Understanding the Transtheoretical Model (TTM)

Transtheoretical Model

TTM_two

 

 

Stages of change

Choosing a healthy diet as a life style can help someone who is looking to reach a leaner body achieve that physique. In fact, choosing a healthier life style can also help decrease the risk for cardiovascular disease, type 2 diabetes, but eating healthy will also help prevent overweight/ obesity and/or reverse it (Look AHEAD research group, 2007). Eating healthy and making it a life style is important for overall health. By putting proper nutrients into the body, it is able to utilize those nutrients to prevent cardiovascular disease, type 2 diabetes, prevent overweight/ obesity, and also to help those whom are trying to build muscle. The transtheoretical model and the components within the model is beneficial when it comes to risk weight management interventions and explains how individuals can change in each step of the process (Blue and Black, 2005).

The TTM is a model that utilizes multiple different theories of behavior view in order to change and uses those changes to interrogate processes and principles of change (Glanz et al, 2008). For this model to be truly successful, it has to be designed for someone in a specific stage, help them to progress in the model, provide barriers and ways to overcome those barriers that are common, and have an understanding that the barriers one might face in action are different than those in maintenance. There are four main constructs in TTM that help one to reach different stages of change. The first stage is, stage of change: having a temporal dimension, stating that changes will occur over a period of time; even the smallest progression, happens in time (Prochaska el al., 1992). Transitioning from an unhealthy lifestyle to a healthy life style takes time. If one were to do a drastic switch, one would have difficulty staying on track with their new lifestyle. Think of the last time you made a big change and how hard it was to not convert back to your old habits. Having the understanding that change takes time is important, but it is even more important to have an understanding of what those stages of change are.

The TTM has five recognized steps; pre-contemplation, contemplation, preparation, action, and maintenance. Pre-contemplation is the first stage in this model. People at this stage are not even considering the change. Some might be in denial that they don’t need to change or have tried and have been unsuccessful before so they have given up (Zimmerman et al. 2000). Some people, even if they have tried before, lack information that is needed in order to progress to the next stage. In this stage it would be beneficial to tailor information to that person. For example, talking to them about the benefit of transitioning to a healthy life style and sharing with them that even small changes can have a big impact on a certain component of their health that needs to be addressed; a patient who just had heart surgery. The point of this stage is to inform the participant and get them to transition in to the contemplation stage where they are thinking about making the change. In the contemplation stage the participant is now aware that a problem exists and are putting serious thought into making the change (Prochaska et al. 1992). Some people, healthy eating might be something they want to change just to see better definition in muscle, but for others it could be a matter of life and death. Many people could be in this stage for years before the progress to the preparation stage, but acknowledging the fact that change needs to happen and thinking about it is the step in the right direction. Many will experience barriers in this phase such as expressing that time or the money it takes to eat healthy is a limiting factor for them, but weighing the benefits is also important in order to reach the preparation stage (Zimmerman et al. 2000). The preparation stage is one that utilizes intention as well as behavior criteria to take the perceived action within a month and who have tried but failed to take action in the past (Prochaska et al. 1992). This is the stage where many people make their game plan to get them ready when taking action. For example, if someone is looking to make healthier life styles they might look at what is the unhealthiest for them and start by taking that out of their diet first. It could also be something as simple as finding recipes in magazines of healthy options. Once the preparation stage has been initiated, the next transition would be to the action stage, actually taking part in the change that they have been contemplating and preparing for. The action stage can be defined as which the participant modifies their behavior, experiences, or environment in order to make changes to the problem (Prochaska et al, 2008). For some participants they might have noticed that they consume a lot of sugary drinks, so taking little steps such as decreasing the amount of sugary drinks and choosing something with no sugar, like water. When your participant takes any type of action it is important that you praise them because they will then be more likely to continue that desired life style (Zimmerman et al. 2000). The last documented stage for the TTM is the maintenance stage. In this stage it is all about the prevention on relapse and incorporating it for the long term (Zimmerman et al, 2000). Most people sticking to a lifelong healthy lifestyle is hard, so the chance for relapse can happen, but if it does just know it’s okay to fall down but you have to pick yourself back up.

The second core construct of the TTM is the process of change. Processes of change is defined as, to convert and overt actions that people use to progress through each phase that will help them reach ones intended goal. There are ten reported processes of change that support people when progressing through each stage of change as previously mentioned. The first change is consciousness raising. This stage can increase awareness about the why and the how as well as informing people about the causes and the effects (Prochaska et al, 1992). By increasing the awareness of healthy eating, it can encourage people to start contemplating on the effects that healthy eating can have. Dramatic relief if a stage that utilizes emotions to progress to another stage (Prochaska et al, 1992). Self-reevaluation uses personal emotions on how one feels and thinks about themselves with respect to an issue (Prochaska et al., 2008). Personal emotion can help someone realize that they need to change and that it will be beneficial to their health if they contemplate, prepare, or take action on healthy eating habits. Environmental reevaluation is used to assess how the issue at hand can have an effect on the environment (Prochaska et al., 1992). This stage is proposed for one to become a role model for others around you, with the intention of being a positive role model. Being a role model can increase one’s self liberation. Self-liberation is described as the belief that once can change and commit to the change (Prochaska et al., 2008). This stage is proposed to show that someone is dedicated to the change that they are willing to make and they are fully committed to it. With healthy eating it can be challenging to stay full committed with all the temptations the environment presents. With the help of society, social liberation can help those whom are looking for a healthier eating style. Social liberation provides alternatives within society for those who need empowerment and an increase in opportunities (Prochaska et al, 1992). This process of change is essentially a procedure that helps people to change. For example, restaurants now have a section of their menus designated to low calorie healthier options, thus making it easier for those who are trying to live a healthy diet lifestyle can still be social and not relapse from a stage. Counterconditioning requires one to learn behaviors that can be beneficial and can substitute problem behaviors, such as positive self-statements (Prochaska, et al., 2008). Making positive self-statements can help someone who is making a change to keep them on track. If they are loving the progress they are making, they will be more inclined to proceed with that behavior. Stimulus control is another part of the process of change. This stage removes any possibly that might provoke one to fall victim to an unhealthy habit and replace it with an alternative that promotes the healthy habit (Prochaska et al., 1992). The purpose of this stage is to reduce the temptations by making then inaccessible and only making the healthy option available. The last two processes are contingency management and helping relationships. Contingency or reinforcement management provides a consequence for taking an action. Researchers have found that positive reinforcement works better when encouraging one to make a change (Prochaska et al., 2008). The purpose for this stage is to help keep the person on tract by acknowledging the changes they have made. Maybe they have lost weight and clothes are starting to fit baggier, so a positive reinforcement would be purchasing them a new outfit that fits, which would encourage them to continue on the right path. Contingency management and helping relationships can relate in such a way that the people whom are in your helping relationship can provide that contingency management. Helping relationship can be described as building trust, acceptance, and openness with a support group (Prochaska et al., 2008). The process is to help when one feels like they are about to stray from their healthy behavior. They are able to call upon their support group for advice, therapy, or counseling. When people are part taking in a healthy behavior it can be easy to resume back to old habits, but having an understanding of each process, people are able to know how the shift between each stage of change occurs. Weighing the pros and cons can also help one to change or prevent a relapse.

The last two core constructs are decisional balance and self-efficacy. During the decisional balance stage, people weight the pros and cons of changing in each stage (Prochaska et al., 2008). When deciding to eat healthy and making it a life style one can weigh the pros and cons of how eating healthy can provide a better figure and decrease diseases. Lastly, self-efficacy is having the confidence that one can cope with the high risk of possible relapse (Prochaska et al., 2008). So let’s talk about relapse. Relapse can occur in any stage and typically cause a complication in progression. With eating healthy this is one of the hardest things to avoid because there are so many temptations that can cause someone who is in the maintenance stage to fall back to the action stage. To get a better look at how people transitioned from one stage of change to another we can further evaluate case studies that provide evidence of how people transitioned.

 

Case Studies

If a person needs to change but is not thinking or denying that they need to take action in this change, how do you motivate them to transition from the pre-contemplation stage to the contemplation stage. This study did just that. The transition between the two stages were analyzed and 2 processes of change were used to help with that transition. This study looked at adults who were successful and unsuccessful in transitioning out of the pre-contemplation stage utilizing the self-liberation as a process of change (Horwath et al., 2013). The people who were unsuccessful were cut from the program for the future to see if the participants whom transitioned out of the pre-contemplation phase could also transition to the preparation phase later on. For this study participants were recruited who knew the benefits of a nutritious diet but had no intention to change. A baseline assessment was taken by calling the participants and having them part-take in 4 different questionnaires that assessed the pros and cons, self, efficacy, decisional balance, and the processes of change in consuming a healthier diet; all tests were valid (Horwath et al., 2013). Most of the participants were women and of an age 45 and older. Every 6 months’ new questionnaires were taken to track the progression of change. After all of the data was collected they discovered that there was a successful transition out of the pre-contemplation phase due to reported self-liberation, choosing or acting to believe in the ability of change (Horwath et al., 2013) and (Prochaska et al, 1992). This study solely relied on the self-liberation process to see if the knowledge of a healthy diet could liberate people enough to transition in to contemplating about a healthier diet. This study proved that over time, people who have enough knowledge about a behavior can transition from a stage or knowing they should or need to change but not doing anything about it, to actually thinking about it, and later down the line take action on that behavior. Once someone knows they need to make a change and are thinking about it they are now in the contemplation stage and then can progress to the preparation stage. This next study looks at just that.

In order to lose one pound, one needs to decrease their caloric intake by 500 calories per day to reach a total of 3500 calories or one pound. This study looked at the readiness of overweight/ obese adult participants who wanted to increase their fruits and vegetable levels, essentially part-taking in a healthier diet (Johnson et al., 2008). The reason overweight/ obese participants were selected was to see if healthy eating, exercise and management of stress could lower the body mass index of a person, essentially they were looking at if participants would lose weight. This study looked at multiple behaviors but focused largely on healthy eating habits (Johnson et al., 2008). Because this study was looking to see if there were transitions that got participants closer to the action and/or maintenance, those whom were already at that stage were excluded from the study (Johnson et al., 2008).

After taking all 1277 participants that applied, baseline assessments were completed over the phone and for months 3, 6, 9, 12 and 24 assessments were mailed to each individual to assess what stage of the TTM they were at (Johnson et al., 2008). Each individual was provided with a tailored report that focused on the core constructs of the TTM. This study focused on the contemplation and preparation stages, to see if there was a change in stage based on the interventions that were mailed out. This study utilized social liberation, providing a policy intervention to help one change, an unhealthy habit (Prochaska et al., 1992). The interventions were mailed out based on when the participants baseline test which determined when they were readiest to change (Johnson et al., 2008). Each report that was mailed out was tailored and provided the guidance of a counselor for those whom were prepared to change. Providing each participant with a helping relationship, it encouraged the participant to progress to the next stage because they had the help that was needed to transition (Johnson et al., 2008). This study offered multiple behavioral changes, but it was concluded that with the changes in healthier nutrition, there was also an increase in exercise as well as participants decreasing their stress levels. Thus concluding that with the help of a tailored plan that utilized both social liberation and helping relationships, people are successful when trying to transition closer to the action and maintenance stage. In order to get the physique that one wants it is important to consume a nutrition filled diet, but with exercise and less stress, one is able to achieve their desired physique.

One would think that with the knowledge of healthy nutrition one would be more inclined to partake in the action. This next study used the TTM to identify if taking a nutrition class would encourage student to transition into the preparation stage of a healthy diet (Reis et al. 2014). Undergraduate freshmen in college were the targeted population for this study. Each student that was enrolled into a freshman level nutrition class was asked to partake in this study but only 219 agreed to participate. This study student filled out a questionnaire to record what their current intake of fruits and vegetables. The students then started their classes for the semester and learned about the benefits of eating a healthy and balanced diet. This study focused on the consciousness raising aspect by increasing the information of the problem and providing observations (Prochaska et al., 1992) and (Rein et al., 2014). The findings of this study showed that with the help of a nutrition class 194 students transitioned from the contemplation stage to the preparation stage which increased their fruit and vegetable intake, thus decreasing their chances for a higher body mass index and cardiovascular disease (Reis et al., 2014). According to the findings provided for this study, it proved that the conscious ness raising of a nutrition class helps student transition into a new stage (Reis et al. 2014). This study hypothesized with the help of a nutrition class, students would transition to the preparation stage of the transtheoretical model, and they did. Along with every other study done, further research needs to be done in order to fully understand and have similar information.

 

Conclusion

Having a healthy and balanced diet is an important part to reaching the physique goals that one wants. Although all of these case studies looked at how the TTM worked in transitioning between stages utilizing the core constructs, each case study found a decrease in weight and inches around participant’s waist when transitioning to the next stage. Healthy eating is a hard behavior to maintain, so utilizing the different steps in the process of change, can help one to maintain a healthy eating behavior. Although the studies did not mention it there was a good possibility that participants relapsed when participating in this study. Most studies do not inform peers about the mortality of participants. But overall, the transtheoretical model has proven to be a beneficial model for people whom are intending to change and start a healthy diet lifestyle. With the many processes of change, there is one process that can work for anyone.

 

 

References 

Blue CL, Black DR. Synthesis of intervention research to modify physical activity and dietary behaviors. Res Theory Nurs Pract. 2005;19(1):25–61.

Glanz, K., Lewis, F. M., Rimer, B. K. (Eds.). (2008). Health behavior and health education  (4th ed.). San Francisco, CA: Jossey-Bass.

Horwath, C. C., Schembre, S. M., Motl, R. W., Dishman, R. K., & Nigg, C. R. (2013). Does the Transtheoretical Model of Behavior Change Provide a Useful Basis for Interventions to Promote Fruit and Vegetable Consumption? American Journal of Health Promotion : AJHP, 27(6), 10.4278/ajhp.110516–QUAN–201. http://doi.org/10.4278/ajhp.110516-QUAN-201

Johnson, S. S., Paiva, A. L., Cummins, C. O., Johnson, J. L., Dyment, S. J., Wright, J. A., … Sherman, K. (2008). Transtheoretical Model-based Multiple Behavior Intervention for Weight Management: Effectiveness on a Population Basis. Preventive Medicine, 46(3), 238–246. http://doi.org/10.1016/j.ypmed.2007.09.010

Look AHEAD Research Group. The look AHEAD study: A description of the lifestyle intervention and the evidence supporting it. Obesity. 2007a;14(5):737–752

Prochaska, J.O., DiClemente, C.C., Norcross, J.C., (1992). In Search of How People Change: Applications to Addictive Behavior. American Psychologist, 47(9), 1102-1114

Prochaska, J.O., Redding, C. A., Evers, K. E., (2008). The Transtheoretial Model and Stages of Change. Glanz, K., Rimer, B. K., Viswanath, K, Health Behavior and Healh Education (97-122). San Francisco: Joseey-Bass

Reis, Lígia Cardoso dos, Correia, Ingrid Chaves, & Mizutani, Edna Shibuya. (2014). Stages of changes for fruit and vegetable intake and their relation to the nutritional status of undergraduate students. Einstein (São Paulo), 12(1), 48-54. https://dx.doi.org/10.1590/S1679-45082014AO2926

Zimmerman, G.L., Olsen, C.G., Bosworth, M.F. (2000). A ‘Stage of Change’ Approach to Helping Patients Change Behavior. American Family Physician, 61(5),1409-1416

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