The Transtheoretical Model (Stages of Change)

The Transtheoretical Model (also called the Stages of Change Model), developed by Prochaska and DiClemente in the late 1970s, evolved through studies examining the experiences of smokers who quit on their own with those requiring further treatment to understand why some people were capable of quitting on their own. It was determined that people quit smoking if they were ready to do so. Thus, the Transtheoretical Model (TTM) focuses on the decision-making of the individual and is a model of intentional change. The TTM operates on the assumption that people do not change behaviors quickly and decisively. Rather, change in behavior, especially habitual behavior, occurs continuously through a cyclical process. The TTM is not a theory but a model; different behavioral theories and constructs can be applied to various stages of the model where they may be most effective.

The TTM posits that individuals move through six stages of change: precontemplation, contemplation, preparation, action, maintenance, and termination. Termination was not part of the original model and is less often used in application of stages of change for health-related behaviors. For each stage of change, different intervention strategies are most effective at moving the person to the next stage of change and subsequently through the model to maintenance, the ideal stage of behavior.

Precontemplation - In this stage, people do not intend to take action in the foreseeable future (defined as within the next 6 months). People are often unaware that their behavior is problematic or produces negative consequences. People in this stage often underestimate the pros of changing behavior and place too much emphasis on the cons of changing behavior.

Contemplation - In this stage, people are intending to start the healthy behavior in the foreseeable future (defined as within the next 6 months). People recognize that their behavior may be problematic, and a more thoughtful and practical consideration of the pros and cons of changing the behavior takes place, with equal emphasis placed on both. Even with this recognition, people may still feel ambivalent toward changing their behavior.

Preparation (Determination) - In this stage, people are ready to take action within the next 30 days. People start to take small steps toward the behavior change, and they believe changing their behavior can lead to a healthier life.

Action - In this stage, people have recently changed their behavior (defined as within the last 6 months) and intend to keep moving forward with that behavior change. People may exhibit this by modifying their problem behavior or acquiring new healthy behaviors.

Maintenance - In this stage, people have sustained their behavior change for a while (defined as more than 6 months) and intend to maintain the behavior change going forward. People in this stage work to prevent relapse to earlier stages.

Termination - In this stage, people have no desire to return to their unhealthy behaviors and are sure they will not relapse. Since this is rarely reached, and people tend to stay in the maintenance stage, this stage is often not considered in health promotion programs.

To progress through the stages of change, people apply cognitive, affective, and evaluative processes. Ten processes of change have been identified with some processes being more relevant to a specific stage of change than other processes. These processes result in strategies that help people make and maintain change.

Consciousness Raising - Increasing awareness about the healthy behavior.

Dramatic Relief - Emotional arousal about the health behavior, whether positive or negative arousal.

Self-Reevaluation - Self reappraisal to realize the healthy behavior is part of who they want to be.

Environmental Reevaluation - Social reappraisal to realize how their unhealthy behavior affects others.

Social Liberation - Environmental opportunities that exist to show society is supportive of the healthy behavior.

Self-Liberation - Commitment to change behavior based on the belief that achievement of the healthy behavior is possible.

Helping Relationships - Finding supportive relationships that encourage the desired change.

Counter-Conditioning - Substituting healthy behaviors and thoughts for unhealthy behaviors and thoughts.

Reinforcement Management - Rewarding the positive behavior and reducing the rewards that come from negative behavior.

Stimulus Control - Re-engineering the environment to have reminders and cues that support and encourage the healthy behavior and remove those that encourage the unhealthy behavior.

Limitations of the Transtheoretical Model

There are several limitations of TTM, which should be considered when using this theory in public health. Limitations of the model include the following:

The theory ignores the social context in which change occurs, such as SES and income.

The lines between the stages can be arbitrary with no set criteria of how to determine a person's stage of change. The questionnaires that have been developed to assign a person to a stage of change are not always standardized or validated.

There is no clear sense for how much time is needed for each stage, or how long a person can remain in a stage.

The model assumes that individuals make coherent and logical plans in their decision-making process when this is not always true.

The Transtheoretical Model provides suggested strategies for public health interventions to address people at various stages of the decision-making process. This can result in interventions that are tailored (i.e., a message or program component has been specifically created for a target population's level of knowledge and motivation) and effective. The TTM encourages an assessment of an individual's current stage of change and accounts for relapse in people's decision-making process.

The Social Norms Theory was first used by Perkins and Berkowitz in 1986 to address student alcohol use patterns. As a result, the theory, and subsequently the social norms approach, is best known for its effectiveness in reducing alcohol consumption and alcohol-related injury in college students. The approach has also been used to address a wide range of public health topics including tobacco use, driving under the influence prevention, seat belt use, and more recently sexual assault prevention. The target population for social norms approaches tends to be college students, but has recently been used with younger student populations (i.e., high school).

This theory aims to understand the environment and interpersonal influences (such as peers) in order to change behavior, which can be more effective than a focus on the individual to change behavior. Peer influence, and the role it plays in individual decision-making around behaviors, is the primary focus of Social Norms Theory. Peer influences and normative beliefs are especially important when addressing behaviors in youth. Peer influences are affected more by perceived norms (what we view as typical or standard in a group) rather than on the actual norm (the real beliefs and actions of the group). The gap between perceived and actual is a misperception, and this forms the foundation for the social norms approach.

The Social Norms Theory posits that our behavior is influenced by misperceptions of how our peers think and act. Overestimations of problem behavior in our peers will cause us to increase our own problem behaviors; underestimations of problem behavior in our peers will discourage us from engaging in the problematic behavior. Accordingly, the theory states that correcting misperceptions of perceived norms will most likely result in a decrease in the problem behavior or an increase in the desired behavior.

Social norms interventions aim to present correct information about peer group norms in an effort to correct misperceptions of norms. In particular, many social norms interventions are social norms media campaigns where misperceptions are addressed through community-wide electronic and print media that promote accurate and healthy norms about the health behavior. The phases of a social norms media campaign include:

Assessment or collection of data to inform the message

Selection of the normative message that will be distributed

Testing the message with the target group to ensure it is well-received

Selection of the mode in which the message will be delivered

Amount, or dosage, of the message that will be delivered

Evaluation of the effectiveness of the message

Social norms media campaigns are currently being funded by many federal agencies, state agencies, foundation grants, and non-profit organizations. Sometimes social norms media campaigns are funded by industry. There has been a good deal of evaluations conducted on social norms campaigns.

There are several limitations of Social Norms Theory that need to be considered prior to using the theory. Limitations of the theory include the following:

Participants of an intervention focused on social norms are likely to question the initial message being presented to them due to misperceptions they hold. Information must be presented in a reliable way to correct those misperceptions.

Poor data collection in the initial stages can lead to unreliable data and poor choice of normative message. This can undermine the campaign and reinforce misperceptions.

Unreliable sources, or sources that are not credible to the target population, can result in an unappealing message that undermines the campaign, even if the message is correctly chosen.

The dose, or amount, of the message received by the target population must be enough to make an impact, but not too much that it becomes commonplace.

Although these limitations exist, when used correctly Social Norms Theory can be very effective in changing individual behavior by focusing on changing misperceptions at the group level. Social norms interventions can be used alone or in conjunction with other types of intervention strategies. The most effective social norms interventions are those that have messages targeted to the at-risk population that are correct and influential. To target messages, a substantial amount of research and data collection has to be invested to understand the norms that exist in the group of interest. Social norms interventions are also most effective when presented in interactive formats that actively engage the target audience.