Table 5.1 briefly describes core constructs of the TTM.
TABLE 5.1.
Transtheoretical Model Constructs.Constructs Description
Processes of Change
Consciousness raising Finding and learning new facts, ideas, and tips that support the healthy behavior change
Dramatic relief Experiencing the negative emotions (fear, anxiety, worry) that go along with unhealthy behavioral risks
Self-reevaluation Realizing that the behavior change is an important part of one’s identity as a person
Environmental Realizing the negative impact of the unhealthy behavior reevaluation or the positive impact of the healthy behavior on one’s
proximal social and/or physical environment Self-liberation Making a firm commitment to change
Helping relationships Seeking and using social support for the healthy behavior change
Counterconditioning Substitution of healthier alternative behaviors and cognitions for the unhealthy behavior
Reinforcement Increasing the rewards for the positive behavior change management and decreasing the rewards of the unhealthy behavior Stimulus control Removing reminders or cues to engage in the unhealthy
behavior and adding cues or reminders to engage in the healthy behavior
Social liberation Realizing that the social norms are changing in the direction of supporting the healthy behavior change
Decisional Balance
Pros Benefits of changing
Cons Costs of changing
Self-Efficacy
Confidence Confidence that one can engage in the healthy behavior across different challenging situations
Temptation Temptation to engage in the unhealthy behavior across different challenging situations
Stages of Change
The stage construct is important, in part, because it represents a temporal dimension.
In the past, behavior change often was construed as a discrete event, such as quit- ting smoking, drinking, or overeating. The TTM posits change as a process that un- folds over time, with progress through a series of six stages, although frequently not in a linear manner.
Precontemplation is the stage in which people do not intend to take action in the near term, usually measured as the next six months. The outcome interval may vary, depending on the behavior. People may be in this stage because they are unin- formed or under-informed about the consequences of their behavior. Or they may have tried to change a number of times and become demoralized about their abili- ties to change. Both groups tend to avoid reading, talking, or thinking about their high-risk behaviors. They are often characterized as resistant or unmotivated clients or as not ready for therapy or health promotion programs. An alternative explanation is that traditional health promotion programs were not ready for such individuals and were not motivated to match their needs.
In contemplation, people intend to change their behaviors in the next six months.
They are more aware than precontemplators of the pros of changing but are also acutely aware of the cons. This balance between the costs and benefits of changing can pro- duce profound ambivalence and keeps people stuck in contemplation for long periods of time. This phenomenon is often characterized as chronic contemplation or behav- ioral procrastination. These folks also are not ready for traditional action-oriented pro- grams that expect participants to take action immediately.
In preparation, people intend to take action soon, usually measured as the next month. Typically, they already have taken some significant step toward the behavior in the past year. They have a plan of action, such as joining a health education class, consulting a counselor, talking to their physician, buying a self-help book, or relying on a self-change approach. These are the people who should be recruited for action- oriented programs, such as traditional smoking-cessation or weight-loss clinics.
People in the action stage have made specific, overt modifications in their lifestyles within the past six months. Because action is observable, behavior change often has been equated with action. In the TTM, action is only one of six stages. Typically, not all modifications of behavior count as action in this model. In most applications, peo- ple have to attain a criterion that scientists and professionals agree is sufficient to re- duce risks for disease. In smoking, for example, the field used to count reduction in number of cigarettes or switching to low tar and nicotine cigarettes as action. Now, the consensus is clear—only total abstinence counts as action, as these other changes do not necessarily lead to quitting and do not lower risks associated with smoking to zero.
Maintenance is the stage in which people have made specific, overt modifications in their lifestyles and are working to prevent relapse, but they do not apply change processes as frequently as people in action. They are less tempted to relapse and are increasingly more confident that they can continue their changes. Based on temptation and self- efficacy data, it was estimated that maintenance lasts from six months to about five years.
Longitudinal data from the 1990 Surgeon General’s Report (U.S. Department of Health
and Human Services, 1990) supported this temporal estimate. After twelve months of continuous abstinence, 43 percent of individuals returned to regular smoking. It was not until five years of continuous abstinence that the risk for relapse dropped to 7 percent.
People in the termination stage have zero temptation and 100 percent self-efficacy.
Whether they are depressed, anxious, bored, lonely, angry, or stressed, they are sure they will not return to their old unhealthy behaviors. It is as if they never acquired the behavior in the first place or their new behavior has become automatic. Examples are adults who buckle their seatbelts as soon as they get in their cars or automatically take their antihypertensive medications at the same time and place each day. In a study of former smokers and alcoholics, we found that less than 20 percent of each group had reached the criterion of zero temptation and total self-efficacy (Snow, Prochaska, and Rossi, 1992). The criterion may be too strict, or this stage may be an ideal goal for the majority of people. In other areas, like exercise, consistent condom use, and weight control, the realistic goal may be a lifetime of maintenance, because relapse temptations are so prevalent and strong. Termination has received much less research attention than other stages.
Processes of Change
Processes of change are the covert and overt activities people use to progress through stages. Processes of change provide important guides for intervention programs, as processes are like independent variables that people need to apply to move from stage to stage. Ten processes have received the most empirical support in research to date (see Table 5.1).
1. Consciousness raising involves increased awareness about the causes, conse- quences, and cures for a particular problem behavior. Interventions that can in- crease awareness include feedback, confrontations, interpretations, bibliotherapy, and media campaigns.
2. Dramatic relief initially produces increased emotional experiences, followed by reduced affect or anticipated relief if appropriate action is taken. Role-playing, grieving, personal testimonies, health risk feedback, and media campaigns are exam- ples of techniques that can move people emotionally.
3. Self-reevaluation combines both cognitive and affective assessments of one’s self-image with and without an unhealthy behavior, such as one’s image as a couch potato and an active person. Values clarification, healthy role models, and imagery are techniques that can move people evaluatively.
4. Environmental reevaluation combines both affective and cognitive assessments of how the presence or absence of a personal behavior affects one’s social environ- ment, such as the impact of one’s smoking on others. It can also include awareness that one can serve as a positive or negative role model for others. Empathy training, documentaries, testimonials, and family interventions can lead to such reassessments.
5. Self-liberation is both the belief that one can change and the commitment and re-commitment to act on that belief. New Year’s resolutions, public testimonies, and multiple rather than single choices can enhance what the public calls willpower.
6. Social liberation requires an increase in social opportunities or alternatives, especially for people who are relatively deprived or oppressed. Advocacy, empow- erment procedures, and appropriate policies can produce increased opportunities for minority health promotion, gay health promotion, and health promotion for impov- erished people. These same procedures can be used to help all people change, as is the case with smoke-free zones, salad bars in school lunchrooms, and easy access to condoms and other contraceptives.
7. Counterconditioning requires learning healthier behaviors that can substitute for problem behaviors. Relaxation, assertion, desensitization, nicotine replacement, and positive self-statements are strategies for safer substitutes.
8. Stimulus control removes cues for unhealthy habits and adds prompts for health- ier alternatives. Avoidance, environmental re-engineering, and self-help groups can provide stimuli that support change and reduce risks for relapse.
9. Contingency management provides consequences for taking steps in a partic- ular direction. Although contingency management can include the use of punishment, we found that self-changers rely on reward much more than punishment. Reinforce- ments are emphasized, since a philosophy of the stage model is to work in harmony with how people change naturally. Contingency contracts, overt and covert reinforce- ments, incentives, and group recognition are procedures for increasing reinforcement and the probability that healthier responses will be repeated.
10. Helping relationships combine caring, trust, openness, and acceptance, as well as support for healthy behavior change. Rapport building, therapeutic alliances, counselor calls, and buddy systems can be sources of social support.
Decisional Balance
Decisional balance reflects an individual’s relative weighing of the pros and cons of changing. Originally, TTM relied on Janis and Mann’s (1977) model of decision mak- ing that included four categories of pros (instrumental gains for self and others and approval from self and others) and four categories of cons (instrumental costs to self and others and disapproval from self and others). Over many studies attempting to produce this structure of eight factors, a much simpler two-factor structure was al- most always found—pros and cons of changing.
Self-Efficacy
Self-efficacy is the situation-specific confidence that people can cope with high-risk situations without relapsing to their former behaviors. This construct was integrated from Bandura’s (1982) self-efficacy theory.
Temptation
Temptation reflects the converse of self-efficacy—the intensity of urges to engage in a specific behavior when in difficult situations. Typically, three factors reflect most common types of temptations: negative affect or emotional distress, positive social situations, and craving.
Critical Assumptions
The TTM has concentrated on five stages of change, ten processes of change, pros and cons of changing, self-efficacy, and temptation. It is also based on critical as- sumptions about the nature of behavior change and interventions that can best facil- itate such change. The following set of assumptions drive theory, research, and practice related to the TTM:
1. No single theory can account for all complexities of behavior change. A more comprehensive model is most likely to emerge from integration across major theories.
2. Behavior change is a process that unfolds over time through a sequence of stages.
3. Stages are both stable and open to change, just as chronic behavioral risk fac- tors are stable and open to change.
4. The majority of at-risk populations are not prepared for action and will not be served effectively by traditional action-oriented behavior change programs.
5. Specific processes and principles of change should be emphasized at specific stages to maximize efficacy.
Empirical Support and Challenges
Each of the core constructs has been subjected to a wide variety of studies across a broad range of behaviors and populations. Early in the process of applying TTM to new behaviors, formative research and measurement work begins (Redding, Maddock, and Rossi, 2006), followed by intervention development and refinement, leading to formal efficacy and effectiveness trials. Ideally, cohorts of individuals should be fol- lowed over time to determine how they respond. Only a sampling of these studies can be reviewed here.
Stage Distribution. If interventions are to match needs of entire populations, we should know the stage distributions for specific high-risk behaviors. A series of studies on smoking in the United States (for example, Velicer and others, 1995; Wewers, Stillman, Hartman, and Shopland, 2003) clearly demonstrated that less than 20 percent of smok- ers were in preparation. Approximately 40 percent of smokers were in contemplation, and another 40 percent were in precontemplation. In countries without a long history of tobacco control campaigns, stage distributions were even more challenging. In Germany, about 70 percent of smokers were in precontemplation, and about 10 per- cent of smokers were in preparation (Etter, Perneger, and Ronchi, 1997); in China, more than 70 percent were in precontemplation and about 5 percent in preparation (Yang and others, 2001). In a sample of 20,000 members of an HMO across fifteen health-risk behaviors, only a small minority were ready for action (Rossi, 1992a).
Pros and Cons Structure Across Twelve Behaviors. Across studies of twelve different behaviors (smoking cessation, quitting cocaine, weight control, dietary fat reduction, safer sex, condom use, exercise acquisition, sunscreen use, radon testing, delinquency
reduction, mammography screening, and physicians practicing preventive medicine), the two-factor structure was remarkably stable (Prochaska and others, 1994).
Integration of Pros and Cons and Stages of Change Across Twelve Health Behaviors.
Stage is a construct, not a theory. A theory requires systematic relationships between a set of constructs, ideally culminating in mathematical relationships. Systematic re- lationships have been found between stage and pros and cons of changing for twelve health behaviors.
In all twelve studies, cons of changing were higher than pros for people in pre- contemplation (Prochaska and others, 1994), and pros increased between precontem- plation and contemplation. From contemplation to action for all twelve behaviors, cons of changing were lower in action than in contemplation. In eleven of the twelve studies, pros of changing were higher than cons for people in action. These relation- ships suggest that to progress from precontemplation to later stages, pros of chang- ing should increase. To progress from contemplation, cons should decrease. To move to action, pros should be higher than cons.
Strong and Weak Principles of Progress Across Forty-Eight Behaviors. Across these same twelve studies, mathematical relationships were found between pros and cons of changing and progress across the stages (Prochaska, 1994).
The Strong Principle is
PC →A ≅1 SD ↑PROS
Progress from precontemplation to action involves about one standard deviation (SD) increase in the pros of changing. On intelligence tests, a one SD increase would be 15 points, which is a substantial increase.
In a recent meta-analysis of forty-eight health behaviors and 120 data sets from ten countries, it was predicted that the pros of changing would increase one SD. The Strong Principle was confirmed to the second decimal with the increase being 1.00 SD (Hall and Rossi, 2008).
The Weak Principle is
PC →A ≅0.5 SD ↓CONS
Progress from precontemplation to action involves ~0.5 SD decrease in the cons of changing.
Evidence from the recent meta-analysis for the Weak Principle was not as pre- cise: 0.56 SD (Hall and Rossi, in press). Nevertheless, the multitude of data on forty- eight behaviors from 120 datasets could be integrated in a single graph that supported two mathematical principles.
Practical implications of these principles are that pros of changing must increase about twice as much as cons must decrease. Perhaps twice as much emphasis should be placed on raising benefits as on reducing costs or barriers to enact recommended behaviors. For example, if couch potatoes in precontemplation can only list five pros of exercise, then being too busy will be a big barrier to change. But if program par- ticipants come to appreciate that there can be more than fifty benefits for exercising most days of the week, being too busy may become a relatively small barrier.
Processes of Change Across Behaviors. One of the assumptions of TTM is that peo- ple can apply a common set of change processes across a broad range of behaviors.
The higher-order measurement structure of the processes (experiential and behav- ioral) has been replicated across problem behaviors better than have specific processes (Rossi, 1992b). Typically, support has been found for the standard set of ten processes across such behaviors as smoking, diet, cocaine use, exercise, condom use, and sun exposure. But the measurement structure of the processes across studies has not been as consistent as the mathematical relationships between the stages and the pros and cons of changing. In some studies, fewer processes are found. Occasionally, evidence for one or two additional processes is found. It is also very possible that for some be- haviors, fewer change processes may be used. With a regular but infrequent behav- ior like yearly mammograms, for example, fewer processes may be required to progress to long-term maintenance (Rakowski and others, 1998).
Relationships Between Stages and Processes of Change. One of the earliest em- pirical integrations was the discovery of systematic relationships between people’s stages and the processes they were applying. Table 5.2 presents the empirical inte- gration (Prochaska, DiClemente, and Norcross, 1992). This integration suggests that, in early stages, people apply cognitive, affective, and evaluative processes to progress through stages. In later stages, people rely more on commitments, conditioning, con- tingencies, environmental controls, and support for progressing toward maintenance or termination.
TABLE 5.2.
Processes of Change That Mediate Progression Between the Stages of Change.Precontemplation Contemplation Preparation Action Maintenance Processes Consciousness
raising Dramatic relief Environmental reevaluation
Self-reevaluation
Self-liberation
Counterconditioning Helping relationships Reinforcement
management Stimulus control Note:Social liberation was omitted due to its unclear relationship to the stages.
Table 5.2 has important practical implications. To help people progress from pre- contemplation to contemplation, such processes as consciousness raising and dra- matic relief should be applied. Applying processes like contingency management, counterconditioning, and stimulus control to people in precontemplation would rep- resent a theoretical, empirical, and practical mistake. But for people in action, such strategies would represent optimal matching.
As with the structure of processes, relationships between the processes and stages have not been as consistent as relationships between stages and pros and cons of changing. Although part of the problem may be due to the greater complexity of in- tegrating ten processes across five stages, processes of change need more basic re- search and may be more specific to each problem behavior.
Applied Studies. Across a large, diverse body of applied studies that used TTM, sev- eral trends are clear. The most common application involves TTM-tailored expert sys- tem communications, which match intervention messages to an individual’s needs across TTM constructs. For example, people in precontemplation could receive feed- back designed to increase pros of changing to help them progress to contemplation.
In the past, these interventions were usually printed either on-site (for example, at a worksite or doctor’s office) or mailed to participants at home. With growth of the Internet, multimedia expert system programs (Redding and others, 1999) can be de- livered in this manner, potentially reaching many more people than programs deliv- ered in fixed sites.
The largest number of TTM-related intervention studies have focused on smoking cessation (Aveyard and others, 1999; Curry and others, 1995; Dijkstra, DeVries, and Roijackers, 1999; Dijkstra, Conijm, and DeVries, 2006; Hall and others, 2006; Hollis and others, 2005; O’Neill, Gillespie, and Slobin, 2000; Pallonen and others, 1998; Pro- chaska, DiClemente, Velicer, and Rossi, 1993; Prochaska and others, 2001a, 2001b;
Strecher and others, 1994; Velicer and others, 1999); diet (Beresford and others, 1997;
Brug and others, 1998; Campbell and others, 1994; Glanz and others, 1998; Horwath, 1999); and exercise (Cardinal and Sachs, 1996; Marcus and others, 1998; Rossi and others, 2005). Recent randomized controlled trial outcome studies include stress man- agement (Evers and others, 2006), medication adherence (Johnson and others, 2006a, 2006b), and bullying prevention (Prochaska and others, 2007). The number of applica- tions is growing, from alcohol abuse (Project Match, 1997; Carbonari and DiClemente, 2000), to condom use (CDC, 1999; Parsons and others, 2000; Redding, Morokoff, Rossi, and Meier, 2007), to domestic violence offenders (Levesque, Driskell, Prochaska, and Prochaska, forthcoming), to organ donation (Robbins and others, 2001) and multiple behavior changes (Gold, Anderson, and Serxner, 2000; Kreuter and Strecher, 1996;
Steptoe, Kerry, Rink, and Hilton, 2001).
TTM has been applied in many settings, including primary care (Goldstein and others, 1999; Hollis and others, 2005), home (Curry and others, 1995; Gold, Ander- son, and Serxner, 2000), churches (Voorhees and others, 1996), schools (Aveyard and others, 1999), campuses (J. M. Prochaska and others, 2004), communities (Centers for Disease Control and Prevention, 1999), and worksites (Prochaska and others, 2008). Although many of these applications have been effective, some have not (for