Kerry E. Evers, Ph.D., is Senior Vice President of Research and Product Development at Pro-Change® Behavior Systems, Inc. Pro-Change helps individuals and communities make healthy lifestyle changes supported by evidence-based behavior change solutions. The O’Neil Center sat down with Dr. Evers to talk about the change process and how it impacts person and family engagement.
Pro-Change is home to the Transtheoretical Model. Tell us about the model. Who developed it and how does it work?
The Transtheoretical Model (TTM) is a theoretical model of how people make behavior changes. It was developed more than 30 years ago by Dr. Jim Prochaska, the founder of Pro-Change Behavior Systems, and his colleagues. It looks at the behavior change process through a series of five stages of change. Instead of simply saying a person is doing something or not doing something, the model looks at how ready a person is to make a change.
The five stages of change are:
- Precontemplation – the person is not yet ready to make a change
- Contemplation – the person is getting ready and thinking about taking action in the next six months
- Preparation – the person is ready and planning to take action in the next 30 days
- Action – the change is made, but it’s been recent, within the past six months
- Maintenance – action was taken more than six months ago
The stages of change are key, but they are only one part of the full model. The TTM also includes the principles and processes of change – the “hows” of change that determine how we interact with people in each of the five stages of change to move them to the next stage. For example, many of us were taught that simply increasing someone’s knowledge about why they should do something – exercise more, for example, or quit smoking or eat more fruits and vegetables – won’t motivate them to take action on that behavior. While education is often not enough, it is certainly a critical part of the overall behavior change process. The success of using a process of change such as increasing knowledge depends on a person’s stage of change. Increasing knowledge of the behavior is especially important in Precontemplation when people are not yet thinking about taking action. By increasing their knowledge about the benefits of why the change is important, we help them move forward to Contemplation, the stage where they start to think about making a change. That’s the first step toward success. So the key is to use the full TTM, which includes tailoring the principles of change to the correct stage of change.
What types of behavior change is the TTM typically used for?
It’s been used in many different areas. Initially, the focus was on smoking cessation and other addiction behaviors including alcohol and substance use. But it’s now been applied to a wide variety of behaviors across many different countries and cultures, languages and age groups. It’s been shown to be effective with older elementary school students, middle school students, high school, college, all the way to older adults. The behaviors include health behaviors such as exercise, healthy eating, weight management, medication adherence, and stress and depression management. The TTM is also used in violence prevention programs such as dating violence prevention, domestic violence prevention and bullying behaviors. It’s also useful for organizational change, financial behavior and more. It’s really wide-reaching in terms of how it’s been applied.
What about its application to person and family engagement?
We have several projects that focus on helping people become more involved in their health care. The Proactive Health Consumer program helps individuals more fully engage with the health care system by becoming more informed about their choices, sharing in decision-making with their health care provider, making financially responsible choices and, of course, engaging in healthy behaviors. The program is targeted to consumers’ roles as patients or users of health care, purchasers of health care, and providers of care to family members such as children or elderly parents. The program focuses on behavior changes that result in people using the tools that are out there, such as claims trackers or decision aids for a health condition. These tools are available from a variety of sources but most people don’t use them. They’re just not ready to become proactive about their health care. So our focus is on the process of getting them to become more proactive and engaged.
Why aren’t people ready to be proactive?
For a variety of reasons. Sometimes, it’s because they don’t realize that there is a need to change. They may not grasp that there is an issue that might be harmful to them. It could be that they have tried to change and failed and they’re demoralized. Or, they think they can’t do it or don’t feel empowered to do it. What our programs focus on is, as I said, each person’s stage of change and what it will take to move them forward to the next stage. We don’t pressure them to take action right away. We actually bring them through the whole change process, one stage at a time. And that leads to much more sustained engagement and behavior change in the long run.
Why do you think change is such an important factor in helping people become more activated in the health journey?
It is a change process. As I mentioned, we know that simply educating people that smoking is bad for them or that they shouldn’t be doing something doesn’t always mean that they’re going to stop. I think for many people, becoming engaged in their health care is something new. As the health care system is changing, people are taking on different roles and responsibilities and it is a change in the way that they behave and interact. By getting them more engaged and proactive about their health care, they take more control of it, they are more educated about what’s happening, and they also make better decisions about their care. There are so many changes going on in the health care system right now that without having some level of engagement, people can feel a little bit lost.
What about engagement from a clinician’s or caregiver’s perspective? How do you motivate them to change?
We do a lot of work with clinicians to help them understand the behavior change process. Clinicians can get very demoralized if they’ve been telling a client that there is something they could be doing that
would improve their health, or their life in general, and the person doesn’t make that change. By educating them on the TTM and the science of behavior change, we can help them refine in small ways how they interact with someone – to recognize the little changes going on and how they can provide more engaging messages to help each individual along the process. Historically, if you have someone who is in Precontemplation you try to move them directly to Action. If you tell someone they need to cut down on their drinking and they have no intention of stopping drinking, the person is either going to lie about it, become very defensive, or find another provider. By helping providers understand what the behavior change process is, we can help not only the patient but also the provider be more effective.
Can outside support such as social media, online communities, etc., help people sustain personal change?
Yes, absolutely. Supportive relationships is one of the key principles of change and we know it’s very important for people to have these relationships, to seek help in whatever form that they can find. So, typically, if you have someone in the Preparation or Action stage of the Transtheoretical Model (TTM), we really focus on finding those relationships that are going to be supportive. People seek support in different ways. Some turn to social media or their online relationships. Some prefer to go to in-person groups, or talk to their friends and family, or seek professional support. Our focus is to make sure that they’re getting helping relationships and then let them choose the ones that will be most beneficial to them.
Do you recommend groups that someone might join for outside support?
What we do is make sure the engagement pieces – the principles, the interventions – are focused specifically on where that person is at that moment in time. If it’s important for them to get helping relationships at that point, or if they need support because they’re struggling, we will make suggestions in our programs. We give them ideas, but it’s important for them to find the best way to be supported.
You mentioned that getting people more engaged in their health care is something new. What do you think is driving this behavioral change?
I think the focus right now in terms of really engaging people in their health care, and not just specific health behaviors, is being driven by a number of factors: the Affordable Care Act, accountable care organizations, and a push for people to take proactive measures about the care they’re getting. Some of that started several years ago when there was a move toward more high-deductible insurance plans and people started realizing they needed to become critical thinkers and make financially responsible decisions about their care.
The Transtheoretical Model was developed more than 30 years ago. Has it changed over time?
One of the biggest things that’s emerged in the field in the past 10 years is what’s called multiple behavior change. How do we approach the whole person who may have multiple behaviors that we’re trying to impact? This is a new scientific area being led by people like Dr. Jim Prochaska, Pro-Change’s founder, and Dr. Sara Johnson. What they’re finding is that we can interact with people about multiple behaviors as long as we’re coming at it from a staged approach using tools such as the TTM. If we used an action-oriented approach, telling people that they have multiple behaviors that have to change, and have to change right now, without taking into account their readiness for change, it’s overwhelming. We also find that by using a TTM approach to multiple behavior change, there is “co-action.” This refers to the increased probability that individuals who progress to effective action on one behavior (i.e., adopt a health behavior) will progress to effective action on a second behavior.
Technology is another big focus in behavior change right now. Take fitness trackers. They are new on the market in the past five years but they’re not new in terms of approach. These devices use what’s called “stimulus control,” which lets people control their environment and track their behavior. It’s an important part of the behavior change process, but it’s not the only part. Fitness trackers are very helpful for someone we know is in Preparation or Action for increasing exercise. But they are not appropriate for everyone in the population. From a TTM perspective, these new trends fit within the processes or principles of change. The way the theory is implemented has changed to incorporate these trends and innovations, while the science behind the theory has remained the same.
What organizations do you partner with to help disseminate your methods and the science behind behavioral change?
Pro-Change has been around since 1997. We are a research and development company and we really have two sides to what we do. The first is the research side. We have many funded grants and research projects through the National Institutes of Health to develop new programs and test them in clinical trials. The other way we work is to partner with organizations such as GetWellNetwork where we either provide our programs to be integrated into their practices, help them develop new programs that incorporate evidence-based behavior change practices, or conduct research. We work with many organizations, in a variety of ways, and with different populations including adolescents, college students, adults and, more recently, military and veteran populations.
Has this work yielded any major breakthroughs?
In addition to coaction, which I already mentioned, one of the biggest new findings came out of our work with veterans: the use of text messaging technology for behavior change. Right now, text messaging is often used to remind people to come back to a program, or for what we call “segmented messaging,” which features three or four different sets of messages that are sent based on demographics. We’ve been able to use our technology tools to determine where someone is in the change process and how that person is doing with the principles and process to change the behavior and create highly tailored text messages for each individual. Not only in terms of content, but also how often those messages are sent.
There is a bank of literally thousands of different text messages people can get to help them move along the behavior change continuum. We’ve seen some dramatic results. When we added these messages to our best practice online program for smoking cessation, we found an 11 percentage point increase in our quit rate, which is really impressive.
Is change harder for some populations than others – seniors, for example? Do you have any senior-specific programs?
It’s interesting that you bring that up. Jim Prochaska says that a lot of people didn’t think we’d be able to use the types of programs we develop with younger populations – because teenagers don’t want to change – or older populations, because they can’t change. What we have found in our research, however, is that those specific populations do better than the general population, as long as we’re using the TTM and we’re meeting them where they’re at and making sure that the messages are appropriate for them. We don’t find that there is a big difference in how the programs work across the different age groups and we don’t necessarily have a senior-specific program. We have a lifestyle management suite, our base program, which focuses on the eight behaviors that are the highest cost behaviors for health care in general. It’s “age agnostic” and many people from all age ranges have used it successfully.