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STAGES OF CHANGE MODELS. Behavior change is a natural process that involves passing through a series of stages. Agenda for Today. Quiz Verity: Transtheoretical Model, Stages of Change Ross: TTM – Processes of Change Erica Precaution Adoption Process Model Moosong

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stages of change models

STAGES OF CHANGE MODELS

Behavior change is a natural process that involves passing through a series of stages

agenda for today
Agenda for Today
  • Quiz
  • Verity:
    • Transtheoretical Model, Stages of Change
  • Ross:
    • TTM – Processes of Change
  • Erica
    • Precaution Adoption Process Model
  • Moosong
    • Bridle et al., 2005 review
  • Marissa
    • West, 2005
transtheoretical model of change

Transtheoretical Model of Change

Verity Bishop | H 571

transtheoretical model of change stages 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
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
pre contemplation
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
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
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
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
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
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.
cycling and re cycling

Movement through the stages

Cycling and re-cycling
  • The amount of time a person is in each stage and the order in which a person experiences each stage can vary greatly.
  • 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
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 balance1
Decisional Balance

Stopping an Unhealthy Behavior

Starting a Healthy Behavior

starting an exercise program
Starting an exercise program

Pros

Cons

I would feel embarrassed if people saw me exercising.

More examples?...

  • 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.
self efficacy temptation
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 Self-efficacy 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.

slide18

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

No

Contemplation

Preparation

applying the tcm
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
Activity: Stage Matching
  • Break into groups of about 5.
  • Match statement to stage.

3. A group member will read your statement to the class and explain which stage your group chose.

slide21

Flay, B.R., & Petraitis, J. (2009). The Theory of Triadic Influence. In R. J. DiCelemente, M.C. Kegler & R.A. Crosby (Eds.) ,Emerging Theories in Health Promotion Practice and Research (Second ed., pp. 451-510). New York: Jossey –Bass.

works cited
Works Cited

Cancer Prevention Research Center. (2000). Detailed Overview of the TranstheoreticalModel. 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/transtheoretical_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.

behavior change
Behavior Change
  • ID individual’s stage of change
  • Processes of change
    • Strategies to promote progression through stages
empirically supported processes
Empirically supported processes
  • Consciousness raising
    • Increasing awareness of health risks and protective behaviors
  • Dramatic relief
    • Enhance emotional reaction to health-risk behaviors
  • Self-reevaluation
    • Visualize oneself and life without health-risk behavior
  • Environmental reevaluation
    • Does health habit adversely affect others in social environment
slide26

Self-liberation

    • Foster the idea one can change and commit to change
  • Helping relationships
    • Utilize supportive others to promote behavior change
  • Counterconditioning
    • Substitute healthier behaviors for unhealthy behaviors
  • Contingency management
    • Reward and punishment
  • Stimulus control
    • Reduction and addition of cues
  • Social liberation
    • Change or transcend socially designated norms or practices
class activity
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 balance2
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
Self-efficacy
  • Albert Bandura (1986)
  • Two components:
    • Confidence
    • Temptation
  • Resilient self-efficacy
slide33

The TTI Developmental-Ecological System

ENVIRONMENT

Situation

E

E

Person

P P

S

S

Values

Environment

Knowledge

Environment

P

S

E

Value

Social

Bonds

Role

Models

Know

Self-

Control

Com-

petence

Cognitive/Competence Substreams

Affective/Control Substreams

Exp

Eval

Mc

NB

Will + Skill

Att

Att

SNB

Self

Efficacy

SNB

Intentions

Behavior

Levels of

Causation

Ultimate

Underlying

Causes

Distal

Predisposing

Influences

Proximal

Immediate

Predictors

33

DEVELOPMENT & TIME

theories evolve
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 papm1
Precaution Adoption Process Model (PAPM)

Unaware of issue

Unengaged by issue

Deciding about acting

Deciding to act

Acting

1

2

5

6

3

Decided not to act

Maintenance

4

7

what is included in a stage theory
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
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
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 tmc1
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
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
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

1

2

5

6

3

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

4

7

applying the papm1
Applying the PAPM

Unaware of issue

Unengaged by issue

Deciding about acting

Deciding to act

Acting

1

2

5

6

3

Decided not to act

Maintenance

4

7

future of papm
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?
resource from http www balancedweightmanagement com change htm
Resource from http://www.balancedweightmanagement.com/change.htm

Article

  • Systematic review of the effectiveness of health behavior interventions based on the transtheoretical model
  • (Bridel et. al., 2005)
  • Moosong, Kim
stage based theory
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
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
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
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

results1
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
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
discussion1
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
discussion2
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

* Accurate 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

Time for a change: putting the Trantheoretical (Stages of Change) Model to restRobert West

Marissa Mark

H 571

October 24, 2013

overview of transtheoretical model ttm
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
concept of stages
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
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
slide61

THE THEORY OF TRIADIC INFLUENCE

Levels of

Causation

Ultimate

CULTURAL

SOCIAL

BIOLOGY/

Causes

ENVIRONMENT

SITUATION

PERSONALITY

1

2

3

4

5

6

a

f

Social/

Personal

Nexus

c

d

e

b

Sense of

Information/

Interpersonal

Others’

Social

Interactions w/

Self/Control

Opportunities

Bonding

Beh & Atts

Competence

Social Instit’s

Distal

Influences

7

8

9

10

11

12

g

r

p

i

q

h

k

n

m

l

j

o

Expectancies

& Evaluations

Self

Skills:

Motivation

Perceived

Values/

Knowledge/

Determination

Social+General

to Comply

Norms

Evaluations

Expectancies

13

14

15

16

17

18

s

x

ATTITUDES

SOCIAL

SELF-EFFICACY

u

w

v

t

Affect and

Cognitions

TOWARD THE

NORMATIVE

BEHAVIORAL

BEHAVIOR

BELIEFS

CONTROL

Proximal

19

20

21

Predictors

Decisions

A

G

B

H

C

I

D

E

F

22

K

Experiences

23

Related Behaviors

J

Intrapersonal Stream

Social/Normative Stream

Cultural/Attitudinal Stream

Biological/Nature

Nurture/Cultural

DECISIONS/INTENTIONS

Trial Behavior

EXPERIENCES: Expectancies -- Social Reinforcements -- Psychological/Physiological

model in practice
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”

promotes poor interventions
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
new model
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
Where did West go with this?
  • PRIME Theory of Motivation (West, 2006)
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