Alcohol and Alcoholism Advance Access originally published online on October 7, 2006
Alcohol and Alcoholism 2006 41(6):616-623; doi:10.1093/alcalc/agl082
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ASSESSING MOTIVATION FOR CHANGE IN SUBJECTS WITH ALCOHOL PROBLEMS: THE MAC2-A QUESTIONNAIRE
1 Department of Dependence, ASL 3, Genova, Italy, 2 Department of Dependence, ASL 20-22, Alessandria, Italy and 3 School of Specialization in Psychiatry, University of Genova, Italy
* Author to whom correspondence should be addressed at: Department of Dependence Via Sampierdarena, 2 16149 Genova, Italy; Tel.: +39 347 3130199; Fax: +39 010 3447016; E-mail: spiller{at}fastwebnet.it
(Received 28 February 2006; first review notified 29 May 2006; in revised form 5 September 2006; accepted 5 September 2006)
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONAPPENDIXREFERENCES |
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Aims: This article presents the validation study of a questionnaire (MAC2-A), created to assess motivation for change in Italian adult subjects with alcohol related problems who require or are referred for assessment and treatment. The questionnaire evaluates readiness to change (RTC), self-efficacy and discrepancy. Methods: The questionnaire was validated on 419 subjects referred to 23 health agencies in Italy. Results: The questionnaire showed good internal consistency and temporal stability. Exploratory and confirmatory factor analysis confirms the consistency with the theoretical assumptions. Test–retest showed high reliability on all scales except one. Visual analogue control scales used for reliability and concurrent validity yielded strong correlations with the corresponding variables. Conclusion: The study confirms the validity of the instrument, and its consistency with the model. The MAC2-A questionnaire is the first psychometric instrument integrating three factors (discrepancy, self-efficacy, RTC) into a 3D model of motivation for change.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONAPPENDIXREFERENCES |
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Assessing motivation for change: international and Italian background
The importance of assessing motivation for change in individuals with alcohol problems is widely acknowledged. Some findings suggest that motivation influences the type of therapy selected, the compliance and, to some extent, the outcome of treatment (Miller, 1989
; Miller et al., 1992; Connors et al., 2001; Demmel et al., 2004).
Most motivational assessment tools used in clinical work refer quite frequently to the readiness to change (RTC) concept as described in the Transtheoretical Model (TTM) (Prochaska and DiClemente, 1982). This model has been the object of enthusiasm, criticism, and comprehensive reviews (Davidson, 1992; Jay et al., 1999; Sutton, 2001; DiClemente, 2005; Etter, 2005; Herzog, 2005; Migneault et al., 2005; Sutton, 2005). In light of the provocative idea of ‘putting the TTM to rest’ (West, 2005), we believe that TTM stimulated a great amount of ‘testable hypotheses that lead to enhancements of our understanding of complex phenomena.’ (Hodgins, 2005) and it is an important starting point for appreciating and evaluating motivation for change.
The assessment of RTC is usually made by classifying a person at a particular stage and/or recording the stages of change profile. The University of Rhode Island Change Assessment Scale (URICA) (McConnaughy et al., 1983; DiClemente et al., 1990), RTC questionnaire (RTCQ) (Rollnick et al., 1992; Heather et al., 1999) and Stage Of Change Readiness And Treatment Eagerness Scale (SOCRATES) (Miller et al., 1996) are the most widely used questionnaires in RTC evaluation (Carey et al., 1999) and the most extensively studied in alcohol problems.
On the other hand, there are also other specific aspects that describe some factors affecting the movement through the ‘stages’. Among these, ‘discrepancy’ and ‘self-efficacy’ seem to have important effects on RTC (Miller and Rollnick 2002) and may be considered dynamic elements of paramount importance in clinical work.
Discrepancy (Miller, 1983) is the painful perception of the contradiction between what one is and what one would like to be. It can be evaluated by considering the concerns, dissatisfactions and distress in the current situation as well as the importance of change related to personal values and expectations. To the best of our knowledge literature does not provide any example of questionnaires expressly designed to evaluate ‘discrepancy’; some tools analyse positive and negative expectations (Brown et al., 1987; McMahon et al., 1993; Donovan, 2003), or costs and benefits of drinking (Sobell et al., 1996; Cunningham et al., 1997; DiClemente, 1999; Noar et al., 2003). Integrated to a greater extent with the discrepancy concept is the analysis of the concerns and dissatisfactions, and their impact on alcohol use, proposed by Cox and Klinger (Klinger et al., 1985; Cox et al., 1988; Cox et al., 2002).
The relevance of self-efficacy (Bandura, 1977; Bandura, 1995) is widely supported and it is considered a very important predictive factor in substance related problems (Rollnick et al., 1982; DiClemente, et al., 1995). In alcohol studies it is mainly evaluated as the confidence for dealing with high-risk situations. Some tools explore predetermined situations (Annis et al., 1988; DiClemente et al., 1994; Annis et al., 1997) while others are designed as personalised semi-structured interviews (Miller et al., 1994).
However, most motivation-for-change-assessment tools only evaluate one of the aforementioned factors.
Motivation for change: a 3D model
Pursuant to these considerations, we thought it was clinically important to integrate the description of the motivation for change into a ‘3D model’ including a profile of the ‘stages of change’ as well as the two other factors, ‘discrepancy’ and ‘self-efficacy’. Thus, we sought to develop a single, easy-to-administer instrument that could evaluate the three aspects in an integrated manner.
These types of assessment tools have begun to be developed in Italy. Following the Italian translation, validation and adaptation of the RTCQ for heroin use (Spiller et al., 1994; Scaglia et al., 1995), we decided to go beyond the simple RTC evaluation and we developed and validated of a new questionnaire for heroin users, involving a simultaneous evaluation of the three factors, named MAC (Italian acronym for ‘motivazione al cambiamento’, translated as motivation for change; Spiller and Guelfi, 1998). Another similar new tool has just been developed for alcohol problems: the MAC2-A (alcohol version) and was evaluated for its psychometric properties in this study.
Aim of the study
The aim of this study was to develop a new psychometrically sound instrument to measure motivation for change using an integrated ‘3D’ model. This paper presents the validation study of the MAC2-A, an Italian self-administered questionnaire designed to evaluate motivation for change in adults who received a recommendation for, requested, are undergoing or completed specific professional interventions for alcohol problems.
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SUBJECTS AND METHODS |
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Questionnaire description
MAC2-A is a single composite instrument that tries to assess separate multiple constructs. It provides a measure of the three above-mentioned factors using separate subscales as well as other subscales within these measures that take into consideration additional aspects.
On the whole, it consists of 36 statements—18 of these items measure stages of change, 12 items measure ‘discrepancy’ and ‘self-efficacy’ and 6 items evaluate ‘help-seeking’. Each item is rated on a 0–6 Likert scale from ‘not at all true’ to ‘completely true’.
Some MAC2-A items were inspired by URICA and RTCQ statements; the majority of them were specifically created to fit Italian language style and cultural context.
Added at the end of the questionnaire were six questions that were used to validate the key concepts measured in the MAC2, including questions that examine drinkers' perceptions of ‘importance’ and ‘temptation’. These six final statements use a 100-point visual analog scale (VAS) response format and each item is assessed on a 0–100 scale from ‘not at all’ to ‘extremely’.
Stage of change items. The evaluation of the stages of change covers the entire cycle of the TTM, comprising pre-contemplation (P), contemplation (C), determination (D) (translated as ‘preparation’ stage of TTM in Italian), action (A), maintenance (M) and termination (T). Three sentences are used to evaluate each of the six stages. The point totals from each of the six stages are used to obtain a graphic summary of the ‘RTC profile’.
We combined (see below) subscale total scores related to the stages of change to produce two summary numerical values, tentatively computed according to clinical experience and prior research results. The first one describes the RTC, (computed as RTC = 54 – 2P – C + D + 2A), that is the degree of progressive approach to the decisional threshold that precedes behaviour change (to quit drinking). We used this method to elaborate a summary score [RTC] in our preceding questionnaire for heroin users (Spiller and Guelfi, 1998) and several research results suggested its consistency with clinical evaluations and treatment outcomes (Spiller, 1998; Spiller and Scaglia, 1998; Spiller and Scaglia, 2001). The second one evaluates stabilization (ST; computed as ST = 54 – 2P – C + M + 2T), that is the degree of consolidation that follows the change.
Discrepancy (DI) and self-efficacy (SE). These are evaluated by six statements each, three of which indicate the presence of the construct to be evaluated [subscales (DI+) and (SE+)] and three representing its absence [subscales (DI–) and (SE–)]. These subscales are only used for calculating (DI = DI+ minus DI–) and (SE = SE+ minus SE–).
Help-seeking items. Help-seeking is evaluated by six statements, where each item is related to one of the six stages of change (Phelp, Chelp, Dhelp, Ahelp, Mhelp, Thelp). This evaluation is used to obtain a graphic summary of the ‘help-seeking profile’. This ‘profile’ was introduced since it was noted that RTC and ‘readiness to help’, do not always have similar development trends (Freyer et al., 2005).
VAS evaluation. The questionnaire included six 100-point (centesimal) VAS scales. The first four scales (readiness to change (CRTC), stabilization (CST), discrepancy (CDI), self-efficacy (CSE) are designed to provide a validation assessment of the four summary scores obtained from the MAC2-A subscales. They provide an alternative way to assess these constructs. The last two VAS scales evaluate the importance attributed to change, importance (CIM), and the level of desire/temptation to use, temptation (CTE).
Thus, administering the questionnaire produces 16 numerical variables that constitute the scores of each subject's motivational assessment. In addition, a graphic profile of RTC is obtained to illustrate the importance of each stage of change, relating to [RTC] and [ST] summary scores. As already mentioned, a profile of ‘readiness to help’ is also produced to evaluate ‘help-seeking’ attitude.
The entire set of statements that were initially developed underwent a preliminary linguistic and semantic evaluation. A ‘linguistic test’ was carried out in eight treatment centres, administering the questionnaire to a few subjects and asking them about comprehensibility of the statements. A total of 72 comment sheets were received and they were used to modify nine items and to revise completely one of the items, since these were often incorrectly understood.
According to current literature the SE score is expected to correlate negatively to early stages, and positively to the advanced ones, and therefore correlates positively to [RTC] and [ST] scores. The DI score is also expected to correlate positively to contemplation and negatively to the advanced stages.
Sample description
The validation involved 23 treatment centres (11 in the North and 10 in the Central-Southern Italy). The clinicians were individually trained in study methodology. During the agreed upon administration period (3 months), the test was proposed to all the subjects who came in contact with the clinicians (a random inclusion criterion had to be introduced in crowded outpatient clinics).
Inclusion and exclusion criteria
The questionnaire was administered to a sample of the same target population for which it was designed. To obtain a more representative sample of all possible motivational conditions, the authors identified and sampled five different ‘categories’ of subjects included in the sample:
- Non-abstinent subjects who did not request treatment for their drinking but did receive formal recommendations to reduce alcohol consumption or undergo a specific treatment (N = 43).
- Hospitalized subjects who underwent a consultation because of suspected alcohol abuse/dependence (N = 10).
- Subjects in therapeutic communities or in specific intensive inpatient programs (N = 70).
- Subjects who requested or were included in outpatient treatments, abstinent for <1 year (N = 249).
- Subjects who were abstinent for at least 1 year, included in any maintenance programs, or not currently included in any program (follow-up; N = 47).
Test–retest reliability
A small subgroup of subjects (N = 22) was asked to repeat the MAC2-A questionnaire after 48–72 h, thus obtaining a subgroup of subjects for test–retest reliability. This evaluation was performed although a high level of temporal stability of this assessment would not necessarily be expected, as rapid fluctuation, especially during therapy, may affect motivation for change.
Concurrent validity
The primary clinicians completed a personalized evaluation of the motivational characteristics of subjects under their treatment, using the same six VAS scales of MAC2-A, to be performed in the same time of the completion of the questionnaire by the patients. It was collected from each studied subject and generated control information (N = 334) about MAC2-A's concurrent validity.
Data analysis
Statistical analysis was performed using SPSS 13.0. Confirmatory factor analysis was performed with LisRel 8.3. Test–retest reliability was estimated with the Pearson correlation coefficient. Cronbach's alpha was used to examine internal consistency of the scales. Factor analysis was performed with Principal component extraction and oblimin with Kaiser normalization rotation. The concurrent validity and the correlations between variables were estimated with Pearson correlation coefficient.
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RESULTS |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONAPPENDIXREFERENCES |
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The sample
We collected 487 questionnaires; 68 of these were excluded due to incomplete data. The validation sample included 419 subjects, 302 males and 112 females (the gender of 5 subjects was not indicated). The average sample age was 44.5 years (range: 19–74). 248 subjects (59.2%) were recorded to have had at least an alcohol related problem. 222 of them had had a current or previous alcohol dependence (193 subjects, 46.1%) or an alcohol abuse diagnosis (29 subject, 13.1%) as defined by DSM-IV TR (APA, 2000
). Diagnosis were not recorded in 40.8% of cases, but 129 of these subjects (30.8%) had a definite alcohol abuse or dependence diagnosis because of their inclusion in specific alcohol programmes in the involved treatment centres. Thus only in 42 cases (10%) were diagnosis not available. Regarding alcohol use, 16.3% of subjects reported not being abstinent when the questionnaire was administered, 14.1% reported being abstinent for <1 week, 16% from 1 week to 1 month, 24.7% from 1 to 6 months, 7.9% from 6 months to 1 year, and 11% for >1 year. No data was reported for 10% of the sample. The distribution of MAC2-A variables values is presented in Table 1.
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Factor analysis
An exploratory statistical procedure was performed using factor analysis, carried out separately on groups of items corresponding to the various theoretical dimensions. The analysis of the 18 items of stages only partially reflects the questionnaire's conceptual structure. Four factors emerged, three perfectly corresponding to the scales P, C, and T, and a fourth factor aggregating the items that contain information about commitment to change D, A, and M (Table 2).
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An additional factorial analysis of the nine items which were loaded on the D-A-M component was performed that discriminated among these three factors in a manner consistent with the hypothesised scales, although these factors are strongly intercorrelated and thus failed to form separate factors in the larger analysis (Table 3).
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The factor analysis of the 12 items of the DI and SE scales unambiguously identified the four factors corresponding to the four subscales DI–, DI+, SE–, and SE+ (Table 4).
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A confirmatory factor analysis was performed to test the actual fit of the factor model to observed data. Goodness-of-fit indices showed fully satisfactory values [non-normed fit index (NNFI) = 0.924; comparative fit index (CFI) = 0.932] even though the Chi-Squared-to-degrees of freedom ratio fell outside the recommended range of 1–3 (
2 = 1852.405, df = 390, 2/df = 4.75) and the root mean square error of approximation (RMSEA) was 0.107, indicating that the model does not fit unequivocally in the sample population. This result appears to be related not only with the number of variables examined (36 items generate 10 different scores) but also with the characteristics of sample distribution. This aspect needs a more profound study with a larger and more balanced sample.
Internal consistency and reliability
Internal consistency of the scales were found to be good for all scales (N = 419; P: 
= 0.66; C: = 0.73; D: = 0. 92; A: = 0.92; M: = 0.90; T: = 0.80; DI+: = 0.65; DI–: = 0.82; SE+: = 0.77; SE–: = 0.65).
The estimate of test–retest reliability performed on the sub-sample of 22 subjects showed very high values, with correlation coefficients ranging from r = 0.77 to r = 0.96, despite the expected fluctuations of the characteristics measured by the scales. Only the VAS scale CSE showed marginal stability, with r = 0.53.
Validity
According to the theoretical assumptions the VAS scales showed strong correlations with the corresponding variables obtained from the MAC2-A sentences (Table 5).
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The summary scores [RTC] and [ST], even though computed using a tentative and rational method of computation, showed good correspondence with respective VAS scales. In addition, a preliminary analysis of linear regression between the stages scores and the VAS evaluations demonstrated that the rational weighting of stage subscale scores was substantially acceptable. Empirically the best computation for the regression using [RTC] subscales appeared to be: 46.2 – 1.6*P – 0.7*C + 1.4*D + 1.7*A. For the [ST] subscales the best regression computation appeared to be: 42.1 – 0.9*P – 0.7*C + 0.9*M + 1.8*U. These results however need further confirmation with a more extensive sample.
The correlations between the scales are consistent with the model. The six stages scales have stronger associations with the adjacent ones and weaker associations with the more distant ones. SE shows increasing correlations from P (r = –0.31) to T (r = 0.55) and a negative correlation with DI (r = –0.58). Conversely, DI shows decreasing correlations from C (r = 0.51) to T (r = –0.43) (Table 6).
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Strong negative correlations were found in the two subscales of SE+ versus SE– (N = 419, r = –0.47, P < 0.001) and DI+ versus DI– (N = 419, r = –0.51, P < 0.001). The VAS scale CTE correlates negatively with SE for both values obtained from MAC2-A, (CTE versus SE, N = 413, r = –0.47, P < 0.001, and CTE versus CSE, N = 413, r = –0.61, P < 0.001). The VAS scale CIM basically shows a linear associations with DI and CDI only with non-abstinent subjects (CIM versus DI, N = 307, r = 0.49, P < 0.001; and CIM versus CDI, N = 305, r = 0.45, P < 0.001). In abstinent individuals no associations were found, due to their ‘divergent’ development after quit drinking.
The questionnaire shows a good capability to discriminate between sample subgroups. The mean scores in the five subgroups are substantially different. The t-test analysis of mean scores between subgroups confirmed that the differences are significant in the majority of comparisons (not reported) (Table 7).
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In their entirety, these results indicate a more than satisfactory congruence between the questionnaire and the assumed variables and relationships in the theoretical reference model.
Concurrent validity with the clinician's ratings of the motivational factors were obtained in a sub-sample (N = 334) of subjects. Strong associations were found between the clinician's evaluations and the corresponding item-based and VAS subscales scores obtainable from the subjects (Table 8).
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Help-seeking
The data from the present study supports the contention that it is useful to distinguish between RTC and ‘readiness for help’. The two ‘profiles’ of scores in this sample are only partially corresponding although each stage of the ‘readiness for help’ scale, correlated highly with corresponding stage of the RTC scale, they also correlated significantly with other adjacent stages. RTC and ‘readiness to help’ show a rather ‘diffused’ association (Table 9).
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Of paramount importance for the clinical evaluation of motivational factors in the target population is that these results indicated that the MAC2-A questionnaire is a promising tool that can support the professionals' clinical experience to evaluate motivation for change in alcohol treatment.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONAPPENDIXREFERENCES |
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The MAC2-A questionnaire demonstrated a structure consistent with the specified theoretical assumptions. The sample distributions of the variable values were satisfactory, with observed and theoretical ranges almost coincident. The factorial model was substantially confirmed, with the limitations discussed below. The confirmatory factor analysis shows good fit indexes. The scales showed good temporal stability and their internal consistency was adequate.
The evaluation of construct validity was satisfactory. Many of the expected correlations between variables were found. The questionnaire shows good discriminatory capability, indicating clear differences between subgroups with different characteristics. Finally the concurrent validity was solid demonstrating high correlations between MAC2-A results and clinicians' evaluations of patient readiness and motivation.
The current study has however some limitations, indicating the need for further research. The sample consisted primarily of subjects in contact with outpatient services, and thus treatment-naïve and post-treatment subjects were few. Hence, subjects in P and T are under-represented.
The arbitrary construction of the two summary variables, [RTC] and [ST], is a methodological shortcoming that can be addressed through further investigation. These two variables suffer from the common problem of single summary scores: different profiles can end up with the same score. For this reason the [RTC] and [ST] evaluation in clinical settings must take into consideration the characteristics of ‘readiness to change’ profile. Beyond the acceptable weighting of stages scores, the collection of more data may lead to a statistically-based creation of these summary scores. At any rate, the high correlations between these two variables and the corresponding VAS (CRTC and CST) rule out any substantial inconsistency.
Factor analysis of all 18 items relating to the stages of change showed only four primary factors, with a weaker differentiation between the stages of determination, action and maintenance, even though a factor analysis of these items showed clear distinction among them.
IN conclusion the MAC2-A questionnaire demonstrates good reliability and validity in measuring motivation for change in Italian adults who received a recommendation for, requested, were undergoing or completed specific professional interventions for alcohol problems. The questionnaire can be considered a promising tool to describe motivation for change as an integrated ‘3D’ model that includes readiness to change, discrepancy and self-efficacy.
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APPENDIX |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONAPPENDIXREFERENCES |
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Translation of the 36 statements of MAC2-A
(This is not a ‘validated’ translation. It is provided only in order to give a general idea of the items of the questionnaire).
[Scale: 0–6, Not true at all – Not true – Not so true – Half true – Quite true – Mostly true – Completely true]
Precontemplation
[IT5] I think I'll go on drinking
[IT10] I drink, and it's OK like that
[IT28] Someone think I'd better quit drinking, but I don't think so
Contemplation
[IT1] On one hand I would continue drinking, and on the other I think I'd better quit.
[IT13] Sometimes my drinking problems make me think that I should quit
[IT31] Every now and then I think to stop drinking
Determination
[IT11] At present I seriously decided to quit drinking
[IT15] At present I feel I'm really resolute to find a way out of drinking
[IT34] Now I have decided to stop drinking, and I'm looking for the way to actually do that
Action
[IT9] I really started doing something to stop drinking
[IT26] I've just quit drinking
[IT29] I've recently stopped drinking, and I'm doing my best to continue this way
Maintenance
[IT7] I've quitted drinking long time ago, and I'm strongly committed to keep on like that
[IT17] I've not been drinking for a lot of time, and I'm trying to stick to this outcome
[IT36] Although I'm not drinking for a long time I think I must still be careful
Termination
[IT3] I think that at this point, drinking for me is a closed question
[IT14] I think that at this point drinking does not affect me any more
[IT20] By now I can say that the thought of drinking is really far away
Presence of discrepancy
[IT6] If I think about my present drinking, I'm very unsatisfied with me
[IT23] In this moment I'm really concerned for the consequences of my drinking
[IT35] I'm annoyed that my drinking makes me so different from what I'd like to be
Absence of discrepancy
[IT4] My present drinking does not concern me
[IT21] I'm satisfied with my current drinking status
[IT30] In this moment my drinking status is OK
Presence of self-efficacy
[IT2] I can stop drinking even when I feel like, or need, drinking
[IT19] I could say ‘no’ if someone invited me to drink
[IT33] I believe I can resist the urge of drinking
Absence of self-efficacy
[IT8] In some circumstances I can't resist the temptation to drink
[IT16] Drinking pleases me so much that I'm not sure I'll be able to get rid of it
[IT25] I think I'm not able to say no to drinking even if I want it
Readiness to help
[IT18] [P]—I'm drinking, and don't need any help for this
[IT22] [C]—Every now and then I think I need some help to quit drinking
[IT27] [D]—I'm looking for a real help to deal with my drinking problem
[IT12] [A]—I started getting really helped for my drinking
[IT24] [M]—I've been getting help for my drinking for a long time
[IT32] [T]—I don't need help any more to maintain my present drinking status
Translation of the six questions of the VAS scales
[Scale: 0–100, Not at all / Extremely]
CDI—How much unhappy and concerned do you feel about your drinking status
CSE—How confident do you feel about being able to quit drinking
CRC—How ready and resolute do you feel of not drinking anymore
CST—How stable and steady do you feel your abstention from drinking
CTE—How strongly do you feel the urge to drink
CIM—How important do you feel abstaining from drinking
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ACKNOWLEDGEMENTS |
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The authors would like to express their gratitude to all clinicians of Addiction Units, Therapeutic Communities and Clinics of Bassano, Bolzano, Cagliari, Caserta, Castelfranco Veneto, Dolo, Firenze, Genova, Gorgonzola, Ivrea, Macerata, Manfredonia, Mestre, Piacenza, Roma, S. Donà di Piave, Torino, Treviso, Vercelli, ‘Hands’ (Bolzano), ‘Parco dei Tigli’ (Teolo), ‘Villa Soranzo’ (Mestre), who collaborated to the collection of the data. In particular we would like to thank Carlo Chiorri (University of Genova) for his help in several statistical issues.
Conflict of Interest Declaration: This is an independent study. No sources of funding.
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