Transtheoretical model

Transtheoretical model
The Transtheoretical Model of Behavior Change assesses an individual's readiness to act on a new healthier behavior, and provides strategies, or processes of change to guide the individual through the stages of change to action and maintenance. The Transtheoretical Model is also known by the acronym "TTM"[1] and by the term "stages of change model."[2] [3] A popular book, Changing for Good[4] , and articles in the news media[5] [6] [7] [8] [9] have discussed the model. It is "arguably the dominant model of health behaviour change, having received unprecedented research attention, yet it has simultaneously attracted exceptional criticism."[10]

History and core constructs of the model

James O. Prochaska of the University of Rhode Island and colleagues developed the transtheoretical model beginning in 1977.[11] It is based on an analysis of different theories of psychotherapy,[12] hence the name "transtheoretical." Prochaska and colleagues refined the model on the basis of research that they published in peer-reviewed journals and books.[13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] The model consists of four "core constructs": "stages of change," "processes of change," "decisional balance,"and "self-efficacy." [25]

TTM research breakthroughs

1980s Discovery of the Stages of Change and the dynamic change processes and principles related to each stage 1990s First computer-tailored intervention based on the Transtheoretical Model (TTM) was developed Demonstrated tailored interventions for smoking cessation effective even when more than 80% were not ready to quit TTM applied to a variety of behaviors beyond smoking cessation 2000s Demonstrated that TTM-based interventions for simultaneous multiple behavior change are effective TTM applied to a wide variety of new behavior change challenges 2010s Innovative strategies implemented to ensure greater impact on multiple behaviors with fewer demands on patients and providers Designed a more cost-effective delivery for coaching and online programs Serving entire populations with inclusive proactive and home-based care Expanding focus from health promotion to well-being

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Stages of change
In the Transtheoretical Model, change is a "process involving progress through a series of stages":[25] Precontemplation "people are not intending to take action in the foreseeable future, and are most likely unaware that their behaviour is problematic" Contemplation "people are beginning to recognize that their behaviour is problematic, and start to look at the pros and cons of their continued actions " Preparation "people are intending to take action in the immediate future, and may begin taking small steps towards change"[27]
Stages of Change from the Transtheoretical Model.

Action "people have made specific overt modifications in their life style, and positive change has occurred" Maintenance "people are working to prevent relapse," a stage which can last indefinitely" Termination "individuals have zero temptation and 100% self-efficacy... they are sure they will not return to their old unhealthy habit as a way of coping"[28] In addition, the researchers conceptualized "relapse" (recycling) which is not a stage in itself but rather the "return from action or maintenance to an earlier stage."[25] [29]

Stage details Stage 1: Precontemplation (Not Ready) People at this stage do not intend to start the healthy behavior in the near future (within 6 months), and may be unaware of the need to change. People here learn more about healthy behavior: they are encouraged to think about the Pros of changing their behavior and to feel emotions about the effects of their negative behavior on others. Precontemplators typically underestimate the Pros of changing, overestimate the Cons, and often are not aware of making such mistakes. These individuals are encouraged to become more mindful of their decision making and more conscious of the multiple benefits of changing an unhealthy behavior. Stage 2: Contemplation (Getting Ready) At this stage, participants are intending to start the healthy behavior within the next 6 months. While they are usually now more aware of the Pros of changing, their Cons are about equal to their Pros. This ambivalence about changing can cause them to keep putting off taking action. People here learn about the kind of person they could be if they changed their behavior and learned more from people who behave in healthy ways. Theyre encouraged to work at reducing the Cons of changing their behavior. Stage 3: Preparation (Ready) People at this stage are ready to start taking action within the next 30 days. They take small steps that they believe can help them make the healthy behavior a part of their lives. For example, they tell

Transtheoretical model their friends and family that they want to change their behavior. People in this stage are encouraged to seek support from friends they trust, tell people about their plan to change the way the act, and think about how they would feel if they behaved in a healthier way. Their number one concern iswhen they act, will they fail? They learn that the better prepared they are the more likely they are to keep progressing. Stage 4: Action People at this stage have changed their behavior within the last 6 months, and need to work hard to keep moving ahead. These participants need to learn how to strengthen their commitments to change and to fight urges to slip back. People in this stage are taught techniques for keeping up their commitments such as substituting activities related to the unhealthy behavior with positive ones, rewarding themselves for taking steps toward changing, and avoiding people and situations that tempt them to behave in unhealthy ways. Stage 5: Maintenance People at this stage changed their behavior more than 6 months ago. It is important for people in this stage to be aware of situations that may tempt them to slip back into doing the unhealthy behaviorparticularly stressful situations. It is recommended that people in this stage seek support from and talk with people whom they trust, spend time with people who behave in healthy ways, and remember to engage in alternative activities to cope with stress instead of relying on unhealthy behavior.

Processes of change
The 10 processes of change are "covert and overt activities that people use to progress through the stages."[25] To progress through the early stages, people apply cognitive, affective, and evaluative processes. As people move toward maintenance or termination, they rely more on commitments, conditioning, contingencies, environmental controls, and support.[30] Prochaska and colleagues state that their research related to the Transtheoretical Model suggests that interventions to change behavior are more effective if they are "stage-matched," that is, "matched to each individual's stage of change."[25] [31] Precontemplation to Contemplation Consciousness Raising Increasing information about self and problem: observations, confrontations, interpretations, and bibliotherapy. Both Dramatic Relief/Emotional Arousal and Environmental Re-Evaluation can be thought of as sub-techniques of Consciousness raising. Dramatic Relief or Emotional Arousal Experiencing and expressing feelings about one's problems and solutions: role playing, "stages" of grieving, etc. Environmental Re-Evaluation Assessing social and physical impacts of behavior: empathy training and documentaries.

Transtheoretical model Contemplation to Preparation Some sources place emotional arousal in this phase.[32] Self-Reevaluation Assessing feeling and thoughts about self with respect to the target behavior: value clarification, imagery, corrective emotional experience. Preparation to Action "Self-liberation" is emphasized. Commitment Choosing and committing to an act: decision-making therapy, social contracts, New Year's resolutions, logo therapy. Action to Maintenance Counter-Conditioning Also known as countering, this is the substitution of thoughts, activities, places, people, and things that could provide stimuli for the old behavior: relaxation, desensitization, assertion, positive self-statements. The below steps can be thought of as also being counter-conditioning as well. Helping Relationships Someone who helps keep one accountable to their commitments, give feedback, supportive emotionally, and offer serves as a model for what change will bring them: therapeutic alliance, social support, self-help groups. Reinforcement Management Continuing the reinforcement of positive benefits to change. Stimulus Control Controlling stimuli that prompt previous behavior. Social Liberation Social Liberation is emphasized across all of the stages and all stages use techniques during the stage, not just during transition.

Decisional balance
This core construct "reflects the individual's relative weighing of the pros and cons of changing."[25] [33] Decision making was conceptualized by Janis and Mann as a decisional "balance sheet" of comparative potential gains and losses."[34] decisional balance measures, the pros and the cons, have become critical constructs in the Transtheoretical model. The pros and cons combine to form a decisional "balance sheet" of comparative potential gains and losses. The balance between the pros and cons varies depending on which stage of change the individual is in. Sound decision-making requires the consideration of the potential benefits (Pros) and costs (Cons) associated with a behavior's consequences. Decisional balance is one of the best predictors of future change. TTM research has found the following relationships between the Pros, Cons, and the stage of change across 48 behaviors and over 100 populations studied. The Cons of changing outweigh the Pros in the Precontemplation stage. The Pros surpass the Cons in the middle stages.

Transtheoretical model The Pros outweigh the Cons in the Action state.[35]

Self-efficacy
This core construct is "the situation-specific confidence people have that they can cope with high risk situations without relapsing to their unhealthy or high risk habit."[25] [36] Self-efficacy[37] conceptualizes a person's perceived ability to perform on a task as a mediator of performance on future tasks. A change in the level of self-efficacy can predict a lasting change in behavior if there are adequate incentives and skills. The Transtheoretical model employs an overall confidence score to assess an individual's self-efficacy. Situational temptations assess how tempted people are to engage in a problem behavior in a certain situation.

How do people move from one stage to another?

In general, for people to progress they need: 1. A growing awareness that the advantages (the Pros) of changing outweigh the disadvantages (the Cons)the TTM calls this decisional balance 2. Confidence that they can make and maintain changes in situations that tempt them to return to their old, unhealthy behaviorthe TTM calls this self-efficacy 3. Strategies that can help them make and maintain changethe TTM calls these processes of change. The ten processes include: 1. Consciousness-Raisingincreasing awareness via information, education, and personal feedback about the healthy behavior. 2. Dramatic Relieffeeling fear, anxiety, or worry because of the unhealthy behavior, or feeling inspiration and hope when they hear about how people are able to change to healthy behaviors 3. Self-Reevaluationrealizing that the healthy behavior is an important part of who they are and want to be 4. Environmental Reevaluationrealizing how their unhealthy behavior affects others and how they could have more positive effects by changing 5. Social Liberationrealizing that society is more supportive of the healthy behavior 6. Self-Liberationbelieving in ones ability to change and making commitments and re-commitments to act on that belief 7. Helping Relationshipsfinding people who are supportive of their change 8. Counter-Conditioningsubstituting healthy ways of acting and thinking for unhealthy ways 9. Reinforcement Managementincreasing the rewards that come from positive behavior and reducing those that come from negative behavior 10. Stimulus Controlusing reminders and cues that encourage healthy behavior as substitutes for those that encourage the unhealthy behavior.

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Controversy
Among the criticisms of the model are the following: Little experimental evidence exists to suggest that application of the model is actually associated with changes in health-related behaviors. In a systematic review published in 2003 of 23 randomized controlled trials, the authors determined that "stage based interventions are no more effective than non-stage based interventions or no intervention in changing smoking behaviour."[38] A second systematic review from 2003 asserted that "no strong conclusions" can be drawn about the effectiveness of interventions based on the transtheoretical model for the prevention of pregnancy and sexually transmitted disease.[39] A 2005 systematic review of 37 randomized controlled trials claimed that "there was limited evidence for the effectiveness of stage-based interventions as a basis for behavior change."[40] According to a randomized controlled trial published in 2006, a stage-matched intervention for smoking cessation in pregnancy was more effective than a non-stage-matched intervention, but this finding could have resulted from the "greater intensity" of the stage-matched intervention.[41] A randomized controlled trial published in 2009 found "no evidence" that a smoking cessation intervention based on the transtheoretical model was more effective than a control intervention that was not tailored for stage of change.[42] A 2009 review stated that "existing data are insufficient for drawing conclusions on the benefits of the transtheoretical model" as related to dietary interventions for people with diabetes.[43] A 2010 systematic review of smoking cessation studies under the auspices of the Cochrane Collaboration found that "stage-based self-help interventions (expert systems and/or tailored materials) and individual counselling were neither more nor less effective than their non-stage-based equivalents."[44] "Arbitrary dividing lines" are drawn between the stages.[45] The model makes predictions that are "incorrect or worse than competing theories."[45] The model "assumes that individuals typically make coherent and stable plans," when in fact they do not.[45] The algorithms and questionnaires that researchers have used to assign people to stages of change have not been standardized, compared empirically, or validated.[46] [47] The designs of many studies supporting the model have been cross-sectional, but longitudinal study data would allow for stronger causal inferences.[46] In a 2002 review, the model's stages were characterized as "not mutually exclusive"; furthermore, there was "scant evidence of sequential movement through discrete stages."[48]

Responses to such criticisms include: Many studies that show the model to be ineffective have tailored interventions only to stage of change; if the studies had tailored interventions based on all core constructs of the model, they might have shown positive findings.[49] In particular, the "processes of change" have been characterized as "under-researched."[10] In 2008 Hutchison and colleagues published a systematic review of 34 articles examining 24 interventions based on the transtheoretical model for behavior change in physical activity; only 7 of the 24 interventions addressed all four dimensions "stages of change," "processes of change," "decisional balance," and "self-efficacy."[50] A 2007 meta-analysis by Noar et al. of 57 studies of tailored print health behavior change interventions found that the "number and type of theoretical concepts tailored on" were associated with behavior change.[51] Specifically, programs that tailor on stage do better than those that do not; programs that tailor on attitudes (e.g., decisional balance) do better than those that do not; programs that tailor on self-efficacy do better than those that do not; programs that tailor on social support do better than those that do not; and programs that tailor on processes of change do better than those that do not.[51] :683

Transtheoretical model Studies that find the model ineffective are poorly designed; for example, they have small sample sizes, poor recruitment rates, or high loss to follow-up.[49] [52] [53] The conversion of continuous data into discrete categories is necessary for the model, similar to how decisions are made about the treatment of high cholesterol levels depending on the discrete category the cholesterol level is placed into.[49]

Notes
The following notes summarize major differences between the well-known 1983,[14] 1992,[22] and 1997[25] versions of the model. Other published versions may contain other differences. For example, Prochaska, Prochaska, and Levesque (2001)[26] do not mention the Termination stage, Self-efficacy, or Temptation.
[1] Prochaska, JO; Butterworth, S; Redding, CA; Burden, V; Perrin, N; Leo, M; Flaherty-Robb, M; Prochaska, JM. Initial efficacy of MI, TTM tailoring and HRI's with multiple behaviors for employee health promotion. (http:/ / dx. doi. org/ 10. 1016/ j. ypmed. 2007. 11. 007) Prev Med 2008 Mar;46(3):22631. Accessed 2009 Mar 21. [2] Greene, GW; Rossi, SR; Rossi, JS; Velicer, WF; Fava, JL; Prochaska, JO. Dietary applications of the stages of change model. (http:/ / dx. doi. org/ 10. 1016/ S0002-8223(99)00164-9) J Am Diet Assoc 1999 Jun;99(6):6738. Accessed 2009 Mar 21. [3] Pro-Change Behavior Systems. About us. Transtheoretical model. (http:/ / www. prochange. com/ ttm) 2008 Mar. Accessed 2009 Mar 21. [4] Prochaska, JO; Norcross, JC; DiClemente, CC. Changing for good: the revolutionary program that explains the six stages of change and teaches you how to free yourself from bad habits. New York: W. Morrow; 1994. ISBN 0688112633. [5] Goleman, Daniel. New addiction approach gets results. (http:/ / query. nytimes. com/ gst/ fullpage. html?res=9F0CEED81E31F932A3575AC0A965958260) New York Times 1993 Sep 1. Accessed 2009 Mar 19. [6] Miller, Kay. Revolving resolutions - Year after new year, we vow to lose weight, stop smoking, find love or a better job -- only to fail. A few simple strategies could set us straight. Star Tribune: Newspaper of the Twin Cities 2001 Dec 29. [7] Stettner, Morey. A methodical way to change bad behavior. Investor's Business Daily 2005 Dec 19. [8] Understanding change: expect a few bumps. (http:/ / www. washingtonpost. com/ wp-dyn/ content/ article/ 2006/ 12/ 29/ AR2006122901742. html) Washington Post 2007 Jan 2. Accessed 2009 Mar 19. [9] Carbine, Michael E. Health plans use a variety of strategies to identify and ensure compliance among diabetics. (http:/ / www. aishealth. com/ Bnow/ hbd030609. html) AIS's Health Business Daily 2009 Mar 6. Accessed 2009 Mar 19. [10] Armitage, CJ. Is there utility in the transtheoretical model? (http:/ / www. ingentaconnect. com/ content/ bpsoc/ bjhp/ pre-prints/ 307784) Br J Health Psychol 2009;14(Pt 2):195210. Epub 2008 Oct 14. Accessed 2009 Mar 17. [11] Prochaska, JO.; DiClemente, CC. The transtheoretical approach. In: Norcross, JC; Goldfried, MR. (eds.) Handbook of psychotherapy integration. 2nd ed. New York: Oxford University Press; 2005. p. 147171. ISBN 0195165799. [12] Prochaska, JO. & Norcross, JC Systems of psychotherapy: a transtheoretical analysis. 7th edition Brooks & Cole, CA 2010. [13] McConnaughy, EA; Prochaska, JO; Velicer, WF. Stages of change in psychotherapy - measurement and sample profiles. Psychotherapy: Theory, Research and Practice 1983;20(3):368375. [14] Prochaska, JO; DiClemente, CC. Stages and processes of self-change of smoking: toward an integrative model of change. (http:/ / www. uri. edu/ research/ cprc/ Publications/ PDFs/ ByTitle/ Stages and Processes of self change. pdf) J Consult Clin Psychol 1983 Jun;51(3):3905. Accessed 2009 Mar 18. [15] DiClemente, CC; Prochaska, JO; Gibertini, M. Self-efficacy and the stages of self-change of smoking. (http:/ / www. springerlink. com/ content/ pn5726319267mt81/ ) Cognit Ther Res 1985;9(2):181200. Accessed 2009 Mar 22. [16] Velicer, WF; DiClemente, CC; Prochaska, JO; Brandenburg, N. Decisional balance measure for assessing and predicting smoking status. (http:/ / www. uri. edu/ research/ cprc/ Publications/ PDFs/ ByTitle/ Decisional Balance measure for assessing and. pdf) J Pers Soc Psychol 1985 May;48(5):127989. Accessed 2009 Mar 18. [17] Prochaska, JO; DiClemente, CC. Toward a comprehensive model of change. (http:/ / www. uri. edu/ research/ cprc/ Publications/ PDFs/ ByTitle/ Toward a comprehensive model of change. pdf) In: Miller, WR; Heather, N. (eds.) Treating addictive behaviors: processes of change. New York: Plenum Press; 1986. p. 327. ISBN 0306422484. Accessed 2009 Mar 18. [18] Prochaska, JO; Velicer, WF; DiClemente, CC; Fava, J. Measuring processes of change: applications to the cessation of smoking. J Consult Clin Psychol 1988 Aug;56(4):5208. PMID 3198809. [19] DiClemente, CC; Prochaska, JO; Fairhurst, SK; Velicer, WF; Velasquez, MM; Rossi, JS. The process of smoking cessation: an analysis of precontemplation, contemplation, and preparation stages of change. (http:/ / www. uri. edu/ research/ cprc/ Publications/ PDFs/ ByTitle/ The Process of smoking cessation an analysis of precomtemplation. pdf) J Consult Clin Psychol 1991 Apr;59(2):295304. Accessed 2009 Mar 18. [20] Velicer, WF; Prochaska, JO; Rossi, JS; Snow, MG. Assessing outcome in smoking cessation studies. Psychol Bull 1992 Jan;111(1):2341. PMID 1539088. [21] Prochaska, JO; DiClemente, CC. Stages of change in the modification of problem behaviors. Prog Behav Modif 1992;28:183218. PMID 1620663. [22] Prochaska, JO; DiClemente, CC; Norcross, JC. In search of how people change. Applications to addictive behaviors. (http:/ / www. uri. edu/ research/ cprc/ Publications/ PDFs/ ByTitle/ In Search of How People Change Applications to Additive Behaviors. pdf) Am Psychol 1992

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Sep;47(9):110214. Accessed 2009 Mar 16. [23] Prochaska, JO; DiClemente, CC; Velicer, WF; Rossi, JS. Standardized, individualized, interactive, and personalized self-help programs for smoking cessation. (http:/ / www. uri. edu/ research/ cprc/ Publications/ PDFs/ ByTitle/ Standardized individualized interactive and Personalized. pdf) Health Psychol 1993 Sep;12(5):399405. Accessed 2009 Mar 18. [24] Prochaska, JO; Velicer, WF; Rossi, JS; Goldstein, MG; Marcus, BH; et al. Stages of change and decisional balance for 12 problem behaviors. (http:/ / www. uri. edu/ research/ cprc/ Publications/ PDFs/ ByTitle/ Stages of Change and decisional balance for. pdf) Health Psychol 1994 Jan;13(1):3946. Accessed 2009 Mar 18. [25] Prochaska, JO; Velicer, WF. The transtheoretical model of health behavior change. (http:/ / www. uri. edu/ research/ cprc/ Publications/ PDFs/ ByTitle/ The Transtheoretical model of Health behavior change. pdf) Am J Health Promot 1997 SepOct;12(1):3848. Accessed 2009 Mar 18. [26] Prochaska, JM; Prochaska, JO; Levesque, DA. A transtheoretical approach to changing organizations. (http:/ / www. springerlink. com/ content/ l461598u104223g8/ ) Adm Policy Ment Health 2001 Mar;28(4):24761. Accessed 2009 Mar 20. [27] In the 1983 version of the model, the Preparation stage is absent. [28] In the 1983 version of the model, the Termination stage is absent. In the 1992 version of the model, Prochaska et al. showed Termination as the end of their "Spiral Model of the Stages of Change," not as a separate stage. [29] In the 1983 version of the model, Relapse is considered one of the five stages of change. [30] Prochaska, JO; Redding, CA; Evers, KE. The Transtheoretical Model and Stages of Change. In: Glanz, K; Rimer, BK; Viswanath, K. (eds.) Health Behavior and Health Education. 4th ed. San Francisco: Jossey-Bass; 2008. p. 105. ISBN 9780787996147. [31] In the 1983 version of the model, the processes of change were said to be emphasized in only the Contemplation, Action, and Maintenance stages. [32] Prochaska, James O., John C. Norcross, and Carlo C. DiClemente. "How You Change." In: Changing for good. New York: Avon Books, 1995. ISBN 038072572X. [33] In the 1983 version of the model, "decisional balance" is absent. In the 1992 version of the model, Prochaska et al. mention "decisional balance" but in only one sentence under the "key transtheoretical concept" of "processes of change." [34] Janis, I.L. & Mann, L. (1977) Decision making: a psychological analysis of conflict, choice and commitment. New York: Free Press. ISBN 0029161606 [35] Hall, K.L. & Rossi, J. S. (2008) Meta-analysis Examination of the sting and weak principals across 48 behaviors. Preventative Medicine, 46, 266-274. [36] In the 1983 version of the model, "self-efficacy" is absent. In the 1992 version of the model, Prochaska et al. mention "self-efficacy" but in only one sentence under the "key transtheoretical concept" of "stages of change." [37] Bandura, A. (1977) Self-efficacy: Toward a unified theory of behavior change. Psychological Review, 84, 191-215 [38] Riemsma, RP; Pattenden, J; Bridle, C; Sowden, AJ; Mather, L; Watt, IS; Walker, A. Systematic review of the effectiveness of stage based interventions to promote smoking cessation. (http:/ / www. bmj. com/ cgi/ content/ full/ 326/ 7400/ 1175) BMJ 2003 May 31;326(7400):11757. Accessed 2009 Mar 18. [39] Horowitz, SM. Applying the transtheoretical model to pregnancy and STD prevention: a review of the literature. (http:/ / hpp. sagepub. com/ cgi/ content/ abstract/ 7/ 4/ 428) Am J Health Promot 2003 MayJun;17(5):30428. Accessed 2009 Mar 18. [40] Bridle, C; Riemsma, RP; Pattenden, J; Sowden, AJ; Mather, L; Watt, IS; Walker, A. Systematic review of the effectiveness of health behavior interventions based on the transtheoretical model. (http:/ / www2. warwick. ac. uk/ fac/ med/ staff/ bridle/ download/ ttm_interventions_ph_05. pdf) Psychol Health 2005;20:283301. Accessed 2009 Mar 18. [41] Aveyard, P; Lawrence, T; Cheng, KK; Griffin, C; Croghan, E; Johnson, C. A randomized controlled trial of smoking cessation for pregnant women to test the effect of a transtheoretical model-based intervention on movement in stage and interaction with baseline stage. (http:/ / www. haps. bham. ac. uk/ primarycare/ cv/ smoking/ docs/ pregnancystage. pdf) Br J Health Psychol 2006 May;11(Pt 2):26378. Accessed 2009 Mar 18. [42] Aveyard, P; Massey, L; Parsons, A; Manaseki, S; Griffin, C. The effect of Transtheoretical Model based interventions on smoking cessation. (http:/ / dx. doi. org/ 10. 1016/ j. socscimed. 2008. 10. 036) Soc Sci Med 2009 Feb;68(3):397403. Accessed 2009 Mar 18. [43] Salmela, S; Poskiparta, M; Kasila, K; Vhsarja, K; Vanhala, M. Transtheoretical model-based dietary interventions in primary care: a review of the evidence in diabetes. (http:/ / her. oxfordjournals. org/ cgi/ content/ full/ cyn015) Health Educ Res 2009 Apr;24(2):23752. Accessed 2009 Mar 19. [44] Cahill, K; Lancaster, T; Green, N. Stage-based interventions for smoking cessation. (http:/ / www2. cochrane. org/ reviews/ en/ ab004492. html) Cochrane Database Syst Rev. 2010 Nov 10;11:CD004492. PMID 21069681. Accessed 2011 Feb 15. [45] West, R. Time for a change: putting the Transtheoretical (Stages of Change) Model to rest. (http:/ / www. psychologie. tu-dresden. de/ i2/ klinische/ studium/ ss07/ west-anti-ttm-pluscommentaries-2005. pdf) Addiction 2005 Aug;100(8):10369. Accessed 2009 Mar 19. [46] Sutton, S. Back to the drawing board? A review of applications of the transtheoretical model to substance use. (http:/ / www. medschl. cam. ac. uk/ gppcru/ userfiles/ ProjectDocs/ BSG/ Paper67. pdf) Addiction 2001 Jan;96(1):17586. Accessed 2009 Mar 19. [47] Adams, J; White, M. Why don't stage-based activity promotion interventions work? (http:/ / her. oxfordjournals. org/ cgi/ content/ full/ 20/ 2/ 237) Health Educ Res 2005 Apr;20(2):23743. Accessed 2009 Mar 22. [48] Littell, JH; Girvin, H. Stages of change. A critique. (http:/ / bmo. sagepub. com/ cgi/ content/ abstract/ 26/ 2/ 223) Behav Modif 2002 Apr;26(2):22373. Accessed 2009 Mar 19.

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[49] Prochaska, JO. Moving beyond the transtheoretical model. (http:/ / doi. wiley. com/ 10. 1111/ j. 1360-0443. 2006. 01404. x) Addiction 2006 Jun;101(6):76874. Accessed 2009 Mar 20. [50] Hutchison, AJ; Breckon, JD; Johnston, LH. Physical activity behavior change interventions based on the Transtheoretical Model: a systematic review. (http:/ / heb. sagepub. com/ cgi/ content/ abstract/ 1090198108318491v1) Health Educ Behav 2008 Jul 7 [Epub ahead of print]. Accessed 2009 Mar 20. [51] Noar, SM; Benac, CN; Harris, MS. Does tailoring matter? Meta-analytic review of tailored print health behavior change interventions. (http:/ / www. gvo. unimaas. nl/ Onderwijs/ Noar2007. pdf) Psychol Bull 2007 Jul;133(4):67393. Accessed 2009 Mar 21. [52] Spencer, L; Pagell, F; Hallion, ME; Adams, TB. Applying the transtheoretical model to tobacco cessation and prevention: a review of literature. (http:/ / healthpromotionjournal. com/ mm5/ merchant. mvc?Screen=PROD& Store_Code=AJHP& Product_Code=JV17I17) Am J Health Promot 2002 SepOct;17(1):771. Accessed 2009 Mar 22. [53] Prochaska, JO. Flaws in the theory or flaws in the study: a commentary on "The effect of Transtheoretical Model based interventions on smoking cessation". (http:/ / dx. doi. org/ 10. 1016/ j. socscimed. 2008. 10. 034) Soc Sci Med 2009 Feb;68(3):4046. Accessed 2009 Mar 21.

References Further reading

Prochaska, JO; DiClemente, CC. The transtheoretical approach: crossing traditional boundaries of therapy. Homewood, IL: Dow Jones-Irwin; 1984. ISBN 087094438X. Miller, WR; Heather, N. (eds.). Treating addictive behaviors. 2nd ed. New York: Plenum Press; 1998. ISBN 0306458527. Connors, GJ; Donovan, DM; DiClemente, CC. Substance abuse treatment and the stages of change: selecting and planning interventions. New York: Guilford Press; 2001. ISBN 1572306572. Velasquez, MM. Group treatment for substance abuse: a stages-of-change therapy manual. New York: Guilford Press; 2001. ISBN 1572306254. Burbank, PM; Riebe, D. Promoting exercise and behavior change in older adults: interventions with the transtheoretical model. New York: Springer; 2002. ISBN 0826115020. DiClemente, CC. Addiction and change: how addictions develop and addicted people recover. New York: Guilford Press; 2003. ISBN 1572300574. Prochaska, JO; Norcross, JC. Systems of psychotherapy: a transtheoretical analysis. 6th ed. Australia: Thomson/Brooks/Cole; 2007. ISBN 9780495007777. Glanz, K; Rimer, BK; Viswanath, K. (eds.) Health behavior and health education: theory, research, and practice, 4th ed. San Francisco, CA: Jossey-Bass; 2008. ISBN 9780787996147.

External links
Cancer Prevention Research Center, University of Rhode Island. Summary overview of the transtheoretical model. (http://www.uri.edu/research/cprc/transtheoretical.htm) HABITS [Health and Addictive Behaviors: Investigating Transtheoretical Solutions] Lab, Psychology Department, University of Maryland Baltimore County. The transtheoretical model of behavior change. (http:// www.umbc.edu/psyc/habits/content/the_model/index.html) Lenio, James A. Analysis of the transtheoretical model of behavior change. (http://www.uwstout.edu/rs/2006/ 14Lenio.pdf) University of Wisconsin Stout, Journal of Student Research, Fifth Edition, 2006. Pro-Change Behavior Systems, Inc. (http://www.prochange.com) Company founded by James O. Prochaska. Mission is to enhance the well-being of individuals and organizations through the scientific development and dissemination of Transtheoretical Model based change management programs. Zimmerman, GL; Olsen, CG; Bosworth, MF. A 'stages of change' approach to helping patients change behavior. (http://www.aafp.org/afp/20000301/1409.html) Am Fam Physician 2000 Mar 1;61(5):140916.

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Article Sources and Contributors

Transtheoretical model Source: http://en.wikipedia.org/w/index.php?oldid=434970793 Contributors: 4Russeteer, Aaron Kauppi, Beatlesfan64, Bobo192, Crathes2, Dartelaar, Doczilla, Dr. Lisa, Dr.S.A.Knight, Elassint, Galoubet, Greenep1, Griffin42, Indolering, Innapoy, Iridescent, J0n, Jeffbrooksharris, Jxb311, M3dicker, Martin451, Mattisse, Nanoxyde, Natalie Erin, Ph.eyes, Philciaccio, Phildubois, PrevMedFellow, Qwfp, Sasuke Sarutobi, Scarian, Skagedal, Velella, Vernon39, Willhaslett, 57 anonymous edits

Image Sources, Licenses and Contributors

File:Stages-of-change.png Source: http://en.wikipedia.org/w/index.php?title=File:Stages-of-change.png License: Creative Commons Zero Contributors: Toddatkins File:Stages.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Stages.jpg License: Creative Commons Attribution 3.0 Contributors: Philciaccio File:Ttmf3.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Ttmf3.jpg License: Creative Commons Attribution 3.0 Contributors: Philciaccio

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