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Transtheoretical model of behaviour change Cambridge Handbook of Psychology, Health and Medicine Stage theories of health behaviour assume that behaviour change involves movement through a set of discrete stages, that different factors influence the different stage transitions and that interventions should be matched to a person’s stage (Sutton, 2005; Weinstein et al., 1998). The transtheoretical model (TTM; Prochaska & DiClemente, 1983; Prochaska et al., 1992, 2002; Prochaska & Velicer, 1997) is the dominant stage model in health psychology and health promotion. It was developed in the 1980s by a group of researchers at the University of Rhode Island. The model has been used in a large number of studies of smoking cessation, but it has also been applied to a wide range of other health behaviours (Prochaska et al., 1994). Although it is often referred to simply as the stages of change model, the TTM includes several different constructs: the ‘stages of change’, the ‘pros and cons of changing’ (together known as ‘decisional balance’), ‘confidence and temptation’ and the ‘processes of change’. The TTM was an attempt to integrate these different constructs drawn from different theories of behaviour change and systems of psychotherapy into a single coherent model; hence the name transtheoretical (for example, see ‘Health belief model’, ‘Self-efficacy and health behaviour’ and ‘Theory of planned behaviour’). The stages of change provide the basic organizing principle. The most widely used version of the model specifies five stages: precontemplation, contemplation, preparation, action and maintenance. The first three stages are pre-action stages and the last two stages are post-action stages (although preparation is sometimes defined partly in terms of behaviour change). People are assumed to move through the stages in order, but they may relapse from action or maintenance to an earlier stage. People may cycle through the stages several times before achieving long-term behaviour change. The pros and cons are the perceived advantages and disadvantages of changing one’s behaviour. Confidence is similar to Bandura’s (1986) construct of self-efficacy. It refers to the confidence that one can carry out the recommended behaviour across a range of potentially difficult situations. The related construct of temptation refers to the temptation to engage in the unhealthy behaviour across a range of difficult situations. Finally, the processes of change are the covert and overt activities that people engage in to progress through the stages. The Rhode Island group has identified 10 such processes that appear to be common to a number of different behaviours: five experiential processes and five behavioural processes. In stage theories, the transitions between adjacent stages are the dependent variables, and the other constructs are variables that are assumed to influence these transitions – the independent variables. The processes of change, the pros and cons of changing and confidence and temptation are all independent variables in this sense. Descriptions of the TTM to date have not specified the causal relationships among these variables. Measures The most commonly used method of measuring stages of change is the staging algorithm, in which a small number of questionnaire items is used to allocate participants to stages in such a way that no individual can be in more than one stage. Table 1 shows a staging algorithm for smoking that has been used in a large number of studies since it was first introduced by DiClemente et al. (1991). Precontemplation, contemplation and preparation are defined in terms of current behaviour, intentions and past behaviour (whether or not the person has made a 24-hour quit attempt in the past year), whereas action and maintenance are defined purely in terms of behaviour; ex-smokers’ intentions are not taken into account. This algorithm has a logical flaw: a smoker cannot be in the preparation stage unless he or she has made a recent quit attempt. Thus, a smoker can never be ‘prepared’ for his or her first quit attempt (Sutton, 2000a). Table 1. TTM staging algorithm for adult smoking, from http://www.uri.edu/research/cprc/measures.htm Are you currently a smoker? Yes, I currently smoke No, I quit within the last 6 months (Action Stage) No, I quit more than 6 months ago (Maintenance Stage) No, I have never smoked (Non-smoker) (For smokers only) In the last year, how many times have you quit smoking for at least 24 hours? (For smokers only) Are you seriously thinking of quitting smoking? Yes, within the next 30 days (Preparation Stage; if they have one 24-hour quit attempt in the past year – refer to previous question . . . if no quit attempt then Contemplation Stage) Yes, within the next 6 months (Contemplation Stage) No, not thinking of quitting (Precontemplation Stage) A problem with most staging algorithms is that the time periods are arbitrary. For instance, action and maintenance are usually distinguished by whether or not the duration of behaviour change exceeds six months. Changing the time periods would lead to different stage distributions. The use of arbitrary time periods casts doubt on the assumption that the stages are qualitatively distinct, that is, that they are true stages rather than pseudo-stages (Bandura, 1997; Sutton, 1996). Staging algorithms and measures of the TTM independent variables for a number of different health behaviours are given on the Rhode Island group’s website (http://www.uri.edu/research/cprc/measures.htm). Evidence Weinstein et al. (1998) specified four research designs that can be used to test predictions from stage theories: cross-sectional studies comparing people in different stages; examination of stage sequences; longitudinal prediction of stage transitions; and experimental studies of matched and mismatched interventions. This section will focus on TTM studies that have used the last two of these designs because in principle they provide the strongest tests of the model. We also consider intervention studies that have compared TTM-based stage-matched interventions with generic, nonmatched interventions or no-intervention control conditions. See Sutton (2000b) for a discussion of the analysis and interpretation of cross-sectional data on stages of change, and Rosen (2000) and Marshall and Biddle (2001) for meta-analyses of cross-sectional studies on the TTM. Longitudinal prediction of stage transitions Longitudinal data can be used to test whether different theoretically relevant variables predict stage transitions among people in different baseline stages. To date, 11 prospective studies have used the TTM variables to predict stage transitions, all in the domain of smoking cessation. Two of these (DiClemente et al., 1985; Prochaska et al., 1985) used an old staging algorithm and an early version of the TTM. They were reviewed by Sutton (2000a). Nine more recent studies were reviewed by Sutton (2006): De Vries and Mudde (1998); Dijkstra and De Vries (2001); Dijkstra et al. (2003); Hansen (1999); Herzog et al. (1999); Segan et al. (2002, 2006a, 2006b); Velicer et al. (1999). These nine studies found some evidence that different predictors are associated with different stage transitions. However, there were few consistent findings, providing little support for the TTM. Most of the studies used relatively long follow-up periods (at least six months). Future studies should use shorter follow-up periods to minimize the likelihood of missing stage transitions (with the proviso that at least six months is required to detect the transition from action to maintenance). Experimental match–mismatch studies The strongest evidence for a stage theory would be to show consistently in randomized experimental studies that stage-matched interventions are more effective than stage-mismatched interventions in moving people to the next stage in the sequence. Only three studies to date have compared matched and mismatched interventions within the framework of the TTM or closely related models (Blissmer & McAuley, 2002; Dijkstra et al., 1998; Quinlan & McCaul, 2000). Dijkstra et al. (1998) compared the effectiveness of individually tailored letters designed either to increase the pros of quitting and reduce the cons of quitting (outcome information) or to enhance self-efficacy or both. Smokers were categorized into four stages of change: preparers (planning to quit within the next month); contemplators (planning to quit within the next six months); precontemplators (planning to quit within the next year or in the next five years); and immotives (planning to quit sometime in the future but not in the next five years, to smoke indefinitely but cut down or to smoke indefinitely without cutting down). The sample size for the main analyses was 1100. Dijkstra et al. (1998) hypothesized that immotives would benefit most from outcome information only, preparers from self-efficacy enhancing information only and the other two groups from both types of information. Thus, counter-intuitively, precontemplators and contemplators were predicted to benefit from the same kind of information. However, the study showed only weak evidence for a beneficial effect of stage-matched information. In respect of the likelihood of making a forward stage transition, assessed at 10-week follow-up, there were no significant differences between the three types of information among smokers in any of the four stages. However, preparers who received the self-efficacy-enhancing information only were significantly more likely to have quit smoking for seven days at follow-up than preparers in the outcome information only condition. Combining immotives and precontemplators, the percentage of smokers who made a forward stage transition did not differ significantly between those who received stage-matched and stage-mismatched information. Among contemplators and preparers combined, the percentage who made a forward stage transition and the percentage who quit for seven days were higher among those who received the stage-matched information than among those who received the stage-mismatched information, but these comparisons were only marginally significant (p < 0.10). It is not clear why the researchers combined the stages in this way (immotives and precontemplators; contemplators and preparers), given the hypothesis of the study. Quinlan and McCaul (2000) compared a stage-matched intervention, a stage-mismatched intervention and an assessment-only condition in a sample of 92 college-age smokers in the precontemplation stage. The stage-matched intervention consisted of activities designed to encourage smokers to think more about quitting smoking. The stage-mismatched intervention consisted of action-oriented information and activities intended for smokers who are ready to quit smoking. At one month, 30 participants had progressed to contemplation, one participant had progressed to preparation and 5 participants had progressed to action. Contrary to the hypothesis, a greater percentage of participants in the stage-mismatched condition (54%) progressed than in the stage-matched (30%) or assessment-only (35%) conditions; however, this difference was not significant. Significantly more smokers in the stage-mismatched condition tried to quit smoking than in the stage-matched condition. Finally, in a study of physical activity, Blissmer and McAuley (2002) randomly assigned 288 university staff to four conditions, including: (1) stage-matched materials (personalized, stage-appropriate covering letter plus stage-matched manuals) delivered via campus mail on a monthly basis; and (2) stage-mismatched materials delivered in the same way. After 16 weeks, 40.4% of the matched group had progressed one or more stages compared with 31.8% of the mismatched group. This difference was in the predicted direction but did not approach significance at the 0.05 level (Sutton, 2005). A limitation of the study, which the authors acknowledge, is that 57% of participants were in the action or maintenance stage at baseline, and the short follow-up period would have prevented those who had recently entered the action stage from progressing to maintenance. Considered together, these three experimental studies of matched and mismatched interventions found little or no evidence for the stage model predictions. Intervention studies Three reviews have summarized the evidence on the effectiveness of TTM-based stage-matched interventions compared with generic, non-matched interventions or no-intervention control conditions (Bridle et al., 2005; Riemsma et al., 2003; Spencer et al., 2002). The second and third of these reviews were restricted to smoking cessation interventions. Both Bridle et al. (2005) and Riemsma et al. (2003) concluded that there was limited evidence for the effectiveness of stage-based interventions, but Spencer et al. (2002) reached a more positive conclusion. However, all these reviews included studies that were not proper applications of the TTM. For an intervention to be labelled as TTM-based, it should (1) stratify participants by stage and (2) target the theory’s independent variables (pros and cons, confidence and temptation, processes of change), focusing on different variables at different stages. Not surprisingly, the interventions that come closest to a strict application of the TTM are those developed by the Rhode Island group. The group’s studies of TTM-based smoking cessation interventions have yielded mainly positive findings (e.g. Pallonen et al., 1998; Prochaska et al., 1993; Prochaska, Velicer, Fava, Rossi et al., 2001; Prochaska, Velicer, Fava, Ruggiero et al., 2001). By contrast, adaptations of these interventions evaluated by other research groups in the UK and Australia have yielded mainly negative results (Aveyard et al., 1999, 2001, 2003; Borland et al., 2003; Lawrence et al., 2003). None of these studies speaks directly to the validity or otherwise of the TTM. Process analyses demonstrating that TTM-based interventions do indeed influence the variables they target in particular stages and that forward stage movement can be explained by these variables have not been published to date. Conclusions The TTM has been very influential and has popularized the idea that behaviour change involves movement through a series of discrete stages. It has also stimulated the development of innovative interventions. However, the model cannot be recommended in its present form. Fundamental problems with the definition and measurement of the stages need to be resolved. Although a cursory glance at the huge literature on the TTM gives the impression of a large body of mainly positive findings, a closer examination reveals that there is remarkably little supportive evidence. It would be helpful if the Rhode Island group presented a fuller specification of the model that (1) stated which variables influence which stage transitions and (2) specified the causal relationships among the pros and cons, confidence and temptation and processes of change. It would also be helpful if the group addressed the detailed critiques of the TTM by, among others, Carey et al. (1999), Joseph et al. (1999), Littell & Girvin (2002), Rosen (2000) and Sutton (1996, 2000a, 2001), and responded to Weinstein and colleagues’ (1998) exposition of the conceptual and methodological issues surrounding stage theories. To date, research on stage theories has been dominated by the TTM. 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