Application of Behavior Change Theory to the Development

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14 BEHAVIOR CHANGE THEORY characteristics; researcher blinded to randomization schedule; and, temporality, the evidence that treatment preceded outcome. The minimum and maximum possible points ranged from 0 to 6. These points were then multiplied by a factor of four to arrive at the final Design Quality score that ranged from 0 to 24. The factor of four was established to emphasize that the design is the most important consideration in research. The quality of the treatment letters was determined from an assessment of the number of TTM elements used in their construction, multiplied by a factor of three for the general methods, a factor of two for the early stage techniques, and a factor of one for the late stage components. The quality scores were allowed to range between 0 and 18, 0 and 10, and 0 and 5 for the general, early, and late stage elements, respectively. Therefore, 33 would represent a perfect score across all 16 TTM components. The general strategies were multiplied by three, the largest TTM factor, because the balance of the methods used in the early and late stages of change will be less powerful in the absence of the general strategies. The factor of two used to multiply the early stage points reflects its relative importance to the general and late stage elements. An evaluation sheet (Appendix A-1) was developed for the purpose of assessing each study containing advisory treatment-letters or sufficiently detailed descriptions of treatment contents. This evaluation sheet recorded the study’s title, author, source, date, design characteristics scores, general strategy scores, early-stage strategy scores, late-stage strategy scores, strength of association, and other factors relevant to the evaluation. The evaluated studies were tabulated by the strength of evidence supporting each treatment in terms of the quality of the research and the validity of the methods as defined by the degree to which they reflected components of the Transtheoretical Model of behavior change that was used as the assessment instrument. Goal Attainment Scaling Goal attainment scaling was also used in an attempt to define five levels of expectation for each of the 16 TTM elements. Originally, it had been thought that this method would provide a framework for an evaluation tool of sufficient sensitivity to distinguish fine gradations of dissimilarity among the sentences used in the various letter treatments to convey messages relevant to specific TTM change elements. Goal Attainment Scaling (GAS) was developed in the 1960’s to address the especially difficult evaluation needs within the mental health community (Kiresuk & Sherman, 1968). Since then, GAS has been applied to an expanding universe of fields including education, social work, psychology, and even business (Kiresuk et al., 1994). The technique requires desirable and undesirable outcomes to be documented in an unambiguous manner through descriptive statements or quantitative data. Because GAS is a dynamic concept, the goals and measurable outcomes defined can be subject to continuous review and assessment to ensure that changing circumstances are not neglected.
BEHAVIOR CHANGE THEORY In the course of collecting and examining the data on the contents of the treatment letters, it was discovered that the letters were not sufficiently developed and varied to permit the use of goal attainment scaling to help discriminate their contents vis-à-vis the TTM change elements. Although goal attainment scaling as developed by Kiresuk and Sherman (1968), ultimately was not used, a three-point scale based on goal attainment scaling was used to assess the contents of treatment letters. Treatment Letters This research project centered upon the contents of advisory letter treatments. Regrettably, research reports rarely enclosed copies of the treatment letters used in the studies. Because many reports are 30 or 40 years old, it is extremely difficult to secure relevant treatment letters. California, for instance, does not archive copies of discarded treatment letters. However, the Research and Development Branch within California’s Department of Motor Vehicles has an informal archive of these valuable research tools. Unfortunately, many of the old letters are not dated and the time periods in which they were used were not recorded. Nonetheless, the vast majority of the 42 treatment letters located and evaluated in this literature review came from this source. Given the potential importance of these letters for further research efforts, their contents were recorded and preserved in Appendices B-1 to B-31. Letters identical or closely similar to other treatments were not duplicated. Therefore, only 31 letters have been memorialized in the Appendices. Generalizability Caution needs to be exercised before deciding to generalize the following results beyond this study. The treatment letters evaluated were selected neither on a random basis nor on information that the recipients were comparable with respect to other risk factors for crashes and citations. Letter treatments were selected on the basis of availability and those associated with the studies conducted from 1985 to 1994 were changed often and may have been used singly or in combination with other treatments in one or more studies. Therefore, the validity of the individual study results is not assured, and it is clearly not possible to generalize an invalid result (Hennekens & Buring, 1987). RESULTS The warning letters evaluated for this critical review varied in their contents. Some incorporated more of the 16 TTM elements than others and a few contained a richer combination of elements across the three major components than most. The evaluation was limited to a total of 42 treatment letters used in 13 negligent operator treatment evaluation studies. 15
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Application of Behavior Change Theory to the Development

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