Transtheoretical model

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]

• 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.^[12]

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.^[13]

Details of each stage

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][14][15][16][17]}

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.

During this stage, participants envision 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 benefit by seeking support from friends they trust, telling people about their plan to change the way they act, and thinking about how they would feel if they behaved in a healthier way. A prominent concern is that if they act they will 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)^{[18][19][20][21]}

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

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.^[22]

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]: 149

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,^[23] Bartholomew et al. (2001) summarised the processes that they identified in a number of studies;^[23] 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:^[23]

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,^[23] some of them are also used in other types of interventions such as travel interventions.^[24] 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.^[25] 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.^[26]

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.^{[citation needed]}

• 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.^[31]

Due to the use of decisional balance and attitude, travel behaviour researchers have begun to combine the TTM with the TPB. Forward^[32] 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.^[32] 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][33][34]

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.^[11][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.^[37][38] Situational temptations assess how tempted people are to engage in a problem behavior in a certain situation.^[37][38]

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.^[39] 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

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.^[40] 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][41]

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.^[42]

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%).^[43]

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.^[44]

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.^[45]

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.^[46] 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.^[46]

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,^[47] non-interactive manual-based programs, and other common interventions.^[48][49] Furthermore, these interventions continued to move pre-Action participants to abstinence even after the program ended.^[48][49][50] For a summary of smoking cessation clinical outcomes, see Velicer, Redding, Sun, & Prochaska, 2007 and Jordan, Evers, Spira, King & Lid, 2013.^[41][51]

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.^{[54][55][56][57]} 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.^{[54][58][59][60][61][62]} Most intervention studies aim to reduce car trips for commute to achieve the minimum recommended physical activity levels of 30 minutes per day.^[54] Other intervention studies using TTM aim to encourage sustainable behaviour.^[63][64][65] 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.^[66][57][67]

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.^[54] 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%.^[24] 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%.^[24] 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.^[24] It highlights the need to develop a standardised approach for travel intervention design.