STAGES OF CHANGE MODELS
Behavior change is a natural process that involves passing through a series of stages
Agenda for Today
• Quiz
• Monica:
– Transtheoretical Model, Stages of Change
• Kristty:
– TTM – Processes of Change
• Liz:
– Precaution Adoption Process Model
• Miyuki, Chidi & Bhakti:
– Bridle et al., 2005 review
• Fran:
– West, 2005
Transtheoretical Model of
Change
Transtheoretical Model of Change
(Stages of Change)
• Transtheoretical Model of Change was originally
explained by Prochaska & DiClemente, 1983.
• The TMC is a model of intentional change. This model
focuses on the decision making of the individual.
• The model describes how people modify a problem
behavior or acquire a positive behavior.
• The TMC is a type of value-expectancy theory
Core constructs
The core constructs of the TMC are:
• The processes of change (which we will discuss
later)
• Decisional balance (value-expectancy aspect)
• Self-efficacy
• Temptation
Stages of Change
Pre-Contemplation:
• People may be in this stage because they are uninformed or
under-informed about the consequences of their behavior.
or
• They may have tried to change a number of times and become
demoralized about their ability to change.
• Both groups tend to avoid reading, talking or thinking about
their high risk behaviors.
Contemplation
 Aware of the pros of changing but are also acutely aware of
the cons.
 This balance between the costs and benefits of changing can
keep people stuck in this stage for long periods of time.
Preparation
• This is the stage in which people are intending to take
action in the immediate future, usually measured as the
next month. They have typically taken some significant
action in the past year.
• Individuals develop a plan of by joining a health
education class, consulting a counselor, talking to their
physician, buying a self-help book or nicotine
replacement.
Action
 This is the stage in which people have made specific overt
modifications in their life-styles within the past six months.
 Since action is observable, behavior change often has been
equated with action. But in the TTM, Action is only one of
five stages.
• Not all modifications of behavior count as action in this
model. People must attain a criterion that scientists and
professionals agree is sufficient to reduce risks for disease.
Maintenance
 This is the stage in which people are working to
prevent relapse but they do not apply change
processes as frequently as do people in action.
They are less tempted to relapse and
increasingly more confident that they can
continue their change.
Relapse
 Regression occurs when an individual reverts to an earlier stage of
change. Relapse is one form of regression, involving regression from
Action or Maintenance to an earlier stage.
 However, people can regress from any stage to an earlier stage.
 Relapse tends to be the rule when action is taken for most health
behavior problems.

For smoking and exercise only about 15% of people regress all the way
to the Precontemplation stage.
Movement through the stages

The amount of time a person is in each stage and the order in
which a person experiences each stage can vary greatly.
Cycling and re-cycling
• Behavior change usually involves multiple attempts and people
may revert to a previous stage at any time
• The process of cycling and re-cycling through the stages a
number of times is a critical concept of the theory
Decisional Balance
• This construct reflects the individual's relative
weighing of the pros and cons of changing.
• The Decisional Balance scale involves weighting
the importance of the Pros and Cons.
• A predictable pattern has been observed of how
the Pros and Cons relate to the stages of change.
For example:
In Precontemplation, the Pros of smoking far
outweigh the Cons of smoking. In Contemplation,
these two scales are more equal. In the advanced
stages, the Cons outweigh the Pros.
Decisional Balance
Stopping an Unhealthy
Behavior
Starting a Healthy
Behavior
Starting an exercise program
Pros
Cons
• I would have more energy
for my family and friends if I
exercised regularly.
• Exercising puts me in a
better mood for the rest of
the day.
• I would feel embarrassed if
people saw me exercising.
More examples?...
Self-efficacy/Temptation
• The Self-efficacy construct represents the situation specific confidence
that people have that they can cope with high-risk situations without
relapsing.
• This construct was adapted from Bandura's self-efficacy theory. This
construct is represented either by a Temptation measure or a Selfefficacy construct.
• The Situational Temptation Measure reflects the intensity of urges to
engage in a specific behavior when in the midst of difficult situations.
It is the converse of self-efficacy and the same set of items can be used
to measure both, using different response formats.
• Stage Matching: Identifying which stage a
person is in can enable the development of
targeted interventions.
Are you thinking of quitting
within the next 6 months?
No
Yes
Precontemplation
Have you tried to quit
smoking for at least 24
hours in the past year?
Yes
Preparation
No
Contemplation
Applying the TCM
N = 1864 women aged 40-74 were recruited from a staff model HMO and
randomly assigned to one of three intervention groups: (a) No
Educational Materials, (b) Standard Materials, and (c) Stage-Matched
Materials (based on the TCM).
The Standard and Stage-Matched groups each received two mailed
educational packets after baseline and follow-up telephone interviews.
Receipt of mammography after the baseline interview was higher for the
Stage-Matched group (63.6%) than for the No Materials group (54.9%; OR
= 1.43, 95% CI = 1.10, 1.86). The Standard group did not differ from the
No Materials group, but did differ from the Stage-Matched group in
multivariate analysis.
Activity: Stage Matching
1. Break into groups of about 5.
2. Match statement to stage.
3. A group member will read your
statement to the class and explain which
stage your group chose.
Works Cited
Cancer Prevention Research Center. (2000). Detailed
Overview of the Transtheoretical Model. URI.edu.
Retrieved October 23, 2013 from
http://www.uri.edu/research/cprc/TTM/detailedoverview.
htm
Current Nursing. (2012). Stages of change
model/transtheoretical model (TTM). Retrieved October
23, 2013 from
http://currentnursing.com/nursing_theory/transtheoretica
l_model.html
Rakowski, W., Ehrich, B., Goldstein, M.G., Rimer, B.,
Pearlma, D.N., Clark, M.A., Velicer, W.F., and Woolverton,
H. (1998). Increasing mammography among women aged
40–74 by use of a stage-matched, tailored intervention.
Preventive Medicine. 27(5), 748–756.
Transtheoretical Model of
Change (TMC)
Processes of change
(POC)
Behavior Change
1. ID individual’s stage of change
2. Processes of change
•
Strategies to promote progression through stages
Empirically supported processes
1. Consciousness raising
•
Increasing awareness of health risks and protective behaviors
2. Dramatic relief
•
Enhance emotional reaction to health-risk behaviors
3. Self-reevaluation
•
Visualize oneself and life without health-risk behavior
4. Environmental reevaluation
•
Does health habit adversely affect others in social environment
5. Self-liberation
•
Foster the idea one can change and commit to change
6. Helping relationships
•
Utilize supportive others to promote behavior change
7. Counterconditioning
•
Substitute healthier behaviors for unhealthy behaviors
8. Contingency management
•
Reward and punishment
9. Stimulus control
•
Reduction and addition of cues
10.Social liberation
•
Change or transcend socially designated norms or practices
Stage-matched interventions
Stage Transition
PC → C
Process of Change
Consciousness raising, dramatic relief,
self-reevaluation, environmental
reevaluation
C→P
Self-reevaluation, environmental
reevaluation, self-liberation, self-efficacy,
stimulus control
P→A
Self-liberation, self-efficacy, stimulus
control, counterconditioning, helping
relationships
A→M
Stimulus control, counterconditioning,
helping relationships, reinforcement
management
Class Activity
• Topic: Self-management blood glucose
(SMBG) – a necessary behavior for diabetics is
to monitor blood glucose levels, yet is
underperformed
– How can we change this behavior?
• Brainstorm techniques to be used for each
processes of change
Decisional balance
• Janis and Mann
(1977)
• Pros and cons of
changing behavior
– Maximize the
pros!
– Minimize the
cons!
• Tipping point
– Strong principle
of progress
– Weak principle
Self-efficacy
• Albert Bandura (1986)
• Two components:
– Confidence
– Temptation
• Resilient self-efficacy
The TTI Developmental-Ecological System
Levels of
Causation
E
Ultimate
Underlying
Causes
Values
Environment
S
ENVIRONMENT
Situation
Person P
P
E
S
P
Knowledge
Environment
S
E
Distal
Predisposing
Influences
Value
Social SelfCom- Role
Bonds Control petence Models
Eval Mc
Att SNB Self
Proximal
Immediate
Predictors
Exp
NB
Will + Skill
SNB
Know
Att
Efficacy
Intentions
Behavior
DEVELOPMENT & TIME
33
Precaution Adoption
Process Model (PAPM)
Theories Evolve
• Theories are seldom static
• The PAPM is similar to the TMC
• The PAPM is the second major stage theory in
health promotion
• The PAPM describes how someone comes to a
decision to adopt a precautionary behavior
Precaution Adoption Process Model
(PAPM)
Unaware
of issue
Unengaged
by issue
Deciding
about acting
Decided not
to act
Deciding to
act
Acting
Maintenance
What is included in a stage theory?
• Four basic assumptions of a stage theory
– A classification system to define stages
– An ordering of stages
– Stages that are defined by common barriers within
stages
– Stages that are defined by different barriers within
different stages
How is PAPM similar to TMC?
• Both theories utilize stage progression
• Both theories have a goal of leading to the
achievement of a sustainable behavior change
• Similar stage names, however…
How is PAPM different than TMC?
• Stage 1 (precontemplation) in TMC is split into
two sub-stages in the PAPM:
– 1. Unaware of the issue
– 2. Unengaged by the issue
• Third assumption of PAPM, barriers of change can
be based on three things:
– Not being aware
– Not being personally engaged
– A rejection of the behavior after failing to attempt to
change or rethinking after the issue
How is PAPM different than TMC?
• PAPM does not prescribe change processes
• In the PAPM, successful movement from any
stage may be due to any number of
intervention techniques
• Each population and health behavior in
question would warrant varied intervention
techniques
Key Difference
• PAPM emphasizes intrapsychic concepts
• Evaluating one’s own attitudes, feelings, behavior
at each stage
• TMC emphasizes environmental factors
• Stimulus control, environmental re-evaluation, social
liberation
Applying the PAPM
Eating
veggies is
healthy?
Aware that
eating
vegetables is
healthy
Friend made
tasty kale
salad, found
veg pamphlet
at SHS
Decided to
search online
for veggie
side dish
recipes
Testing three
new recipes
every week
Healthy or
not, they still
don’t taste
good
I don’t feel
any different
and I still
don’t like
vegetables
Vegetables
become a
part of every
dinner
Applying the PAPM
Unaware
of issue
Unengaged
by issue
Deciding
about acting
Decided not
to act
Deciding to
act
Acting
Maintenance
Future of PAPM?
• These models, like all in behavior change, are
dynamic – continue to evolve
• New empirical data are discovered and integrated
• Although the PAPM is similar to the TMC, it has
additional stages and is a bit more precise
• Where is PAPM most applicable?
The PAPM and the TTI
Article
Systematic review of the effectiveness
of health behavior interventions based
on the transtheoretical model
(Bridle et. al., 2005)
Resource from
http://www.balancedweightmanagement.com/change.htm
Stage based theory
• Stage based theories propose
- Behavior change based on a series of discrete stages
- Different barriers at different stages
- The most effective interventions (Tailored to individual’s
current stage)
• TTM (Prochaska & DiClemente, 1983)Constructions
-
Stage of change
Process of change
Decision balance
Self-efficacy
Whether stage based interventions are more
effective than non-stage based ones ?
• Recent previous reviews : little evidence about
effectiveness of TTM based interventions in health
related behavior
• Three explanations
- Including different types of research design
- Fundamental differences between health behaviors
- Stage movement = Behavior change?
Purpose of Study
• The purpose of this study
-
To assess the methodological quality of interventions based on TTM
( collecting only 37 RCT designs)
-
To determine whether TTM interventions are effective
( analyzing data only using 37 RCT designs)
-
To examine whether some behaviors are more suitable or amenable to
TTM
( Dividing health behaviors into 8 different behaviors)
-
To investigate whether TTM interventions are effective in stage
progression
Results
• Study quality
- Lack of methods for randomization, blinding, and fail
to use intention to treat analysis
- Implementation assessment (12 out of 37 RCT
reported validation)
• Evidence of effectiveness
- Overall, limited evidence about whether TTM based
interventions are more effective
• Stage movement
-
6 comparisons out of 18 favored stage based
interventions
Results
• Evidence of effectiveness according to types of
behavior
- Smoking cessation : 4 trials out of 12 favored stage-based
interventions.
- Physical activity : 1 trials out of 6 favored.
- Dietary change : 2 comparisons out of 6 favored.
- Multiple lifestyle changes : 1 comparison out of 7 favored.
- Screening mammography : 2 comparisons out of 3 favored.
- Treatment adherence : 1 trials out of 1 favored.
- Prevention : none trials favored.
Discussion
• Overall conclusions
- Common limitations in the methodological quality
- Only limited evidence for effectiveness of TTM based
interventions
- No evidence for effectiveness on the behavior being targeted
- Little evidence for effectiveness on promoting stage
movement
• Two issues that contributed the lack of evidence
about TTM interventions
- Lack of model specification
- Poor application
Discussion
• Lack of model specification
- Process of change fail to specify the process that related to
particular stages
* General views : Experiential process of change – early stages
Behavioral process of change - later stages
- Fail to predict about the nature of the barriers themselves
- Consistent with continuous stages rather than discrete stages
Discussion
• Poor application
- Inappropriate interventions design
* tailored only to “stage of change” neglecting other variables
* Stage of change – not theory but a single variable
- Inappropriate intervention delivery
* Inaccurate identification for an individual’s readiness to
change
* Interventions that reflect changes in the individual’s readiness
to change
- Static intervention (only one point in time)
* Repeated and evolving interventions
Time for a change: putting the
Trantheoretical (Stages of
Change) Model to rest
Robert West
Overview of Transtheoretical Model
(TTM)
• Individuals belong to one of five (or six) stages
– Precontemplation
– Contemplation
– Preparation
– Action
– Maintenance
– Termination (in some versions)
• Interventions can target people
in specific stages
Problems with the
Transtheoretical Model (TTM)
Concept of Stages
• Arbitrary dividing lines
• Confusing stage definitions
– Based on days and previous attempts at behavior
change
– Not based on readiness to change
Model as a Whole
• Based on the assumption that individuals
make thought-out plans
– Intentions to make behavior changes are not
always based on conscious decision making and
do not always involve clear planning
– Neglects the role of reward and punishment
THE THEORY OF TRIADIC INFLUENCE
Levels of
Causation
Intrapersonal Stream
Biological/Nature
BIOLOGY/
PERSONALITY
Ultimate
Causes
1
Social/
Personal
Nexus
2
Sense of
Self/Control
Distal
Influences
7
13
8
h
Skills:
Social+General
14
Proximal
Predictors
b
c
B
C
Others’
Beh & Atts
9
i
k
j
l m
u
d
e
n
16
SOCIAL
NORMATIVE
BELIEFS
o
11
w
20
q
Values/
Evaluations
x
v
6
Interactions w/
Social Instit’s
p
Perceived
Norms
15
5
f
10
Motivation
to Comply
s
CULTURAL
ENVIRONMENT
4
Interpersonal
Bonding
19
A
Nurture/Cultural
3
SELF-EFFICACY t
BEHAVIORAL
CONTROL
Affect and
Cognitions
Cultural/Attitudinal Stream
SOCIAL
SITUATION
a
Social
Competence
g
Self
Determination
Expectancies
& Evaluations
Decisions
Social/Normative Stream
Information/
Opportunities
Knowledge/
Expectancies
17
F
21
I
22
Trial Behavior
EXPERIENCES: Expectancies -- Social Reinforcements -- Psychological/Physiological
Experiences
18
ATTITUDES
TOWARD THE
BEHAVIOR
DECISIONS/INTENTIONS
D E
12
r
23
J
K
Related Behaviors
H
G
Model in Practice
• Model predicts no more than common
sense
“However, [the model] says no more than that
individuals who are thinking of changing their behaviour
are more likely to try to do so than those who are not, or
that individuals who are in the process of trying to
change are more likely to change than those who are just
thinking about it. Put that way, it is simply a statement of
the obvious: people who want or plan to do something
are obviously more likely to try to do it; and people who
try to do something are more likely to succeed than
those who do not”
Why the Model Should be
Abandoned
Promotes Poor Interventions
• Individuals at various stages may be excluded
from potentially effective interventions
• Creates interventions aimed at helping people
“move along stages” rather than changing
their behavior
Next Steps
New Model
• Should include the ways people can change
with apparent suddenness
• Should encompass decision-making and
motivational processes
• State of readiness to change
Where did West go with this?
• PRIME Theory of Motivation (West, 2006)
Another View of PRIME
The best View of the
PRIME Theory of Motivation
West’s foray into Chaos Theory:
Bifurcation at a Cusp