Although research results to date are encouraging, much still needs to be done to ad- vance TTM. Basic research should be done with other theoretical variables, such as processes of resistance, framing, and problem severity, to determine if such variables relate systematically to the stages and predict progress across particular stages. More
research is needed on the structure or integration of processes and stages of change across a broad range of behaviors, such as acquisition behaviors, like exercise, and extinction behaviors, like smoking cessation (Rosen, 2000). It is important to exam- ine what modifications are needed for specific types of behaviors, such as fewer processes perhaps for infrequent behaviors, like mammography screening, or behav- iors that may relapse less often, such as sunscreen use.
Since tailored communications represent the most promising interventions for applying TTM to entire populations, more research is needed to compare effective- ness, cost-effectiveness, and impacts of alternative technologies. The Internet is ex- cellent for delivering individualized interactions at low cost, but it cannot produce the high participation rates generated by person-to-person outreach via telephone or primary care practitioners (Prochaska and others, 2008; Prochaska, Velicer, Prochaska, and Johnson, 2004; Prochaska and others, 2005).
Although application of TTM-tailored interventions with diverse populations has been promising, more research needs to be done comparing alternative modalities for reaching and helping these populations. Perhaps menus of alternative intervention modalities (such as telephone, Internet, neighborhood or church leaders, person-to- person, or community programs) could empower diverse populations to best match health-enhancing programs to their particular needs.
Changing multiple behaviors represents special challenges, such as the demands placed on participants and providers. Alternative strategies need to be tried beyond the sequential (one at a time) and simultaneous (each treated intensely at the same time). Integrative approaches are promising. With bullying prevention, multiple be- haviors (for example, hitting, stealing, ostracizing, mean gossiping and labeling, dam- aging personal belongings) and multiple roles (bully, victim, and passive bystander) required treatment. Available classroom intervention time was only thirty minutes. If behavior change is construct-driven (for example, by stage or self-efficacy), what is a higher-order construct that could integrate all of these more concrete behaviors and roles? “Relating with respect” was used and, as indicated earlier, significant and im- portant improvements across roles and behaviors were found for elementary, middle, and high school students (Prochaska and others, 2007). As with any theory, effec- tive applications may be limited more by our creativity and resources for testing than by the ability of the theory to drive significant research and effective interventions.
The Transtheoretical Model is a dynamic theory of change, and it should remain open to modifications and enhancements as more students, scientists, and practitioners apply the stage paradigm to a growing number and diversity of theoretical issues, public health problems, and at-risk populations.
SUMMARY
In this chapter, we described the fifteen core constructs of TTM and how these con- structs can be integrated across the stages of change. Empirical support for the basic constructs of TTM and for applied research was presented, along with conceptual and empirical challenges from critics of TTM. Applications of TTM-tailored interventions
with entire populations were explored with examples for the single behavior of smok- ing and for multiple-health-risk behaviors. A major theme is that programmatically building and applying the core constructs of TTM at the individual level can ulti- mately lead to high-impact programs for enhancing health at the population level.
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