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Members of Pro-Change Behavior Systems, Inc. recently presented to standing room only audiences at the Society of Behavioral Medicine Annual Conference in San Diego. Topics ranged from depression prevention to multiple health risk intervention to smoking cessation. Also presented as part of symposia were findings on theory-based approaches to health interventions across various communication channels and a Transtheoretical Model based approach to health coaching using Computerized Tailored Interventions (CTIs).

The first symposium, organized by Dr. Kerry Evers and entitled “Innovative, Theory-Based Approaches to Health Interventions Across Various Communication Channels,” included overviews of three health interventions being distributed through distinct communication channels. All three interventions utilized a theoretical framework as the centerpiece for content development and offered examples of successfully disseminating innovative, science-based health interventions. The presentation by Dr. Leanne Mauriello reviewed the overarching use of theory in the development of healthy lifestyle and obesity prevention CTIs for student populations.

The second symposium entitled “Disseminating and Implementing Computerized Tailored Intervention Now and in the Future: Who’s Reached and Who’s Not” focused on how new technologies can contribute to health disparities due to the relatively slow diffusion of innovations, particularly to underserved populations. CTIs have growing evidence of efficacy and effectiveness as innovative technologies but also have barriers to reaching those who could benefit from them. Dissemination and implementation research is critical to an understanding of how best to expand the reach and impact of CTIs. Dr. Evers discussed barriers from the industry perspective and strategies for dissemination and commercialization.

Dr. Janet Johnson, presenting for Dr. Deborah Levesque, described a randomized trial of a stage-based CTI for depression in primary care. The treatment produced reliable and clinically significant improvement in level of depression, prevention of major depression among patients experiencing only subclinical symptoms at baseline, and progress to the Action or Maintenance stage among patients in a Pre-Action stage at baseline. Strengths of the Pro-Change approach include its low cost, easy access at home, and foundation in an empirically validated model of behavior change.

Another presentation discussed a study of a brief stage-tailored health risk CTI delivered by Quality Health Solutions, Inc. The study conducted by Pro-Change investigated the prevalence of multiple behavioral risk factors among a set of employees, changes in risk status following the brief stage-matched intervention, and relationships between changes in risk status and worker productivity and quality of life. Dr. Janet Johnson presented evidence supporting relationships between the reductions in behavioral risks and improvements in productivity and quality of life.

The final presentation discussed a meta-analytic study of the effectiveness of Transtheoretical Model (TTM) based smoking interventions over time. The TTM is the theoretical foundation for many diverse smoking cessation interventions, with variable outcomes. Systematic, narrative reviews of the TTM’s efficacy have arrived at conflicting conclusions. The current study found, in general, that participants in treatment conditions were anywhere from 25% to 56% more likely to have quit smoking compared to participants in comparison conditions. Moreover, effect sizes were sustained at long-term 24-month follow-ups. Patricia Castle, M.A. showed that the patterns of effects over time support the efficacy of TTM cessation interventions across a range of settings. Pro-Change’s programs apply TTM tailoring in the manner that produces the best effects.

About the Presentations

“Innovative, Theory-Based Approaches to Health Interventions Across Various Communication Channels,” Kerry E. Evers, Ph.D., Pro-Change Behavior Systems, Inc.; Jay Maddock, University of Hawaii at Manoa; Leanne M. Mauriello, Ph.D., Pro-Change Behavior Systems, Inc. abstract

Abstract: In the past decade the development and testing of health promotion and behavior change interventions have proliferated. Some of the challenges for the future include wider reach, broader dissemination channels, and continued attention focused on promoting science and evidence-based practices. Innovative strategies for integrating theoretical models in the development of health interventions and for designing for dissemination from the start of development are important for the future. The appeal and disadvantages of different communication channels in regard to implementation and practicality need to be considered, as well as recommendations for integration of health interventions across communication channels.

“A Transtheoretical Model-Based Approach to Health Coaching using Computerized Tailored Interventions.” Kerry E. Evers, Ph.D., Sara S. Johnson, Ph.D., Janice M. Prochaska, Ph.D., Pro-Change Behavior Systems, Inc. abstract

Abstract: The World Health Organization (WHO) has estimated that by 2015, world deaths from lifestyle diseases will double unless major efforts are taken to change lifestyle behaviors (WHO, 2007). Computerized Tailored Interventions (CTIs) based on the Transtheoretical Model (TTM) have been shown to be effective for a variety of behaviors. Using assessment data from all of the constructs of the TTM, CTIs often use expert system technology to provide dynamically tailored, individualized feedback to participants. The programs rely on empirically derived decision rules and expert system logic to match intervention strategies to where individuals are in the process of change and facilitate forward stage movement. This theoretically driven, individualized approach has been successful for increasing stress management, exercise, and weight management in home- and worksite-based interventions delivered via print or the Internet in participants’ homes or through their employers. CTI can also enhance the delivery and maximize the effectiveness of telephone coaching sessions, a common communication vehicle for health behavior change and disease management programs that is in high demand among many employers and health plans. The expert system technology that is central to CTIs can increase fidelity of the intervention by replacing traditional clinical decision making on the part of the coach with evidence-based behavior change guidance. The coach is ushered through brief but reliable and valid assessments that are tailored to the individual participant. The expert system can then generate feedback based on empirical decision-making rules. An added advantage of the integration of CTIs into coaching calls is that the participant can interact with the intervention online between sessions to further facilitate progress.

“Randomized Trial of a Stage-Based Intervention for Depression in Primary Care,” Deborah A. Levesque, Ph.D., Deborah F. Van Marter, M.P.H., Janice M. Prochaska, Ph.D., Pro-Change Behavior Systems, Inc.; Robert J. Schneider, Ed.D., Mark R. Bauer, M.D., Harvard Vanguard Medical Associates, David N. Goldberg, M.D., John Stroger Hospital of Cook County; James O. Prochaska, Ph.D., University of Rhode Island. abstract

Abstract: Depression Prevention: Nine hundred and two adults at risk for depression were recruited from primary care waiting rooms and by telephone. The treatment group received a stage-based manual and an individualized printed report in the mail at baseline, and additional individualized reports at 1 and 3 months follow-up. The treatment and control groups were assessed by phone at 0 and 9 months. At nine months with individuals who were in a Pre-Action stage for depression prevention at baseline, treatment group participants were significantly more likely than controls to experience a clinically significant reduction in depression (37% vs. 17%, respectively), to be in the Action or Maintenance stage for depression prevention (70% vs. 55% respectively), and to be taking antidepressant medication if prescribed (71% vs. 50%). Among study participants who were in the Action or Maintenance stage at baseline, the intervention prevented the onset of depression (11% of treatment participants vs. 19% of control participants experienced a new episode of Major Depression during the follow-up period).

“Results of a brief stage tailored health risk intervention and relationship to quality of life and productivity,” Janet L. Johnson, Ph.D. and Patricia H. Castle, M.A. abstract

Abstract: This study looks at behavior change and impacts on quality of life and productivity among employees who participated in a health risk intervention that provided stage targeted messages on multiple health behaviors. Participants who completed an assessment in both 2006 and 2007 included 3492 employees at a Midwestern university. The majority were female (73.1%) and white (92.7%) with a mean age of 42 (sd=10.9). Among those at risk for each behavior at time 1, 25.8% stopped smoking, 34.0% began exercising regularly, 30.3% began eating a healthy diet, 58.8% began effectively managing stress, 52.4% began drinking responsibly, 68.0% began preventing depression at time 2. The behaviors that showed the greatest proportion of people who had not been at risk regressing into at-risk status were exercise (21.4%), fruit and vegetable intake (20.5%), healthy eating (10.8%), and stress management (11.6%). Individuals showed positive change (i.e. reduced risk) on an average of .68 behaviors, t(3491)=43.46, p<.001, d=.74. The negative change (increased risk) averaged .49 behaviors (t(3491)=39.14, p<.001, d=.66). The negative change appears to be driven by the higher rates of new risk for exercise and eating behaviors. By summing the change scores we calculate an average net change of .19 behaviors which represents a small significant improvement in overall behavioral risk status, t(3491)=8.94, p<.001, d=.15. The relationship of behavior change to quality of life and productivity measures were also examined. Among those who were at risk for a behavior at time 1, small improvements on productivity and quality of life were found for those who were not at risk at time 2, (eta-squared= .01 to .07). Similarly, among those who were not at risk at time 1, those who became at risk at time 2 showed small declines in productivity and quality of life (eta-squared=.01 to .07). Behavior change can significantly impact quality of life and productivity. By using stage tailored messages to improve behavior change, quality of life and productivity can also be impacted.

“The Use of Theory in Developing Interactive Interventions to Promote Healthy Lifestyles among Student Populations,” Leanne M. Mauriello, Ph.D., Carol O. Cummins, M.Ed., M.L.I.S., Karen J. Sherman, B.A., & Sharon J. Dyment, M.P.H., Pro-Change Behavior Systems, Inc. abstract

Abstract: As the rates of obesity increase and the consequences become more severe, the successful promotion of healthy lifestyle behaviors to student populations becomes ever more important. Risk factors for chronic disease begin in childhood, adolescence, and young adulthood, and consequently, prevention efforts must begin early. Interactive technologies are a promising means for developing and disseminating health behavior change interventions on a population basis to students. With improved program retention, wider reach, and less reliance on staff for delivery, interactive technologies offer a cost-effective means of delivering interventions. In addition, youthful users enjoy the appeal and interactivity of such programs. Despite the benefits, to date there has been a lack of effective evidence-based, theory-grounded interactive interventions for youth in the areas of obesity prevention and healthy lifestyle promotion. Innovative, multiple behavior, theory-based, interactive interventions are in development for student populations, ranging from elementary school to college populations. The Transtheoretical Model (TTM) guided the development of each of these interventions, including the development of measures, the creation of tailored feedback messages, the selection of images, and the design of interactive components such as online workbooks, videos, and testimonials. It is important to carefully and thoroughly utilize a theoretical framework throughout all aspects of intervention development.

“A Meta-Analytic Study of TTM Smoking Cessation Interventions,” Patricia H. Castle, M.A., Pro-Change Behavior Systems, Inc.; Colleen A. Redding, Joseph S. Rossi, University of Rhode Island. abstract

Abstract: Smoking causes 35% of all cancers, 33% of all heart attacks and strokes, and 90% of COPD. In spite of its risks, 22% of the population still smokes. These facts underscore the importance of population-based smoking cessation interventions. The Transtheoretical Model (TTM) is the theoretical foundation for many diverse smoking cessation interventions, with variable outcomes. Systematic reviews of the TTM’s efficacy have arrived at conflicting conclusions. This study compared effect sizes across 24 randomized controlled trials (including a combined sample size of N=27,190) of TTM cessation treatments using meta-analytic procedures to examine the 24-hour point prevalence smoking abstinence rates across time. These 24 studies were conducted in a range of community (37.5%), school (4.2%), and health care (58.3%) settings; most targeted smoking only (91.7%), many used proactive recruitment strategies (79.2%), and more than half were conducted outside the U. S. (62.5%). Intervention modalities ranged from counseling (41.9%) to computer-based expert systems (32.3%). Most comparison groups were usual care (79.2%) and the remainder were assessment only (20.8%). Odds ratios (OR) and 95% confidence intervals were computed revealing a series of significant pooled ORs over time ranging from 1.25 – 1.56 across time points ranging from 1 month to 24 months. Overall effect sizes were larger for studies that used (1) three/four TTM constructs compared to one/two constructs, and (2) a computerized tailored expert system modality compared to counseling. In general, participants in treatment conditions were anywhere from 25% to 56% more likely to have quit smoking compared to participants in comparison conditions. Moreover, effect sizes were sustained at long-term 24-month follow-ups. These patterns of pooled effect sizes over time support the efficacy of TTM cessation interventions across a range of settings.

Pro-Change has received a grant from the Centers for Disease Control and Prevention (CDC) to develop a computer-based tailored intervention to promote healthy behaviors during pregnancy. The pilot program will be conducted in July and August 2008 at sites of the Community Health Center, Inc., one of the leading health care providers in Connecticut.

Focus groups and interviews with underserved pregnant women and key informants are guiding the development of an intervention that is acceptable, medically accurate, and easily disseminated. The intervention is based on the Transtheoretical Model of Behavior Change, which matches change principles and processes to each person’s stage readiness to guide individuals through the change process. It is designed to promote the adoption and maintenance of healthy behaviors among pregnant women, ultimately for use in health clinics and provider offices throughout the country, as well as health promotion and wellness organizations.

The intervention will address three important behaviors for a healthy pregnancy: smoking cessation and maintenance, stress management, and healthy eating, with an emphasis on fruit and vegetable consumption. The intervention content will assist women with behavior changes during pregnancy, with an emphasis on strategies for sustaining behavior changes postpartum.

One of the specific aims of the program is to assess the most cost-effective and acceptable methods for disseminating the proposed intervention. Input from leaders in maternal and child health, and the disease management industry including Healthways, Inc. will help identify dissemination channels.

Roughly 100 participants are being recruited from the Community Health Center, Inc. of Connecticut. Leanne Mauriello, Ph.D. the principal investigator of the grant stated that, “A population-based, healthy pregnancy behavioral intervention suite based on scientific and theoretical underpinnings and designed for broad and flexible dissemination provides an innovative approach to supporting maternal and child health.”

The Journal of Preventive Medicine’s (AJPM) March 2008 issue is a special issue on multiple behavior change. All three articles submitted by Pro-Change were accepted and appear in this special issue.

Until recently, there was no programmatic research demonstrating the effectiveness of interventions designed to simultaneously change two or more target behaviors. In this special issue, the Pro-Change team demonstrated simultaneous behavior change applying tailored interventions based on the Transtheoretical Model (TTM).

The first article features an intervention for healthy weight management. The study demonstrated the ability of tailored feedback to improve healthy eating, exercise, weight, and managing emotional distress on a population basis. The treatment produced the highest population impact to date on multiple health risk behaviors. The article citation and abstract are available on our Weight Management page.

The study in the second article was designed to compare the initial efficacy of Motivational Interviewing (MI) and Pro-Change’s online TTM-tailored communications on four health risk factors (inactivity, weight, stress, and smoking) to a brief Health Risk Intervention (HRI) delivered by Quality Health Solutions in a worksite sample. The results found that the MI and TTM groups, when compared with an HRI-only group, had significantly more participants in the Action stage for exercise and effective stress management and significantly fewer risk behaviors at six months. This was the first study to demonstrate that MI and online TTM could produce significant multiple behavior changes. The article citation and abstract are available on our TTM page.

The third article features measurement development on the topic of childhood and adolescent obesity prevention. Nationwide samples of students in grades 4 through 12 completed self-administered questionnaires assessing TTM constructs and behavioral indicators for physical activity, fruit and vegetable consumption, and limiting television time. Analyses were conducted to compare the prevalence of students at-risk for the target behaviors across the age groups and to examine the interrelationships of the target behavior risks. Across the three age groups, physical activity and fruit and vegetable consumption declined, while limiting TV time increased. Across all three samples, being at-risk for one behavior almost always significantly increased the odds of being at-risk for another behavior. The findings of this study provide further evidence for the need for early promotion of healthy lifestyle behaviors. The article citation and abstract are available on our Adolescent Obesity Prevention page.

“Given a window of intervention opportunity, a higher impact paradigm is to target multiple behaviors,” states Janice M. Prochaska, president & CEO of Pro-Change Behaviors Systems, Inc. “Our growing evidence supports the ability of multiple risk behavior change interventions to produce increased impacts on public health.”

The National Registry of Evidence-Based Programs and Practices (NREPP), a service of the Substance Abuse and Mental Health Services Administration (SAMHSA), recently gave high ratings to the Pro-Change Stress Management Program.

Supported by a grant from the National Cancer Institute, the Pro-Change Stress Management Program assists individuals in managing their stress more effectively using practices such as relaxation, time management, and social support activities.

NREPP is an interactive resource for professionals in the fields of Substance Abuse and Mental Health. Their ratings and intervention summaries synthesize and evaluate research so as to help potential users of interventions better understand their scientific evidence base. NREPP rates the quality of the research supporting intervention outcomes and the quality and availability of training and implementation materials on a scale of 0.0 – 4.0.

The Pro-Change Stress Management program received overall ratings ranging from 2.9 – 3.5 for the quality of the research and a 3.8 overall rating for readiness for dissemination. Specific strengths cited included rigorous study design, relatively long-term follow-up (18 months), use of two well-recognized measures of stress and depression, assessors blind to the experimental condition, and appropriate statistical analyses.

Both online and offline versions of the Stress Management program are available for implementation. The program is completely self-directed; no training is required. Technical assistance is available to support users before and during implementation. The computerized nature of the program ensures implementation fidelity, and the interactive computer application allows administrators to monitor program use and progress.

In a clinical trial of the program’s effectiveness, Dr. Kerry Evers of Pro-Change conducted a study of a national sample of adults who received the Stress Management intervention. At the 18-month follow-up, a significantly larger proportion of the treatment group (62%) was effectively managing their stress when compared to the control group. The intervention also produced significant reductions in stress and depression, and an increase in the use of stress management techniques when compared to the control group.

To view a demo of the stress management program go to www.prochange.com/stressdemo. To read the full outcome article see Evers, K.E., Prochaska, J.O., Mauriello, L.M., Padula, J.A. and Prochaska, J.M. (2006). A randomized clinical trial of a population and transtheoretical-based stress management intervention. Health Psychology 25 (4), 521-529. An abstract of this article is available on our Stress Management product page.

President Elvira Craig de Silva of the National Association of Social Workers has appointed Janice M. Prochaska, Ph.D., President and CEO of Pro-Change Behavior Systems, Inc., as one of the seven members of the Social Work Editorial Board.

The Social Work journal, established in 1956, is the professional journal published by the National Association of Social Work (NASW), which is provided to all NASW members as a membership benefit. The journal’s purpose is to improve practices and advance knowledge in social work and social welfare.

Drs. Janice and James Prochaska of Pro-Change Behavior Systems Inc., along with Paul Mastrangelo, Ph.D. of Genesee Survey Services, Inc. will present a Master Tutorial on How People Change: In the Workplace at the 23rd Annual Society for Industrial and Organizational Psychology (SIOP) Conference in San Francisco on April 12, 2008.

Pro-Change now has training available via DVD, web conference or on site in person for using the Transtheoretical Model of Behavior Change with clients. Focus of the training includes:

• Background and history of the Model
• Highlights of TTM research
• Stages of Change
• Decisional Balance
• Self-Efficacy
• Processes of Change
• Intervention strategies to facilitate principles and processes of change use 

The journal of Preventive Medicine in early 2008 will publish a special issue on multiple behavior change. All three articles submitted by Pro-Change were accepted. They include: Transtheoretical Model-based Multiple Behavior Intervention for Weight Management: Effectiveness on a Population Basis; Relationships Among Multiple Behaviors for Childhood and Adolescent Obesity Prevention; and Initial Efficacy of MI, TTM Tailoring, and HRI’s with Multiple Behaviors for Employee Health Promotion.

Recognized for its authoritative contributions to the entire field of preventive medicine and public health, Preventive Medicine: An International Journal Devoted to Practice and Theory is a respected source of information on applied research into all aspects of prevention.

Pro-Change director Sara Johnson, Ph.D. was recently invited to present a full-day workshop for IBM’s Global Well-being Services and Health Benefits Division.

The workshop outlined strategic approaches to elicit employee behavior change and drive smarter, more cost-effective use of health services and greater attention to healthy living. Attendees reviewed a definition of “proactive health consumerism” and the Transtheoretical Model of Behavior Change, which demonstrates that individuals progress through a series of distinct stages en route to adopting and maintaining health behaviors.

Dr. Johnson presented examples of the Transtheoretical Model’s successful application to multiple behavior change (e.g., weight management). These findings support the notion that different intervention and communication strategies are needed to engage and impact people in different stages. Current activities within Global Health and Well-being that leverage a stage-based approach to promoting proactive health consumerism were discussed, and participants then were challenged to outline intervention strategies that employ a stage-based approach to promoting proactive health consumerism among employees.

Tailoring Information Therapy: Applying Next-Generation Analytics and Behavior Change Theory was the key note address delivered by James O. Prochaska, Ph.D., Founder of Pro-Change Behavior Systems, Inc. at the sixth Annual Information Therapy Conference in Park City, Utah.

The science for how we tailor interventions, target health information, and engage consumers is expanding rapidly. Dr. Prochaska spoke on how this new science can be effectively translated into Information Theory innovation. Following the key note, Kerry Evers, Ph.D. demonstrated Pro-Change’s LifeStyle management programs and how they are presently being used by Healthways, Inc.

Pro-Change Behavior Systems, Inc. received a Tibbetts Award in recognition of significant achievements involving technological innovation related to the Small Business Innovation Research Program (SBIR). Pro-Change President & CEO, Janice M. Prochaska, accepted the award at a ceremony in Washington, D. C. on October 10, 2007. Pro-Change was selected for its outstanding SBIR research, dissemination, and commercialization of health behavior change programs funded by grants from the National Institutes of Health and the Centers for Disease and Prevention.

Named for Roland Tibbetts, acknowledged as the father of the SBIR Program, these prestigious national awards are given annually to small firms judged to exemplify the best in SBIR achievement. The Small Business Technology Council (SBTC), a council of the National Small Business Association, is the lead sponsor of the award.

Janice Prochaska with Roland Tibbetts, left and Jere Glover.

The Centers for Disease Control and Prevention (CDC) has awarded Pro-Change a Phase I Small Business Innovation Research (SBIR) grant to develop a computer-based healthy pregnancy program for underserved pregnant women. The program will offer tailored advice on smoking cessation and maintenance, stress management, and healthy eating. Dr. Leanne Mauriello, Principal Investigator, is leading formative research and pilot testing in collaboration with the Community Health Center, Inc. of Connecticut.

HealthString signed a contract with Pro-Change Behavior Systems, Inc. to license seven online Transtheoretical Model health behavior change programs: stress management, weight management, depression prevention, exercising regularly, smoking cessation, and managing high blood pressure and managing high cholesterol through medication adherence, diet, and exercise.

HealthString is a secure, online, dynamic personal health network that improves accessibility and use of important personal health information via the Internet. HealthString empowers individuals to proactively manage their health by enabling behavior changes that lead to a healthier lifestyle. With HealthString consumers have access to personal RN Health Coaches and technology to improve the quality of care and the quality of personal health.

A study done at Oregon Health & Science University demonstrated that Motivational Interviewing and Pro-Change’s LifeStyle online programs produced significant multiple behavior changes. A total of 25.2% of eligible employees were recruited for the online Pro-Change interventions. Quality Health Solutions brokered the collaboration of Pro-Change, OHSU, and the University of Rhode Island for the grant funded by the Centers for Disease Control and Prevention.

For more information, see:
Prochaska, J.O., et al., Initial efficacy of MI, TTM tailoring and HRI’s with multiple behaviors for employee health promotion, Preventive Medicine (2007).

Abstract:
Objective. This study was designed to compare the initial efficacy of Motivational Interviewing (MI), Online Transtheoretical Model (TTM)-tailored communications and a brief Health Risk Intervention (HRI) on four health risk factors (inactivity, BMI, stress and smoking) in a worksite sample.

Method. A randomized clinical trial assigned employees to one of three recruitment strategies and one of the three treatments. The treatment protocol included an HRI session for everyone and in addition either a recommended three TTM online sessions or three MI in person or telephone sessions over 6 months. At the initial post-treatment assessment at 6 months, groups were compared on the percentage who had progressed from at risk to taking effective action on each of the four risks.

Results. Compared to the HRI only group, the MI and TTM groups had significantly more participants in the Action stage for exercise and effective stress management and significantly fewer risk behaviors at 6 months. MI and TTM group outcomes were not different.

Conclusion. This was the first study to demonstrate that MI and online TTM could produce significant multiple behavior changes. Future research will examine the long-term impacts of each treatment, their cost effectiveness, effects on productivity and quality of life and process variables mediating outcomes.

Pro-Change has completed a Phase 2 NIH Small Business Innovation Research (SBIR) grant for Depression Prevention.

Research Findings:

Nine hundred and two adults at risk for depression were recruited from primary care waiting rooms and by telephone. The treatment group received a stage-based manual and an individualized printed report in the mail at baseline, and additional individualized reports at 1 and 3 months follow-up. The treatment and control groups were assessed by phone at 0 and 9 months. At nine months with individuals who were in a pre-Action stage for depression prevention at baseline, treatment group participants were significantly more likely than controls to experience a clinically significant reduction in depression (37% vs. 17%, respectively), to be in the Action or Maintenance stage for depression prevention (70% vs. 55% respectively), and to be taking antidepressant medication if prescribed (71% vs. 50%). Among study participants who were in the Action or Maintenance stage at baseline, the intervention prevented the onset of depression (11% of treatment participants vs. 19% of control participants experienced a new episode of Major Depression during the follow-up period).

Ten years ago today, Pro-Change began as a company with its first contract with Electronic Data Systems (EDS).