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USING THE TRANSTHEORETICAL MODEL TO PROMOTE PHYSICAL ACTIVITY

Pekmezi, Dori Ph.D.; Barbera, Brooke M.A.; Marcus, Bess H. Ph.D.

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ACSM's Health & Fitness Journal: July 2010 - Volume 14 - Issue 4 - p 8-13
doi: 10.1249/FIT.0b013e3181e37e11
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INTRODUCTION TO THE TRANSTHEORETICAL MODEL

The Transtheoretical Model is an integrative model of behavior change that developed from many different psychological theories, such as Social Cognitive Theory (1) and Learning Theory (11). Dr. James Prochaska and Dr. Carlo DiClemente (9) were the first to describe this model after noting that people vary in terms of motivational readiness to quit smoking and move through specific stages of motivational readiness along the path to behavior change. The strategies and techniques that people use to advance through these stages of changes were described as processes of change. Theoretical constructs, such as decisional balance (weighing the advantages and disadvantages of engaging in physical activity) and self-efficacy (confidence in the ability to be active despite barriers), also play an important role in the adoption and maintenance of health behaviors. Although the Transtheoretical Model originated in the addictions research field, it has since been applied to numerous health behaviors such as weight control, condom use for human immunodeficiency virus protection, use of sunscreens to prevent skin cancer, low-fat diet, medical compliance, mammography screening, stress management, and exercise.

IMPORTANT CONSTRUCTS IN THE TRANSTHEORETICAL MODEL

Stages of Change

The five stages of motivational readiness to change posited by Drs. Prochaska and DiClemente are precontemplation, contemplation, preparation, action, and maintenance. For example, a client who is not even thinking about increasing his physical activity is considered in precontemplation. If the client is thinking about becoming more active but has not taken any actual steps toward that goal, this would constitute being in the contemplation stage. In preparation, the client is engaging in some physical activity, but not yet meeting the national guidelines of at least 150 minutes per week of moderate intensity (or greater) physical activity. Other clients may be exercising regularly (action) and can be considered in maintenance once regularly active for at least 6 months.

It is important to note that this model is considered cyclical as people tend to move back and forth through these stages of change (Figure). For example, a client may become interested in increasing her physical activity, so she finds a walking partner and eventually works up to walking regularly. But after a few months, a big life change occurs (e.g., promotion at work), which makes finding time for walks with her friend difficult. Her priorities are temporarily more focused on the new work responsibilities, so the walks become less and less frequent. But once adjusted to the new work load, she decides to make exercise a high priority again and recommits to taking regular walks with her friend. Thus, numerous attempts at becoming more active are often required before making physical activity a habit.

Figure
Figure:
Stages of change.

Processes of Change

Whereas the stages of change explain when people change, the processes of change describe how people change. These processes of change are divided into two categories: cognitive (involving thinking) and behavioral (involving actions). The cognitive processes of change are consciousness raising, dramatic relief, environmental reevaluation, self-reevaluation, and social liberation. Consciousness raising involves gaining new information about physical activity and could entail talking to a physician about the benefits of walking. Dramatic relief is the process of expressing feelings about the health problem (e.g., fear and concern regarding the dangers of sedentary lifestyle) and discussing potential solutions through such methods as role playing. Environmental reevaluation involves considering how your behavior affects others. For example, a sedentary father may have concerns about setting a poor example for his children. Self-reevaluation is the assessment of an individual's self-image in relation to a particular health behavior. This could involve your client thinking about how exercise could make her a happier healthier person. Social liberation is accomplished by increasing the opportunities for alternative healthier behaviors. For example, many workplaces have begun encouraging employees to be active by offering fitness classes and time off to exercise.

The behavioral processes of change are counterconditioning, helping relationships, reinforcement management, self-liberation, and stimulus control. Counterconditioning is typically achieved by substituting alternatives for the problem behavior. A common counterconditioning technique is to take a walk rather than eat unhealthy snacks when feeling stressed. Helping relationships involve garnering social support for physical activity from family and friends. Reinforcement management refers to rewarding oneself or receiving rewards from others for meeting physical activity goals. Self-liberation involves believing that you can change and making a commitment to that belief. For example, a client could make a promise to himself to be more active and perhaps even share this resolution with family and friends to further his accountability. Stimulus control techniques focus on prompting healthy behavior and can include placing walking shoes in a highly visible spot, such as by the front door. Please see Table 1 for tips on how you can encourage your clients to use these strategies.

TABLE 1
TABLE 1:
Processes of Change

The Transtheoretical Model suggests that people use different strategies and techniques or different amounts of these strategies and techniques at different stages in the change process. For example, in the beginning, when the client is not even thinking about becoming more active, learning more about the health benefits of regular physical activity (consciousness raising) may be helpful. But as the client progresses, other strategies, such as social support (helping relationships) and rewarding oneself for reaching exercise goals (reinforcement management), also may play an important role in attaining and maintaining an active lifestyle. Thus, intervention approaches are likely to be more appropriate and beneficial if geared toward the clients' specific level of motivational readiness for physical activity behavior change (or stage matched).

Self-efficacy

Self-efficacy (1) is a construct derived from the Social Cognitive Theory and refers to confidence in one's ability to perform specific behaviors in specific situations. Self-efficacy is a good predictor of physical activity behavior; for example, if a client is convinced that she can be physically active even in bad weather, she will be more likely to take a walk on a rainy day than someone who has low self-efficacy for that situation. Thus, you will want to work with clients on increasing self-efficacy regarding their ability to become and stay physically active.

Figure
Figure

Strategies for promoting self-efficacy often include reminding the client of past successes with physical activity. You could praise the client for walking a mile without stopping for a break the previous week and then express confidence in his or her ability to reach this week's goal of walking a mile and a half. You also may want to encourage the client to observe "similar others" engage in physical activity. For example, you could ask an elderly client to sit in on a water aerobics group for senior citizens to increase confidence that people her age can be active. Please see Recommended Readings for texts that review this construct.

Decisional Balance

This construct comes from Janis and Mann's (4) Decision-Making Theory and states that individuals weigh the perceived advantages and disadvantages of being physically active when making decisions regarding the adoption and maintenance of physical activity. Furthermore, the Transtheoretical Model suggests that clients will begin to see more advantages to being physically active than disadvantages as they progress through the stages of change. For example, in the beginning, the client may see a lot of barriers (e.g., lack of time, low energy) but few benefits to being active. But as the client gains experience with exercise, he may begin to notice more benefits (e.g., more energy, improved mood) than disadvantages. Thus, you can assist the client with this process by encouraging him or her to learn more about the benefits to physical activity and help him or her identify and problem solve personal barriers to being active.

RATIONALE AND RECOMMENDATIONS FOR ASSESSING CONSTRUCTS FROM THE TRANSTHEORETICAL MODEL

The Transtheoretical Model encourages us to take into consideration an individual's level of motivational readiness for change when setting physical activity goals and developing an exercise program and avoid suggesting changes that the client will be hesitant to adopt. This can be accomplished by assessing the clients' stage of change before starting the program (see Table 2 for the recommended four-item measure developed by Marcus and colleagues), using this information to select realistic goals with your clients, and providing them with personally relevant physical activity information. For example, if your client is thinking about exercising but has not taken any steps (contemplation), she may not be ready to discuss training for a race and may find information regarding an upcoming 10K less than helpful. Given her current stage of change and lack of activity, determining the barriers to getting started and brainstorming solutions would probably be an appropriate place to intervene.

Figure
Figure
TABLE 2
TABLE 2:
Physical Activity Stages of Change Measure

You also may wish to assess your clients' processes of change, self-efficacy, and decisional balance regularly (i.e., every 3 months), as improved scores are good early indicators that the client is becoming more active. Recommended measures for assessing processes of change, self-efficacy, and decisional balance were developed by Marcus and colleagues (8).

STAGE-SPECIFIC STRATEGIES FOR PROMOTING PHYSICAL ACTIVITY

According to this model, your exercise goals for a client should vary depending on his or her stage of motivational readiness for change. Stage-specific strategies are detailed in Table 3, but we will provide a brief overview in this section. For example, in precomtemplation, the client is not even thinking about physical activity so your goal will be to help him or her become more aware of the potential health benefits to be gained from regular physical activity participation. You could recommend that the client read an article or watch a video to learn more about the advantages to an active lifestyle. If your client is in contemplation, he or she is interested in becoming more active, but has not taken any steps yet. You could encourage him or her to take the first step toward becoming physically active by discussing what activities she would like to try (walking) and then setting up a detailed plan (on Thursday, in the park, with a neighbor). When your client is in preparation, he/she has taken some steps but is not exercising regularly. Your goal is to encourage him/her to be more consistent and gradually increase his/her physical activity to the recommended levels (30 minutes or more of at least moderate-intensity physical activity on most days of the week). At this stage, your client may find strategies, such as scheduling exercise appointments (and putting them on the calendar) and using pedometers and activity logs to track progress, helpful.

TABLE 3
TABLE 3:
Stage-Specific Strategies for Promoting Physical Activity

Once the participant reaches the action stage and is exercising regularly, the goal is to help her maintain this healthy habit. You may want to discuss situations that could potentially interfere with being active in the future, such as vacations or inclement weather, and help the client develop a plan for how to overcome these barriers. For example, the client could visit the hotel fitness center during vacation and/or walk on an indoor track during winter. In maintenance, the client has already been exercising regularly for at least 6 months. At this point, you may want to discuss how to get back on track after a break in physical activity and focus on keeping physical activity fun by listening to music and trying new activities.

RESEARCH ON PHYSICAL ACTIVITY INTERVENTIONS BASED ON THE TRANSTHEORETICAL MODEL

Several studies have shown that people are more successful and less likely to drop out when interventions are matched to their motivational readiness for change (8). For example, in a study examining the efficacy of stage-matched physical activity counseling (2), 255 primary care patients completed questionnaires to determine their exercise stage of change. Then patients assigned to the intervention group received 3 to 5 minutes of structured stage-matched physical activity counseling from their physician. Patients in precontemplation were encouraged to think about the personal benefits of physical activity and strongly consider starting a program. For patients in contemplation, physicians focused on establishing an initial physical activity goal and identifying benefits and barriers to activity, as well as potential sources of social support. And when patients were regularly active, the physicians reviewed their physical activity practices, offered praise, and discussed ways to avoid slipping back into a sedentary lifestyle. These counseling sessions were followed by brief booster telephone calls from a health educator 2 weeks later. Results indicated that the intervention improved motivational readiness to adopt physical activity and produced greater increases in walking (+37 minutes per week) than the control condition (+7 minutes per week).

Figure
Figure

Other studies have used self-help print materials based on the Transtheoretical Model to increase motivational readiness for physical activity among community volunteers (6) and in worksite samples (7). Furthermore, stage-matched physical activity interventions have shown promise when used to increase physical activity, as well as balance and strength, among diverse groups (older Iranian women, low-income African Americans) who are at increased risk for health problems related to a sedentary lifestyle, such as osteoporosis and obesity (10,12). And several researchers have even tested stage-matched interventions in medically ill populations. In fact, findings from two such studies conducted among individuals with Type 2 diabetes indicated significant improvements in motivational readiness for exercise (3,5) and exercise behavior (5), as well as HbA1c and other diabetes-related variables (5). Thus, physical activity programs based on the Transtheoretical Model have been delivered through various channels and in different populations and settings with promising results.

CONDENSED VERSION AND BOTTOM LINE

The Transtheoretical Model suggests that individuals vary in terms of motivation and progress through certain stages of motivational readiness toward behavior change. Furthermore, this model suggests that people use different strategies and techniques at each stage of change. In developing a physical activity program, this model recommends early and ongoing assessment of a client's readiness for change and exercise goals and use of this information to set realistic goals to fit the client's needs. Such precautions can help a health professional avoid making recommendations that the client might be hesitant to adopt or find not personally relevant. The application of the Transtheoretical Model can help you build on the client's current motivation and gain momentum toward adopting and maintaining healthy behaviors.

References

1. Bandura A. Self-efficacy: Towards a unifying theory of behavior change. Psychol Rev. 1977;84:192-215.
2. Calfas KJ, Long BJ, Sallis JF, Wooten WJ, Pratt M, Patrick K. A controlled trial of physician counseling to promote the adoption of physical activity. Prev Med. 1996;25(3):225-33.
3. Dutton GR, Provost BC, Tan F, Smith D. A tailored print-based physical activity intervention for patients with type 2 diabetes. Prev Med. 2008;47(4):409-11.
4. Janis IL, Mann L. Decision Making: A Psychological Analysis of Conflict, Choice, and Commitment. New York (NY): Free Press; 1977.
5. Kim CJ, Hwang AR, Yoo JS. The impact of a stage-matched intervention to promote exercise behavior in participants with type 2 diabetes. Int J Nurs Stud. 2004;41(8):833-41.
6. Marcus BH, Banspach SW, Lefebvre RC, Rossi JS, Carleton RA, Abrams DB. Using the stages of change model to increase the adoption of physical activity among community participants. Am J Health Promot. 1992;6(6):424-9.
7. Marcus BH, Emmons KM, Simkin-Silverman LR, et al. Evaluation of motivationally tailored vs. standard self-help physical activity interventions at the workplace. Am J Health Promot. 1998;12(4):246-53.
8. Marcus BH, Forsyth LH. Motivating People to Be Physically Active. Champaign (IL): Human Kinetics; 2009.
9. Prochaska JO, DiClemente CC, Norcross JC. In search of how people change: Applications to addictive behaviors. Am Psychol. 1992;47(9):1102-14.
10. Shirazi KK, Wallace LM, Niknami S, et al. A home-based, transtheoretical change model designed strength training intervention to increase exercise to prevent osteoporosis in Iranian women aged 40-65 years: A randomized controlled trial. Health Educ Res. 2007;22(3):305-17.
11. Skinner BF. Science and Human Behavior. New York (NY): Free Press; 1953.
12. Whitehead D, Bodenlos JS, Jones GN, Cowles M, Brantley PJ. A stage targeted physical activity intervention among a predominantly low-income African American primary care population. Am J Health Promot. 2007;21(3):160-3.

Recommended Readings

Marcus BH, Forsyth LH. Motivating People to Be Physically Active. Champaign (IL): Human Kinetics; 2009.
    Pekmezi D, Jennings E, Marcus BH. Assessing and enhancing self-efficacy for physical activity. ACSM's Health Fitness J. 2009;13(2):16-21.
    Keywords:

    Stages of Change Model; Exercise; Behavior Change; Health Promotion; Stage-Matched Interventions

    © 2010 American College of Sports Medicine.