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Transtheoretical model

The transtheoretical model of behavior change is an integrative theory of therapy that assesses an individual's readiness to act on a new healthier behavior, and provides strategies, or processes of change to guide the individual.[1] The model is composed of constructs such as: stages of change, processes of change, levels of change, self-efficacy, and decisional balance.[1]

Stages of change, according to the transtheoretical model.

The transtheoretical model is also known by the abbreviation "TTM"[2] and sometimes by the term "stages of change",[3] although this latter term is a synecdoche since the stages of change are only one part of the model along with processes of change, levels of change, etc.[1][4] Several self-help booksChanging for Good (1994),[5] Changeology (2012),[6] and Changing to Thrive (2016)[7]—and articles in the news media[8] have discussed the model. It has been called "arguably the dominant model of health behaviour change, having received unprecedented research attention, yet it has simultaneously attracted criticism".[9]

History and core constructs

James O. Prochaska of the University of Rhode Island, and Carlo Di Clemente and colleagues developed the transtheoretical model beginning in 1977.[1] It is based on analysis and use of different theories of psychotherapy, hence the name "transtheoretical".

Prochaska and colleagues refined the model on the basis of research that they published in peer-reviewed journals and books.[10]

Stages of change

This construct refers to the temporal dimension of behavioural change. In the transtheoretical model, change is a "process involving progress through a series of stages":[11][12]

  • Precontemplation ("not ready") – "People are not intending to take action in the foreseeable future, and can be unaware that their behaviour is problematic"
  • Contemplation ("getting ready") – "People are beginning to recognize that their behaviour is problematic, and start to look at the pros and cons of their continued actions"
  • Preparation ("ready") – "People are intending to take action in the immediate future, and may begin taking small steps toward behaviour change"[nb 1]
  • Action – "People have made specific overt modifications in modifying their problem behaviour or in acquiring new healthy behaviours"
  • Maintenance – "People have been able to sustain action for at least six months and are working to prevent relapse"
  • Termination – "Individuals have zero temptation and they are sure they will not return to their old unhealthy habit as a way of coping"[nb 2]

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".[11][nb 3]

The quantitative definition of the stages of change (see below) is perhaps the most well-known feature of the model. However it is also one of the most critiqued, even in the field of smoking cessation, where it was originally formulated. It has been said that such quantitative definition (i.e. a person is in preparation if he intends to change within a month) does not reflect the nature of behaviour change, that it does not have better predictive power than simpler questions (i.e. "do you have plans to change..."), and that it has problems regarding its classification reliability.[13]

Communication theorist and sociologist Everett Rogers suggested that the stages of change are analogues of the stages of the innovation adoption process in Rogers' theory of diffusion of innovations.[14]

Details of each stage

 
Stages of change
Stage Precontemplation Contemplation Preparation Action Maintenance Relapse
Standard time more than 6 months in the next 6 months in the next month now at least 6 months any time

Stage 1: Precontemplation (not ready)[5][11][15][16][17][18]

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.

One of the most effective steps that others can help with at this stage is to encourage them 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.

Others can influence and help effectively at this stage by encouraging them 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 should be 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 (current 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 progress by being 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 (monitoring)

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 healthy activities (such as exercise and deep relaxation) to cope with stress instead of relying on unhealthy behavior.

Relapse (recycling)[19][20][21][22]

Relapse in the TTM specifically applies to individuals who successfully quit smoking or using drugs or alcohol, only to resume these unhealthy behaviors. Individuals who attempt to quit highly addictive behaviors such as drug, alcohol, and tobacco use are at particularly high risk of a relapse. Achieving a long-term behavior change often requires ongoing support from family members, a health coach, a physician, or another motivational source. Supportive literature and other resources can also be helpful to avoid a relapse from happening.

Processes of change

 
Processes of change

The 10 processes of change are "covert and overt activities that people use to progress through the stages".[11]

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, counter conditioning, rewards, environmental controls, and support.[23]

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".[11][nb 4]

In general, for people to progress they need:

  • A growing awareness that the advantages (the "pros") of changing outweigh the disadvantages (the "cons")—the TTM calls this decisional balance.
  • 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.
  • Strategies that can help them make and maintain change—the TTM calls these processes of change.

The ten processes of change include:

  1. Consciousness-raising (Get the facts) — increasing awareness via information, education, and personal feedback about the healthy behavior.
  2. Dramatic relief (Pay attention to feelings) — feeling fear, anxiety, or worry because of the unhealthy behavior, or feeling inspiration and hope when hearing about how people are able to change to healthy behaviors.
  3. Self-reevaluation (Create a new self-image) — realizing that the healthy behavior is an important part of who they want to be.
  4. Environmental reevaluation (Notice your effect on others) — realizing how their unhealthy behavior affects others and how they could have more positive effects by changing.
  5. Social liberation (Notice public support) — realizing that society is supportive of the healthy behavior.
  6. Self-liberation (Make a commitment) — believing in one's ability to change and making commitments and re-commitments to act on that belief.
  7. Helping relationships (Get support) — finding people who are supportive of their change.
  8. Counterconditioning (Use substitutes) — substituting healthy ways of acting and thinking for unhealthy ways.
  9. Reinforcement management (Use rewards) — increasing the rewards that come from positive behavior and reducing those that come from negative behavior.
  10. Stimulus control (Manage your environment) — using reminders and cues that encourage healthy behavior and avoiding places that don't.

Health researchers have extended Prochaska's and DiClemente's 10 original processes of change by an additional 21 processes. In the first edition of Planning Health Promotion Programs,[24] Bartholomew et al. (2006) summarised the processes that they identified in a number of studies;[24] however, their extended list of processes was removed from later editions of the text, perhaps because the list mixes techniques with processes. There are unlimited ways of applying processes. The additional strategies of Bartholomew et al. were:[24]

  1. Risk comparison (Understand the risks) – comparing risks with similar dimensional profiles: dread, control, catastrophic potential and novelty
  2. Cumulative risk (Get the overall picture) – processing cumulative probabilities instead of single incident probabilities
  3. Qualitative and quantitative risks (Consider different factors) – processing different expressions of risk
  4. Positive framing (Think positively) – focusing on success instead of failure framing
  5. Self-examination relate to risk (Be aware of your risks) – conducting an assessment of risk perception, e.g. personalisation, impact on others
  6. Reevaluation of outcomes (Know the outcomes) – emphasising positive outcomes of alternative behaviours and reevaluating outcome expectancies
  7. Perception of benefits (Focus on benefits) – perceiving advantages of the healthy behaviour and disadvantages of the risk behaviour
  8. Self-efficacy and social support (Get help) – mobilising social support; skills training on coping with emotional disadvantages of change
  9. Decision making perspective (Decide) – focusing on making the decision
  10. Tailoring on time horizons (Set the time frame) – incorporating personal time horizons
  11. Focus on important factors (Prioritise) – incorporating personal factors of highest importance
  12. Trying out new behaviour (Try it) – changing something about oneself and gaining experience with that behaviour
  13. Persuasion of positive outcomes (Persuade yourself) – promoting new positive outcome expectations and reinforcing existing ones
  14. Modelling (Build scenarios) – showing models to overcome barriers effectively
  15. Skill improvement (Build a supportive environment) – restructuring environments to contain important, obvious and socially supported cues for the new behaviour
  16. Coping with barriers (Plan to tackle barriers) – identifying barriers and planning solutions when facing these obstacles
  17. Goal setting (Set goals) – setting specific and incremental goals
  18. Skills enhancement (Adapt your strategies) – restructuring cues and social support; anticipating and circumventing obstacles; modifying goals
  19. Dealing with barriers (Accept setbacks) – understanding that setbacks are normal and can be overcome
  20. Self-rewards for success (Reward yourself) – feeling good about progress; reiterating positive consequences
  21. Coping skills (Identify difficult situations) – identifying high risk situations; selecting solutions; practicing solutions; coping with relapse

While most of these processes and strategies are associated with health interventions such as stress management, exercise, healthy eating, smoking cessation and other addictive behaviour,[24] some of them are also used in other types of interventions such as travel interventions.[25] Some processes are recommended in a specific stage, while others can be used in one or more stages.[1]

Decisional balance

This core construct "reflects the individual's relative weighing of the pros and cons of changing".[11][nb 5] Decision making was conceptualized by Janis and Mann as a "decisional balance sheet" of comparative potential gains and losses.[26] 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. TTM research has found the following relationships between the pros, cons, and the stage of change across 48 behaviors and over 100 populations studied.

  • The cons of changing outweigh the pros in the Precontemplation stage.
  • The pros surpass the cons in the middle stages.
  • The pros outweigh the cons in the Action stage.[27]

The evaluation of pros and cons is part of the formation of decisional balance. During the change process, individuals gradually increase the pros and decrease the cons forming a more positive balance towards the target behaviour. Attitudes are one of the core constructs explaining behaviour and behaviour change in various research domains.[28] Other behaviour models, such as the theory of planned behavior (TPB)[29] and the stage model of self-regulated change,[30] also emphasise attitude as an important determinant of behaviour. The progression through the different stages of change is reflected in a gradual change in attitude before the individual acts. Most of the processes of change aim at evaluating and reevaluating as well as reinforcing specific elements of the current and target behaviour.

Due to the use of decisional balance and attitude, travel behaviour researchers have begun to combine the TTM with the TPB. Forward[31] uses the TPB variables to better differentiate the different stages. Especially all TPB variables (attitude, perceived behaviour control, descriptive and subjective norm) are positively show a gradually increasing relationship to stage of change for bike commuting. As expected, intention or willingness to perform the behaviour increases by stage.[31] Similarly, Bamberg[30] uses various behavior models, including the transtheoretical model, theory of planned behavior and norm-activation model, to build the stage model of self-regulated behavior change (SSBC). Bamberg claims that his model is a solution to criticism raised towards the TTM.[30] Some researchers in travel, dietary, and environmental research have conducted empirical studies, showing that the SSBC might be a future path for TTM-based research.[30][32][33]

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".[11][nb 6] The construct is based on Bandura's self-efficacy theory and conceptualizes a person's perceived ability to perform on a task as a mediator of performance on future tasks.[34][35] In his research Bandura already established that greater levels of perceived self-efficacy leads to greater changes in behavior.[35] Similarly, Ajzen mentions the similarity between the concepts of self-efficacy and perceived behavioral control.[36] This underlines the integrative nature of the transtheoretical model which combines various behavior theories. 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.

Levels of change

This core construct identifies the depth or complexity of presenting problems according to five levels of increasing complexity.[1][4] Different therapeutic approaches have been recommended for each level as well as for each stage of change.[1][10] The levels are:

  1. Symptom/situational problems: e.g., motivational interviewing, behavior therapy, exposure therapy
  2. Current maladaptive cognitions: e.g., Adlerian therapy, cognitive therapy, rational emotive therapy
  3. Current interpersonal conflicts: e.g., Sullivanian therapy, interpersonal therapy
  4. Family/systems conflicts: e.g., strategic therapy, Bowenian therapy, structural family therapy
  5. Long-term intrapersonal conflicts: e.g., psychoanalytic therapies, existential therapy, Gestalt therapy

In one empirical study of psychotherapy discontinuation published in 1999, measures of levels of change did not predict premature discontinuation of therapy.[37] Nevertheless, in 2005 the creators of the TTM stated that it is important "that both therapists and clients agree as to which level they attribute the problem and at which level or levels they are willing to target as they work to change the problem behavior".[1]: 152 

Psychologist Donald Fromme, in his book Systems of Psychotherapy, adopted many ideas from the TTM, but in place of the levels of change construct, Fromme proposed a construct called contextual focus, a spectrum from physiological microcontext to environmental macrocontext: "The horizontal, contextual focus dimension resembles TTM's Levels of Change, but emphasizes the breadth of an intervention, rather than the latter's focus on intervention depth."[4]: 57 

Outcomes of programs

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

Stress management

A national sample of pre-Action adults was provided a 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 statistically significant reductions in stress and depression and an increase in the use of stress management techniques when compared to the control group.[38] Two additional clinical trials of TTM programs by Prochaska et al. and Jordan et al. also found significantly larger proportions of treatment groups effectively managing stress when compared to control groups.[2][39]

Adherence to antihypertensive medication

Over 1,000 members of a New England group practice who were prescribed antihypertensive medication participated in an adherence to antihypertensive medication intervention. The vast majority (73%) of the intervention group who were previously pre-Action were adhering to their prescribed medication regimen at the 12-month follow-up when compared to the control group.[40]

Adherence to lipid-lowering drugs

Members of a large New England health plan and various employer groups who were prescribed a cholesterol lowering medication participated in an adherence to lipid-lowering drugs intervention. More than half of the intervention group (56%) who were previously pre-Action were adhering to their prescribed medication regimen at the 18-month follow-up. Additionally, only 15% of those in the intervention group who were already in Action or Maintenance relapsed into poor medication adherence compared to 45% of the controls. Further, participants who were at risk for physical activity and unhealthy diet were given only stage-based guidance. The treatment group doubled the control group in the percentage in Action or Maintenance at 18 months for physical activity (43%) and diet (25%).[41]

Depression prevention

Participants were 350 primary care patients experiencing at least mild depression but not involved in treatment or planning to seek treatment for depression in the next 30 days. Patients receiving the TTM intervention experienced significantly greater symptom reduction during the 9-month follow-up period. The intervention's largest effects were observed among patients with moderate or severe depression, and who were in the Precontemplation or Contemplation stage of change at baseline. For example, among patients in the Precontemplation or Contemplation stage, rates of reliable and clinically significant improvement in depression were 40% for treatment and 9% for control. Among patients with mild depression, or who were in the Action or Maintenance stage at baseline, the intervention helped prevent disease progression to Major Depression during the follow-up period.[42]

Weight management

Five-hundred-and-seventy-seven overweight or moderately obese adults (BMI 25-39.9) were recruited nationally, primarily from large employers. Those randomly assigned to the treatment group received a stage-matched multiple behavior change guide and a series of tailored, individualized interventions for three health behaviors that are crucial to effective weight management: healthy eating (i.e., reducing calorie and dietary fat intake), moderate exercise, and managing emotional distress without eating. Up to three tailored reports (one per behavior) were delivered based on assessments conducted at four time points: baseline, 3, 6, and 9 months. All participants were followed up at 6, 12, and 24 months. Multiple Imputation was used to estimate missing data. Generalized Labor Estimating Equations (GLEE) were then used to examine differences between the treatment and comparison groups. At 24 months, those who were in a pre-Action stage for healthy eating at baseline and received treatment were significantly more likely to have reached Action or Maintenance than the comparison group (47.5% vs. 34.3%). The intervention also impacted a related, but untreated behavior: fruit and vegetable consumption. Over 48% of those in the treatment group in a pre-Action stage at baseline progressed to Action or Maintenance for eating at least 5 servings a day of fruit and vegetables as opposed to 39% of the comparison group. Individuals in the treatment group who were in a pre-Action stage for exercise at baseline were also significantly more likely to reach Action or Maintenance (44.9% vs. 38.1%). The treatment also had a significant effect on managing emotional distress without eating, with 49.7% of those in a pre-Action stage at baseline moving to Action or Maintenance versus 30.3% of the comparison group. The groups differed on weight lost at 24 months among those in a pre-Action stage for healthy eating and exercise at baseline. Among those in a pre-Action stage for both healthy eating and exercise at baseline, 30% of those randomized to the treatment group lost 5% or more of their body weight vs. 16.6% in the comparison group. Coaction of behavior change occurred and was much more pronounced in the treatment group with the treatment group losing significantly more than the comparison group. This study demonstrates the ability of TTM-based tailored feedback to improve healthy eating, exercise, managing emotional distress, and weight on a population basis. The treatment produced the highest population impact to date on multiple health risk behaviors.[43]

The effectiveness of the use of this model in weight management interventions (including dietary or physical activity interventions, or both, and also combined with other interventions) for overweight and obese adults was assessed in a 2014 systematic review.[44] The results revealed that there is inconclusive evidence regarding the impact of these interventions on sustainable (one year or longer) weight loss. However, this approach may produce positive effects in physical activity and dietary habits, such as increased in both exercise duration and frequency, and fruits and vegetables consumption, along with reduced dietary fat intake, based on very low quality scientific evidence.[44]

Smoking cessation

Multiple studies have found individualized interventions tailored on the 14 TTM variables for smoking cessation to effectively recruit and retain pre-Action participants and produce long-term abstinence rates within the range of 22% – 26%. These interventions have also consistently outperformed alternative interventions including best-in-class action-oriented self-help programs,[45] non-interactive manual-based programs, and other common interventions.[46][47] Furthermore, these interventions continued to move pre-Action participants to abstinence even after the program ended.[46][47][48] For a summary of smoking cessation clinical outcomes, see Velicer, Redding, Sun, & Prochaska, 2007 and Jordan, Evers, Spira, King & Lid, 2013.[39][49]

Example for TTM application on smoke control

In the treatment of smoke control, TTM focuses on each stage to monitor and to achieve a progression to the next stage.[19][20][21][50]

Stage Precontemplation Contemplation Preparation Action Maintenance Can Relapse to an
earlier stage
Standard time more than 6 months in the next 6 months in the next month now at least 6 months any time
Action and intervention not ready to quit or demoralized ambivalent intend to quit take action and quit sustained back to smoke
Related source Book, newspaper, friend Book, newspaper, friend doctor, nurse, friend... doctor, nurse, friend... friend, family temptation, stress, distress

In each stage, a patient may have multiple sources that could influence their behavior. These may include: friends, books, and interactions with their healthcare providers. These factors could potentially influence how successful a patient may be in moving through the different stages. This stresses the importance to have continuous monitoring and efforts to maintain progress at each stage. TTM helps guide the treatment process at each stage, and may assist the healthcare provider in making an optimal therapeutic decision.

Travel research

The use of TTM in travel behaviour interventions is rather novel. A number of cross-sectional studies investigated the individual constructs of TTM, e.g. stage of change, decisional balance and self-efficacy, with regards to transport mode choice. The cross-sectional studies identified both motivators and barriers at the different stages regarding biking, walking and public transport.[51][52][53][54] The motivators identified were e.g. liking to bike/walk, avoiding congestion and improved fitness. Perceived barriers were e.g. personal fitness, time and the weather. This knowledge was used to design interventions that would address attitudes and misconceptions to encourage an increased use of bikes and walking. These interventions aim at changing people's travel behaviour towards more sustainable and more active transport modes. In health-related studies, TTM is used to help people walk or bike more instead of using the car.[51][55][56][57][58][59] Most intervention studies aim to reduce car trips for commute to achieve the minimum recommended physical activity levels of 30 minutes per day.[51] Other intervention studies using TTM aim to encourage sustainable behaviour.[60][61][62] By reducing single occupied motor vehicle and replacing them with so called sustainable transport (public transport, car pooling, biking or walking), greenhouse gas emissions can be reduced considerably. A reduction in the number of cars on our roads solves other problems such as congestion, traffic noise and traffic accidents. By combining health and environment related purposes, the message becomes stronger. Additionally, by emphasising personal health, physical activity or even direct economic impact, people see a direct result from their changed behaviour, while saving the environment is a more general and effects are not directly noticeable.[63][54][64]

Different outcome measures were used to assess the effectiveness of the intervention. Health-centred intervention studies measured BMI, weight, waist circumference as well as general health. However, only one of three found a significant change in general health, while BMI and other measures had no effect.[51] Measures that are associated with both health and sustainability were more common. Effects were reported as number of car trips, distance travelled, main mode share etc. Results varied due to greatly differing approaches. In general, car use could be reduced between 6% and 55%, while use of the alternative mode (walking, biking and/or public transport) increased between 11% and 150%.[25] These results indicate a shift to action or maintenance stage, some researchers investigated attitude shifts such as the willingness to change. Attitudes towards using alternative modes improved with approximately 20% to 70%.[25] Many of the intervention studies did not clearly differentiate between the five stages, but categorised participants in pre-action and action stage. This approach makes it difficult to assess the effects per stage. Also, interventions included different processes of change; in many cases these processes are not matched to the recommended stage.[25] It highlights the need to develop a standardised approach for travel intervention design. Identifying and assessing which processes are most effective in the context of travel behaviour change should be a priority in the future in order to secure the role of TTM in travel behaviour research.

Criticisms

The TTM has been called "arguably the dominant model of health behaviour change, having received unprecedented research attention, yet it has simultaneously attracted criticism".[9] Depending on the field of application (e.g. smoking cessation, substance abuse, condom use, diabetes treatment, obesity and travel) somewhat different criticisms have been raised.

In a systematic review, published in 2003, of 23 randomized controlled trials, the authors found that "stage based interventions are no more effective than non-stage based interventions or no intervention in changing smoking behaviour.[65] However, it was also mentioned that stage based interventions are often used and implemented inadequately in practice. Thus, criticism is directed towards the use rather the effectiveness of the model itself. Looking at interventions targeting smoking cessation in pregnancy found that stage-matched interventions were more effective than non-matched interventions. One reason for this was the greater intensity of stage-matched interventions.[66] Also, the use of stage-based interventions for smoking cessation in mental illness proved to be effective.[67] Further studies, e.g. a randomized controlled trial published in 2009, found no evidence that a TTM based smoking cessation intervention was more effective than a control intervention not tailored to stage of change. The study claims that those not wanting to change (i.e. precontemplators) tend to be responsive to neither stage nor non-stage based interventions. Since stage-based interventions tend to be more intensive they appear to be most effective at targeting contemplators and above rather than pre-contemplators.[68] A 2010 systematic review of smoking cessation studies under the auspices of the Cochrane Collaboration found that "stage-based self-help interventions (expert systems and/or tailored materials) and individual counselling were neither more nor less effective than their non-stage-based equivalents.[69]

Main criticism is raised regarding the "arbitrary dividing lines" that are drawn between the stages. West claimed that a more coherent and distinguishable definition for the stages is needed.[13] Especially the fact that the stages are bound to a specific time interval is perceived to be misleading. Additionally, the effectiveness of stage-based interventions differs depending on the behavior. A continuous version of the model has been proposed, where each process is first increasingly used, and then decreases in importance, as smokers make progress along some latent dimension.[70] This proposal suggests the use of processes without reference to stages of change.

West claimed that the model "assumes that individuals typically make coherent and stable plans", when in fact they often do not.[13] However, the model does not require that all people make a plan: for example, the SAMSHA document Enhancing Motivation for Change in Substance Use Disorder Treatment, which uses the TTM, also says: "Don't assume that all clients need a structured method to develop a change plan. Many people can make significant lifestyle changes and initiate recovery from SUDs without formal assistance".[71]

Within research on prevention of pregnancy and sexually transmitted diseases, a systematic review from 2003 comes to the conclusion that "no strong conclusions" can be drawn about the effectiveness of interventions based on the transtheoretical model.[72] Again this conclusion is reached due to the inconsistency of use and implementation of the model.[72] This study also confirms that the better stage-matched the intervention the more effect it has to encourage condom use.[72]

Within the health research domain, a 2005 systematic review of 37 randomized controlled trials claims that "there was limited evidence for the effectiveness of stage-based interventions as a basis for behavior change.[73] Studies with which focused on increasing physical activity levels through active commute however showed that stage-matched interventions tended to have slightly more effect than non-stage matched interventions.[56] Since many studies do not use all constructs of the TTM, additional research suggested that the effectiveness of interventions increases the better it is tailored on all core constructs of the TTM in addition to stage of change.[74] In diabetes research the "existing data are insufficient for drawing conclusions on the benefits of the transtheoretical model" as related to dietary interventions. Again, studies with slightly different design, e.g. using different processes, proved to be effective in predicting the stage transition of intention to exercise in relation to treating patients with diabetes.[75]

TTM has generally found a greater popularity regarding research on physical activity, due to the increasing problems associated with unhealthy diets and sedentary living, e.g. obesity, cardiovascular problems.[76] A 2011 Cochrane Systematic Review found that there is little evidence to suggest that using the transtheoretical model stages of change (TTM SOC) method is effective in helping obese and overweight people lose weight.[citation needed] There were only five studies in the review, two of which were later dropped due to not being relevant since they did not measure weight. Earlier in a 2009 paper, the TTM was considered to be useful in promoting physical activity.[77] In this study, the algorithms and questionnaires that researchers used to assign people to stages of change lacked standardisation to be compared empirically, or validated.[13]

Similar criticism regarding the standardisation as well as consistency in the use of TTM is also raised in a recent review on travel interventions.[25] With regard to travel interventions only stages of change and sometimes decisional balance constructs are included. The processes used to build the intervention are rarely stage-matched and short cuts are taken by classifying participants in a pre-action stage, which summarises the precontemplation, contemplation and preparation stage, and an action/maintenance stage.[25] More generally, TTM has been criticised within various domains due to the limitations in the research designs. For example, many studies supporting the model have been cross-sectional, but longitudinal study data would allow for stronger causal inferences. Another point of criticism is raised in a 2002 review, where the model's stages were characterized as "not mutually exclusive".[78] Furthermore, there was "scant evidence of sequential movement through discrete stages".[78] While research suggests that movement through the stages of change is not always linear, a study of smoking cessation conducted in 1996 demonstrated that the probability of forward stage movement is greater than the probability of backward stage movement.[79] Due to the variations in use, implementation and type of research designs, data confirming TTM are ambiguous. More care has to be taken in using a sufficient amount of constructs, trustworthy measures, and longitudinal data.[25]

See also

Notes

The following notes summarize major differences between the well-known 1983,[80] 1992,[81] and 1997[11] versions of the model. Other published versions may contain other differences. For example, Prochaska, Prochaska, and Levesque (2001)[17] 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".

References

  1. ^ a b c d e f g h Prochaska, James O.; DiClemente, Carlo C. (2005). "The transtheoretical approach". In Norcross, John C.; Goldfried, Marvin R. (eds.). Handbook of psychotherapy integration. Oxford series in clinical psychology (2nd ed.). Oxford; New York: Oxford University Press. pp. 147–171. ISBN 978-0195165791. OCLC 54803644.
  2. ^ a b Prochaska, James O.; Butterworth, Susan; Redding, Colleen A.; Burden, Verna; Perrin, Nancy; Leo, Michael; Flaherty-Robb, Marna; Prochaska, Janice M. (March 2008). "Initial efficacy of MI, TTM tailoring and HRI's with multiple behaviors for employee health promotion". Preventive Medicine. 46 (3): 226–231. doi:10.1016/j.ypmed.2007.11.007. PMC 3384542. PMID 18155287.
  3. ^ For example: Greene, GW; Rossi, SR; Rossi, JS; Velicer, WF; Fava, JL; Prochaska, JO (June 1999). "Dietary applications of the stages of change model". Journal of the American Dietetic Association. 99 (6): 673–8. doi:10.1016/S0002-8223(99)00164-9. PMID 10361528.
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  7. ^ Prochaska, James O.; Prochaska, Janice M. (2016). Changing to thrive: using the stages of change to overcome the top threats to your health and happiness. Center City, MN: Hazelden. ISBN 9781616496296. OCLC 956501910.
  8. ^ Examples of articles in the news media include:
    • Goleman, Daniel (1 September 1993). "New addiction approach gets results". The New York Times. p. C10. Retrieved 19 March 2009.
    • Miller, Kay (29 December 2001). "Revolving resolutions – Year after new year, we vow to lose weight, stop smoking, find love or a better job – only to fail. A few simple strategies could set us straight". Star Tribune. p. 1E.
    • Stettner, Morey (19 December 2005). "A methodical way to change bad behavior". Investor's Business Daily. p. A11.
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    • "Understanding change: expect a few bumps". The Washington Post. 2 January 2007. Retrieved 19 March 2009.
    • Carbine, Michael E. (6 March 2009). . AIS's Health Business Daily. Archived from the original on 2009-06-01. Retrieved 19 March 2009.
    • "Why behavior change is hard – and why you should keep trying". Harvard Women's Health Watch. Vol. 19, no. 7. Harvard Health Publishing. March 2012. pp. 4–5. PMID 22550732.
    • Gropper, Michael (23 June 2015). "Overcoming your psychological inertia". The Jerusalem Post. p. Features, 25. Retrieved 18 February 2021.
    • Wu, Fiona (21 February 2020). "Get psyched: starting fresh". The Vanderbilt Hustler. Retrieved 18 February 2021.
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Further reading

  • Prochaska, JO; DiClemente, CC. The transtheoretical approach: crossing traditional boundaries of therapy. Homewood, IL: Dow Jones-Irwin; 1984. ISBN 0-87094-438-X.
  • Miller, WR; Heather, N. (eds.). Treating addictive behaviors. 2nd ed. New York: Plenum Press; 1998. ISBN 0-306-45852-7.
  • Velasquez, MM. Group treatment for substance abuse: a stages-of-change therapy manual. New York: Guilford Press; 2001. ISBN 1-57230-625-4.
  • Burbank, PM; Riebe, D. Promoting exercise and behavior change in older adults: interventions with the transtheoretical model. New York: Springer; 2002. ISBN 0-8261-1502-0.
  • Prochaska, J. O., & Norcross, J. C. (2002). Stages of change. In J. C. Norcross (Ed.), Psychotherapy relationships that work (303-313). New York: Oxford University Press.
  • DiClemente, CC. Addiction and change: how addictions develop and addicted people recover. New York: Guilford Press; 2003. ISBN 1-57230-057-4.
  • Glanz, K; Rimer, BK; Viswanath, K. (eds.) Health behavior and health education: theory, research, and practice, 4th ed. San Francisco, CA: Jossey-Bass; 2008. ISBN 978-0-7879-9614-7.
  • Prochaska, J.O.; Wright, J. A.; Velicer, W.F. (2008). "Evaluating Theories of Health Behavior Change: A hierarchy of Criteria Applied to the Transtheoretical Model". Applied Psychology. 57 (4): 561–588. doi:10.1111/j.1464-0597.2008.00345.x.
  • Patterson, D. A.; Buckingham, S. L. (2010). "Does motivational interviewing stages of change increase treatment retention among persons who are alcohol and other drug dependant and HIV-infected?". Journal of HIV/AIDS and Social Services. 9 (1): 45–57. doi:10.1080/15381500903584346. S2CID 57341833.
  • Patterson, D. A.; Nochajski, T.H. (2010). "Using the Stages of change model to help clients through the 12-steps of Alcoholics Anonymous". Journal of Social Work Practice in the Addictions. 10 (2): 224–227. doi:10.1080/15332561003730262. PMC 3520431. PMID 23243392.
  • Connors, GJ; Donovan, DM; DiClemente, CC. Substance abuse treatment and the stages of change: selecting and planning interventions. 2nd ed. New York: Guilford Press, 2013. ISBN 978-1-4625-0804-4.
  • Prochaska, JO; Norcross, JC. Systems of psychotherapy: a transtheoretical analysis. 9th ed. New York: Oxford University Press, 2018. ISBN 978-0-1908-8041-5.

External links

  • Pro-Change Behavior Systems, Inc. Company founded by James O. Prochaska. Mission is to enhance the well-being of individuals and organizations through the scientific development and dissemination of Transtheoretical Model-based change management programs.

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The transtheoretical model of behavior change is an integrative theory of therapy that assesses an individual s readiness to act on a new healthier behavior and provides strategies or processes of change to guide the individual 1 The model is composed of constructs such as stages of change processes of change levels of change self efficacy and decisional balance 1 Stages of change according to the transtheoretical model The transtheoretical model is also known by the abbreviation TTM 2 and sometimes by the term stages of change 3 although this latter term is a synecdoche since the stages of change are only one part of the model along with processes of change levels of change etc 1 4 Several self help books Changing for Good 1994 5 Changeology 2012 6 and Changing to Thrive 2016 7 and articles in the news media 8 have discussed the model It has been called arguably the dominant model of health behaviour change having received unprecedented research attention yet it has simultaneously attracted criticism 9 Contents 1 History and core constructs 1 1 Stages of change 1 1 1 Details of each stage 1 2 Processes of change 1 3 Decisional balance 1 4 Self efficacy 1 5 Levels of change 2 Outcomes of programs 2 1 Stress management 2 2 Adherence to antihypertensive medication 2 3 Adherence to lipid lowering drugs 2 4 Depression prevention 2 5 Weight management 2 6 Smoking cessation 2 6 1 Example for TTM application on smoke control 2 7 Travel research 3 Criticisms 4 See also 5 Notes 6 References 7 Further reading 8 External linksHistory and core constructs EditJames O Prochaska of the University of Rhode Island and Carlo Di Clemente and colleagues developed the transtheoretical model beginning in 1977 1 It is based on analysis and use of different theories of psychotherapy hence the name transtheoretical Prochaska and colleagues refined the model on the basis of research that they published in peer reviewed journals and books 10 Stages of change Edit This construct refers to the temporal dimension of behavioural change In the transtheoretical model change is a process involving progress through a series of stages 11 12 Precontemplation not ready People are not intending to take action in the foreseeable future and can be unaware that their behaviour is problematic Contemplation getting ready People are beginning to recognize that their behaviour is problematic and start to look at the pros and cons of their continued actions Preparation ready People are intending to take action in the immediate future and may begin taking small steps toward behaviour change nb 1 Action People have made specific overt modifications in modifying their problem behaviour or in acquiring new healthy behaviours Maintenance People have been able to sustain action for at least six months and are working to prevent relapse Termination Individuals have zero temptation and they are sure they will not return to their old unhealthy habit as a way of coping nb 2 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 11 nb 3 The quantitative definition of the stages of change see below is perhaps the most well known feature of the model However it is also one of the most critiqued even in the field of smoking cessation where it was originally formulated It has been said that such quantitative definition i e a person is in preparation if he intends to change within a month does not reflect the nature of behaviour change that it does not have better predictive power than simpler questions i e do you have plans to change and that it has problems regarding its classification reliability 13 Communication theorist and sociologist Everett Rogers suggested that the stages of change are analogues of the stages of the innovation adoption process in Rogers theory of diffusion of innovations 14 Details of each stage Edit Stages of change Stage Precontemplation Contemplation Preparation Action Maintenance RelapseStandard time more than 6 months in the next 6 months in the next month now at least 6 months any timeStage 1 Precontemplation not ready 5 11 15 16 17 18 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 One of the most effective steps that others can help with at this stage is to encourage them 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 Others can influence and help effectively at this stage by encouraging them 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 should be 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 current 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 progress by being 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 monitoring 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 healthy activities such as exercise and deep relaxation to cope with stress instead of relying on unhealthy behavior Relapse recycling 19 20 21 22 Relapse in the TTM specifically applies to individuals who successfully quit smoking or using drugs or alcohol only to resume these unhealthy behaviors Individuals who attempt to quit highly addictive behaviors such as drug alcohol and tobacco use are at particularly high risk of a relapse Achieving a long term behavior change often requires ongoing support from family members a health coach a physician or another motivational source Supportive literature and other resources can also be helpful to avoid a relapse from happening Processes of change Edit Processes of change The 10 processes of change are covert and overt activities that people use to progress through the stages 11 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 counter conditioning rewards environmental controls and support 23 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 11 nb 4 In general for people to progress they need A growing awareness that the advantages the pros of changing outweigh the disadvantages the cons the TTM calls this decisional balance 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 Strategies that can help them make and maintain change the TTM calls these processes of change The ten processes of change include Consciousness raising Get the facts increasing awareness via information education and personal feedback about the healthy behavior Dramatic relief Pay attention to feelings feeling fear anxiety or worry because of the unhealthy behavior or feeling inspiration and hope when hearing about how people are able to change to healthy behaviors Self reevaluation Create a new self image realizing that the healthy behavior is an important part of who they want to be Environmental reevaluation Notice your effect on others realizing how their unhealthy behavior affects others and how they could have more positive effects by changing Social liberation Notice public support realizing that society is supportive of the healthy behavior Self liberation Make a commitment believing in one s ability to change and making commitments and re commitments to act on that belief Helping relationships Get support finding people who are supportive of their change Counterconditioning Use substitutes substituting healthy ways of acting and thinking for unhealthy ways Reinforcement management Use rewards increasing the rewards that come from positive behavior and reducing those that come from negative behavior Stimulus control Manage your environment using reminders and cues that encourage healthy behavior and avoiding places that don t Health researchers have extended Prochaska s and DiClemente s 10 original processes of change by an additional 21 processes In the first edition of Planning Health Promotion Programs 24 Bartholomew et al 2006 summarised the processes that they identified in a number of studies 24 however their extended list of processes was removed from later editions of the text perhaps because the list mixes techniques with processes There are unlimited ways of applying processes The additional strategies of Bartholomew et al were 24 Risk comparison Understand the risks comparing risks with similar dimensional profiles dread control catastrophic potential and novelty Cumulative risk Get the overall picture processing cumulative probabilities instead of single incident probabilities Qualitative and quantitative risks Consider different factors processing different expressions of risk Positive framing Think positively focusing on success instead of failure framing Self examination relate to risk Be aware of your risks conducting an assessment of risk perception e g personalisation impact on others Reevaluation of outcomes Know the outcomes emphasising positive outcomes of alternative behaviours and reevaluating outcome expectancies Perception of benefits Focus on benefits perceiving advantages of the healthy behaviour and disadvantages of the risk behaviour Self efficacy and social support Get help mobilising social support skills training on coping with emotional disadvantages of change Decision making perspective Decide focusing on making the decision Tailoring on time horizons Set the time frame incorporating personal time horizons Focus on important factors Prioritise incorporating personal factors of highest importance Trying out new behaviour Try it changing something about oneself and gaining experience with that behaviour Persuasion of positive outcomes Persuade yourself promoting new positive outcome expectations and reinforcing existing ones Modelling Build scenarios showing models to overcome barriers effectively Skill improvement Build a supportive environment restructuring environments to contain important obvious and socially supported cues for the new behaviour Coping with barriers Plan to tackle barriers identifying barriers and planning solutions when facing these obstacles Goal setting Set goals setting specific and incremental goals Skills enhancement Adapt your strategies restructuring cues and social support anticipating and circumventing obstacles modifying goals Dealing with barriers Accept setbacks understanding that setbacks are normal and can be overcome Self rewards for success Reward yourself feeling good about progress reiterating positive consequences Coping skills Identify difficult situations identifying high risk situations selecting solutions practicing solutions coping with relapseWhile most of these processes and strategies are associated with health interventions such as stress management exercise healthy eating smoking cessation and other addictive behaviour 24 some of them are also used in other types of interventions such as travel interventions 25 Some processes are recommended in a specific stage while others can be used in one or more stages 1 Decisional balance Edit Main article Decisional balance sheet This core construct reflects the individual s relative weighing of the pros and cons of changing 11 nb 5 Decision making was conceptualized by Janis and Mann as a decisional balance sheet of comparative potential gains and losses 26 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 TTM research has found the following relationships between the pros cons and the stage of change across 48 behaviors and over 100 populations studied The cons of changing outweigh the pros in the Precontemplation stage The pros surpass the cons in the middle stages The pros outweigh the cons in the Action stage 27 The evaluation of pros and cons is part of the formation of decisional balance During the change process individuals gradually increase the pros and decrease the cons forming a more positive balance towards the target behaviour Attitudes are one of the core constructs explaining behaviour and behaviour change in various research domains 28 Other behaviour models such as the theory of planned behavior TPB 29 and the stage model of self regulated change 30 also emphasise attitude as an important determinant of behaviour The progression through the different stages of change is reflected in a gradual change in attitude before the individual acts Most of the processes of change aim at evaluating and reevaluating as well as reinforcing specific elements of the current and target behaviour Due to the use of decisional balance and attitude travel behaviour researchers have begun to combine the TTM with the TPB Forward 31 uses the TPB variables to better differentiate the different stages Especially all TPB variables attitude perceived behaviour control descriptive and subjective norm are positively show a gradually increasing relationship to stage of change for bike commuting As expected intention or willingness to perform the behaviour increases by stage 31 Similarly Bamberg 30 uses various behavior models including the transtheoretical model theory of planned behavior and norm activation model to build the stage model of self regulated behavior change SSBC Bamberg claims that his model is a solution to criticism raised towards the TTM 30 Some researchers in travel dietary and environmental research have conducted empirical studies showing that the SSBC might be a future path for TTM based research 30 32 33 Self efficacy Edit 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 11 nb 6 The construct is based on Bandura s self efficacy theory and conceptualizes a person s perceived ability to perform on a task as a mediator of performance on future tasks 34 35 In his research Bandura already established that greater levels of perceived self efficacy leads to greater changes in behavior 35 Similarly Ajzen mentions the similarity between the concepts of self efficacy and perceived behavioral control 36 This underlines the integrative nature of the transtheoretical model which combines various behavior theories 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 Levels of change Edit This core construct identifies the depth or complexity of presenting problems according to five levels of increasing complexity 1 4 Different therapeutic approaches have been recommended for each level as well as for each stage of change 1 10 The levels are Symptom situational problems e g motivational interviewing behavior therapy exposure therapy Current maladaptive cognitions e g Adlerian therapy cognitive therapy rational emotive therapy Current interpersonal conflicts e g Sullivanian therapy interpersonal therapy Family systems conflicts e g strategic therapy Bowenian therapy structural family therapy Long term intrapersonal conflicts e g psychoanalytic therapies existential therapy Gestalt therapyIn one empirical study of psychotherapy discontinuation published in 1999 measures of levels of change did not predict premature discontinuation of therapy 37 Nevertheless in 2005 the creators of the TTM stated that it is important that both therapists and clients agree as to which level they attribute the problem and at which level or levels they are willing to target as they work to change the problem behavior 1 152 Psychologist Donald Fromme in his book Systems of Psychotherapy adopted many ideas from the TTM but in place of the levels of change construct Fromme proposed a construct called contextual focus a spectrum from physiological microcontext to environmental macrocontext The horizontal contextual focus dimension resembles TTM s Levels of Change but emphasizes the breadth of an intervention rather than the latter s focus on intervention depth 4 57 Outcomes of programs EditThe outcomes of the TTM computerized tailored interventions administered to participants in pre Action stages are outlined below Stress management Edit A national sample of pre Action adults was provided a 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 statistically significant reductions in stress and depression and an increase in the use of stress management techniques when compared to the control group 38 Two additional clinical trials of TTM programs by Prochaska et al and Jordan et al also found significantly larger proportions of treatment groups effectively managing stress when compared to control groups 2 39 Adherence to antihypertensive medication Edit Over 1 000 members of a New England group practice who were prescribed antihypertensive medication participated in an adherence to antihypertensive medication intervention The vast majority 73 of the intervention group who were previously pre Action were adhering to their prescribed medication regimen at the 12 month follow up when compared to the control group 40 Adherence to lipid lowering drugs Edit Members of a large New England health plan and various employer groups who were prescribed a cholesterol lowering medication participated in an adherence to lipid lowering drugs intervention More than half of the intervention group 56 who were previously pre Action were adhering to their prescribed medication regimen at the 18 month follow up Additionally only 15 of those in the intervention group who were already in Action or Maintenance relapsed into poor medication adherence compared to 45 of the controls Further participants who were at risk for physical activity and unhealthy diet were given only stage based guidance The treatment group doubled the control group in the percentage in Action or Maintenance at 18 months for physical activity 43 and diet 25 41 Depression prevention Edit Participants were 350 primary care patients experiencing at least mild depression but not involved in treatment or planning to seek treatment for depression in the next 30 days Patients receiving the TTM intervention experienced significantly greater symptom reduction during the 9 month follow up period The intervention s largest effects were observed among patients with moderate or severe depression and who were in the Precontemplation or Contemplation stage of change at baseline For example among patients in the Precontemplation or Contemplation stage rates of reliable and clinically significant improvement in depression were 40 for treatment and 9 for control Among patients with mild depression or who were in the Action or Maintenance stage at baseline the intervention helped prevent disease progression to Major Depression during the follow up period 42 Weight management Edit Five hundred and seventy seven overweight or moderately obese adults BMI 25 39 9 were recruited nationally primarily from large employers Those randomly assigned to the treatment group received a stage matched multiple behavior change guide and a series of tailored individualized interventions for three health behaviors that are crucial to effective weight management healthy eating i e reducing calorie and dietary fat intake moderate exercise and managing emotional distress without eating Up to three tailored reports one per behavior were delivered based on assessments conducted at four time points baseline 3 6 and 9 months All participants were followed up at 6 12 and 24 months Multiple Imputation was used to estimate missing data Generalized Labor Estimating Equations GLEE were then used to examine differences between the treatment and comparison groups At 24 months those who were in a pre Action stage for healthy eating at baseline and received treatment were significantly more likely to have reached Action or Maintenance than the comparison group 47 5 vs 34 3 The intervention also impacted a related but untreated behavior fruit and vegetable consumption Over 48 of those in the treatment group in a pre Action stage at baseline progressed to Action or Maintenance for eating at least 5 servings a day of fruit and vegetables as opposed to 39 of the comparison group Individuals in the treatment group who were in a pre Action stage for exercise at baseline were also significantly more likely to reach Action or Maintenance 44 9 vs 38 1 The treatment also had a significant effect on managing emotional distress without eating with 49 7 of those in a pre Action stage at baseline moving to Action or Maintenance versus 30 3 of the comparison group The groups differed on weight lost at 24 months among those in a pre Action stage for healthy eating and exercise at baseline Among those in a pre Action stage for both healthy eating and exercise at baseline 30 of those randomized to the treatment group lost 5 or more of their body weight vs 16 6 in the comparison group Coaction of behavior change occurred and was much more pronounced in the treatment group with the treatment group losing significantly more than the comparison group This study demonstrates the ability of TTM based tailored feedback to improve healthy eating exercise managing emotional distress and weight on a population basis The treatment produced the highest population impact to date on multiple health risk behaviors 43 The effectiveness of the use of this model in weight management interventions including dietary or physical activity interventions or both and also combined with other interventions for overweight and obese adults was assessed in a 2014 systematic review 44 The results revealed that there is inconclusive evidence regarding the impact of these interventions on sustainable one year or longer weight loss However this approach may produce positive effects in physical activity and dietary habits such as increased in both exercise duration and frequency and fruits and vegetables consumption along with reduced dietary fat intake based on very low quality scientific evidence 44 Smoking cessation Edit Multiple studies have found individualized interventions tailored on the 14 TTM variables for smoking cessation to effectively recruit and retain pre Action participants and produce long term abstinence rates within the range of 22 26 These interventions have also consistently outperformed alternative interventions including best in class action oriented self help programs 45 non interactive manual based programs and other common interventions 46 47 Furthermore these interventions continued to move pre Action participants to abstinence even after the program ended 46 47 48 For a summary of smoking cessation clinical outcomes see Velicer Redding Sun amp Prochaska 2007 and Jordan Evers Spira King amp Lid 2013 39 49 Example for TTM application on smoke control Edit In the treatment of smoke control TTM focuses on each stage to monitor and to achieve a progression to the next stage 19 20 21 50 Stage Precontemplation Contemplation Preparation Action Maintenance Can Relapse to anearlier stageStandard time more than 6 months in the next 6 months in the next month now at least 6 months any timeAction and intervention not ready to quit or demoralized ambivalent intend to quit take action and quit sustained back to smokeRelated source Book newspaper friend Book newspaper friend doctor nurse friend doctor nurse friend friend family temptation stress distressIn each stage a patient may have multiple sources that could influence their behavior These may include friends books and interactions with their healthcare providers These factors could potentially influence how successful a patient may be in moving through the different stages This stresses the importance to have continuous monitoring and efforts to maintain progress at each stage TTM helps guide the treatment process at each stage and may assist the healthcare provider in making an optimal therapeutic decision Travel research Edit The use of TTM in travel behaviour interventions is rather novel A number of cross sectional studies investigated the individual constructs of TTM e g stage of change decisional balance and self efficacy with regards to transport mode choice The cross sectional studies identified both motivators and barriers at the different stages regarding biking walking and public transport 51 52 53 54 The motivators identified were e g liking to bike walk avoiding congestion and improved fitness Perceived barriers were e g personal fitness time and the weather This knowledge was used to design interventions that would address attitudes and misconceptions to encourage an increased use of bikes and walking These interventions aim at changing people s travel behaviour towards more sustainable and more active transport modes In health related studies TTM is used to help people walk or bike more instead of using the car 51 55 56 57 58 59 Most intervention studies aim to reduce car trips for commute to achieve the minimum recommended physical activity levels of 30 minutes per day 51 Other intervention studies using TTM aim to encourage sustainable behaviour 60 61 62 By reducing single occupied motor vehicle and replacing them with so called sustainable transport public transport car pooling biking or walking greenhouse gas emissions can be reduced considerably A reduction in the number of cars on our roads solves other problems such as congestion traffic noise and traffic accidents By combining health and environment related purposes the message becomes stronger Additionally by emphasising personal health physical activity or even direct economic impact people see a direct result from their changed behaviour while saving the environment is a more general and effects are not directly noticeable 63 54 64 Different outcome measures were used to assess the effectiveness of the intervention Health centred intervention studies measured BMI weight waist circumference as well as general health However only one of three found a significant change in general health while BMI and other measures had no effect 51 Measures that are associated with both health and sustainability were more common Effects were reported as number of car trips distance travelled main mode share etc Results varied due to greatly differing approaches In general car use could be reduced between 6 and 55 while use of the alternative mode walking biking and or public transport increased between 11 and 150 25 These results indicate a shift to action or maintenance stage some researchers investigated attitude shifts such as the willingness to change Attitudes towards using alternative modes improved with approximately 20 to 70 25 Many of the intervention studies did not clearly differentiate between the five stages but categorised participants in pre action and action stage This approach makes it difficult to assess the effects per stage Also interventions included different processes of change in many cases these processes are not matched to the recommended stage 25 It highlights the need to develop a standardised approach for travel intervention design Identifying and assessing which processes are most effective in the context of travel behaviour change should be a priority in the future in order to secure the role of TTM in travel behaviour research Criticisms EditThe TTM has been called arguably the dominant model of health behaviour change having received unprecedented research attention yet it has simultaneously attracted criticism 9 Depending on the field of application e g smoking cessation substance abuse condom use diabetes treatment obesity and travel somewhat different criticisms have been raised In a systematic review published in 2003 of 23 randomized controlled trials the authors found that stage based interventions are no more effective than non stage based interventions or no intervention in changing smoking behaviour 65 However it was also mentioned that stage based interventions are often used and implemented inadequately in practice Thus criticism is directed towards the use rather the effectiveness of the model itself Looking at interventions targeting smoking cessation in pregnancy found that stage matched interventions were more effective than non matched interventions One reason for this was the greater intensity of stage matched interventions 66 Also the use of stage based interventions for smoking cessation in mental illness proved to be effective 67 Further studies e g a randomized controlled trial published in 2009 found no evidence that a TTM based smoking cessation intervention was more effective than a control intervention not tailored to stage of change The study claims that those not wanting to change i e precontemplators tend to be responsive to neither stage nor non stage based interventions Since stage based interventions tend to be more intensive they appear to be most effective at targeting contemplators and above rather than pre contemplators 68 A 2010 systematic review of smoking cessation studies under the auspices of the Cochrane Collaboration found that stage based self help interventions expert systems and or tailored materials and individual counselling were neither more nor less effective than their non stage based equivalents 69 Main criticism is raised regarding the arbitrary dividing lines that are drawn between the stages West claimed that a more coherent and distinguishable definition for the stages is needed 13 Especially the fact that the stages are bound to a specific time interval is perceived to be misleading Additionally the effectiveness of stage based interventions differs depending on the behavior A continuous version of the model has been proposed where each process is first increasingly used and then decreases in importance as smokers make progress along some latent dimension 70 This proposal suggests the use of processes without reference to stages of change West claimed that the model assumes that individuals typically make coherent and stable plans when in fact they often do not 13 However the model does not require that all people make a plan for example the SAMSHA document Enhancing Motivation for Change in Substance Use Disorder Treatment which uses the TTM also says Don t assume that all clients need a structured method to develop a change plan Many people can make significant lifestyle changes and initiate recovery from SUDs without formal assistance 71 Within research on prevention of pregnancy and sexually transmitted diseases a systematic review from 2003 comes to the conclusion that no strong conclusions can be drawn about the effectiveness of interventions based on the transtheoretical model 72 Again this conclusion is reached due to the inconsistency of use and implementation of the model 72 This study also confirms that the better stage matched the intervention the more effect it has to encourage condom use 72 Within the health research domain a 2005 systematic review of 37 randomized controlled trials claims that there was limited evidence for the effectiveness of stage based interventions as a basis for behavior change 73 Studies with which focused on increasing physical activity levels through active commute however showed that stage matched interventions tended to have slightly more effect than non stage matched interventions 56 Since many studies do not use all constructs of the TTM additional research suggested that the effectiveness of interventions increases the better it is tailored on all core constructs of the TTM in addition to stage of change 74 In diabetes research the existing data are insufficient for drawing conclusions on the benefits of the transtheoretical model as related to dietary interventions Again studies with slightly different design e g using different processes proved to be effective in predicting the stage transition of intention to exercise in relation to treating patients with diabetes 75 TTM has generally found a greater popularity regarding research on physical activity due to the increasing problems associated with unhealthy diets and sedentary living e g obesity cardiovascular problems 76 A 2011 Cochrane Systematic Review found that there is little evidence to suggest that using the transtheoretical model stages of change TTM SOC method is effective in helping obese and overweight people lose weight citation needed There were only five studies in the review two of which were later dropped due to not being relevant since they did not measure weight Earlier in a 2009 paper the TTM was considered to be useful in promoting physical activity 77 In this study the algorithms and questionnaires that researchers used to assign people to stages of change lacked standardisation to be compared empirically or validated 13 Similar criticism regarding the standardisation as well as consistency in the use of TTM is also raised in a recent review on travel interventions 25 With regard to travel interventions only stages of change and sometimes decisional balance constructs are included The processes used to build the intervention are rarely stage matched and short cuts are taken by classifying participants in a pre action stage which summarises the precontemplation contemplation and preparation stage and an action maintenance stage 25 More generally TTM has been criticised within various domains due to the limitations in the research designs For example many studies supporting the model have been cross sectional but longitudinal study data would allow for stronger causal inferences Another point of criticism is raised in a 2002 review where the model s stages were characterized as not mutually exclusive 78 Furthermore there was scant evidence of sequential movement through discrete stages 78 While research suggests that movement through the stages of change is not always linear a study of smoking cessation conducted in 1996 demonstrated that the probability of forward stage movement is greater than the probability of backward stage movement 79 Due to the variations in use implementation and type of research designs data confirming TTM are ambiguous More care has to be taken in using a sufficient amount of constructs trustworthy measures and longitudinal data 25 See also EditChange management Decision cycleNotes EditThe following notes summarize major differences between the well known 1983 80 1992 81 and 1997 11 versions of the model Other published versions may contain other differences For example Prochaska Prochaska and Levesque 2001 17 do not mention the Termination stage Self efficacy or Temptation In the 1983 version of the model the Preparation stage is absent 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 In the 1983 version of the model Relapse is considered one of the five stages of change In the 1983 version of the model the processes of change were said to be emphasized in only the Contemplation Action and Maintenance stages 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 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 References Edit a b c d e f g h Prochaska James O DiClemente Carlo C 2005 The transtheoretical approach In Norcross John C Goldfried Marvin R eds Handbook of psychotherapy integration Oxford series in clinical psychology 2nd ed Oxford New York Oxford University Press pp 147 171 ISBN 978 0195165791 OCLC 54803644 a b Prochaska James O Butterworth Susan Redding Colleen A Burden Verna Perrin Nancy Leo Michael Flaherty Robb Marna Prochaska Janice M March 2008 Initial efficacy of MI TTM tailoring and HRI s with multiple behaviors for employee health promotion Preventive Medicine 46 3 226 231 doi 10 1016 j ypmed 2007 11 007 PMC 3384542 PMID 18155287 For example Greene GW Rossi SR Rossi JS Velicer WF Fava JL Prochaska JO June 1999 Dietary applications of the stages of change model Journal of the American Dietetic Association 99 6 673 8 doi 10 1016 S0002 8223 99 00164 9 PMID 10361528 a b c Fromme Donald K 2011 Systems of psychotherapy dialectical tensions and integration New York Springer Verlag pp 34 36 doi 10 1007 978 1 4419 7308 5 ISBN 9781441973078 OCLC 696327398 a b Prochaska James O Norcross John C DiClemente Carlo C 1994 Changing for good the revolutionary program that explains the six stages of change and teaches you how to free yourself from bad habits 1st ed New York William Morrow and Company ISBN 978 0688112639 OCLC 29429279 Norcross John C Loberg Kristin Norcross Jonathon 2012 Changeology 5 steps to realizing your goals and resolutions New York Simon amp Schuster ISBN 9781451657616 OCLC 779265892 Prochaska James O Prochaska Janice M 2016 Changing to thrive using the stages of change to overcome the top threats to your health and happiness Center City MN Hazelden ISBN 9781616496296 OCLC 956501910 Examples of articles in the news media include Goleman Daniel 1 September 1993 New addiction approach gets results The New York Times p C10 Retrieved 19 March 2009 Miller Kay 29 December 2001 Revolving resolutions Year after new year we vow to lose weight stop smoking find love or a better job only to fail A few simple strategies could set us straight Star Tribune p 1E Stettner Morey 19 December 2005 A methodical way to change bad behavior Investor s Business Daily p A11 Why it s hard to change unhealthy behavior and why you should keep trying Harvard Women s Health Watch Vol 14 no 5 Harvard Health Publishing January 2007 pp 4 5 PMID 17304698 Understanding change expect a few bumps The Washington Post 2 January 2007 Retrieved 19 March 2009 Carbine Michael E 6 March 2009 Health plans use a variety of strategies to identify and ensure compliance among diabetics AIS s Health Business Daily Archived from the original on 2009 06 01 Retrieved 19 March 2009 Why behavior change is hard and why you should keep trying Harvard Women s Health Watch Vol 19 no 7 Harvard Health Publishing March 2012 pp 4 5 PMID 22550732 Gropper Michael 23 June 2015 Overcoming your psychological inertia The Jerusalem Post p Features 25 Retrieved 18 February 2021 Wu Fiona 21 February 2020 Get psyched starting fresh The Vanderbilt Hustler Retrieved 18 February 2021 a b Armitage Christopher J 2009 05 01 Is there utility in the transtheoretical model British Journal of Health Psychology 14 Pt 2 195 210 doi 10 1348 135910708X368991 ISSN 1359 107X PMID 18922209 a b Prochaska James O Norcross John C 2014 1979 Systems of psychotherapy a transtheoretical analysis 8th ed Australia Stamford CT Cengage Learning ISBN 9781133314516 OCLC 851089001 a b c d e f g h Prochaska JO Velicer WF The transtheoretical model of health behavior change Archived 2010 06 02 at the Wayback Machine Am J Health Promot 1997 Sep Oct 12 1 38 48 Accessed 2009 Mar 18 Prochaska JO Velicer WF 1997 The transtheoretical model of health behavior change American Journal of Health Promotion 12 1 38 48 doi 10 4278 0890 1171 12 1 38 PMID 10170434 S2CID 46879746 a b c d West Robert August 2005 Time for a change putting the Transtheoretical Stages of Change Model to rest Addiction 100 8 1036 1039 doi 10 1111 j 1360 0443 2005 01139 x PMID 16042624 See also the responses to West in the same issue doi 10 1111 add 2005 100 issue 8 Rogers Everett M 2003 1962 Diffusion of innovations 5th ed New York Free Press pp 198 201 ISBN 978 0743222099 OCLC 52030797 Prochaska JO Velicer WF Rossi JS Goldstein MG Marcus BH et al Stages of change and decisional balance for 12 problem behaviors Archived 2011 06 06 at the Wayback Machine Health Psychol 1994 Jan 13 1 39 46 Accessed 2009 Mar 18 Prochaska JO Velicer WF DiClemente CC Fava J Aug 1988 Measuring processes of change applications to the cessation of smoking Journal of Consulting and Clinical Psychology 56 4 520 8 doi 10 1037 0022 006X 56 4 520 PMID 3198809 a b Prochaska Janice M Prochaska James O Levesque Deborah A 2001 A transtheoretical approach to changing organizations Administration and Policy in Mental Health 28 4 247 261 doi 10 1023 A 1011155212811 PMID 11577653 S2CID 23075352 McConnaughy EA Prochaska JO Velicer WF 1983 Stages of change in psychotherapy measurement and sample profiles Psychotherapy Theory Research amp Practice 20 3 368 375 doi 10 1037 h0090198 a b DiClemente CC Prochaska JO Gibertini M Self efficacy and the stages of self change of smoking Cognit Ther Res 1985 9 2 181 200 Accessed 2009 Mar 22 a b Velicer WF DiClemente CC Prochaska JO Brandenburg N May 1985 Decisional balance measure for assessing and predicting smoking status PDF Journal of Personality and Social Psychology 48 5 1279 89 doi 10 1037 0022 3514 48 5 1279 PMID 3998990 a b Velicer WF Prochaska JO Rossi JS Snow MG Jan 1992 Assessing outcome in smoking cessation studies Psychological Bulletin 111 1 23 41 doi 10 1037 0033 2909 111 1 23 PMID 1539088 Prochaska James O DiClemente Carlo C Velicer Wayne F Rossi Joseph S September 1993 Standardized individualized interactive and personalized self help programs for smoking cessation Health Psychology 12 5 399 405 doi 10 1037 0278 6133 12 5 399 PMID 8223364 Prochaska JO Redding CA Evers KE The Transtheoretical Model and Stages of Change In Glanz K Rimer BK Viswanath K eds Health Behavior and Health Education 4th ed San Francisco Jossey Bass 2008 p 105 ISBN 978 0 7879 9614 7 a b c d Bartholomew L K K Parcel G S S Kok G Gottlieb N H H 2006 Planning Health Promotion Programs An Intervention Mapping Approach 1st ed San Francisco Jossey Bass a b c d e f g Friman M Huck J Olsson L 2017 Transtheoretical Model of Change during Travel Behavior Interventions An Integrative Review International Journal of Environmental Research and Public Health 14 6 581 596 doi 10 3390 ijerph14060581 PMC 5486267 PMID 28556810 Janis I L amp Mann L 1977 Decision making a psychological analysis of conflict choice and commitment New York Free Press ISBN 0 02 916160 6 Hall K L Rossi J S 2008 Meta analysis Examination of the sting and weak principals across 48 behaviors Preventive Medicine 46 3 266 274 doi 10 1016 j ypmed 2007 11 006 PMID 18242667 Bagozzi R P Yi Y 1989 The degree of intention formation as a moderator of the attitude behavior relationship Social Psychology Quarterly 52 4 266 279 doi 10 2307 2786991 JSTOR 2786991 Ajzen I 1991 The theory of planned behavior Organizational Behavior and Human Decision Processes 50 2 179 211 doi 10 1016 0749 5978 91 90020 t a b c d Bamberg S 2013 Changing environmentally harmful behaviors A stage model of self regulated behavioral change Journal of Environmental Psychology 34 151 159 doi 10 1016 j jenvp 2013 01 002 a b Forward S E 2014 Exploring people s willingness to bike using a combination of the theory of planned behavioural and the transtheoretical model European Review of Applied Psychology 64 3 151 159 doi 10 1016 j erap 2014 04 002 Klockner C A 2017 A stage model as an analysis framework for studying voluntary change in food choices The case of beef consumption reduction in Norway Appetite 108 434 449 doi 10 1016 j appet 2016 11 002 PMID 27818301 S2CID 3656567 Klockner C A Nayum A 2016 Specific barriers and drivers in different stages of decision making about energy efficiency upgrades in private homes Frontiers in Psychology 7 1362 doi 10 3389 fpsyg 2016 01362 PMC 5014904 PMID 27660618 Prochaska J O Velicer W F 1997 The transtheoretical model of health behavior change American Journal of Health Promotion 12 1 38 48 doi 10 4278 0890 1171 12 1 38 PMID 10170434 S2CID 46879746 a b Bandura A 1977 Self efficacy toward a unifying theory of behavioral change Psychological Review 84 2 191 216 doi 10 1037 0033 295x 84 2 191 PMID 847061 Ajzen I 2002 Perceived behavioral control self efficacy locus of control and the theory of planned behavior Journal of Applied Social Psychology 32 4 665 683 doi 10 1111 j 1559 1816 2002 tb00236 x Brogan Mary M Prochaska James O Prochaska Janice M 1999 Predicting termination and continuation status in psychotherapy using the transtheoretical model Psychotherapy Theory Research Practice Training 36 2 105 113 doi 10 1037 h0087773 Evers K E Prochaska J O Johnson J L Mauriello L M Padula J A Prochaska J M 2006 A randomized clinical trial of a population and transtheoretical model based stress management intervention Health Psychology 25 4 521 529 doi 10 1037 0278 6133 25 4 521 PMID 16846327 a b Jordan P J Evers K E Spira J L King L A amp Lid V 2013 Computerized tailored interventions improve outcomes and reduce barriers to care Poster presented at the 17th Annual International meeting and Exposition of the American Telemedicine Association in Austin TX May 5 7 2013 Johnson S S Driskell M M Johnson J L Prochaska J M Zwick W Prochaska J O 2006b Efficacy of a transtheoretical model based expert system for antihypertensive adherence Disease Management 9 5 291 301 doi 10 1089 dis 2006 9 291 PMID 17044763 Johnson S S Driskell M M Johnson J L Dyment S J Prochaska J O Prochaska J M et al 2006a Transtheoretical model intervention for adherence to lipid lowering drugs Disease Management 9 2 102 114 doi 10 1089 dis 2006 9 102 PMID 16620196 Levesque D A Van Marter D F Schneider R J Bauer M R Goldberg D N Prochaska J O Prochaska J M 2011 Randomized trial of a computer tailored intervention for patients with depression American Journal of Health Promotion 26 2 77 89 doi 10 4278 ajhp 090123 quan 27 PMID 22040388 S2CID 207525699 Johnson S S Paiva A L Cummins C O Johnson J L Dyment S J Wright J A Prochaska J O Prochaska J M Sherman K 2008 Transtheoretical model based multiple behavior intervention for weight management Effectiveness on a population basis Preventive Medicine 46 3 238 246 doi 10 1016 j ypmed 2007 09 010 PMC 2327253 PMID 18055007 a b Mastellos Nikolaos Gunn Laura H Felix Lambert M Car Josip Majeed Azeem 2014 02 05 Transtheoretical model stages of change for dietary and physical exercise modification in weight loss management for overweight and obese adults Cochrane Database of Systematic Reviews 2 CD008066 doi 10 1002 14651858 cd008066 pub3 ISSN 1465 1858 PMID 24500864 Prochaska J O DiClemente C C Velicer W F Rossi J S 1993 Standardized individualized interactive and personalized self help programs for smoking cessation Health Psychology 12 5 399 405 doi 10 1037 0278 6133 12 5 399 PMID 8223364 a b Prochaska J O Velicer W F Fava J L Ruggiero L Laforge R G Rossi J S et al 2001a Counselor and stimulus control enhancements of a stage matched expert system intervention for smokers in a managed care setting Preventive Medicine 32 1 23 32 doi 10 1006 pmed 2000 0767 PMID 11162323 a b Prochaska J O Velicer W F Fava J L Rossi J S Tsoh J Y 2001b Evaluating a population based recruitment approach and a stage based expert system intervention for smoking cessation Addictive Behaviors 26 4 583 602 doi 10 1016 s0306 4603 00 00151 9 PMID 11456079 S2CID 13568299 Velicer Wayne F Fava Joseph L Prochaska James O Abrams David B Emmons Karen M Pierce John P July 1995 Distribution of smokers by stage in three representative samples Preventive Medicine 24 4 401 411 doi 10 1006 pmed 1995 1065 PMID 7479632 Velicer W F Redding C A Sun X Prochaska J O 2007 Demographic variables smoking variables and outcome across five studies Health Psychology 26 3 278 287 doi 10 1037 0278 6133 26 3 278 PMID 17500614 Prochaska JO DiClemente CC Velicer WF Rossi JS Standardized individualized interactive and personalized self help programs for smoking cessation Archived 2011 06 06 at the Wayback Machine Health Psychol 1993 Sep 12 5 399 405 Accessed 2009 March 18 a b c d Mutrie N Carney C Blamey A Crawford F Aitchison T Whitelaw A 2002 Walk in to work out A randomised controlled trial of a self help intervention to promote active commuting Journal of Epidemiology and Community Health 56 6 407 412 doi 10 1136 jech 56 6 407 PMC 1732165 PMID 12011193 van Bekkum J E Williams J M Graham Morris P 2011 Cycle commuting and perceptions of barriers stages of change gender and occupation PDF Health Education 111 6 476 497 doi 10 1108 09654281111180472 hdl 20 500 11820 04647e05 7246 4c69 b80a 0d610f43a385 Crawford F Mutrie N Hanlon P 2001 Employee attitudes towards active commuting International Journal of Health Promotion and Education 39 14 20 doi 10 1080 14635240 2001 10806142 S2CID 167880702 a b Mundorf Norbert Redding Colleen A Fu Tat Paiva Andrea Brick Leslie Prochaska James O 2015 2013 Promoting sustainable transportation across campus communities using the transtheoretical model of change 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Bicycling to university Evaluation of a bicycle sharing program in spain Health Promotion International 30 2 350 358 doi 10 1093 heapro dat045 PMID 23813668 Wen L M Orr N Bindon J Rissel C 2005 Promoting active transport in a workplace setting Evaluation of a pilot study in Australia Health Promotion International 20 2 123 133 doi 10 1093 heapro dah602 PMID 15722366 Rose G Marfurt H 2007 Travel behaviour change impacts of a major ride to work day event Transportation Research Part A Policy and Practice 41 4 351 364 doi 10 1016 j tra 2006 10 001 Gatersleben B Appleton K M 2007 Contemplating cycling to work Attitudes and perceptions in different stages of change Transportation Research Part A Policy and Practice 41 4 302 312 doi 10 1016 j tra 2006 09 002 Meloni I Sanjust B Sottile E Cherchi 2013 Propensity for Voluntary Travel Behavior Changes An Experimental Analysis Procedia Social and Behavioral Sciences 87 31 43 doi 10 1016 j sbspro 2013 10 592 Cooper C 2007 Successfully changing individual travel behavior Transportation Research Record 2021 89 99 doi 10 3141 2021 11 S2CID 109283569 Rissel C E New C Wen L M Merom D Bauman A E Garrard J 2010 The effectiveness of community based cycling promotion Findings from the cycling connecting communities project in Sydney Australia International Journal of Behavioral Nutrition and Physical Activity 7 1 1 8 doi 10 1186 1479 5868 7 8 PMC 2828973 PMID 20181019 Riemsma Robert Paul Pattenden Jill Bridle Christopher Sowden Amanda J Mather Lisa Watt Ian S Walker Anne May 2003 Systematic review of the effectiveness of stage based interventions to promote smoking cessation BMJ 326 7400 1175 1177 doi 10 1136 bmj 326 7400 1175 PMC 156457 PMID 12775617 Aveyard Paul Lawrence Terry Cheng K K Griffin Carl Croghan Emma Johnson Carol May 2006 A randomized controlled trial of smoking cessation for pregnant women to test the effect of a transtheoretical model based intervention on movement in stage and interaction with baseline stage British Journal of Health Psychology 11 Pt 2 263 278 doi 10 1348 135910705X52534 PMID 16643698 Hall Sharon M Tsoh Janice Y Prochaska Judith J Eisendrath Stuart Rossi Joseph S Redding Colleen A Rosen Amy B Meisner Marc Humfleet Gary L Gorecki Julie A October 2006 Treatment for cigarette smoking among depressed mental health outpatients a randomized clinical trial American Journal of Public Health 96 10 1808 1814 doi 10 2105 AJPH 2005 080382 PMC 1586139 PMID 17008577 Aveyard P Massey L Parsons A Manaseki S Griffin C Feb 2009 The effect of transtheoretical model based interventions on smoking cessation Social Science amp Medicine 68 3 397 403 doi 10 1016 j socscimed 2008 10 036 PMID 19038483 Cahill K Lancaster T Green N 2010 Stage based interventions for smoking cessation Cochrane Database of Systematic Reviews 11 11 CD004492 doi 10 1002 14651858 CD004492 pub4 PMID 21069681 Noel Yvonnick June 1999 Recovering unimodal latent patterns of change by unfolding analysis application to smoking cessation Psychological Methods 4 2 173 191 doi 10 1037 1082 989X 4 2 173 Enhancing motivation for change in substance abuse treatment Treatment improvement protocol TIP series Vol 35 2019 ed Rockville MD U S Dept of Health and Human Services Substance Abuse and Mental Health Services Administration 2019 PMID 34106565 a b c Horowitz Stephen M June 2003 Applying the transtheoretical model to pregnancy and STD prevention a review of the literature American Journal of Health Promotion 17 5 304 328 doi 10 4278 0890 1171 17 5 304 PMID 12769045 S2CID 22672316 Bridle Christopher Riemsma Robert Paul Pattenden Jill Sowden Amanda J Mather Lisa Watt Ian S Walker A June 2005 Systematic review of the effectiveness of health behavior interventions based on the transtheoretical model Psychology amp Health 20 3 283 301 doi 10 1080 08870440512331333997 S2CID 42170484 Prochaska JO Jun 2006 Moving beyond the transtheoretical model Addiction 101 6 768 74 doi 10 1111 j 1360 0443 2006 01404 x PMID 16696617 Kirk A MacMillan F Webster N 2010 Application of the Transtheoretical model to physical activity in older adults with Type 2 diabetes and or cardiovascular disease Psychology of Sport and Exercise 11 4 320 324 doi 10 1016 j psychsport 2010 03 001 Spencer L Adams T B Malone S Roy L Yost E 2006 Applying the transtheoretical model to exercise a systematic and comprehensive review of the literature Health Promotion Practice 7 4 428 443 doi 10 1177 1524839905278900 PMID 16840769 S2CID 8922808 Sallis JF Glanz K 2009 Physical activity and food environments solutions to the obesity epidemic Milbank Quarterly 87 1 123 54 doi 10 1111 j 1468 0009 2009 00550 x PMC 2879180 PMID 19298418 a b Littell Julia H Girvin Heather April 2002 Stages of change a critique Behavior Modification 26 2 223 273 doi 10 1177 0145445502026002006 PMID 11961914 S2CID 34392875 Martin R Velicer WF Fava JL 1996 Latent transition analysis to the stages of change for smoking cessation Addictive Behaviors 21 1 67 80 doi 10 1016 0306 4603 95 00037 2 PMID 8729709 Prochaska JO DiClemente CC Stages and processes of self change of smoking toward an integrative model of change Archived 2011 06 06 at the Wayback Machine J Consult Clin Psychol 1983 Jun 51 3 390 5 Accessed 2009 Mar 18 Prochaska JO DiClemente CC Norcross JC In search of how people change Applications to addictive behaviors Archived 2008 07 23 at the Wayback Machine Am Psychol 1992 Sep 47 9 1102 14 Accessed 2009 Mar 16 Further reading EditProchaska JO DiClemente CC The transtheoretical approach crossing traditional boundaries of therapy Homewood IL Dow Jones Irwin 1984 ISBN 0 87094 438 X Miller WR Heather N eds Treating addictive behaviors 2nd ed New York Plenum Press 1998 ISBN 0 306 45852 7 Velasquez MM Group treatment for substance abuse a stages of change therapy manual New York Guilford Press 2001 ISBN 1 57230 625 4 Burbank PM Riebe D Promoting exercise and behavior change in older adults interventions with the transtheoretical model New York Springer 2002 ISBN 0 8261 1502 0 Prochaska J O amp Norcross J C 2002 Stages of change In J C Norcross Ed Psychotherapy relationships that work 303 313 New York Oxford University Press DiClemente CC Addiction and change how addictions develop and addicted people recover New York Guilford Press 2003 ISBN 1 57230 057 4 Glanz K Rimer BK Viswanath K eds Health behavior and health education theory research and practice 4th ed San Francisco CA Jossey Bass 2008 ISBN 978 0 7879 9614 7 Prochaska J O Wright J A Velicer W F 2008 Evaluating Theories of Health Behavior Change A hierarchy of Criteria Applied to the Transtheoretical Model Applied Psychology 57 4 561 588 doi 10 1111 j 1464 0597 2008 00345 x Patterson D A Buckingham S L 2010 Does motivational interviewing stages of change increase treatment retention among persons who are alcohol and other drug dependant and HIV infected Journal of HIV AIDS and Social Services 9 1 45 57 doi 10 1080 15381500903584346 S2CID 57341833 Patterson D A Nochajski T H 2010 Using the Stages of change model to help clients through the 12 steps of Alcoholics Anonymous Journal of Social Work Practice in the Addictions 10 2 224 227 doi 10 1080 15332561003730262 PMC 3520431 PMID 23243392 Connors GJ Donovan DM DiClemente CC Substance abuse treatment and the stages of change selecting and planning interventions 2nd ed New York Guilford Press 2013 ISBN 978 1 4625 0804 4 Prochaska JO Norcross JC Systems of psychotherapy a transtheoretical analysis 9th ed New York Oxford University Press 2018 ISBN 978 0 1908 8041 5 External links Edit Wikiversity has learning resources about Public health Pro Change Behavior Systems Inc Company founded by James O Prochaska Mission is to enhance the well being of individuals and organizations through the scientific development and dissemination of Transtheoretical Model based change management programs Retrieved from https en wikipedia org w index php title Transtheoretical model amp oldid 1130517042, wikipedia, wiki, book, 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