The transtheoretical model posits that health action change involves improvement through six levels of change: precontemplation, contemplation, prep, action, maintenance, and termination. Ten functions of change have been determined for producing improvement along with decisional balance, self-efficacy, and temptations.
Basic research has made a guideline for at-risk populations: 40% in precontemplation, 40% in contemplation, and 20% in preparation. Across 12 health behaviours, consistent habits have been found between your pros and cons of changing and the stages of change. Applied research has proven dramatic advancements in recruitment, retention, and improvement using stage-matched interventions and proactive recruitment types of procedures.
The most promising outcomes to data have been found with computer-based individualized and interactive interventions. The best promising improvement to the computer-based programs are customized counselors. One of the most striking results to particular date for stage-matched programs is the similarity between participants reactively recruited who reached us for help and those proactively recruited who we come to out to help.
If results with stage-matched interventions continue being replicated, health promotion programs can produce unprecedented impacts on entire at-risk populations.
The paper will discuss at size the various phases of the model, the limitations of the model that impact the way it is implemented practically by medical practitioners and end with concluding remarks about the comparative effectiveness of the data.
Development of the Model
This can be an overview of the Transtheoretical Model of Change, a theoretical style of behavior change, which has been the basis for growing effective interventions to promote health behavior change. The Transtheoretical Model (Prochaska & DiClemente, 1983; Prochaska, DiClemente, & Norcross, 1992; Prochaska & Velicer, 1997) can be an integrative model of patterns change.
The Transtheoretical model happens to be conceptualized in conditions of several major proportions. The center constructs, around that your other measurements are planned, is the periods of change. These represent purchased categories along a continuum of motivational readiness to change a problem habit. Transitions between the periods of change are effected by a set of independent parameters known as the procedures of change.
The model also incorporates some intervening or outcome variables. Included in these are decisional balance (the pros and drawbacks of change), self-efficacy (self confidence in the ability to change across problem situations), situational temptations to engage in the problem behavior, and behaviors which can be specific to the challenge area.
Also included among these intermediate or based mostly parameters would be some other psychological, environmental, ethnic, socioeconomic, physiological, biochemical, or even hereditary variables or behavior specific to the challenge being examined.
Key constructs from other ideas are integrated. The model represents how people modify a problem behavior or acquire a positive patterns. The central managing build of the model is the Periods of Change.
The model also includes some independent factors, the Techniques of Change, and a series of outcome measures, including the Decisional Balance and the Enticement scales. The Procedures of Change are ten cognitive and behavior activities that accomplish change.
The Transtheoretical Model is a style of intentional change. It really is a model that focuses on the decision making of the individual. Other approaches to health promotion have focused mainly on social influences on action or on biological influences on action.
The stage build is the key organizing construct of the model. It is important in part because it symbolizes a temporal dimension. Change means phenomena occurring as time passes. However, this aspect was essentially ignored by alternate theories of change. Behavior change was often construed as a meeting, such as quitting smoking, drinking alcohol, or over-eating. The Transtheoretical Model construes change as a process involving progress through some five levels.
Precontemplation, the first stage, is the level where people aren't intending to take action later on, usually measured as another six months. People may be at this stage because they are uninformed or under-informed about the results of their action.
Or they could have tried to change a number of times and be demoralized about their potential to change. Both groups have a tendency to avoid reading, talking or considering their high risk behaviors. They are often characterized in other ideas as immune or unmotivated or as not ready for health campaign programs.
The simple truth is traditional health campaign programs tend to be not designed for such individuals and are not matched to their needs.
Contemplation, the second level, is the stage in which people are intending to change in the next six months. They can be more aware of the pros of changing but are also acutely alert to the negative aspects.
This balance between your costs and benefits of changing can produce profound ambivalence that will keep people stuck in this stage for long periods of time. This can often be characterized by occurrence such as chronic contemplation or behavioral procrastination. These folks are also not ready for traditional action focused programs.
Preparation, the 3rd level of the model, is the stage in which people are intending to take action in the immediate future, usually assessed as another month. They have typically considered some significant action in the past year.
These people have a plan of action, such as joining a health education class, consulting with a counselor, talking to their physician, buying a self-help booklet or relying on a self-change approach. These are the individuals who should be recruited for action- oriented smoking cessation, weight reduction, or exercise programs.
Action, the fourth and considered by many to be the main stage in which people have made specific overt alterations in their life-styles within days gone by half a year. Since action is observable, patterns change often has been equated with action. But in the Transtheoretical Model, Action is merely one of five phases.
Not all changes of behavior count number as action in this model. People must attain a criterion that experts and professionals recognize is sufficient to reduce risks for disease. In smoking, for example, the field used to count up reduction in the number of smoking cigarettes as action, or moving over to low tar and nicotine cigarette smoking.
Now the consensus is clear--only total abstinence matters. In the diet area, there is certainly some consensus that significantly less than 30% of calorie consumption should be used from excess fat. The Action level is also the main point where vigilance against relapse is critical.
Maintenance, the fifth and final stage is the level where people will work to avoid relapse nonetheless they do not apply change procedures as frequently as do people doing his thing. These are less lured to relapse and a lot more confident that they can continue their change.
Regression occurs when individuals revert to a youthful stage of change. Relapse is one form of regression, relating regression from Action or Maintenance to an earlier level. However, people can regress from any stage to a youthful level. The bad news is the fact relapse tends to be the guideline when action is taken for some health habit problems. The good news is that for smoking and exercise only about 15% of individuals regress all the way to the Precontemplation stage. The vast majority regress to Contemplating or Prep.
In a recently available review (Velicer, Fava, Prochaska, Abrams, Emmons, & Pierce, 1995), it was proven that the syndication of smokers over the first three Levels of Change was around indistinguishable across three large representative samples. About 40% of the smokers were in the Precontemplation stage, 40% were in the Contemplation stage, and 20% were in the Planning stage.
However, the distributions may vary in various countries. A recent newspaper (Etter, Perneger, & Ronchi, 1997) summarized the stage distributions from four recent samples from different countries in Europe (one each from Spain and the Netherlands, and two from Switzerland).
The distributions were very similar across the Western samples but completely different from the American examples. In the Western european samples, around 70% of the smokers were in the Precontemplation level, 20% were in the Contemplation stage, and 10% were in the Prep stage.
While the level distributions for smoking cessation have now been set up in multiple examples, the stage distributions for other problem manners aren't as well known. This is especially true for countries apart from the United States.
Regression occurs when individuals revert to an earlier stage of change. Relapse is one form of regression, regarding regression from Action or Maintenance to an earlier level. However, people can regress from any stage to an earlier stage. The bad news is the fact relapse tends to be the guideline when action is taken for some health action problems.
The very good news is the fact for smoking and exercise only about 15% of people regress completely to the Precontemplation level. The vast majority regress to Contemplating or Preparation.
In a recently available study (Velicer, Fava, Prochaska, Abrams, Emmons, & Pierce, 1995), it was proven that the distribution of smokers over the first three Stages of Change was around similar across three large representative samples. Roughly 40% of the smokers were in the Precontemplation stage, 40% were in the Contemplation stage, and 20% were in the Preparation stage.
However, the distributions may vary in different countries. A recent newspaper (Etter, Perneger, & Ronchi, 1997) summarized the stage distributions from four recent samples from different countries in European countries (one each from Spain and the Netherlands, and two from Switzerland).
The distributions were very similar across the Western samples but very different from the American examples. In the Western european samples, about 70% of the smokers were in the Precontemplation stage, 20% were in the Contemplation stage, and 10% were in the Preparation stage.
While the stage distributions for smoking cessation have now been proven in multiple samples, the stage distributions for other problem behaviors aren't as popular. This is specifically true for countries other than the United States.
The Decisional Balance build demonstrates the individual's comparative weighing of the pros and drawbacks of changing. It really is produced from the Janis and Mann's model of decision making (Janis and Mann, 1985) that included four categories of pros (instrumental benefits for self and more and authorization for self and others).
The four categories of negative aspects were instrumental costs to do it yourself and others and disapproval from self among others. However, an empirical test of the model led to a easier composition. Only two factors, the professionals and Negatives, were found (Velicer, DiClemente, Prochaska, & Brandenberg, 1985). In an extended series of studies (Prochaska, et al. 1994), this much simpler structure has always been found.
The Decisional Balance range involves weighting the value of the professionals and Drawbacks. A predictable routine has been detected of how the Pros and Cons relate with the phases of change. Body 2 illustrates this design for smoking cessation. In Precontemplation, the Pros of smoking significantly outweigh the Cons of smoking. In Contemplation, both of these scales are usually more equal. In the advanced phases, the Cons outweigh the Pros.
A different design has been observed for the acquisition of healthy actions. The patterns are similar over the first three periods. However, for the last two stages, the Pros of performing exercises remain high. This probably demonstrates the actual fact that maintaining an application of regular exercise requires a continual group of decisions while smoking eventually becomes irrelevant. Both of these scales capture some of the cognitive changes that are necessary for progress in the first stages of change.
The Self-efficacy construct represents the problem specific confidence that individuals have that they can manage high-risk situations without relapsing with their poor or high-risk habit. This construct was modified from Bandura's self-efficacy theory (Bandura, 1977, 1982). This build is symbolized either by a Temptation strategy or a Self-efficacy build.
The Situational Temptation Measure (DiClemente, 1981, 1986; Velicer, DiClemente, Rossi, & Prochaska, 1990) shows the depth of urges to activate in a particular behavior when in the midst of difficult situations. It really is, in effect, the converse of self-efficacy and the same group of items may be used to assess both, using different response types. The Situational Self-efficacy Strategy reflects the self-confidence of the individual not to take part in a specific tendencies across some difficult situations.
Self-efficacy can be represented by a monotonically increasing function across the five levels. The enticement is represented by way of a monotonically lowering function over the five periods.
Processes of Change are the covert and overt activities that folks use to progress through the periods. Operations of change provide important courses for treatment programs because the processes are the independent variables that people need to use or be involved in, to move from stage to level.
Ten functions (Prochaska & DiClemente, 1983; Prochaska, Velicer, DiClemente, & Fava, 1988) have obtained the most empirical support in our research thus far. The first five are categorized as Experiential Processes and are used primarily for the early stage transitions. The very last five are tagged Behavioral Procedures and are used primarily for later stage transitions.
Consciousness Raising involves increased understanding about the causes, consequences, and solutions for a particular problem action. Interventions that can increase consciousness include opinions, education, confrontation, interpretation, bibliotherapy, and advertising campaigns.
Dramatic Relief at first produces increased mental experiences followed by reduced impact if appropriate action can be taken. Psychodrama, role using, grieving, personal testimonies and press campaigns are examples of techniques that can move people emotionally.
Environmental Reevaluation combines both affective and cognitive assessments of how the presence or absence of a personal habit affects one's social environment including the effect of smoking on others. Additionally, it may include the recognition that one can serve as a positive or negative role model for others. Empathy training, documentaries, and family interventions can result in such re-assessments.
Social Liberation requires a rise in interpersonal opportunities or alternatives especially for folks who are relatively deprived or oppressed. Advocacy, empowerment techniques, and appropriate procedures can produce increased opportunities for minority health campaign, gay health advertising, and health campaign for impoverished people. These same strategies can even be used to help all people change such as smoke-free zones, salad bars in institution lunches, and easy access to condoms and other contraceptives.
Self-reevaluation combines both cognitive and affective assessments of your respective self-image with and without a particular unhealthy habit, such as one's image as a couch potato or an active person. Value clarification, healthy role models, and imagery are techniques that can move people evaluatively.
Stimulus Control gets rid of cues for unhealthy habits and provides prompts for healthier alternatives. Avoidance, environmental re-engineering, and self-help groupings provides stimuli that support change and reduce hazards for relapse. Planning parking a lot with a two-minute walk to any office and putting fine art shows in stairwells are types of reengineering that can encourage more exercise.
Helping Relationships incorporate caring, trust, openness and approval as well as support for the healthy patterns change. Rapport building, a healing alliance, counselor cell phone calls and buddy systems can be resources of interpersonal support.
Counter Conditioning requires the learning of healthier behaviors that can replacement for problem behaviors. Leisure can counter stress; assertion can counter peer pressure; nicotine replacement unit can replacement for cigarettes, and extra fat free foods can be safer substitutes.
Reinforcement Management provides consequences when planning on taking steps in a particular direction. While encouragement management range from the utilization of punishments, we found that self-changers count on rewards much more than punishments. So reinforcements are emphasized, since a idea of the level model is to work in harmony with how people change naturally. Contingency contracts, overt and covert reinforcements, positive self-statements and group popularity are steps for increasing encouragement and the likelihood that healthier replies will be repeated.
Self-liberation is both the belief that one may change and the dedication and recommitment to do something on that opinion. New Year's resolutions, consumer testimonies, and multiple somewhat than single choices can enhance self-liberation or what the public calls willpower. Inspiration research indicates that folks with two alternatives have greater dedication than people with one choice; those with three choices have sustained commitment; four alternatives will not further enhance perseverence. So with smokers, for example, three excellent action selections they can be given are cool turkey, nicotine fading and nicotine replacement.
Application to practice
This section discusses the way the Transtheoretical model can be utilized effectively in assisting people beat problems like aiding smokers to avoid smoking. The model has previously been applied to a wide variety of problem behaviors. These include smoking cessation, exercise, low fat diet, radon evaluation, alcohol mistreatment, weight control, condom use for HIV safeguard, organizational change, use of sunscreens to prevent skin cancer, substance abuse, medical compliance, mammography verification, and stress management.
The model has became especially effective in assisting pregnant women who are string smokers by causing them recognize that their smoking behavior may cause irreparable harm to the fetus.
For smoking, a good example of social affects would be peer influence models (Flay, 1985) or plan changes (Velicer, Laforge, Levesque, & Fava, 1994). A good example of biological affects would be nicotine legislation models (Leventhal & Cleary, 1980; Velicer, Redding, Richmond, Greeley, & Swift, 1992) and replacement unit therapy (Fiore. Smith, Jorenby, & Baker, 1994). Inside the framework of the Transtheoretical Model, these are viewed as exterior affects, impacting through the average person.
Though the prevalence of using tobacco has declined it still remains the main cause of early death from persistent disease. In the prevention of cigarette associated disease the advertising of smoking cessation is a key strategy.
Tailored marketing communications are one of the most promising methods to smoking cessation interventions for complete populations. Assessments predicated on the Transtheoretical Model are prepared by computer-based expert systems that create feedback reports personalized to each individual to accelerate their improvement through the levels of change for smoking cessation.
A series of three tailored communications was found to create long-term point prevalence abstinence rates within the slim range of 22-26% abstinence. This same range of abstinence was found even though two or three other behaviours (e. g. diet and sun safety) were cared for in the populace.
These results point to a future where health behavior risk interventions will be evaluated not only by their efficacy but by their people impact.
The model includes thoughts, cognitions, and tendencies. This calls for a reliance on self-report. For instance, in smoking cessation, self-report has been demonstrated to be very appropriate (Velicer, Prochaska, Rossi, & Snow 1992).
Accurate measurement takes a group of unambiguous items which the average person can react to accurately with little chance for distortion. Dimension issues are very important and one of the critical steps for the use of the model requires the introduction of short, reliable, and valid steps of the key constructs.
This model combines elements of theories found in psychotherapy and tendencies modification. Within the model are five levels (precontemplation, contemplation, preparation, action, and maintenance) that explain when patterns change occurs. To be most effective, a health care provider's interventions should match the patient's stage of change. The model also includes 10 cognitive and behavioral functions that explain how change occurs while one is moving one of the stages. The procedures (public liberation, dramatic pain relief, helping human relationships, consciousness-raising, environmental reevaluation, encouragement management, self-reevaluation, stimulus control, counterconditioning, and self-liberation) define change in terms of the coping strategies used. Before intervening, the pharmacist needs to ask questions about the patient's tendencies that will identify the stage.
If smokers in the precontemplation stage are acquiring medications for serious diseases, pharmacists can make them aware of the negative effects of smoking on their specific conditions. People in the contemplation stage are available to education about smoking and health, and those in the planning stage are prepared to arranged goals and choose methods for cessation.
Smokers in the action level are trying to quit. Pharmacists can provide support, support, and guidance to people in the action and maintenance stages. Pharmacists may use the transtheoretical model to categorize patients by their stage of change and then devise and deliver appropriate and individualized interventions.
While intensive research has reviewed the first five periods of change for the acquisition and adherence to exercise behavior (e. g. , Cardinal, 1997; Marcus et al, 1992; Nigg & Courneya, 1998), research investigating the validity of the termination level for exercise is bound and equivocal (Cardinal, 1999; Cardinal & Levy, 2000; Courneya & Bobick, 2000).
Furthermore, research evaluating the TTM for exercise has been criticized because nearly all researchers never have looked into all five of the TTM constructs all together (Culos-Reed, Gyurcsik, & Brawley, 2001). In keeping with this criticism, no studies examining the termination level have used all five of the TTM constructs. Because of this, it is problematic for researchers to develop accurate and regular knowledge of how the psychosocial constructs of the TTM result exercise patterns. Thus, research examining the partnership between all the TTM constructs with the termination level is warranted.
Many of todays health problems are due in part to long-standing behavioral patterns. Habits of eating, exercise, tobacco and liquor use contribute to health problems such as diabetes, hypertension, heart disease, stroke and malignancy. An understanding of the factors that enable individual change in health conducts is critical to growing new treatments and interventions that can prevent and ameliorate serious disease conditions caused by lifestyle selections.
Behaviour change is probably the most difficult form of 'inside-out' change. The Transtheoretical Model of Change shows itself to be the most effective intervention in protecting real and enduring change in behavior.
Surprisingly, it is little understood or applied outside the health field. People are coached into modify a problem behavior or get a positive one. For example, when supporting people give up smoking or lose weight.
The five phases of change concentrate on choice or decision-making. The model depends on the leadership for real change coming from individuals or teams with help from an exterior Change Mentor.
Should suggestive proof be obtained, these details could be utilized to design a new set of involvement studies that derive from a more specific understanding of how peoples expectations and identified satisfaction affect the behavioral decisions they make. These studies would focus on specifying the most effective way to design interventions in a way that they are able to maximize peoples objectives about the advantages of action change without undermining their succeeding satisfaction with the final results afforded by patterns change.
The Transtheoretical Model does indeed explicitly recognize between people in the action and maintenance periods of the tendencies change process, however the basis for this classification rests on a somewhat arbitrary distinction in the length of time that a habit has been implemented (Weinstein et al. , 1998). In addition, the set of cognitive and behavioral strategies that are thought to facilitate initial action are likewise forecasted to help them sustain that action as time passes (Prochaska et al. , 1992; Prochaska and Velicer, 1997.
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