The Effect of Psychoeducation Based on the Transtheoretical Model on Healthy Lifestyle Behaviors in Individuals With Schizophrenia: Randomized Controlled Trial
Phase: NA
Conditions: Schizophrenia
Sponsor: Hatay Training and Research Hospital

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
The Effect of Psychoeducation Based on the Transtheoretic Model on Healthy Lifestyle 
Behaviors in Individuals with Schizophrenia: Randomized Controlled Trial 
02.11.2020 

MATERIALS AND METHODS ABOUT STUDY 
 
Aim and design 
 
This study is conducted in pretest-posttest randomized controlled experimental research type. 
 
Setting and time 
 
The study was conducted in a Community Mental Health Center (CMHC) in Hatay in Turkey 
between April 2019-November 2020. 
Sample 
 
The population of the study are the individuals with schizophrenia who registered in a CMHC 
and are under observation (N=230). The sample number is determined based on another similar 
study (Erbaba 2018) with power analysis. In the evaluation completed according to the healthy 
lifestyle behaviours score, the sample number needed to participate in the study was determined 
to be at least 42 (intervention group=21 - control group=21) in order for research results for 
Power: 0.80, β:0,20 and α:0,05 to have a meaningful effect. The data were collected from 82 
individuals with schizophrenia, as 41 intervention and 41 control groups. 
Criteria for the participation in the project was determined as meeting at least one below: 
 
Between the ages 18 and 65 
 
Being diagnosed with schizophrenia according to DSM-V 
Being literate 
Not having education and language problem that can block the interview 
Being open to communication and cooperation 
Being in one of the three stages of the TTM: contemplation, preparation and action 

Randomization 
 
In order to decrease the selection bias in the determination of intervention and control groups, 
three people who have no direct role in the study listed from 1 to 82 and intervention and control 
groups were formed using the simple random sampling method. The numbers to include in the 
sample were determined with the number generator www.random.org. 
Measurements 
 
Personal Information Form: This form prepared by the researcher using literature knowledge 
consists of total of 22 questions related to their personal features, their disorder’s specifications 
and lifestyles of the individuals with schizophrenia in the study (Selçuk Tosun and Zincir 2016; 
Demirel Döngel and ark 2018; Erginer and Günüşen 2018; Gerçik 2018; Sungur et al. 2019; 
İpekçioğlu and Kök Kendirlioğlu 2019; Holt et al. 2019). 
Behavioural Change stage Identification Form: It is formed using behavioural change phases 
of the TTM and based to the literature by the researcher in order to determine the behavioural 
chance stages of the patients in the fields of taking responsibility for own health, nutrition, 
physical exercise, spiritual development, interpersonal relationships and stress management 
(Ay and Temel 2008; Baysal 2013; Tosun 2015). In the TTM developed by psychologists James 
Prochaska and Carlo Diclemente (1982), it is stated that behavioural change is a process that 
develops stage by stage and a framework in the classification of the behaviour’s stage (Van Nes 
and Sawatzky 2010). This study only focuses on the stages of change. Stages of change deal 
with the time dimension of the model and include five stages. The structure of the model 
consists of stages as pre-contemplation, contemplation, preparation, action, maintenance and 
termination (Nigg 2001; Prapavessis et al. 2004; Erol and Erdoğan 2007). These stages also 
explain the interests and the motivations of individuals towards change with time of intention, 
attitude and behavioural change (Kim et al. 2006). 

Healthy Lifestyle Behaviours Scale (HLBS II): It was developed to measure behaviours of 
individuals that improve their well being associated with a healthy lifestyle by Walker, Sechrist 
and Pender (1987). The scale was reviewed in 1996 and renamed HLBS II. The scale consists 
of 52 items and six subfactors and it is a 4-point Likert type scale (never (1), sometimes (2), 
often (3), regularly (4)). The lowest and highest scores on the scale are 52 and 208 respectively. 
It is considered that individuals’ healthy lifestyle behaviours increase with the increasing total 
score. According to the results of the study on validity and reliability of HLBS II and its 
subscales, conducted by Walker et al. (1995); Cronbach’s Alpha is 0.94 in the whole scale and 
changes between 0.79-0.87 for six subscales. The Turkish adaptation of the HLBS II was 
performed by Bahar et al. (2008). As the result of the Turkish reliability and validity study of 
the scale; Cronbach’s Alpha is 0.92 in the whole scale and it was found out to be 0.77 for the 
responsibility of health subscale; 0.79 for the physical activity subscale; 0.68 for the nutrition 
subscale; 0.79 for the spiritual development subscale; 0.80 for the interpersonal relationships 
subscale; 0.64 for the stress management subscale. As to this study, Cronbach’ Alpha is 
determined to be 0.94 in the intervention group for the whole scale, and for the sub-dimensions, 
in pretest to be respectively 0.67, 0.87, 0.73, 0.81, 0.76 and 0.76 whereas in posttest to be 
respectively 0.71, 0.87, 0.71, 0.83, 0.78 and 0.74. As to the control group, it is determined to 
be 0.95 for the whole scale, and for the sub-dimensions, in pretest to be respectively 0.88, 0.88, 
0.79, 0.85, 0.93 and 0.50 whereas in posttest to be respectively 0.86, 0.89, 0.77, 0.82, 0.92 and 
0.61. 
 
Research Process 
 
The behavioural change identification form was applied to individuals with schizophrenia, who 
agreed to participate in the study, and their stage of the TTM was detected. The participants 
meeting the criteria in the participation stage (contemplation, preparation, action) were assigned 
to the intervention and control groups with the randomization. Pretests (personal information 

Assessed for eligibility (n=230) 
Power Analysis=42 
Randomized (n= 82) 
Intervention Group 
Applying pretest (n=41) 
Control Group 
Applying pretest (n=41) 
Applying Healthy Lifestyle Behaviours 
Psychoeducation Programme (n=41) 
Phone Interview 
(n=41) 
Applying posttests (n=41) 
Applying posttests (n=41) 
form, behavioural change identification form, HLBS II) were applied to the intervention and 
control groups before the psychoeducation. In addition to the rehabilitation activities conducted 
in the CMHC, healthy lifestyle behaviours psychoeducation programme (HLBPP), based on 
the TTM, with 6 sessions (healthcare responsibility, nutrition, physical activity, spiritual 
development, interpersonal relationships, stress management) was applied to the intervention 
group for 6 weeks as three days in the weekdays and two sessions in a day. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fig 1. Flow Diagram 
 
Psychoeducation was carried out by the researcher on the same day but within different time 
zones. Each psychoeducation session took 90-120 minutes with the breaks taken considering 

the participants’ mood. After completing six sessions, the behavioural change identification 
form and HLBS II were applied to the intervention group again. On the other hand, the control 
group continued their rehabilitation practices prepared for themselves in the CMHC. It was 
contacted with the control group three times, two face to face and one via phone. In the third 
and final meeting, when the intervention group’s sessions are completed, the behavioural 
change identification form and HLBS II were applied again to the control group. All the 
participants remained in the study at the end of it. The study was completed with 41 individuals 
in the intervention group and 41 individuals in the control group (Figure 1). 
Ethical Considerations 
 
The permission for the use of HLBS II was granted by the researcher from those who conducted 
Turkish validity and reliability studies thorough email. Permission was received from Hatay 
Mustafa Kemal University Tayfur Ata Sökmen Faculty of Medicine Clinical Research Ethical 
Board (Date: 26.09.2019-Decree No. 06). Using this permission, an application was made to 
Hatay Provincial the Health Directorate and institution permission from Hatay State Hospital 
was obtained (Date: 23.10.2019). The individuals with schizophrenia in the study and their 
families were informed according to the Helsinki Declaration and written and verbal approval 
were collected. 
Data analysis 
 
SPSS v23.0, which is a statistical analysis programme, was used to evaluate the findings of the 
study. It was benefited from descriptive statistics such as frequency, percentage, arithmetic 
average, standard deviation, minimum and maximum during data analysis. Parametric tests 
were used for the data analysis. The chi-squared test was used for relation analysis of two 
different categorized variables whereas the t-test was used while comparing averages of two 
independent groups. To determine the alteration of individuals’ behavioural change stages 
before and after receiving psychoeducation, the McNemar test was used. Analysis of covariance 

(ANCOVA) while detecting the effect of the intervention study in the researches designed in 
the entrepreneurial pattern. In ANCOVA, to detect how big the effect of the independent 
variable on the dependent variable the eta squared (effect size) was calculated and the eta 
squared value (η2) was interpreted that it presents which parts of the change explain the total 
variant that the independent variable has on the dependent variable and it received a value 
between 0 and 1 (Büyüköztürk 2011; Pallant 2017). 
Eta squared is interpreted as 0,01 as the minor effect, 0,06 as medium effect and 0,14 as large 
effect (Cohen 1992). All test results were evaluated in terms of p<0.05 meaningfulness level.