Evidence-based health and well-being for entire populations.

The Transtheoretical Model

Evidence-based Behavior Change

Pro-Change programs are grounded in the proven effective Transtheoretical Model of Behavior Change (TTM), sometimes called the Stages of Change.

Change is a process, not an event. The TTM matches the change processes with distinct stages of readiness, and provides approaches to help move people forward through the stages.

People in the earliest stage are not intending to make a behavior change (Precontemplation). They may not even be aware that their behavior is unhealthy or they may be demoralized from past failed attempts. People in the final stage have made a change and are working to keep it up (Maintenance). And in the middle—we have some who are just starting to think about changing their behavior (Contemplation), others who have decided to make a behavior change (Preparation), and still others who have just begun to take action to change their behavior (Action).

Research has shown that up to 80% of people are not ready to go to action right away. It’s something they have to work up to, and not everyone moves at the same pace. People can resist pressure to take action if they are not ready for it.

Our programs are effective because at each step they deliver individualized guidance that reflect each participant’s view of a particular behavior and readiness to change. At each stage they receive expert feedback on which principles and processes of change they are applying appropriately, which they are overutilizing and underutilizing, and specific steps they can take to progress to the next stage. A single behavior program can provide many thousands of possible interactions over time.

More About the Transtheoretical Model

The TTM:

  • uses the Stages of Change to integrate the most powerful principles and processes of change from leading theories of counseling and behavior change;
  • 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.

Stages of Change Overview

Stages of Change
Stage 1: Precontemplation (Not Ready)

Participants at this stage do not intend to start the healthy behavior in the near future (within 6 months), and may be unaware of the need to change.

Participants here learn more about healthy behavior: they are encouraged to think about the Pros of changing their behavior and to feel emotions about the effects of their negative behavior on others.

Precontemplators typically underestimate the Pros of changing, overestimate the Cons, and often are not aware of making such mistakes. These individuals are encouraged to become more mindful of their decision making and more conscious of the multiple benefits of changing an unhealthy behavior.

Stage 2: Contemplation (Getting Ready)

At this stage, participants are intending to start the healthy behavior within the next 6 months. While they are usually now more aware of the Pros of changing, their Cons are about equal to their Pros. This ambivalence about changing can cause them to keep putting off taking action.

Participants here learn about the kind of person they could be if they changed their behavior and learn more from people who behave in healthy ways. They’re encouraged to work at reducing the Cons of changing their behavior.

Stage 3: Preparation (Ready)

Participants at this stage are ready to start taking action within the next 30 days. They take small steps that they believe can help them make the healthy behavior a part of their lives. For example, they tell their friends and family that they want to change their behavior.

During this stage, participants are encouraged to seek support from friends they trust, tell people about their plan to change the way they act, and think about how they would feel if they behaved in a healthier way. Their number one concern is—when they act, will they fail? They learn that the better prepared they are the more likely they are to keep progressing.

Stage 4: Action

Participants at this stage have changed their behavior within the last 6 months, and need to work hard to keep moving ahead. These participants need to learn how to strengthen their commitments to change and to fight urges to slip back.

Strategies taught here include substituting activities related to the unhealthy behavior with positive ones, rewarding themselves for taking steps toward changing, and avoiding people and situations that tempt them to behave in unhealthy ways.

Stage 5: Maintenance

Participants at this stage changed their behavior more than 6 months ago. It is important for people in this stage to be aware of situations that may tempt them to slip back into doing the unhealthy behavior—particularly stressful situations.

Participants here learn to seek support from people they trust, spend time with people who behave in healthy ways, and remember to engage in alternative activities to cope with stress instead of relying on unhealthy behavior.

How do people move from one stage to another?

TTM

The Transtheoretical Model

In general, for people to progress they need:

  1. A growing awareness that the advantages (the “Pros”) of changing outweigh the disadvantages (the “Cons”)—the TTM calls this decisional balance
  2. Confidence that they can make and maintain changes in situations that tempt them to return to their old, unhealthy behavior—the TTM calls this self-efficacy
  3. Strategies that can help them make and maintain change—the TTM calls these processes of change. The ten processes include:
    1. Consciousness Raising—increasing awareness via information, education, and personal feedback about the healthy behavior.
    2. Dramatic Relief—feeling fear, anxiety, or worry because of the unhealthy behavior, or feeling inspiration and hope when they hear about how people are able to change to healthy behaviors
    3. Self-Reevaluation—realizing that the healthy behavior is an important part of who they are and want to be
    4. Environmental Reevaluation—realizing how their unhealthy behavior affects others and how they could have more positive effects by changing
    5. Social Liberation—realizing that society is more supportive of the healthy behavior
    6. Self-Liberation—believing in one’s ability to change and making commitments to act on that belief
    7. Helping Relationships—finding people who are supportive of their change
    8. Counter Conditioning—substituting healthy ways of acting and thinking for unhealthy ways
    9. Reinforcement Management—increasing the rewards that come from positive behavior and reducing those that come from negative behavior
    10. Stimulus Control—using reminders and cues that encourage healthy behavior.

Different strategies are most effective at different Stages of Change. For example, Counter Conditioning and Stimulus Control can really help people in the Action and Maintenance stages. But these processes are not helpful for someone who is not intending to take action. Consciousness Raising and Dramatic Relief work better for someone in that stage–Precontemplation. That is why Pro-Change programs tailor feedback to each individual in stage-matched interventions.

More detail on the Transtheoretical Model is available on the University of Rhode Island’s CPRC TTM Detailed Overview page.

Transtheoretical Model Research Breakthroughs

1980s

  • Discovery of the Stages of Change and the dynamic change processes and principles related to each stage

1990s

  • First computer-tailored intervention based on the Transtheoretical Model (TTM) was developed
  • Demonstrated tailored interventions for smoking cessation effective even when more than 80% were not ready to quit
  • TTM applied to a variety of behaviors beyond smoking cessation

2000s

  • Demonstrated that TTM-based interventions for simultaneous multiple behavior change are effective
  • TTM applied to a wide variety of new behavior change challenges
  • Serving entire populations with inclusive proactive and home-based care

2010s

  • Innovative strategies implemented to ensure greater impact on multiple behaviors with fewer demands on patients and providers
  • Designed a more cost-effective delivery for coaching and online programs
  • The addition of tailored text messaging increased the efficacy of our best practices by 31.7% percent
  • Synergistic insights into how changing one behavior increases the chance of changing other behaviors (coaction)
  • Improving well-being by increasing productivity and thriving

Tailoring Matters

A recent meta-analyses, by Noar et al., of 57 studies demonstrated greater effects in programs that are tailored on each of the Transtheoretical Model constructs. Specifically, programs that tailor on stage do better than those that do not; programs that tailor on Pros and Cons do better than those that do not; programs that tailor on self-efficacy do better than those that do not, and programs that tailor on processes of change do better than those that do not.

  • Noar, S.M., Benac, C.N., and Harris, M.S. (2007) Does tailoring matter? Meta-analytic review of tailored print health behavior change interventions. Psychological Bulletin, 4, 673-693. abstract
    Abstract: Although there is a large and growing literature on tailored print health behavior change interventions, it is currently not known if or to what extent tailoring works. The current study provides a meta-analytic review of this literature, with a primary focus on the effects of tailoring. A comprehensive search strategy yielded 57 studies that met inclusion criteria. Those studies, which contained a cumulative N = 58,454, were subsequently meta-analyzed. The sample-size weighted mean effect size of the effects of tailoring on health behavior change was found to be r = .074. Variables that were found to significantly moderate the effect included 1) type of comparison condition; 2) health behavior; 3) type of subject population (both type of recruitment and country of sample); 4) type of print material; 5) number of intervention contacts; 6) length of follow-up; 7) number and type-of theoretical concepts tailored on; and 8) whether or not demographics and/or behavior were tailored on. Implications of these results are discussed and future directions for research on tailored health messages and interventions are offered.

To learn about the efficacy of our online programs, see the citations on each of our products pages, or our program effectiveness summary. A 2008 replication study at Oregon Science and Health University also shows program effectiveness; see:

  • Prochaska, J.O., Butterworth, S., Redding, C.A., Burden, V., Perrin, N., Lea, Michael, Flaherty, Robb M., and Prochaska, J.M. (2008). Initial efficacy of MI, TTM tailoring, and HRI’s in multiple behaviors for employee health promotion. Preventive Medicine, 46, 226-231. abstract

    Abstract:
    Objective. This study was designed to compare the initial efficacy of Motivational Interviewing (MI), Online Transtheoretical Model (TTM)-tailored communications and a brief Health Risk Intervention (HRI) on four health risk factors (inactivity, BMI, stress and smoking) in a worksite sample.

    Method. A randomized clinical trial assigned employees to one of three recruitment strategies and one of the three treatments. The treatment protocol included an HRI session for everyone and in addition either a recommended three TTM online sessions or three MI in person or telephone sessions over 6 months. At the initial post-treatment assessment at 6 months, groups were compared on the percentage who had progressed from at risk to taking effective action on each of the four risks.

    Results. Compared to the HRI only group, the MI and TTM groups had significantly more participants in the Action stage for exercise and effective stress management and significantly fewer risk behaviors at 6 months. MI and TTM group outcomes were not different.

    Conclusion. This was the first study to demonstrate that MI and online TTM could produce significant multiple behavior changes. Future research will examine the long-term impacts of each treatment, their cost effectiveness, effects on productivity and quality of life and process variables mediating outcomes.

To learn how the Internet can be used for health behavior change, see:

  • Evers, K.E. (2006). eHealth Promotion: The use of the internet for health promotion. American Journal of Health Promotion, 20(4), suppl 1-7, iii.
  • Evers, K.E., Cummins, C.O., Prochaska, J.O., & Prochaska, J.M. (2005). Online Health Behavior and Disease Management Programs: Are We Ready for Them? Are They Ready for Us? Journal of Medical Internet Research 7(3), e27.
  • Cummins, C.O., Evers, K.E., Johnson, J.L., Paiva, A. Prochaska, J.O., & Prochaska, J.M., (2004). Assessing stage of change and informed decision making for Internet participation for health promotion and disease management. Managed Care Interface, 17(8), 27-32.
  • Evers, K.E., Prochaska, J.M., Prochaska, J.O., Driskell, M.M., Cummins, C.O., & Velicer, W.F. (2003). Strengths and weaknesses of health behavior change programs on the Internet. Journal of Health Psychology, 8(1), 63-71.
  • Cummins, C.O., Prochaska, J.O., Driskell, M.M., Evers, K.E., Wright, J.A., Prochaska, J.M., Velicer, W.F. (2003). Development of review criteria to evaluate health behavior change websites. Journal of Health Psychology, 8(1), 55-63.
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