina et al. (2001) suggested that examining the relationships between stage of change and standard stress-coping measures, such as the Rhode Island Stress and Coping Inventory (RISCI) (Fava, Ruggiero, & Grimley, 1998), would provide more clues by which to further validate stage classification.the RISCI consists of two subscales: stress and coping. The RISCI was developed as part of research regarding stress, coping, and consequent disease risks such as smoking, based on the hypothesis that physical health may be negatively affected by personal perceptions that individuals are stressed or not able to cope with stress adequately (Fava et al., 1998).

3 Stage and perceived stress and coping 293 The stress subscale of the RISCI reflects how often a person felt stressed over the past month. The coping subscale reflects how often a person felt that he or she was able to cope with stressful situations over the past month. Individuals in the maintenance and action stages perform healthy activities to manage stress; therefore, it is hypothesized that a more frequent experience of feeling able to cope, measured by the coping subscale of RISCI, is associated with a later stage. Confirming hypothesized patterns between stage of change and perceived coping would provide further empirical evidence to support stage classification. Only one study has been conducted with regard to the relationships between perceived coping and the stages of change for stress management behavior. The intervention study conducted by Evers et al. (2006) measured the RISCI subscales as outcome measures. In this investigation, participants in the first three stages were assigned to two groups, the treatment and the control group. Approximately 60% of the participants in the treatment group and 40% of those in the control group progressed to action or maintenance stages after 6 months, which was maintained until the 18-month time point. The researchers found that the changes in the scores on the coping subscale did not differ between the two groups, while they observed a significant improvement in the stress score only in the treatment group. The first three stages and the later two stages were combined in the analyses, and we consider that it is difficult to clarify the relations between perceived coping, measured using the coping subscale of the RISCI, and the five stages of change for stress management behavior from the results of Evers et al. (2006). Because of the lack of empirical research comparing directly perceived coping in all five stages of change for stress management behavior, the main aim of this study was to examine the relationships between stage of change for stress management behavior and perceived stress and coping in Korea. First, we developed the Korean version of the RISCI through two surveys (Step 1). Then we related perceived stress and coping to stage of change (Step 2). Step 1 Development of measure Method Respondents and procedure. We recruited 530 students (160 male and 370 female) from a university located in Jeonju, Korea, in survey 1.They responded to the 10 RISCI items that were translated into Korean and to the staging algorithm described in Step 2, before or after psychology lectures. The mean age of the male students was 23.5 years with a standard deviation of 3.35 years, and 22.8 years with a standard deviation of 2.92 years for the female students. Data were collected from November 2006 to February A total of 299 Korean university students (161 male and 138 female) participated in survey 2. The mean age of the male students was 22.5 years with a standard deviation of 3.35 years, and 20.8 years with a standard deviation of 2.92 years for female students. Survey 2 was conducted in July Either before or after psychology lectures, each participant responded to the Korean versions of the RISCI, the Beck Depression Inventory-II (BDI-II) (Beck, Steer, & Brown, 1996; Kim, Lee, & Lee, 2007), and the staging algorithm described in Step 2. Measures. We translated 10 of the 12 items of the original RISCI into Korean after obtaining permission from the original authors (Table 1). Four Korean researchers participated in the translation. One of these researchers translated the items into Korean. The other three, belonging to two institutions that were different from that of the translator, confirmed that the translation did not change the meanings of the original sentences. These 10 items have been used in an intervention study (Evers et al., 2006). Each respondent rated how often he or she had felt stressed, or had been able to cope with stressful situations over the past month, on a 5-point Likert scale (1 = never to 5 = repeatedly). The scores of the two subscales potentially range from 5 to 25. Depressive symptoms were assessed using the Korean version of the BDI-II, which is a self-report questionnaire and consists of items

4 294 S. Horiuchi, A. Tsuda, E. Kim, K.-S. Hong, Y.-S. Park, and U. Kim Table 1 Standardized path coefficients and internal consistency of the Korean version of the Rhode Island Stress and Coping Inventory Survey 1 Survey 2 Stress subscale (Cronbach s a) (.78) (.80) 1. I felt there was not enough time to complete my daily tasks I felt I had more stress than usual I took on more than I could handle I was pressured by others I felt stressed by unexpected events Coping subscale(cronbach s a) (.80) (.85) 6. I successfully solved problems that came up I was able to cope with unexpected problems I was able to cope with difficult situations I was able to cope meeting demand I felt that I was able to cope with stress Interfactor related to feelings of depression. Its total score ranges from 0 to 60; higher scores show stronger depressive states. The internal consistency and validity of the BDI-II have been confirmed in Korean female students (Kim et al., 2007). Statistics. Confirmatory factor analyses were conducted to examine whether the factor structure of the Korean version of the RISCI was the same as that of the original RISCI. We expected that items 1 5 would be related to the stress factor, while items 6 10 would be linked to the coping factor. Model fitness was evaluated with the four indices of fit: the goodness of fit index (GFI), the adjusted goodness of fit index (AGFI), the root mean square error of approximation (RMSEA), and the comparative fitness index (CFI). As Byrne (2001) discussed, we considered that a higher GFI (>.9), a higher AGFI (>.8), a lower RMSEA (<.1), and a higher CFI (>.9) reflected desirable fit. The standardized path coefficients were calculated, and a coefficient <.4 was assumed to be low. If the levels of more than one model fitness index or path coefficient were not fulfilled, we removed relevant item(s). Cronbach s alpha coefficient was calculated as an indicator of internal consistency. To validate the Korean version of the RISCI, the relationship between the scores of the two subscales and that of the Korean BDI-II were examined. It was hypothesized that the BDI-II score was related positively to the stress subscale and negatively to the coping subscale. Results Survey 1. Table 1 shows the standardized path coefficients obtained in survey 1. The path coefficients were all above.4, suggesting that all items were related to each factor as expected. The fit indices were within the tolerance levels: GFI =.95, AGFI =.91, RMSEA =.08, and CFI =.91. From these model fitness values, we considered that the model fit the data well. The Cronbach s alpha coefficients were.78 for subscale 1 (stress) and.80 for subscale 2 (coping), as shown in Table 1. These findings suggest that the Korean version of the RISCI showed acceptable structural validity and internal consistency. Survey 2. As shown in Table 1, the standardized path coefficients in survey 2 were all above.4. All fit indices were within the tolerance levels: GFI =.95, AGFI =.87, RMSEA =.09, and CFI =.91. We understood that the model fit to the data well.the Cronbach s alpha coefficients were.80 for subscale 1 (stress) and.85 for subscale 2 (coping), as shown in Table 1. As hypothesized, the BDI-II score was related

5 Stage and perceived stress and coping 295 positively to the stress subscale (r =.54, p <.01) and negatively to the coping subscale (r =-.43, p <.01), suggesting acceptable criterion-related validity of the Korean version of the RISCI. Method Step 2 Stage of Change and Stress-Coping Respondents. The data from surveys 1 and 2 were combined to examine the relationships between stage of change and perceived stress and coping. Data for a total of 321 male and 508 female students were pooled. Measures. The stage of change for the stress management behavior of each respondent was assessed using the Korean version of the Pro-Change staging algorithm (Kim et al., 2009). First, stress management behavior was defined as any form of healthy activity one practices to reduce perceived stress, such as regular relaxation and physical activity, talking with others, and/or engaging in social activities for at least 20 minutes per day. Respondents were then asked whether they practice stress management behavior in everyday life. They had to select one of six items representing stage of change: No. I have no intention to begin in the next 6 months. (precontemplation); No. But I intend to begin in the next 6 months. (contemplation); No. But I intend to begin in the next month. (preparation); Yes. I have been practicing for less than 6 months. (action); and Yes. I have been practicing for at least 6 months. (maintenance). To exclude respondents who had not experienced stress, the item No. I have not been stressed. was included. The temporal stability of the algorithm was confirmed by a high Kapp index. In addition, the stage of change was related to depressive mood in the expected direction, confirming the validity of the Korean version of the Pro-Change staging algorithm (Kim et al., 2009). Perceived stress and coping were measured using the Korean version of the RISCI. Statistical Analysis. Differences in the mean values for the scores on the stress and coping subscales were examined using one-way analysis of variance (ANOVA) with Tukey s post hoc tests, with stage of change as independent variables; 13 male and 12 female students who had not experienced stress over the past month were excluded. Results Stage Distribution. The stage distribution was: 13.2% precontemplation, 16.7% contemplation, 28.7% preparation, 15.9% action, and 25.5% maintenance. A chi-squared test indicated that the distribution was dependent on sex, c 2 = 1.2, p <.05. The proportion of Korean students who belonged to the precontemplation stage was greater among male than female students. The proportion of students who belonged to the action stage was greater among female than male students. Stage and the RISCI. For the stress subscale, an ANOVA revealed a significant main effect for stage, F(4,794) = 4.95, p <.01. Tukey s post hoc test revealed that the stress score was significantly lower in maintenance than in the other four stages (Figure 1, p <.05, vs. precontemplation and contemplation; p <.01, vs. preparation and action). Neither the main effect of sex nor the interaction effect was significant, sex: F(1,794) = 1.18, ns; interaction: F(4,794) =.48, ns. For the coping subscale, an ANOVA revealed a significant main effect for stage, F(4,794) = 14.14, p <.01. Tukey s post hoc test indicated that the coping scores were significantly higher in maintenance and action than in the first three stages (Figure 2, p <.01, vs. the other three stages). Neither the main effect of sex nor the interaction effect was significant, sex: F(1,794) =.27, ns; interaction: F(4,794) = 1.54, ns. Discussion The main purpose of this study was to examine the relationship between stages of change for

6 296 S. Horiuchi, A. Tsuda, E. Kim, K.-S. Hong, Y.-S. Park, and U. Kim stress management behavior and perceived coping, as well as the level of stress as measured using the Korean version of the RISCI. A Korean version of the RISCI, with acceptable internal consistency and criterion-related validity, was first developed. The main findings are summarized as follows: (a) Korean students in the maintenance and action stages more frequently felt that they could cope with stressful situations as compared with those in the first ** ** ** * Stress score PC C PR A M Figure 1 Perceived stress levels across the five stages of change. Note. A = action; C = contemplation; M = maintenance; PC = precontemplation; PR = preparation. *p <.05 **p <.01 (vs. M). 25 Coping score ** ## ++ ** ## PC C PR A M Figure 2 Perceived coping levels across the five stages of change. Error bars are standard errors of mean. Note. A = action; C = contemplation; M = maintenance; PC = precontemplation; PR = preparation. **p <.01 (vs. PC), ##p <.01 (vs. C), ++p <.01 (vs. PR).

7 Stage and perceived stress and coping 297 three stages. (b) Korean students in the maintenance stage showed a lower perceived stress level compared with those in the other stages. The former finding was the first evidence in Korea that stage of change for stress management is related to personal perception of the ability to manage stressful situations. The latter finding replicated previous results (Horiuchi et al., 2009; Kim et al., 2009; Nakamura et al., 2002; Padlina et al., 2001). These findings provide further empirical evidence to support the application of the TTM to stress management behavior. The main limitation of the study is that it is unknown what kind of healthy activity each participant engaged in to manage stress. Therefore, in future studies, it will be necessary to identify these activities. Another limitation is that it is also unclear whether the relationship between stage of change and perceived coping ability can be generalized to other samples. So it will be necessary to examine whether our findings can be generalized to other samples. References Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck Depression Inventory (2nd manual). San Antonio, TX: The Psychological Corporation. Byrne, B. M. (2001). Structural equation modeling with AMOS: Basic concepts, applications, and programming. Mahwah, NJ: Lawrence Erlbaum. Evers, K. E., Prochaska, J. O., Johnson, J. L., Mauriello, L. M., Padula, J. A., & Prochaska, J. M. (2006). A randomized clinical trial of a population- and transtheoretical model-based stress-management intervention. Health Psychology, 25, Fava, J. L., Ruggiero, L., & Grimley, D. M. (1998). The development and structural confirmation of the Rhode Island Stress and Coping Inventory. Journal of Behavioral Medicine, 21, Horiuchi, S., Tsuda, A., Tanaka, Y., Okamura, H., Yajima, J., & Tsuda, S. (2009). Stage of change distribution of stress management behavior in Japanese university students. Japanese Journal of Health Promotion, 11, 1 7. Kim, M. S., Lee, I. S., & Lee, C. S. (2007). The validation study I of Korean BDI-II: In female university students sample. Korean Journal of Clinical Psychology, 26, Kim, E., Tsuda, A., Horiuchi, S., Park, Y. S., Kim, U., & Hong, K. S. (2009). The relationship between stage of change for stress management and depressive symptoms in a sample of Korean university students. Kurume University Psychological Research, 8, Nakamura, N. (2005). Problems for applying the transtheoretical model to stress management. In K. Takenaka (Ed.), Stress management. Tokyo: Yumani, pp (In Japanese, translated by the author of this article.) Nakamura, N., Oka, K., Matsuo, N., Takenaka, K., & Agari, I. (2002). The relationship between stages of change for stress management and depressive symptoms in a sample of Japanese elderly. Japanese Journal of Stress Science, 17, Padlina, O., Aubert, L., Gehring, T. M., Martin- Diener, E., & Somaini, B. (2001). Stages of change for perceived stress in a Swiss population sample: An explorative study. Sozial-und Präventivmedizin, 46, Prochaska, J. M., Prochaska, J. O., & Evers, K. (2005). Stress management using the transtheoretical model. In K. Takenaka (Ed.), Stress management. Tokyo: Yumani, pp (In Japanese, translated by the author of this article.) 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, Prochaska, J. O., & DiClemente, C. C. (1986). Toward a comprehensive model of behavior change. In W. M. Miller & N. Heather (Eds.), Treating addictive behaviors: Processes of change. New York: Plenum Press, pp Riley, T.A., & Fava, J. L. (2003). Stress and transtheoretical model indicators of stress management behaviors in HIV-positive women. Journal of Psychosomatic Research, 54, Takenaka, K. (2005). Behavior modification theory and stress management. In K. Takenaka (Ed.), Stress management. Tokyo: Yumani, pp (In Japanese, translated by the author of this article.) (Received January 7, 2009; accepted January 30, 2010)

Nanako Nakamura * Shimokume, Kato-shi, Hyogo Japan [Received February 9, 2009 ; Accepted December 8, 2009]

Nanako Nakamura * Shimokume, Kato-shi, Hyogo Japan [Received February 9, 2009 ; Accepted December 8, 2009] Material : Mental Health Services Stages of change for stress management behavior in Japanese university students The relationships among stages of change for stress management, stress responses, self-efficacy,