Tinnitus is common, and some individuals with tinnitus display high levels of distress. Cognitive behavioural therapy (CBT) is effective in reducing tinnitus distress, but is rarely available. CBT-based self-help, with or without guidance, has yielded positive results in other problem areas, and one initial randomized controlled trial (RCT) has shown promising results for tinnitus. This thesis is based on four studies; Study I showed that Internet-based self-help treatment with e-mail guidance alleviated tinnitus distress among consecutive patients and was rated as credible as traditional treatments. Active participation in treatment predicted outcome. Study II, an RCT, showed that an extended and more interactive version of the Internet-based self-help treatment with e-mail therapist support appeared to be equally effective as a group treatment. In study III, another RCT, a self-help book with weekly telephone support was superior to a wait-list control group. No strong evidence for the importance of telephone contact on outcome was found. In both study II and III, the positive outcome remained after one year and self-help approaches appeared more therapist time-effective compared to group treatment. Also, the received treatment-dose for patients in guided self-help was not lower than in the group treatment. Study IV found that the ‘Stages of Change’, from the transtheoretical model, are probably not the right theoretical framework to use with tinnitus patients. Predictors of outcome were found, but they were not in line with the theory behind the Stages of Change. The predictors were better understood when conceptualized as coping, showing that helplessness and less coping before treatment correlated with better outcome. In sum, guided cognitive behavioural self-help can decrease tinnitus distress. It appears to be therapist time-effective and shows effects comparable to or slightly below traditional CBT for tinnitus. Effects remain one year after treatment and generalize to a routine clinical setting.

Parent and child readiness to change have been identified as emerging areas informing pediatric obesity interventions. The purpose of this study was to increase understanding of child and parent readiness to change in obese youth by examining how these constructs are related to demographic variables, as well as to psychosocial functioning, in a sample of obese youth presenting for weight- management treatment. A secondary aim was to examine consistency between parent and child readiness to change. Two hundred twenty-eight 7- to 17-year-old children and their parents participated during the child’s initial assessment at a multidisciplinary weight-management clinic. Demographic variables included in analyses were child Body Mass Index, parent Body Mass Index, child age, child gender, child race, and family income. Children completed measures of quality of life, depression, social anxiety, internalizing and externalizing symptoms, and readiness to change. Parents completed assessments of children’s quality of life, children’s internalizing and externalizing symptoms, and parents’ own readiness to change. The child’s Body Mass Index was significantly related to both parent and child readiness to change. There was also a significant positive relation between child readiness to change and the child’s own report of social anxiety symptoms, as well as a curvilinear relation with internalizing symptoms, such as depression. In addition to the child’s Body Mass Index, parent readiness to change was positively related to the child’s age and was higher in African American parents than in European American parents. Race moderated the relation between parent readiness to change and health-related quality of life, internalizing symptoms, and externalizing problems. Parents and children were discordant in their ratings of readiness to change, with parents tending to report higher levels; the child’s Body Mass Index moderated the relation between parent and child report of readiness to change. Clinical implications and future directions are discussed.

The purposes of this study were to examine (a) physical activity participation levels, (b) exercise stages of change levels and (c) physical activity preferences of the Middle East Technical University undergraduate students with respect to gender, residence and faculty. Participants were 953 students from 5 different faculties (496 male, and 547 female). For the data collection, International Physical Activity Questionnaire (IPAQ), Physical Activity Stages of Change Questionnaire, and Physical Activity Preferences Questionnaire were used. Descriptive statistics (frequency, mean, median, percentage), and nonparametric statistical methods (Mann Whitney U test, Kruskal-Wallis test, Pearson chi-square test) were used for the data analysis. According to the IPAQ, male students were more physically active than female counterparts. Students who were living in campus had higher physical activity levels, and faculty of architecture students were more sedentary compared to other faculty students (p &lt / 0.05). In general, 24.8% of the students were physically active, 59.9% of the students were moderately active, and 15.3% of them were inactive. The results on exercise stages of change revealed that male students were at upper stages as compared to the female students. Faculty of architecture students were at lower stages compared to the other faculty students (p &lt / 0.05). There was no significant differences on the stages of students who were living in and out of the campus (p &gt / 0.05). In general, students at pre-contemplation, contemplation, preparation, action and maintenance stages were 15.2%, 31.4%, 25.3%, 7.5%, and 20.6% respectively. Swimming (59.2%), walking (56.7%), cycling (36.2%) and football (30.4%) were the most frequently preferred physical activities. Dancing and tennis were preferred more with the female students while football and basketball preferred more with the male students. Physical activity preferences of students living in and out of campus were similar. In conclusion, female students, students living out of the campus and students of faculty of architecture were more at risk. Approximately 75% of the METU undergraduate students&rsquo / physical activity levels were not satisfactory for a healthy life. University physical activity facilities, extracurricular programs and the courses should be reconsidered based on the findings of this study.

Tobaksbruk är förknippat med ohälsa, stor risk finns att drabbas av följdsjukdomar. Syftet var att beskriva distriktssköterskors erfarenheter och upplevelser av att arbeta med tobaksavväjning i grupp. En studie med kvalitativ ansats och deskriptiv design har gjorts. Åtta distriktssköterskor som arbetar med tobaksavväjning i grupp har intervjuats. Materialet har analyserats med hjälp av kvalitativ innehållsanalys. I resultatets första kategori ”Viktigt med tydliga arbetsrutiner vid tobaksavvänjning i grupp” beskrevs exempelvis arbetsrutiner såsom att hemuppgifter gavs mellan grupptillfällena, tobaksstoppdatum planerades och uppföljningar gjordes. Dock beskrevs svårigheter att rekrytera deltagare till tobaksavvänjningsgrupperna, vilket innebar att personerna hänvisades till individuell tobaksavväjning. Det rapporterades vara psykiskt påfrestande att leda grupper om deltagare hade psykisk ohälsa och komplexa sociala problem. Andra kategorin ”Möjligheter och svårigheter vid gruppbehandling” beskrev att motiverande samtal användes och deltagarnas motivation ansågs avgörande för tobaksstoppet. Tobaksavväjningen uppgavs fungera när distriktssköterskan inte ”föreläste” utan uppmuntrade alla till att bli hörda, så att erfarenheter delades och stöd gavs åt varandra. Distriktssköterskorna upplevde arbetet stimulerande men även frustrerande, möjligheter till stöd av tobakssamordnare eller kollegor fanns, dock saknades stöd av läkare. Önskvärt enligt distriktssköterskorna vore att vara två som genomförde gruppträffarna tillsammans, ha tillräckligt med administrativ tid samt ha tid för fortbildning. Slutsatsen är att distriktssköterskorna arbetade efter tydliga arbetsrutiner. De upplevde både möjligheter och svårigheter med att genomföra gruppbehandling. Dock behövs mer fokus läggas på att rekrytera personer till grupperna så att grupper inte behöver ställas in, samt att ökad möjlighet till vidareutveckling av tobaksavvänjnings arbete i grupp bör ges till distriktssköterskorna.

xiv, 134 p. A print copy of this thesis is available through the UO Libraries. Search the library catalog for the location and call number. / Recent mandates for increased multicultural competence training in a variety of fields have stimulated a growing need for reliable and valid multicultural competence assessment instruments. Existing instruments have demonstrated varying levels of reliability and validity in assessing multicultural knowledge, awareness, and skills and have been critiqued for limitations in scope, applicability, and ability to capture the developmental nature of multicultural competence. In an attempt to address limitations of existing measures, this study investigated an original measure of multicultural competence utilizing a stages of change framework. The stages of change model has been applied to many types of behavior change but not yet to the construct of multicultural competence. The participants in this study were undergraduate and graduate students in human services (assessed one time), graduate students in education (assessed before and after participation in a required diversity course), and student services professionals (assessed before and after participation in a multicultural training). Findings suggest that the proposed measure, the Multicultural Competence Stage of Change Scale (MCSCS), has a six factor structure corresponding to the five stages of change and one social acceptability factor. The reliability of the measure was adequate, with values of Cronbach's α above .70 for 4 out of 6 subscales and .82 for the full scale score. The validity of the MCSCS was demonstrated by significant correlations with the Multicultural Awareness, Knowledge, and Skills Scale, Counselor Edition, Revised. Results indicate that student affairs professionals scored significantly higher than education students on the Pre-Contemplation and Preparation subscales and that pre-test scores were significantly lower than post-test scores on the Pre-Contemplation, Contemplation, and Action subscales. This study provides evidence that the MCSCS is a promising measure of multicultural competence stage of change. A discussion of the findings includes strengths of the MCSCS, limitations of this study, future research directions, recommended measure revisions, and applications of the MCSCS to clinical and vocational settings. / Committee in charge: Dr. Ellen McWhirter, Chair; Dr. Krista Chronister; Dr. Joseph Stevens; Dr. Mia Tuan

Introdução: Durante o processo de modificação de comportamentos de saúde, os indivíduos passam por diferentes fases, denominadas estágios de mudança de comportamento. O desenvolvimento de intervenções nutricionais específicas para cada estágio pode contribuir para a adoção de práticas alimentares saudáveis na adolescência. Objetivo: avaliar os estágios de mudança de comportamento e verificar sua relação com o consumo alimentar de adolescentes. Métodos: Trata-se de um estudo observacional transversal com adolescentes de escolas públicas de Piracicaba. Foram coletados dados demográficos, antropométricos, de maturação sexual e de consumo alimentar (questionário de freqüência). Realizou-se uma avaliação da percepção alimentar, por meio da comparação entre o consumo alimentar e a classificação individual do aspecto saudável da dieta. Os participantes foram classificados nos estágios de mudança de comportamento (pré-contemplação, contemplação, decisão, ação e manutenção) por meio de algoritmo específico. Resultados: Foram avaliados 390 adolescentes: média de idade de 12,4 anos, 46,4% meninos, 78,7% púberes e 21,1% com excesso de peso. Observou-se consumo médio de 3645kcal, sendo que 36,7% da amostra apresentou alto teor de lipídios na dieta. O consumo médio de frutas, hortaliças e doces foi de 2,3, 2,4 e 4,5 porções diárias, respectivamente. Mais de 44% dos adolescentes mostrou percepção errônea da dieta e não manifestou motivação para modificá-la. Cerca de 40% da amostra foi classificada no estágio de manutenção. Observou-se relação significativa entre os estágios de mudança e o consumo alimentar. Foi realizada uma reclassificação dos adolescentes nos estágios de mudança para identificar indivíduos com características semelhantes segundo o consumo e a percepção alimentares. Conclusão: A classificação dos adolescentes nos estágios de mudança, em associação com os dados de consumo e percepção alimentares, permitiram a identificação de grupos de risco por suas práticas alimentares inadequadas e pelo não-reconhecimento destas. Destaca-se a necessidade do desenvolvimento de intervenções nutricionais futuras direcionadas à população estudada. / Introduction: Over the process of health-related behavior change, people move through different steps called stages of change. The development of nutritional intervention tailored to each stage of change can contribute to the adoption of healthy dietary practices among adolescents. Objective: to evaluate the stages of change and their relationship with dietary intake among adolescents. Methods: Observational cross-sectional study with adolescents from public schools of Piracicaba. Demographic and anthropometric data, sexual maturation and dietary intake (food frequency questionnaire) were examined. Food perception was evaluated comparing dietary intake with self-rated diet. Stages of change classification (precontemplation, contemplation, preparation, action, maintenance) was assessed by a specific algorithm. Results: The sample included 390 adolescents: mean age of 12.4 years, 46.4% boys, 78.7% pubescents and 21,1% overweight. Mean daily energy intake was 3645kcal and 36,7% of adolescents had excessive intake of dietary fat. Average intake of fruits, vegetables and sweets were respectively 2.3, 2.4 and 4.5 portions per day. More than 44% of adolescents were unaware of their unfavourable dietary intake and were not interested in change it. About 40% of adolescents were assigned in maintenance stage. A significant relationship was observed between stages of change and dietary intake. Adolescents were re-classified into stages of change to identify individuals with similar characteristics according to their dietary intake and their food perception. Conclusion: The stage of change assignment, in association with dietary intake and food perception data, allowed the identification of risk groups, considering their inadequate dietary practices and the lack of awareness about them. It should be emphasize the necessity of the development of future nutritional intervention tailored to this population.

Communication concerning the care one wishes to receive at the end of life (EOL) is central to ensuring that wishes are honored. Many studies have examined doctor-patient or doctor-family EOL communication. However, relatively few studies have focused on the occurrence of EOL care discussions among family members. This is an important topic, as research suggests that advance directives (ADs) are ineffective if patients have not involved surrogate decision-makers, most of whom are family members. This study examined EOL care discussions among family members. It used quantitative and qualitative data from a diverse sample of older adults from West Central Florida collected for the purpose of this examination. The quantitative and qualitative data were analyzed separately and together. This study employed the Transtheoretical Model, which proposes that individuals are in varying behavioral “stages of change” and that bringing about a behavioral change requires understanding their particular stage and adapting interventions appropriately. Statistical analysis of the quantitative data (N=364) using multinomial logistic regression showed that participants were in distinct stages that were associated with several factors, including family involvement with health care decision-making and communications with doctors. Racial and ethnic differences were not found in controlled analysis, though Hispanics were less likely to be in more advanced EOL care discussion stages in unadjusted analyses. Several themes were found in qualitative analysis of focus groups (n=36) drawn from the larger sample. Findings suggested that those who engaged in family EOL care discussions were more careful planners overall, more accepting of death, and able to manage complex family dynamics. They also had greater knowledge of EOL matters, largely related to knowledge of loved ones EOL wishes. The quantitative-qualitative (mixed-methods) study reinforced the role of family relationships in general in whether EOL care discussions occurred. It also highlighted the role of being proactive and having EOL care knowledge. All three studies – the quantitative, qualitative, and mixed methods showed the potential for doctors and other health professionals to help families with EOL care discussions and ACP overall.

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