Introduction
Industrialization of societies and an increasingly mechanical lifestyle has led to increased prevalence of chronic diseases (CDs) such as obesity, heart diseases, osteoporosis, and chronic back pain.[1] The increasing prevalence of CDs has serious health implications for individuals especially nurses and may also impact general health and workforce participation.[2] Studies show that obesity in nurses will lead to various problems such as lower back pain, heart diseases, and reduced on-duty times.[3] In prevention of CDs, the main focus is on education and lifestyle improvements. One of the methods of improving lifestyle is changing behavioral patterns.[45]
Transtheoretical model (TTM) of behavioral change is one of the behavioral change models which states that changing a behavior is not a coincidence but instead is a process and different people are in different stages of change (SC) and readiness. In this process, people pass through five stages: precontemplation, contemplation, preparation, action, and maintenance.[6]
In this pattern, it is possible to return to a previous level as well. There are three factors controlling the transfer between different stages and the time necessary for change which include the following: process of change (PC), decisional balance (DB), and self-efficiency (SE).[7] Due to its cost and time-effective nature, TTM has been used in prevention interventions for chronic conditions such as diabetes and various forms of cancers. The results of these studies show the effectiveness of TTM in this regard.[8]
Due to the importance of this topic, this study focused on use of TTM especially in the context of healthcare with emphasis on the impacts of TTM on information-seeking behaviors of patients with CDs. The current systematic review (SR) was conducted to present a comprehensive and complete review of the studies for the following research objectives: Which studies have used different aspects of TTM? Why studies have used TTM to improve health behaviors in CDs? What are the pros and cons of TTM in the studies?
Materials and Methods
To start, a literature review coordination session was conducted in May 2015 for the research team to determine the inclusion criteria. The following core national and international databases were searched: Magiran, SID, Scopus, PubMed, and ISI-WOS. Two Persian core databases are the most widely used and reliable Persian databases. There are a lot of interdisciplinary articles in the field of medical sciences in Scopus, PubMed, and ISI-WOS; therefore, they were chosen based on inclusion criteria and their ability to adequately respond to the research team. There was also an overlap between articles of different databases.
The search was carried out with the following search strategies: “Stages of change model" in title, abstract, keywords, subject, or mesh, “Stages of change model" AND “pros OR cons" in title, abstract, keywords, “Trans theoretical model" OR “Stages of change model" AND “chronic diseases" in title, abstract, keywords, subject, or mesh.
All English language articles published between 2009 and 2015 were included if they met the following eligibility criteria: (a) using different aspects of TTM, (b) using TTM in CDs, (c) examining pros and cons of TTM, and (d) being written in English or Persian languages. These articles were screened by title and abstract content for inclusion by AR and MH. The references of the included articles were hand-searched for other eligible articles. Following this comprehensive process, the included articles were distributed for review among all the authors according to their expertise and experience.
All articles were reviewed by AR, MH, and all of coauthors. The authors used a data extraction template [Table 1] based on previous studies of SR team leader (AR).[9] The template kept the extracted information consistent: study types, subject area, results, goals, methods, outputs, society, dimension of data quality, and critical thinking about research. Three consensus meetings were arranged among AR, MH, and each of the coauthors to discuss and achieve final consensus and synthesis of the findings. Table 2 is used as a tool to gather opinions and similarities and differences of reviewers' opinions. Using this method, a total of 57 articles were analyzed.
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Table 1: Reviewers’ critical appraisal template
Table 2: Summary template to summarize critical appraisal differences between reviewers
Ethical consideration
Research ethics confirmation was received from the Ethical Review Board at Isfahan University of Medical Sciences. The approval number of the project is 3995540.
Results
In the first iteration, we identified 103 articles after applying the search strategies, of which 27 were excluded in abstract review because they did not meet inclusion criteria or they were duplicates, leaving 76 articles. After full-text review, 34 articles were excluded which left 42 articles for critical appraisal [Figure 1]. After reviewing references of selected articles in previous round, a total 70 articles were retrieved, of which 50 were excluded in abstract review and 5 in full-text review. Finally, 15 articles were analyzed. Of 57 finalized articles, 28 articles examined different aspects of TTM, 8 articles used TTM in CDs, 21 articles studied pros and cons of TTM, 21 articles were in Persian, and 36 articles were in English [Figure 2].
Figure 1: Retrieved articles in searching selected databases in the first iteration
Figure 2: Finalized articles by the language
One article responded to questions a and c at the same time.[8] Articles relevant to first research question were divided based on their subject area in Table 3 which shows various mentioned aspects of TTM such as 5 SC,[48101112131415161718192021222324252627] PC,[28] DB,[293031] and SE.[32333435] However, the results indicated that the majority of studies focused on 5 SC in both Iran and other countries. Therefore, it can be concluded that the most important achievement of the TTM was the change in five-step behavior.
Table 3: The aspects of TTM in various contexts
Table 4a shows the extensive use of TTM in healthcare. These results show that the majority of studies applied TTM specifically for some chronic conditions such as inflammatory bowel disease,[36] type 2 diabetes,[37] cancer,[38] AIDS,[39] breast cancer,[40] osteoporosis,[41] high blood pressure,[42] and anorexia nervosa.[43] The results reported that TTM was used more in healthcare context than treatment and prevention of CDs. In healthcare context, TTM was used to change exercise behaviors,[8444546474849] change the attitude of diet behaviors,[5051525354] addiction treatment behaviors,[55565758] air pollution prevention behaviors,[43] and oral health behaviors.[59]
Table 4a: Use of TTM in changing the behavior of chorionic patients
Table 4b: Advantages and disadvantages of TTM
Table 4b also describes some studies focusing on pros and cons of TTM.[84445464748495051525354555657585960616263] The results of these studies show evidence of TTM's success in treatment[54] and prevention of CDs.[59] However, few studies show some weakness of TTM effectiveness in various healthcare context such as quitting smoking,[62] diet intervention in diabetic patients,[60] and physical activities of youth.[63] Hence, it can be said that this pattern can be implemented in other areas and diseases with successful results.
Discussion
The aim of this study was to conduct an SR on utility of the TTM in health behavioral change. Overall, the result of this study indicated the applicability of TTM for creating strong change in human behavior and increasing SE which can be applied in the prevention of CDs and can also corroborate the extended use of five SC. The results not only confirmed previous results but also lead to new information in this area which are mentioned below.
Applying different aspects of TTM
A large number of retrieved articles have used one of the aspects of TTM including SC, PC, DB, and SE. Noia et al. in their SR of selected databases showed the use for different aspects of this model in different subject areas. The results of their study showed that the most common aspect was the five SC.[29] Moattari et al. reported an increase in scores of SC, DB, and SE in nursing and midwifery students.[34] The results of this study also confirm the extended use of five SC.
The usage of TTM in CDs
The results of the review showed that only a small number of studies used this model for CDs. Despite this small number, these studies have led to positive and meaningful results. Lower popularity of this model for CDs can be due to unfamiliarity with this model and its use in medicine. Karimzadeh et al. in an intervention based on TTM on osteoporosis patients reported improved knowledge about increasing calcium levels and disease prevention.[39] It might be possible that the reason behind the low number of results regarding CDs is the fact that this study does not specifically target use of TTM in CDs.
The mentioned pros and cons of TTM
A small number of studies had led to negative results after using this model. Sanna Salmela et al. reported negative results in their SR of studies using TTM in diet studies for diabetic patients.[60] Most retrieved articles reported positive and significant results. Although many studies have been conducted on TTM and its uses, no study had specifically investigated the pros and cons of this model despite the fact that pros can lead to improved behavioral changes, whereas cons can lead to stagnation. Therefore, such studies seem necessary in this field. By knowing the possible cons of this model, it is possible to predict areas where this model is ineffective and knowing, different advantages this model can help determine what aspects of the model are useful in which condition. Restrictions existed on the full access to some databases such as Wiley and Ovid. Therefore, the research team selected the core and comprehensive databases that were used continuously and were readily accessible.
Based on the result of this study, there are insufficient studies in the application of TTM in health context. This study has also determined that few studies have used TTM in the prevention of CDs. The findings showed that TTM was not used at all for the prevention and treatment of obesity in children.
Conclusion
This review provided strong evidences for extended and effective use of TTM for changing health behaviors. According to the results, a large number of studies were about five SC, PC, DB, and SE. The majority of the current studies had investigated the five SC. Expertise behavior and physical activities were the areas in which the model was used most. Therefore, the effectiveness of TTM was proved in numerous studies while a small number of studies had reported some weakness of TTM.
Only a small number of studies had used TTM in CDs, but despite this low number, all these articles had reported positive results. Given the fact that chronic conditions are among important issues in society, it is suggested that this model can be used for areas such as obesity, multiple sclerosis, and problems in groups such as nurses who are in a greater danger of chronic conditions due to their occupation. Investigations showed that very few studies investigate the use of TTM in these areas. Therefore, it is suggested that more studies should be conducted in these subjects.
Financial support and sponsorship
Isfahan University of Medical Sciences
Conflicts of interest
Nothing to declare.
Acknowledgement
The authors would like to thank Dr. Gholamreza Asghari for comments on drafts.
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