Behavior Change Tailoring: The Transtheoretical Model Kerry E. Evers, Ph.D. Pro-Change Behavior Systems, Inc.
Behavior Change
“Up to 40 percent of annual deaths from each of five leading US causes are preventable” CDC, Morbidity and Mortality Weekly Report, May 2014
• Health behavior change is a science • Health behavior change interventions should be grounded in a leading
theoretical model
Theore.cal Base
“Programs to influence health behavior, including health promo8on and educa8on programs and interven8ons, are most likely to benefit par8cipants and communi8es when the program or interven8on is guided by a theory of health behavior.” Glanz, et al., 2008 -‐
There is nothing as prac8cal as a good theory. Lewin, 1935
Glanz, K, et al (Eds.) (2008). Health Behavior and Health Educa4on: Theory, Research, and Prac4ce, 4th Edi4on. San Francisco, CA: Jossey-‐Bass
Lewin, K. (1935) A dynamic theory of personality. New York: McGraw-‐Hill.
“The transtheore.cal model has been around since the late 1970s but is no less powerful now and even has special u.lity when two-‐thirds of Americans are overweight or obese and 600,000 of us are killed by cardiovascular disease per year."
Dr. Oz, Time Magazine, October 2012
Google Search conducted 3/17/2014
184,000 results for “Transtheore.cal
Model”
442,000 results for “Stages of Change”
TTM in the Public Eye
• Search of PubMed Journal Articles • Pubmed 1983-Present: 14,617 • 2013 Alone: 1,129
• Search of Google Scholar • Stage of Change Model: 1,270 • Transtheoretical Model: 21,400
TTM in the Academic Literature
History of the TTM
• Smoking cessa.on • Stress management • Depression preven.on • Weight management • Exercise acquisi.on • Healthy diet • Responsible drinking • Medica.on adherence • Sun exposure • Mammography screening • Obesity preven.on • Debt Reduc.on
Transtheore.cal Model Applica.ons § Collabora.on in health care § Organ dona.on § Returning to work § Bullying preven.on § Juvenile delinquency § Da.ng violence § Domes.c violence § Advancing women scien.sts § Adop.on readiness § Professional prac.ces § Mastering change in the workplace § Pain Self Management § Informed decision making
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• Integrates ideas from several different theories and therapies • Involves progression through five stages of change:
§ Precontempla.on – Not yet ready § Contempla.on – Geing ready § Prepara.on -‐ Ready § Ac.on -‐ Doing the healthy behavior § Maintenance -‐ Keeping up the healthy behavior
• Certain principles and processes of change work best at each stage to reduce resistance and facilitate progress
Overview of the TTM
• is based on principles developed from over 35 years of scientific research, intervention development, and scores of empirical studies;
• applies the results of research funded by over $80 million worth of grants and conducted with over 150,000 research participants; and
• is currently in use by professionals around the world.
Transtheore.cal Model:
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"Most theories are about behavior, not about behavior change." – James O. Prochaska
• Index of readiness • Tells WHEN people change • Predicts who will change successfully • A dynamic, not static, client characteristic • Inclusive, empathic, optimistic • Guides member-treatment matching
Stage of Change
Not Ready Have no inten4on to start taking ac4on in next 6 months
Precontempla.on
Geing Ready Intend to start in next 6 months
Contempla.on
Ready
Prac4cing the behavior Intend to start in next 30 days
Prepara.on
Recently Started to Change Overt Behavior Consistently for less than 6 months
Ac.on
Has Overtly Changed Behavior Consistently for 6 months or more
Maintenance
Pros = Advantages Of Changing
Cons = Disadvantages Of Changing
Decisional Balance:
A growing awareness that the advantages (Pros) of changing outweigh the disadvantages (Cons)
How do people move from one stage to another?
Confidence
Degree to which individuals believe they can achieve a healthy goal even under temp.ng
situa.ons
DiClemente CC, Prochaska JO, Fairhurst SK, Velicer WF. The Process of Smoking Cessa.on: An Analysis of Precontempla.on, Contempla.on, and Prepara.on Stages of Change. J Consult Clin Psychol. 1991; 59:295-‐304.
Self-‐Efficacy
• HOW people change • Experiential and behavioral strategies and techniques used to change
behavior • Facilitate transitions between stages • Used as basis of intervention design
Processes of Change
Prochaska, J.O., DiClemente, C.C., & Norcross, J.C. (1992). In search of how people change: Applica.ons to addic.ve behaviors. American Psychologist, 47(9), 1102-‐1114.
Precontempla?on Contempla?on Prepara?on Ac?on Maintenance
Self-‐Reevalua?on
Self-‐Libera?on
Helping Rela?onships
Counter Condi?oning
Reinforcement Management
S?mulus Control
Social Libera?on
Drama?c Relief
Consciousness Raising
Environmental Reevalua?on
Processes of Change: The “How” of Change
GeNng the Facts
Use Subs?tutes
Make a Commitment
Get Support
Use Rewards
Manage your Environment
No?ce your Effects on Others
Pay AVen?on to Feelings
Create a New Self-‐Image
No?ce Social Trends
Experiential
Behavioral
One Size Fits All Targeted
Stage Matched Ac?on Oriented
Levels of Tailoring
Precontempla?on Contempla?on Prepara?on Ac?on Maintenance
Environmental Reevalua?on No?ce your Effects on Others
Precontempla?on Contempla?on Prepara?on Ac?on Maintenance
Drama?c Relief Pay AVen?on to Feelings
Precontempla?on Contempla?on Prepara?on Ac?on Maintenance
Helping Rela?onships Get Support
Prepara?on Ac?on Maintenance
Reinforcement Management Use Rewards
Contempla?on Prepara?on Ac?on Maintenance
S?mulus Control Manage your Environment
A-CHESS (Addiction – Comprehensive Health Enhancement Support System)
Personal Ac.vity Center (PAC)
Stage Matched Feedback
One Size Fits All Targeted Tailored
Stage Matched Stage + Pros + Cons + Self-‐Efficacy + 10 Processes
Ac?on Oriented
Depth of Tailoring
Hall, K. L. & Rossi, J. S. (2008). Meta-‐analy.c examina.on of the strong and weak principles across 48 health behaviors. Preven4ve Medicine, 46, 266-‐274.
The Pros & Cons of Changing Across Stage of Change: 48 Behaviors
Confidence
Degree to which individuals believe they can achieve a healthy goal even under temp.ng
situa.ons
DiClemente CC, Prochaska JO, Fairhurst SK, Velicer WF. The Process of Smoking Cessa.on: An Analysis of Precontempla.on, Contempla.on, and Prepara.on Stages of Change. J Consult Clin Psychol. 1991; 59:295-‐304.
Self-‐Efficacy
Computer-‐Tailored Interven.ons (CTI)
Reliable, valid assessments of most important behavior change constructs
Evidence-‐based, sta.s.cally-‐derived decision-‐making rules
Individualized, tailored behavior change guidance
Feedback dynamically updated based on new
assessment data
Questions
Internet-based expert system Data collection/analysis/feedback/assessment
Responses
Tailored Feedback
Individuals
0
5
10
15
20
25
Precontemplation Contemplation
Norma.ve Tailoring
0
5
10
15
20
25
30
35
Precontemplation Contemplation Preparation Action Maintenance
Rate of Change
Rate of Change
Rate of Change
Norma.ve & Ipsa.ve Clinical Guidance
Norma.ve & Ipsa.ve Tailored Feedback
Processes Feedback: Sample Screen
• Fred Pennic Outlined findings from Mobiuity Report • Create an individualized solu.on • Analy.c models that trigger the appropriate interven.ons and outcomes for each user
• Personalized communica.ons to increase engagement • Low-‐effort data collec.on
4 Best Prac.ces for Crea.ng Behavior Changing Mobile Health Apps
hop://www.hitconsultant.net/2013/07/26/4-‐best-‐prac.ces-‐for-‐crea.ng-‐behavior-‐changing-‐mobile-‐health-‐apps/
• Theore.cal variables that produce large effect sizes when included in tailored communica.ons compared to tailored communica.ons that exclude these variables:
§ Stages of Change § Pros and Cons of Changing § Self-‐Efficacy § Processes of Change § Aitudes § Social Support
Tailored Communica.ons that Tailor Each of the Following Variables
Theore.cal Variables that Produce Smaller Effect Sizes
Perceived Suscep.bility
Noar, S. M., Benac, C. N., & Harris, M. S. (2007). Does tailoring maoer? Meta-‐analy.c review of tailored print health behavior change interven.ons. Psychological Bulle4n, 133, 673-‐693.
Theore.cal Variables that DO NOT Make a Difference
Behavior Inten.ons
Social Norms
Noar, S. M., Benac, C. N., & Harris, M. S. (2007). Does tailoring maoer? Meta-‐analy.c review of tailored print health behavior change interven.ons. Psychological Bulle4n, 133, 673-‐693.
Number of Tailoring Variables that make a difference
0-‐2 < 3-‐5 > 6-‐9
Compara.ve Outcomes of Interven.ons
Johnson, J.L., Prochaska, J.O., Paiva, A.L., Fernandez, A.C., DeWees, S.L., and Prochaska, J.M. (2013) Advancing Bodies of Evidence for Popula.on-‐based Health Promo.on Programs: Randomized Controlled Trials and Case Studies. Popula4on Health Management, 16(6), 373-‐380.
Well-‐Being: Change Over Time
Prochaska, J.O., Evers, K.E., Castle, P.H., Johnson, J.L., Prochaska, J.M., Rula, E.Y., Coberley, C., & Pope, J.E. (2012). Enhancing Mul.ple Domains of Well-‐being by Decreasing Mul.ple Health Risk Behaviors: A Randomized Clinical Trial. Popula4on Health Management, 15 (5), 276-‐286.
Improvements in Well-‐Being
Overall Individual Domains
Prochaska, J.O., Evers, K.E., Castle, P.H., Johnson, J.L., Prochaska, J.M., Rula, E.Y., Coberley, C., & Pope, J.E. (2012). Enhancing Mul.ple Domains of Well-‐being by Decreasing Mul.ple Health Risk Behaviors: A Randomized Clinical Trial. Popula4on Health Management, 15 (5), 276-‐286.
Contacts
Pro-‐Change Behavior Systems, Inc. • www.prochange.com
Online Basic Transtheore?cal Model Training • www.prochange.com/e-learning
Demo of Domes?c Violence Program • www.prochange.com/domesticviolencedemo
Demo of Healthy Pregnancy Program • www.prochange.com/pregnancydemo
Coaches Guide for Using TTM with Clients • www.prochange.com
Online MyHealth Behavior Change Programs • www.prochange.com/myhealth
Mastering Change in the Workplace • www.prochange.com/products
Janice M. Prochaska • [email protected]