Documente Academic
Documente Profesional
Documente Cultură
The following is subject to Copyright 2000 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material
and may use that printout only for his or her personal, non-commercial reference. This material may
not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium,
whether now known or later invented, except as authorized in writing by the AAFP. Contact
afpserv@aafp.org for copyright questions and/or permission requests.
2 | Page40
One role of family physicians is to assist patients in understanding their health and
to help them make the changes necessary for health improvement. Exercise
programs, stress management techniques and dietary restrictions represent some
common interventions that require patient motivation. A change in patient lifestyle is
necessary for successful management of long-term illness, and relapse can often be
attributed to lapses in healthy behaviour by the patient. Patients easily understand
lifestyle modifications (i.e., "I need to reduce the fat in my diet in order to control my
weight.") but consistent, life-long behaviour changes are difficult.
Much has been written about success and failure rates in helping patients change,
about barriers to change and about the role of physicians in improving patient
outcomes. Recommendations for physicians helping patients to change have ranged
from the "just do it" approach to suggesting extended office visits, often
incorporating behaviour modification, record-keeping suggestions and follow-up
telephone calls. Repeatedly educating the patient is not always successful and can
become frustrating for the physician and patient. Furthermore, promising patients
an improved outcome does not guarantee their motivation for long-term change.
Patients may view physicians who use a confrontational approach as being critical
rather than supportive. Relapse during any treatment program is sometimes viewed
as a failure by the patient and the physician. A feeling of failure, especially when
repeated, may cause patients to give up and avoid contact with their physician or
avoid treatment altogether. After physicians invest time and energy in promoting
change, patients who fail are often labelled "noncompliant" or "unmotivated."
Labelling a patient in this way places responsibility for failure on the patient's
character and ignores the complexity of the behaviour change process.
1-3
3 | Page40
7-10
11-16
17,18
Understanding Change
Physicians should remember that behaviour change is rarely a discrete, single event.
Physicians sometimes see patients who, after experiencing a medical crisis and being
advised to change the contributing behaviour, readily comply. More often, physicians
encounter patients who seem unable or unwilling to change. During the past decade,
behaviour change has come to be understood as a process of identifiable stages
through which patients pass. Physicians can enhance those stages by taking specific
action. Understanding this process provides physicians with additional tools to assist
patients, who are often as discouraged as their physicians with their lack of change.
The Stages of Change model shows that, for most persons, a change in behaviour
occurs gradually, with the patient moving from being uninterested, unaware or
unwilling to make a change (pre-contemplation), to considering a change
(contemplation), to deciding and preparing to make a change. Genuine, determined
action is then taken and, over time, attempts to maintain the new behaviour occur.
Relapses are almost inevitable and become part of the process of working toward
life-long change.
4
Pre-contemplation Stage
During the pre-contemplation stage, patients do not even consider changing.
Smokers who are "in denial" may not see that the advice applies to them personally.
Patients with high cholesterol levels may feel "immune" to the health problems that
strike others. Obese patients may have tried unsuccessfully so many times to lose
weight that they have simply given up.
4 | Page40
Contemplation Stage
During the contemplation stage, patients are ambivalent about changing. Giving up
an enjoyed behaviour causes them to feel a sense of loss despite the perceived gain.
During this stage, patients assess barriers (e.g., time, expense, hassle, fear, "I know I
need to, doc, but ...") as well as the benefits of change.
Preparation Stage
During the preparation stage, patients prepare to make a specific change. They may
experiment with small changes as their determination to change increases. For
example, sampling low-fat foods may be an experimentation with or a move toward
greater dietary modification. Switching to a different brand of cigarettes or
decreasing their drinking signals that they have decided a change is needed.
Action Stage
The action stage is the one that most physicians are eager to see their patients reach.
Many failed New Year's resolutions provide evidence that if the prior stages have
been glossed over, action itself is often not enough. Any action taken by patients
should be praised because it demonstrates the desire for lifestyle change.
Maintenance and Relapse Prevention
Maintenance and relapse prevention involve incorporating the new behaviour "over
the long haul." Discouragement over occasional "slips" may halt the change process
and result in the patient giving up. However, most patients find themselves
"recycling" through the stages of change several times before the change becomes
truly established.
The Stages of Change model encompasses many concepts from previously
developed models. The Health Belief model, the Locus of Control model and
behavioural models fit together well within this framework. During the precontemplation stage, patients do not consider change. They may not believe that
their behaviour is a problem or that it will negatively affect them (Health Belief
Model ), or they may be resigned to their unhealthy behaviour because of previous
failed efforts and no longer believe that they have control (external Locus of
Control ). During the contemplation stage, patients struggle with ambivalence,
weighing the pros and cons of their current behaviour and the benefits of and
barriers to change (Health Belief model ). Cognitive-behavioural models of change
(e.g., focusing on coping skills or environmental manipulation) and 12-Step
programs fit well in the preparation, action and maintenance stages (Table 1).
4
19
20
19
20
19
4,6
5 | Page40
TABLE 1
Stages of Change Model
Stage in Transtheoretical
Incorporating other
model of change
Patient stage
explanatory/treatment models
Pre-contemplation
Locus of Control
May be resigned
Feeling of no control
Motivational interviewing
Motivational interviewing
Preparation
Action
Cognitive-behavioural therapy
change
12-Step program
Cognitive-behavioural therapy
time
12-Step program
Motivational interviewing
process of change
12-Step program
Maintenance
Relapse
Interventions
6 | Page40
21
22-27
7 | Page40
TABLE 3
Questions for Patients in the Pre-contemplation and Contemplation Stages*
Pre-contemplation stage
Goal: patient will begin thinking about change.
"What would have to happen for you to know that this is a problem?"
"What warning signs would let you know that this is a problem?"
"Have you tried to change in the past?"
Contemplation stage
Goal: patient will examine benefits and barriers to change.
"Why do you want to change at this time?"
"What were the reasons for not changing?"
"What would keep you from changing at this time?"
"What are the barriers today that keep you from change?"
"What might help you with that aspect?"
"What things (people, programs and behaviours) have helped in the past?"
"What would help you at this time?"
"What do you think you need to learn about changing?"
*--The change can be applied to any desirable behaviour (e.g., smoking or drinking cessation, losing
weight, exercise).
Information from Miller WR, Rollnick S. Motivational interviewing: preparing people to change
addictive behavior. New York: Guilford, 1991:191-202.
8 | Page40
Additional Tools
Two techniques useful in the primary care setting are the Readiness to Change Ruler
and the Agenda-Setting Chart. The Readiness to Change Ruler, which is
incorporated in Figure 1, is a simple, straight line drawn on a paper that represents
a continuum from the left "not prepared to change" to the right "ready to change."
26,27
4,26,27
9 | Page40
/ Already changing
10 | P a g e 4 0
Pick one of the barriers to change and list some things that could help you overcome this barrier.
Pick one of those things that could help and decide to do it by _______________________ (write in
a specific date).
If you've taken a serious step in making a change:
3. The following are stages people go through in making important changes in their health
behaviours. All the stages are important. We learn from each stage.
We go from "not thinking about it" to "weighing the pros and cons" to "making little changes and
figuring out how to deal with the real hard parts" to "doing it!" to "making it part of our lives. "
Many people "fall off the wagon" and go through all the stages several times before the change really
lasts.
FIGURE 1.The Readiness to Change Ruler can be used with patients contemplating any desirable
behaviour, such as smoking cessation, losing weight, exercise or substance-abuse cessation.
Information from references 4, 26 and 27.
11 | P a g e 4 0
Involving Others
While no research is available that uses the Stages of Change model in teaching
families how to intervene with their loved one's health-risk behaviour, training about
this model may help family members view the situation differently.
Physicians can enlist the help of other health care professionals (e.g., nutritionists,
nurses, mental health personnel) to reinforce the message that a change in behaviour
is needed and to provide additional education and skill information to the patient.
Referral can also reduce some patient care burden for physicians. Physicians should
document the content and outcome of patient conversations, including specific tasks
and plans for follow-up.
4
Final Comment
Family physicians need to develop techniques to assist patients who will benefit from
behaviour change. Traditional advice and patient education does not work with all
patients. Understanding the stages through which patients pass during the process
of successfully changing a behaviour enables physicians to tailor interventions
individually. These methods can be applied to many areas of health changing
behaviour.
Members of various medical faculties develop articles for "Practical Therapeutics." This article is one
in a series coordinated by the Department of Family Medicine at Wright State University School of
Medicine, Dayton, Ohio. Guest editors of this series are Cynthia G. Olsen, M.D., and Gordon
S.Walbroehl, M.D.
The Authors
GRETCHEN L. ZIMMERMAN, PSY.D.,
is an assistant professor in the Department of Family Medicine at Wright State
University School of Medicine, Dayton, Ohio. She is also a faculty member in the
Dayton Community Family Practice Residency Program. She received a doctorate in
psychology at Wright State University School of Professional Psychology in Dayton.
CYNTHIA G. OLSEN, M.D.,
is a professor and executive vice-chair in the Department of Family Medicine, Wright
State University School of Medicine, where she obtained her medical degree. She
completed a family practice residency at Good Samaritan Hospital in Dayton.
MICHAEL F. BOSWORTH, D.O.,
is an associate professor in the Department of Family Medicine, Wright State
University School of Medicine, and residency director of the Dayton Community
12 | P a g e 4 0
REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Miller NH, Smith PM, DeBusk RF, Sobel DS, Taylor CB. Smoking cessation in hospitalized
patients. Arch Intern Med 1997;157:409-15.
Kahan M, Wilson L, Becker L. Effectiveness of physician-based interventions with problem
drinkers: a review. CMAJ 1995;152:851-9.
Glynn TJ, Manley MW. How to help your patients stop smoking: a National Cancer Institute
Manual for Physicians. U.S. Department of Health and Human Services, Public Health Service,
National Institutes of Health, National Cancer Institute, Division of Cancer Prevention and Control.
NIH publication no. 95-3064;1995.
Prochaska JO, DiClemente CC, Norcross JC. In search of how people change. Am Psychol
1992; 47:1102-4.
Miller WR. What really drives change? Addiction 1993;88:1479-80.
Miller WR, Rollnick S. Motivational interviewing: preparing people to change addictive
behavior. New York: Guilford, 1991.
Prochaska JO, Velicer WF, Rossi JS, Goldstein MG, Marcus BH, Rakowski W, et al. Stages of
change and decisional balance for 12 problem behaviors. Health Psychol 1994;13:39-46.
Grimley DM, Riley GE, Bellis JM, Prochaska JO. Assessing the stages of change and decisionmaking for contraceptive use for the prevention of pregnancy, sexually transmitted diseases, and
acquired immunodeficiency syndrome. Health Educ Q 1993;29:455-70.
Hellman EA. Use of the stages of change in exercise adherence model among older adults
with a cardiac diagnosis. J Cardiopulm Rehabil 1997;17:145-55.
Glanz K, Patterson RE, Kristal AR, DiClemente CC, Heimendinger J, Linnan L, et al. Stages of
change in adopting healthy diets: fat, fiber, and correlates of nutrient intake. Health Educ Q
1994;21:499-519.
Hughes JR. An algorithm for smoking cessation. Arch Fam Med 1994;3:280-5.
Barnes HN, Samet JH. Brief interventions with substance-abusing patients. Med Clin North
Am 1997;81:867-79.
Campbell MK, DeVellis BM, Strecher VJ, Ammerman AS, DeVellis RF, Sandler RS. Improving
dietary behavior: the effectiveness of tailored messages in primary care settings. Am J Public
Health 1994; 84:783-7.
Calfas KJ, Sallis JF, Oldenburg B, French M. Mediators of change in physical activity following
an intervention in primary care: PACE. Prev Med 1997;26:297-304.
Weinstein ND, Lyon JE, Sandman PM, Cuite CL. Experimental evidence for stages of health
behavior change: the precaution adoption process model applied to home radon testing. Health
Psychol 1998;17:445-53.
Cabral RJ, Galavotti C, Gargiullo PM, Armstrong K, Cohen A, Gielen AC, et al.
Paraprofessional delivery of a theory based HIV prevention counseling intervention for women.
Public Health Rep 1996: 111(suppl 1):75-82.
A cross-national trial of brief interventions with heavy drinkers. WHO Brief Intervention
Study Group. Am J Public Health 1996;86:948-55.
13 | P a g e 4 0
Oliansky DM, Wildenhaus KJ, Manlove K, Arnold T, Schoener EP. Effectiveness of brief
interventions in reducing substance use among at-risk primary care patients in three communitybased clinics. Substance Abuse 1997;18:95-103.
19.
Janz NK, Becker MH. The Health Belief Model: a decade later. Health Educ Q 1984;11:1-47.
20.
21.
22.
23.
24.
25.
26.
27.
Transtheoretical model
The Transtheoretical model in health psychology assesses an individual's readiness
to act on a new healthier behavior, and provides strategies, or processes of change to
guide the individual through the stages of change to action and maintenance.
The Transtheoretical model is also known by the acronym "TTM" and by the term
"stages of change model." A popular book and articles in the news media have
discussed the model. It is "arguably the dominant model of health behaviour change,
having received unprecedented research attention, yet it has simultaneously
attracted exceptional criticism."
Action "people have made specific overt modifications in their life styles
within the past 6 months"
15 | P a g e 4 0
To progress through the early stages, people apply cognitive, affective, and
evaluative processes. As people move toward maintenance or termination, they rely
more on commitments, conditioning, contingencies, environmental controls, and
support.
Prochaska and colleagues state that their research related to the Transtheoretical
model suggests that interventions to change behavior must be "stage-matched," that
is, "matched to each individual's stage of change.
Decisional balance
This core construct "reflects the individual's relative weighing of the pros and cons of
changing.
Self-efficacy
This core construct is "the situation-specific confidence people have that they can
cope with high risk situations without relapsing to their unhealthy or high risk habit.
Temptation
This core construct "reflects the intensity of urges to engage in a specific habit when
in the midst of difficult situations.
Controversy
Among the criticisms of the model are the following:
16 | P a g e 4 0
The model makes predictions that are "incorrect or worse than competing
theories."
The model "assumes that individuals typically make coherent and stable
plans," when in fact they do not.
17 | P a g e 4 0
The designs of many studies supporting the model have been cross-sectional,
but longitudinal study data would allow for stronger causal inferences.
Many studies that show the model to be ineffective have tailored interventions
only to stage of change; if the studies had tailored interventions based on all
core constructs of the model, they might have shown positive findings. In
particular, the "processes of change" have been characterized as "underresearched." A 2007 meta-analysis of tailored print health behavior change
interventions found that the "number and type of theoretical concepts tailored
on," including stage of change and processes of change, were associated with
behavior change. In 2008 Hutchison and colleagues published a systematic
review of 34 articles examining 24 interventions based on the Transtheoretical
model for behavior change in physical activity; only 7 of the 24 interventions
addressed all four dimensions "stages of change," "processes of change,"
"decisional balance," and "self-efficacy."
Studies that find the model ineffective are poorly designed; for example, they
have small sample sizes, poor recruitment rates, or high loss to follow-up. The
conversion of continuous data into discrete categories is necessary for the
model, similar to how decisions are made about the treatment of high
cholesterol levels depending on the discrete category the cholesterol level is
placed into.
Notes
The following notes summarize major differences between the well-known 1983,
1992, and 1997 versions of the model. Other published versions may contain other
differences. For example, Prochaska, Prochaska, and Levesque (2001) do not mention
the Termination stage, Self-efficacy, or Temptation.
1.
2. In the 1983 version of the model, the Termination stage is absent. In the 1992 version
of the model, Prochaska et al. showed Termination as the end of their "Spiral Model
of the Stages of Change," not as a separate stage.
18 | P a g e 4 0
References
1. Prochaska, JO; Butterworth, S; Redding, CA; Burden, V; Perrin, N; Leo, M; FlahertyRobb, M; Prochaska, JM. Initial efficacy of MI, TTM tailoring and HRI's with multiple
behaviors for employee health promotion. Prev Med 2008 Mar;46(3):22631. Accessed
2009 Mar 21.
2. Greene, GW; Rossi, SR; Rossi, JS; Velicer, WF; Fava, JL; Prochaska, JO. Dietary
applications of the stages of change model. J Am Diet Assoc 1999 Jun;99(6):6738.
Accessed 2009 Mar 21.
3. Pro-Change Behavior Systems. About us. Transtheoretical model. 2008 Mar. Accessed
2009 Mar 21.
4. Prochaska, JO; Norcross, JC; DiClemente, CC. Changing for good: the revolutionary
program that explains the six stages of change and teaches you how to free yourself
from bad habits. New York: W. Morrow; 1994. ISBN 0688112633.
5. Goleman, Daniel. New addiction approach gets results. New York Times 1993 Sep 1.
Accessed 2009 Mar 19.
6. Miller, Kay. Revolving resolutions - Year after new year, we vow to lose weight, stop
smoking, find love or a better job -- only to fail. A few simple strategies could set us
straight. Star Tribune: Newspaper of the Twin Cities 2001 Dec 29.
7. Stettner, Morey. A methodical way to change bad behavior. Investor's Business Daily
2005 Dec 19.
19 | P a g e 4 0
Further reading
22 | P a g e 4 0
Miller, WR; Heather, N. (eds.). Treating addictive behaviors. 2nd ed. New York:
Plenum Press; 1998. ISBN 0306458527.
Connors, GJ; Donovan, DM; DiClemente, CC. Substance abuse treatment and the
stages of change: selecting and planning interventions. New York: Guilford Press;
2001. ISBN 1572306572.
Burbank, PM; Riebe, D. Promoting exercise and behavior change in older adults:
interventions with the transtheoretical model. New York: Springer; 2002. ISBN
0826115020.
DiClemente, CC. Addiction and change: how addictions develop and addicted
people recover. New York: Guilford Press; 2003. ISBN 1572300574.
Glanz, K; Rimer, BK; Viswanath, K. (eds.) Health behavior and health education:
theory, research, and practice, 4th ed. San Francisco, CA: Jossey-Bass; 2008. ISBN
9780787996147.
External links
23 | P a g e 4 0
24 | P a g e 4 0
26 | P a g e 4 0
Figure 1. The Temporal Dimension as the Basis for the Stages of Change
Regression occurs when individuals revert to an earlier stage of
change. Relapse is one form of regression, involving regression from
Action or Maintenance to an earlier stage. However, people can
regress from any stage to an earlier stage. The bad news is that
relapse tends to be the rule when action is taken for most health
behaviour problems. The good news is that for smoking and exercise
only about 15% of people regress all the way to the Pre-contemplation
stage. The vast majority regress to Contemplating or Preparation.
In a recent study (Velicer, Fava, Prochaska, Abrams, Emmons, &
Pierce, 1995), it was demonstrated that the distribution of smokers
across the first three Stages of Change was approximately identical
across three large representative samples. Approximately 40% of the
smokers were in the Pre-contemplation stage, 40% were in the
Contemplation stage, and 20% were in the Preparation stage.
However, the distributions may be different in different countries. A
recent paper (Etter, Perneger, & Ronchi, 1997) summarized the stage
distributions from four recent samples from different countries in
Europe (one each from Spain and the Netherlands, and two from
Switzerland). The distributions were very similar across the European
samples but very different from the American samples. In the
European samples, approximately 70% of the smokers were in the
Pre-contemplation stage, 20% were in the Contemplation stage, and
10% were in the Preparation stage.
While the stage distributions for smoking cessation have now been
28 | P a g e 4 0
Figure 2. The Relationship between Stage and the Decisional Balance for an
Unhealthy Behaviour
A different pattern has been observed for the acquisition of healthy
behaviours. Figure 3 illustrates this pattern for exercise. The patterns
are similar across the first three stages. However, for the last two
stages, the Pros of exercising remain high. This probably reflects the
fact that maintaining a program of regular exercise requires a
continual series of decisions while smoking eventually becomes
irrelevant. These two scales capture some of the cognitive changes
that are required for progress in the early stages of change.
Figure 3. The Relationship between Stage and the Decisional Balance for a
Healthy Behaviour
Self-efficacy/Temptations. The Self-efficacy construct represents the
30 | P a g e 4 0
situation specific confidence that people have that they can cope with
high-risk situations without relapsing to their unhealthy or high-risk
habit. This construct was adapted from Bandura's self-efficacy theory
(Bandura, 1977, 1982). This construct is represented either by a
Temptation measure or a Self-efficacy construct.
The Situational Temptation Measure (DiClemente, 1981, 1986; Velicer,
DiClemente, Rossi, & Prochaska, 1990) reflects the intensity of urges
to engage in a specific behaviour when in the midst of difficult
situations. It is, in effect, the converse of self-efficacy and the same set
of items can be used to measure both, using different response
formats. The Situational Self-efficacy Measure reflects the confidence
of the individual not to engage in a specific behaviour across a series
of difficult situations.
Both the Self-efficacy and Temptation measures have the same
structure (Velicer et al., 1990). In our research we typically find three
factors reflecting the most common types of tempting situations:
negative affect or emotional distress, positive social situations, and
craving. The Temptation/Self-efficacy measures are particularly
sensitive to the changes that are involved in progress in the later
stages and are good predictors of relapse.
Self-efficacy can be represented by a monotonically increasing
function across the five stages. Temptation is represented by a
monotonically decreasing function across the five stages. Figure 4
illustrates the relation between stage and these two constructs.
31 | P a g e 4 0
32 | P a g e 4 0
_____________________________________________________________
_
References
Bandura, A. (1977). Self-efficacy: Toward a unifying theory of
behaviour change. Psychological Review, 84, 191-215.
Bandura, A. (1982). Self-efficacy mechanism in human agency.
American Psychologist, 37, 122-147.
Bollen, K. A. (1989). A new incremental fit index for general structural
equation models. Sociological Methods of Research, 17, 303-316.
Botelho, R. J., Velicer, W. F., & Prochaska, J. O. (1998). Expert systems
for motivating health behavior change: II. Evaluating the future
prospects for dissemination. Manuscript under review.
Cohen, J. (1977). Statistical power analysis for the behavioural
37 | P a g e 4 0
38 | P a g e 4 0
Fava, JL, Velicer, WF, & Prochaska, JO. (1995). Applying the
Transtheoretical Model to a representative sample of smokers.
Addictive Behaviours, 20, 189-203.
Fiore, M. C., Smith, S. S., Jorenby, D. E., & Baker, T. B. (1994). The
effectiveness of the nicotine patch for smoking cessation: A metaanalysis. Journal of the American Medical Association, 271, 19401947.
Flay, B. R. (1985). Psychosocial approaches to smoking prevention: A
review of findings. Health Psychology, 4, 449-488.
Jackson, D. N. (1970). A sequential system for personality scale
development. In CD Spielberger, (ed.), Current topics in community
and clinical psychology, Vol. 2. Orlando, FL: Academic Press, pp. 6196.
Jackson, D. N. (1971). The dynamics of structured personality tests.
Psychological Review, 78, 229-248.
Janis, I. L., & Mann, L. (1977). Decision making: A psychological
analysis of conflict, choice and commitment. New York: Free Press.
Johnson, S. S., Norman, G. J., & Fava, J. L. (1998). Are Subjects in
Maintenance for Stress Management at Risk for Relapse? Paper
presented at the Nineteenth Annual Scientific Sessions of the Society
of Behavioural Medicine, New Orleans, March.
Jreskog, K. C., & Srbom, D. (1989). LISREL 7: A guide to the
program and applications. (2nd ed.). Chicago: SPSS Inc.
Kohut, F.J., Berkman, L.F., Evans, D. A., & Cornoni-Huntley, J. (1993)
Two shorter forms of the CES-D Depression Symptoms Index. Journal
of Aging and Health, 5, 179-193.
Lazarus, R. S. (1966). Psychological stress and the coping process.
New York: McGraw-Hill Book Co.
Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal and coping.
New York: Springer Publishing Co.
Leventhal, H. & Cleary, P. D. (1980). The smoking problem: A review
39 | P a g e 4 0
42 | P a g e 4 0
43 | P a g e 4 0