THEORIES AND MODELS OF CHANGE

In order to help patients make change and to maximize the success of interventions, it is important that healthcare professionals have a theoretical understanding of change. Such theory comes from the accumulated knowledge about what mediates and moderates change behavior.

Following are four major theories and models of behavior change:

  • Transtheoretical Model (TTM) (also referred to as Stages of Change): Change is a process involving progress through a series of stages.
  • Theory of Planned Behavior (TBP): Change in behavior is determined by intention to perform the behavior.
  • Health Belief Model (HBM): Behaviors are based on attitudes and beliefs.
  • Social Cognitive Theory (SCT): Change is driven through interaction between environment, personal factors, and attitudes.

Transtheoretical Model (TTM)

Of the four major theories and models, the most widely applied and tested is the Transtheoretical Model, also referred to as Stages of Change. This model identifies six sequential stages that people move through as they change from old behaviors to new ones:

  1. Precontemplation
  2. Contemplation
  3. Preparation
  4. Action
  5. Maintenance
  6. Termination
    (UMBC, n.d.; Gold, 2018)

STAGE 1: PRECONTEMPLATION

Precontemplation is the stage when there is no conscious intent to make a change. In this stage, people are not even thinking about changing their behaviors. They may not see current behaviors as problematic or may think that the problem is being exaggerated.

STAGE 2: CONTEMPLATION

Contemplation is the stage when individuals are aware that the behavior is a problem and intend to change behavior relatively soon, but they may vacillate for a long period of time. Often, people in the contemplation stage are not yet truly ready to change. They may procrastinate or doubt their ability to change. Individuals in this stage are often highly ambivalent, may be interested in learning about how to make change, but still cannot make a decision (Moore, 2021).

STAGE 3: PREPARATION

Preparation is the stage in which individuals know they must change and become committed to take action to change. The pros of change outweigh the cons. Often something happens to motivate a person to take action, such as an emotion-laden crisis, recent illness, or plea from an important person in their life. During this stage, not all ambivalence has been resolved, but it is no longer an impossible barrier to overcome. The person may develop a plan of action but not yet be completely committed to actually changing the behavior (UMBC, n.d.).

STAGE 4: ACTION

This is the stage where people believe they have the ability to change behavior and are actively involved in taking steps to do so (Gold, 2018). This is the beginning of actual change, when goals and objectives are identified. It is also the stage when relapse and subsequent regression to an earlier stage is most likely (UMBC, n.d.). Clinicians should be aware of this potential and help patients/families to be especially vigilant. The patient needs support from family and friends as well as from the healthcare team. Members of the team should check in more often with patients and listen to concerns and issues affecting change.

This is the stage when patients develop new habits and work toward what some have called “SMART objectives” (see table below).

SMART OBJECTIVES
Objective Example
(CDC, n.d.)
Specific Answers the question “What is to be done?” (e.g., deciding, “I will no longer smoke cigarettes or any other substance.”)
Measurable Answers the question “How will I know I’ve met expectations?” (e.g., determining that “I will not keep any cigarettes, even an ‘emergency smoke,’ in my environment.”)
Achievable Answers the question “Can I do this?” (e.g., reassuring oneself by thinking, “I have overcome other cravings. Other people have stopped smoking, and I can too.”)
Relevant Answers the question, “Should it be done and why?” (e.g., realizing that “Smoking is not necessary for me to enjoy life; in fact, it may kill me.”)
Time-bound Answers the question, “When will this be accomplished?” (e.g., setting the goal, “I will stop smoking by January 1, the beginning of a new year.”)

STAGE 5: MAINTENANCE

Patients are thought to be in maintenance when they have attained and maintained desired behavioral change for at least six months. Although the risk for relapse still exists, it is less, and patients need to exert less effort to maintain the change (UMBC, n.d.).

STAGE 6: TERMINATION

Termination is the point at which temptation to relapse is no longer a threat. The person now has complete confidence that change has been accomplished and no longer fears relapse (Moore, 2021; UMBC, n.d.).

CASE

Stages of Change

Anna has smoked cigarettes for more than 35 years. She knows that smoking is bad for one’s health, and she’s even tried to quit in the past without success. Recently, family members have begun urging her that she really must quit this time, but this angers her, and she tells them to stop harassing her about it. (Precontemplation)

Over the last couple of months, Anna has developed a cough, especially at night, excessive sputum, and some shortness of breath. She has also felt more fatigued lately. She is hoping maybe she just has a cold, but she also suspects it might be related to her smoking and wonders whether her family is right about the need to quit. Finally, after a few more weeks of procrastinating, she makes an appointment to see her healthcare provider.

At her appointment, the physician examines Anna and eventually diagnoses her with chronic obstructive pulmonary disease (COPD). Faced with this new diagnosis, Anna is strongly urged to quit smoking. She is given information about the disease process and pamphlets that offer suggestions for stopping smoking. She takes them home, reads them, and thinks a lot about quitting. But other days, after enjoying her cigarette and morning cup of coffee, she can’t imagine giving it up. Then she remembers, “I’m not really enjoying this coughing and shortness of breath.” (Contemplation)

One very cold day, on the walk from her mailbox back up her long driveway, Anna becomes shorter and shorter of breath. Her chest feels tight, she begins to wheeze, and she can’t stop coughing. She barely makes it back into the house, lays down, and waits fearfully until she can breathe again. At that point, she decides it’s time to quit smoking. She calls her doctor’s office and says she wants to sign up for the smoking cessation classes mentioned in the pamphlets. (Preparation)

Anna is now ready to quit. At her first smoking cessation class at the local hospital, the educator helps her identify times when she usually smokes, plan other activities at those times, and arrange with friends for support when she needs it. The educator teaches Anna the “SMART” objectives. Anna decides to work on achieving realistic goals. First, she targets January 1 as the date to decrease her smoking from one pack to five cigarettes per day. Once January 1 rolls past and Anna reduces her smoking, she begins to struggle and cannot stick with her goal each day. At their next appointment, Anna and the educator acknowledge that relapse is not uncommon at this stage. Anna will need support, not condemnation, and together they reevaluate her goals for achievability. (Action)

With encouragement, Anna is able to meet her goal over the next couple of months, but she’s still finding it challenging and realizes she needs additional help to stick with it. She joins a community support group of other long-time smokers, all of whom are determined to stop smoking. Over the next few months, the other members encourage Anna and give her tips to prevent relapse. (Maintenance)

One year later, Anna no longer smokes and no longer wants to. In fact, she is turned off by the smell of secondhand smoke. Her COPD has not progressed any further, and she intends to keep it that way. (Termination)

Other Theories and Models of Change

Although the TTM is the most widely applied and tested model, there are other theories and models of change in use. Some of the more common ones are briefly explained below.

THEORY OF PLANNED BEHAVIOR (TBP)

The Theory of Planned Behavior has been successfully used to predict and explain a wide variety of health behaviors such as smoking, drinking, utilization of health services, breastfeeding, and substance use. TBP is composed of six components:

  1. Attitudes: Refers to the degree to which patients have a favorable or unfavorable view of the behavior that needs to be changed
  2. Behavioral intention: Refers to the factors that influence the intention to change behavior
  3. Subjective norms: Refers to the belief about whether most people approve or disapprove of the behavior; relates to how peers and other people important to the patient feel about the need for the behavioral change
  4. Social norms: Refers to customary codes of behavior in a group of people or in a culture
  5. Perceived power: Refers to patients’ perceptions of factors that may facilitate or inhibit behavioral change
  6. Perceived behavioral control: Refers to patients’ perceptions of how easy or how hard changing behavior is going to be
    (BU, 2019a)

HEALTH BELIEF MODEL (HBM)

The Health Belief Model was developed to understand the failure of people to adopt disease prevention strategies or undergo screening tests for the early detection of disease. Its foundation comes from psychological and behavioral theory that proposes two components of health-related behavior: 1) the desire to avoid illness or to get well if already sick and 2) the belief that a specific health behavior will prevent or cure illness. A patient’s course of action depends on their perceptions of the benefits and barriers related to health behavior (BU, 2019b).

SOCIAL COGNITIVE THEORY (SCT)

The foundation of Social Cognitive Theory is an emphasis on social influence and external and internal social reinforcement. SCT examines the unique ways in which individuals acquire and maintain behavior, taking into account the patient’s social environment and past experiences. Past experiences are believed to influence expectations, which shape whether a person will engage in a specific behavior and the reasons why a person engages in that behavior (BU, 2019c).

CHOOSING A MODEL OF CHANGE

In choosing a model of change, it is important to decide which one is appropriate to the patient’s desired outcomes and circumstances. For example, the HBM does not account for environmental and social-cultural factors, whereas the SCT relies on interactions between people and their environments. Thus, if a patient’s lack of physical activity is heavily influenced by peers, work, or family, SCT might be the better approach (Luque, n.d.).