Transtheoretical model

The Transtheoretical Model of Behavior Change assesses an individual's readiness to act on a new healthier behavior, and provides strategies, or processes of change to guide the individual through the stages of change to action and maintenance.

The Transtheoretical Model is also known by the acronym "TTM"[1] and by the term "stages of change model."[2][3] A popular book, Changing for Good,[4] and articles in the news media[5][6][7][8][9] have discussed the model. It is "arguably the dominant model of health behaviour change, having received unprecedented research attention, yet it has simultaneously attracted criticism."[10]

Contents

History and core constructs of the model

James O. Prochaska of the University of Rhode Island and colleagues developed the transtheoretical model beginning in 1977.[11] It is based on analysis and use of different theories of psychotherapy,[12] hence the name "transtheoretical."

Prochaska and colleagues refined the model on the basis of research that they published in peer-reviewed journals and books.[13][14][15][16][17][18][19][20][21][22][23][24][25][26] The model consists of four "core constructs": "stages of change," "processes of change," "decisional balance," and "self-efficacy."[25]

TTM research breakthroughs

1980s
1990s
2000s
2010s

Stages of change

In the Transtheoretical Model, change is a "process involving progress through a series of stages":[25]

In addition, the researchers conceptualized "relapse" (recycling) which is not a stage in itself but rather the "return from action or maintenance to an earlier stage."[25][nb 3]

Stage details

Stage 1: Precontemplation (Not Ready)
People at this stage do not intend to start the healthy behavior in the near future (within 6 months), and may be unaware of the need to change. People here learn more about healthy behavior: they are encouraged to think about the Pros of changing their behavior and to feel emotions about the effects of their negative behavior on others.

Precontemplators typically underestimate the pros of changing, overestimate the cons, and often are not aware of making such mistakes. These individuals are encouraged to become more mindful of their decision making and more conscious of the multiple benefits of changing an unhealthy behavior.

Stage 2: Contemplation (Getting Ready)
At this stage, participants are intending to start the healthy behavior within the next 6 months. While they are usually now more aware of the pros of changing, their cons are about equal to their Pros. This ambivalence about changing can cause them to keep putting off taking action.

People here learn about the kind of person they could be if they changed their behavior and learn more from people who behave in healthy ways. They're encouraged to work at reducing the cons of changing their behavior.

Stage 3: Preparation (Ready)
People at this stage are ready to start taking action within the next 30 days. They take small steps that they believe can help them make the healthy behavior a part of their lives. For example, they tell their friends and family that they want to change their behavior.

People in this stage are encouraged to seek support from friends they trust, tell people about their plan to change the way they act, and think about how they would feel if they behaved in a healthier way. Their number one concern is: when they act, will they fail? They learn that the better prepared they are the more likely they are to keep progressing.

Stage 4: Action
People at this stage have changed their behavior within the last 6 months, and need to work hard to keep moving ahead. These participants need to learn how to strengthen their commitments to change and to fight urges to slip back.

People in this stage are taught techniques for keeping up their commitments such as substituting activities related to the unhealthy behavior with positive ones, rewarding themselves for taking steps toward changing, and avoiding people and situations that tempt them to behave in unhealthy ways.

Stage 5: Maintenance
People at this stage changed their behavior more than 6 months ago. It is important for people in this stage to be aware of situations that may tempt them to slip back into doing the unhealthy behavior—particularly stressful situations.

It is recommended that people in this stage seek support from and talk with people whom they trust, spend time with people who behave in healthy ways, and remember to engage in alternative activities to cope with stress instead of relying on unhealthy behavior.

Processes of change

The 10 processes of change are "covert and overt activities that people use to progress through the stages."[25]

To progress through the early stages, people apply cognitive, affective, and evaluative processes. As people move toward action and maintenance, they rely more on commitments, conditioning, contingencies, environmental controls, and support.[27]

Prochaska and colleagues state that their research related to the Transtheoretical Model shows that interventions to change behavior are more effective if they are "stage-matched," that is, "matched to each individual's stage of change."[25][nb 4]

Decisional balance

This core construct "reflects the individual's relative weighing of the pros and cons of changing."[25][nb 5] Decision making was conceptualized by Janis and Mann as a "decisional balance sheet" of comparative potential gains and losses."[28] decisional balance measures, the pros and the cons, have become critical constructs in the Transtheoretical Model. The pros and cons combine to form a decisional "balance sheet" of comparative potential gains and losses. The balance between the pros and cons varies depending on which stage of change the individual is in.

Sound decision-making requires the consideration of the potential benefits (pros) and costs (cons) associated with a behavior's consequences. Decisional balance is one of the best predictors of future change. TTM research has found the following relationships between the pros, cons, and the stage of change across 48 behaviors and over 100 populations studied.

Self-efficacy

This core construct is "the situation-specific confidence people have that they can cope with high risk situations without relapsing to their unhealthy or high risk habit."[25][nb 6] Self-efficacy[30] conceptualizes a person's perceived ability to perform on a task as a mediator of performance on future tasks. A change in the level of self-efficacy can predict a lasting change in behavior if there are adequate incentives and skills. The Transtheoretical Model employs an overall confidence score to assess an individual's self-efficacy. Situational temptations assess how tempted people are to engage in a problem behavior in a certain situation.

How do people move from one stage to another?

In general, for people to progress they need:

  1. A growing awareness that the advantages (the "pros") of changing outweigh the disadvantages (the "cons")—the TTM calls this decisional balance
  2. Confidence that they can make and maintain changes in situations that tempt them to return to their old, unhealthy behavior—the TTM calls this self-efficacy
  3. Strategies that can help them make and maintain change—the TTM calls these processes of change. The ten processes include:
    1. Consciousness-Raising—increasing awareness via information, education, and personal feedback about the healthy behavior.
    2. Dramatic Relief—feeling fear, anxiety, or worry because of the unhealthy behavior, or feeling inspiration and hope when they hear about how people are able to change to healthy behaviors
    3. Self-Reevaluation—realizing that the healthy behavior is an important part of who they are and want to be
    4. Environmental Reevaluation—realizing how their unhealthy behavior affects others and how they could have more positive effects by changing
    5. Social Liberation—realizing that society is more supportive of the healthy behavior
    6. Self-Liberation—believing in one’s ability to change and making commitments and re-commitments to act on that belief
    7. Helping Relationships—finding people who are supportive of their change
    8. Counter-Conditioning—substituting healthy ways of acting and thinking for unhealthy ways
    9. Reinforcement Management—increasing the rewards that come from positive behavior and reducing those that come from negative behavior
    10. Stimulus Control—using reminders and cues that encourage healthy behavior as substitutes for those that encourage the unhealthy behavior.

Outcomes of TTM Programs

The outcomes of TTM computerized tailored interventions administered to participants in pre-Action stages are outlined below.

Stress Management

Adherence to Antihypertensive Medication

Adherence to Lipid-Lowering Drugs

Depression Prevention

Weight Management

Smoking Cessation

Important Note: It is important to note that TTM interventions have a significantly greater impact than other programs because of their ability to:

For example, out of 1,000 people needing to make a lifestyle change (those in a pre-Action stage), a TTM intervention targets 100% of that population while other programs typically target only the 20% of that population in the Preparation stage. In addition, TTM interventions typically have 70-80% participation rate with proactive recruitment while other programs typically have a 10% participation rate. Based on the following illustration, TTM interventions clearly have a more substantial impact than action oriented programs even when they share the same efficacy rates.

Target Population x Participation Rate x Hypothetical Efficacy = # of People that changed lifestyle
TTM Interventions 1,000 (100%) x 80% x 30% = 240
Other Programs 200 (20%) x 10% x 30% = 30

TTM Criticisms

Among the criticisms of the model are the following:

Responses to Criticisms:

Criticism: Little experimental evidence exists to suggest that application of the model is actually associated with changes in health-related behaviors.

• In a systematic review of 23 randomized controlled trials published in 2003, the authors reported that "stage based interventions are no more effective than non-stage based interventions or no intervention in changing smoking behaviour"[55]

• A 2005 systematic review of 37 randomized controlled trials claimed that "there was limited evidence for the effectiveness of stage-based interventions as a basis for behavior change"[56]

• A randomized controlled trial published in 2009 found "no evidence" that a smoking cessation intervention based on the Transtheoretical Model was more effective than a control intervention that was not tailored for stage of change.[57]

• The designs of many studies supporting the model have been cross-sectional, but longitudinal study data would allow for stronger causal inferences.[58]

Response:

• A number of longitudinal randomized controlled trials demonstrate that tailored TTM-based interventions do change behaviors.[59][60][61] In fact, the Pro-Change LifeStyle Suite had sufficient longitudinal evidence to be awarded the 2009 Gold Award for Best Practices in Health Management by URAC.

• Many studies that show the model to be ineffective have tailored interventions only to stage of change; if the studies had tailored interventions based on all core constructs of the model, they might have shown positive findings.[62] In particular, the "processes of change" have been characterized as "under-researched."[63] A 2007 meta-analysis of tailored print health behavior change interventions found that the "number and type of theoretical concepts tailored on," including stage of change and processes of change, were associated with behavior change (Noar et al., 2007).[64] Hutchison et al. (2008) published a systematic review of 34 articles examining 24 physical activity interventions based on the Transtheoretical Model; only 7 of the 24 interventions addressed all four dimensions "stages of change," "processes of change," "decisional balance," and "self-efficacy."[65]

• Studies that find the model ineffective are poorly designed; for example, they have small sample sizes, poor recruitment rates, or high loss to follow-up.[66][67][68]

• Velicer et al. (2007) examined predictors of smoking cessation at 12 and 24 months among nearly 3000 smokers from 5 randomized effectiveness trials. They reported that stage was of the strongest predictors of smoking status at 12 and 24 months, refuting the claim that stage of change is descriptive rather than predictive.[69]

Criticism: “Arbitrary dividing lines" are drawn between the stages.[70]

Response: The conversion of continuous data into discrete categories is necessary for the model, similar to how decisions are made about the treatment of high cholesterol levels depending on the discrete category the cholesterol level is placed into.[71]

Criticism: The model makes predictions that are "incorrect or worse than competing theories."[72]

Response: Velicer at al. (1999) conducted a study to examine the validity of 40 predictions based on the Transtheoretical Model regarding movement from one of three initial stages (precontemplation, contemplation, or preparation) to stage membership 12 months later. Thirty-six predictions were confirmed in these longitudinal analyses.[73]

Criticism: In a 2002 review, the model's stages were characterized as "not mutually exclusive"; furthermore, there was "scant evidence of sequential movement through discrete stages". [74].

Response: The TTM does not suggest that movement through the stages is always linear. Latent transition analyses on data from effectiveness trials of tailored interventions (e.g., Martin, Velicer, & Fava, 1996) reveal that movement through the stages is not always linear, that the probability of forward stage movement is greater than the probability of backward stage movement, and that the probability of adjacent stage movement is greater than the probability of two-stage progression.[75]

Criticism: Spencer et al. (2002) reviewed 22 studies evaluating TIM tailored or stage-matched interventions.[76] In their later review on stage-based interventions for smoking cessation, Riemsma et al. (2003) reviewed 23 studies.[77]

Response:

• The interventions included in the review are treated as comparable even though they differ dramatically on which TTM variables are used for tailoring, length of follow-up, sample size, percentage of eligible smokers recruited, and intervention modalities used. Based on our analysis, approximately 60% of the studies in Spencer et al. (2002) and 70% in Riemsma et al. (2003) only used the stage variable from the TTM. Tailoring only on stage is the most common application of the TTM. Five studies in Spencer et al., and three in Riemsma et al., tested interventions tailored on a partial set of TTM variables, namely stage, decisional balance, and/or self-efficacy. Five studies in Spencer et al. and four in Riemsma et al. tested interventions tailored on the full set of TTM variables, including processes of change.

• To assume that tailoring simply on stage would be TTM-based is analogous to assuming that tailoring simply on self-efficacy is based on social cognitive theory. In both situations, important theoretical constructs are not being used, and an important percentage of variance is not being accounted for or controlled. From a practical perspective, it could mean that the only tailored information specific to an individual is based on a single variable. All other information must be general information that has to be assumed to be valid for all people in a particular stage. However, theory and data both contradict this assumption, as individuals in a particular stage, such as precontemplation, are theoretically expected and have been empirically demonstrated to differ on key TTM variables like the pros and cons of changing and experiential processes of change.

• If effective tailoring requires feedback that is accurate for individuals, then tailoring on stage alone should be less effective than tailoring on a larger set of TTM variables. Of 13 studies in Spencer et al. (2002) and 16 in Riemsma et al. (2003) that used the single variable of stage only 10 had positive results (about 35%). Of the eight that applied partial TTM tailoring, four (50%) had significant effects. Finally, of the seven studies that applied full tailoring, five (about 70%) had significant effects. The two fully tailored studies that were negative were involved teenagers. The number of fully tailored TTM studies was relatively small, but the number of smokers studied was large (>10,000).

• The impact of fully tailored TTM interventions for smoking has been repeatedly demonstrated in randomized, population-based studies with diverse populations since these reviews. These studies tended to produce the same magnitude of effects at long-term follow-up (22% to 26% point-prevalence abstinence), as was found in our first sample of convenience[78], a representative sample of 5130 smokers[79], and an HMO population of 4653 smokers[80]. Similar abstinence rates (23.9%) have been found when treating a population of adolescents in primary care.[81] Hall et al., 2006 reported comparable results in a population of smokers being treated for depression.[82] With pregnant smokers in the UK, adding a TTM-tailored intervention to the traditional treatment of midwife counseling produced more than eight times the impact compared to the traditional treatment alone.[83][84]

• Recent research demonstrated the same range of abstinence when treating populations with TTM fully tailored interventions for multiple behaviors. This was the case with a population of 2460 parents of teenagers who were treated for three behaviors.[85] The significant abstinence rate was 22.9% with an even higher success for those progressing from high-fat to low-fat diets (38.2%) and for those progressing from high-risk to low-risk ultraviolet (UV) exposure (35.2%). Similar results were produced with a population of 5545 primary care patients (Prochaska et al. 2005). Long-term significant abstinence was 25.6%with even greater success for diet and sun exposure. Such studies are causing us to change traditional impact equations from (impact = participation rate x efficacy) to (impact = participation rate x efficacy x number of behaviors changed). As far as we know, the impact rates produced in these studies utilizing TTM-tailoring with multiple behaviors are unprecedented.

Criticism: On Wednesday, October 5th, 2011, Cochrane published a narrative review of five studies by Tuah, Amiel, Qureshi, Car, Kaur, and Majeed that claimed to assess the effectiveness of dietary and physical activity interventions based on the Transtheoretical Model of behavior change (TTM) to produce sustainable weight loss in overweight and obese adults. The review included a series of serious flaws that call into question the validity of the conclusions drawn.

Response:

Page 2: Main Results. The overall sample size is technically inaccurate because only 445 of 1,029 individuals in Jones et al. (2003), study were overweight or obese and therefore included in the healthy eating condition.
Page 6: The authors state that for a study to be included in the review “the intervention had to be delivered by health care professionals or trained lay-people.” However, two of five studies do not meet these inclusion criteria. Johnson et al. (2008) applied a computer and mail-based intervention, and Dinger (2007) delivered the intervention through e-mail.
Page 6: The authors state that “another review done on TTM application found that it is difficult to apply the model looking at dietary change….” (Ni Mhurchu, 1997). However, the Ni Mhurchu citation never appears in the reference list, making it difficult for interested readers to evaluate this claim.
Page 7: The authors erroneously report that all interventions included in the study were “tailored” to individuals who were overweight or obese. Dinger (2007), used a one size fits all intervention that was not tailored. All participants received the same intervention messages through e-mail regardless of their stage of change.
Page 13: Erroneously reported that all participants in the included trials were analyzed based on traditional Intention to Treat (ITT). Johnson et al. (2008) conducted contemporary ITT analyses on data derived from Multiple Imputation rather than using traditional ITT analyses to address missing data.
Page 13: Erroneously reported that Johnson et al. (2008) showed no weight loss despite the fact that this study reported statistically significant long-term weight loss outcomes. The Johnson et al. (2008) outcomes are correctly reported on page 17.
Page 14 & Page 20: Criticized Johnson et al. (2008) for not reporting which study personnel delivered the intervention when Johnson et al. (2008) clearly reported that the intervention was computer-tailored and reports were mailed to participants’ homes.
Page 17: Mis-reported Jones outcomes. The authors reported that “There was a significant weight loss amongst participants in the action stage (individuals are ready to change their behavior) compared to those in the pre-action stage (individuals are not ready to change behavior) for the intervention in both the self-monitoring of blood glucose (SMBG) and healthy eating groups at 12 months.” The definitions of stages provided are incorrect: Being in the Action stage does not mean being ready to change— Action is having recently made the change/adopted the new behavior. Preparation, which is a pre-action stage, is defined as being ready to change. Furthermore, to clarify, the authors should have reported that weight loss was significantly greater for those receiving the intervention for SMBG & healthy eating who progressed to Action or Maintenance for SMBG.
Page 17: The authors mis-reported changes in self-reported dietary intake for Logue et al. (2005), but Logue reports no differences on self-reported energy expenditure or intake;
Page 17: The authors erroneously defined progress to action/maintenance.
Page 22: In the same paragraph, the authors report that “This review provides evidence for the efficacy of dietary and physical activity interventions based on the TTM SOC in producing sustainable weight loss in overweight and obese adults.” Immediately before stating “TTM SOC and a combination of physical activities, diet, and other interventions resulted in minimal weight loss, and there was no conclusive evidence for sustainable weight loss.”

See also

Notes

The following notes summarize major differences between the well-known 1983,[14] 1992,[22] and 1997[25] versions of the model. Other published versions may contain other differences. For example, Prochaska, Prochaska, and Levesque (2001)[26] do not mention the Termination stage, Self-efficacy, or Temptation.
  1. ^ In the 1983 version of the model, the Preparation stage is absent.
  2. ^ In the 1983 version of the model, the Termination stage is absent. In the 1992 version of the model, Prochaska et al. showed Termination as the end of their "Spiral Model of the Stages of Change," not as a separate stage.
  3. ^ In the 1983 version of the model, Relapse is considered one of the five stages of change.
  4. ^ In the 1983 version of the model, the processes of change were said to be emphasized in only the Contemplation, Action, and Maintenance stages.
  5. ^ In the 1983 version of the model, "decisional balance" is absent. In the 1992 version of the model, Prochaska et al. mention "decisional balance" but in only one sentence under the "key transtheoretical concept" of "processes of change."
  6. ^ In the 1983 version of the model, "self-efficacy" is absent. In the 1992 version of the model, Prochaska et al. mention "self-efficacy" but in only one sentence under the "key transtheoretical concept" of "stages of change."

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Further reading

External links