Chapter 2: Stages of Change or Transtheoretical Model

Vocabulary

• Esteem

The regard and respect one holds for oneself or others; a positive opinion or valuation.

• Informational

Pertaining to the communication or provision of information; conveying knowledge or facts.

• Circular

Shaped like a circle; involving or following a circular path or pattern. A circular process is also called a cycle.

• Linear

Having the form of a line; characterized by a straight or nearly straight arrangement or progression.

• Relapse

The return to a negative condition or pattern of behavior, often after a period of improvement or recovery. 

• Personalize

To tailor or customize something to meet individual needs or preferences; to make something distinctive to a person.

• Nicotine

A stimulant and psychoactive substance found in tobacco products, responsible for the addictive properties of smoking.

• Mammogram

An X-ray examination of the breast, commonly used as a screening tool for the early detection of breast cancer.

• Continuum

A continuous sequence or range, without clear divisions; a progression or spectrum.

• Overdose

The ingestion or exposure to an excessive amount of a substance, typically a drug, leading to harmful or toxic effects.

Self-Efficacy is basic to behavior change, and is a component of several health theories. Developed by Alfred Bandura, self-efficacy refers to a person’s belief about their ability to perform a task.

• • The following are similar terms but with different meanings:

• • • Self Esteem: an appraisal of a person’s own worth, and the opinion they have about themselves, which can change depending on moods or approval of others.

    • Self Worth: core beliefs about a person’s value, usually does not change over time.

    • Individual Worth: related to self worth, this is one of the Young Women values and corresponds to D&C 18:10, “Remember the worth of souls is great in the sight of God”

    • Self-Efficacy: a person’s belief in their ability to complete a task or achieve a goal and their confidence in controlling their behavior. A person can use their belief in their Individual worth to help build their self-efficacy.

• • How does efficacy relate to behavior change?

Bandura and other researchers have found that self-efficacy plays a major role in whether people are successful in changing their own behavior. A person with high self-efficacy forms a stronger sense of commitment, recovers more quickly after setbacks, and views challenges as tasks to master.

• • Examples:

• • • If I believe I can be successful at exercising more, I will feel more enthusiastic about making plans to improve my fitness.
    • If I doubt my ability to control my eating, I’m more likely to drop my resolution to avoid sweets.
    • A person who is trying to stop smoking will be more successful if they are confident they can stop.

Stages of Change (Transtheoretical Model)

The purpose of the Stages of Change Model is to explain behavior change. The Stages of Change Model came from studies comparing the experiences of smokers who quit on their own with those of smokers receiving professional treatment. The model’s basic premise is that behavior change is a process that moves through the following five stages:

• Precontemplation
• Contemplation
• Preparation
• Action
• Maintenance

Interventions can be designed for each stage and tailored for different points along this continuum.

Although everyone goes through some form of these stages, the manner in which an individual progresses can vary greatly depending on the type of behavior change. For example, a smoker may be in precontemplation and then in contemplation for many years. A person who wants to eat more fruits and vegetables may be in precontemplation briefly and then in preparation for a very short time.

The Stages of Change Model can be applied to individual behaviors as well as to organizational change. The Model is circular, not linear. In other words, progress from one stage to the next does not always happen at the same rate. Individuals can enter the change process at any stage, and can go backward, relapsing to an earlier stage. They can also cycle through the process more than once.

The following stages will be explained in more detail and have suggested strategies of change.

Precontemplation

• Explanation: Has no intention of taking action within the next six months.
• Examples:

• • Mr S has heard about risks of smoking but has no intention of quitting.
  • Mrs T has never had a mammogram and does not know they are recommended after age 45.
  • Ms M does not like flossing her teeth and never does it.

• Change Strategies:

• • Increase awareness of the need for change.
  • Personalize information about risks and benefits.

Contemplation

• Explanation: Intends to take action in the next six months.
• Examples:

• • Mr. B wants to lose weight and thinks he will start a diet next month after the holidays.
  • Ms. C knows she should exercise and is waiting for the weather to get warmer.
  • Mrs. D might go walking if she can find a friend to walk with her.

• Change Strategies:

• • Provide motivation.
  • Encourage making specific plans.

Preparation

• Explanation: Intends to take action within the next 30 days and has taken some behavioral steps in this direction.
• Examples:

• • Mr. S promised his wife he will stop smoking and he bought some nicotine gum to help him stop
  • Mrs. T learned she needs a mammogram and she made an appointment for it.
  • Ms. M went to the dentist who told her to floss her teeth, and she told him she will. She bought some dental floss on the way home.

• Change Strategies:

• • Assist with developing and implementing concrete action plans.
  • Help set gradual goals.

Action

• Explanation: Has changed behavior for less than six months.

• • Examples

• • • Mr. S stopped smoking and has not smoked for 1 month.
    • Mrs. T went for her mammogram.
    • Ms. M has been flossing her teeth for 2 months.

• Change Strategies:

• • Assist with feedback and problem solving.
  • Give social support and reinforcement.

Maintenance

• Explanation: Has changed behavior for more than six months.

• • Examples:

• • • Mr. S considers himself a nonsmoker, having quit for one year.
    • Mrs. T has her future mammograms on her calendar to stay compliant with getting one each year.
    • Ms. M has been flossing for 8 months and her dentist is pleased with the improvement in her teeth.

• Change Strategies:

• • Assist with coping and reminders.
  • Help find alternatives.
  • Help to avoid relapses.

Case Study Example for Stages of Change

(U.S. Department of Health & Human Services et al., 2005)

A large company hires a health educator to plan a smoking cessation program for 200 employees who smoke. They offer free group smoking cessation clinics. However, only 50 of the smokers sign up for the clinics. How can they reach the 150 smokers who did not sign up? 

The Stages of Change Model suggests an approach, by understanding why they are not attending, and suggesting strategies to help them. By asking a few simple questions, the health educator can assess what stages of change the smokers are in. The following are some examples of questions that can be used in each stage:

• Are you interested in trying to quit smoking? (Pre-contemplation)
• Are you thinking about quitting smoking soon? (Contemplation)
• Are you ready to plan how you will quit smoking? (Preparation)
• Are you in the process of trying to quit smoking? (Action)
• Are you trying to stay smoke-free? (Maintenance)

The health educator can tailor messages and programs appropriate to their stage.

• Individuals who enjoy smoking are not interested in trying to quit, and therefore will not attend a smoking cessation clinic; an educational intervention about risks of smoking may help move them out of the precontemplation stage and into contemplation.
• Those who are thinking about quitting (contemplation stage) may need encouragement to sign up and enter the preparation stage.
• Individuals who are in the preparation stage can be helped to plan how to quit smoking and move into the action stage.
• Someone who already quit (action stage) may come to the classes for support in staying smoke-free (maintenance).

Best Fit Health Interventions for Stages of Change

Health Communication Strategies

• Description: presenting health messages can raise awareness to help move someone from precontemplation to contemplation.
• Examples:

• • Public service announcements about the need for vaccinations.
  • Billboards reminding people to wear seatbelts.
  • Campaigns to prevent drug overdose deaths with Naloxone.

Health Education Strategies

• Description: providing information on health risks can help move a person from contemplation to preparation.
• Examples:

• • Telling people with type 2 diabetes about risks of complications may motivate them to learn about better eating patterns.
  • Informing people with high blood pressure about the risk of stroke and heart disease may help them see the need for taking their prescribed medications.
  • Warning people of colon cancer risks may motivate them to schedule a colonoscopy.

Behavior Modification Activities

• Description: techniques to replace unhealthy behaviors with desirable habits, such as positive or negative reinforcement, will help support people at the action and maintenance stages.
• Examples:

• • Reminders and encouraging messages to help someone stop smoking.
  • Buying new clothes to reward yourself for losing weight.
  • Providing recognition awards for days of sobriety in Alcoholics Anonymous.

Additional Resources

Helping Populations Progress Through Stages of Change

References

U.S. Department of Health & Human Services, National Institutes of Health, & National Cancer Institute. (2005). Theory at a Glance: A guide for health promotion practice (2nd ed.). https://cancercontrol.cancer.gov/sites/default/files/2020-06/theory.pdf