Behavioral Change Models

Introduction

Public health is a multi-disciplinary field that aims to 1) prevent disease and death, 2) promote a
better quality of life, and 3) create environmental conditions in which people can be healthy by
intervening at the institutional, community, and societal level. 

Whether public health practitioners can achieve this mission depends upon their ability to
accurately identify and define public health problems, assess the fundamental causes of these
problems, determine populations most at-risk, develop and implement theory- and evidence-
based interventions, and evaluate and refine those interventions to ensure that they are
achieving their desired outcomes without unwanted negative consequences.

To be effective in these endeavors, public health practitioners must know how to apply the basic
principles, theories, research findings, and methods of the social and behavioral sciences to
inform their efforts.   A thorough understanding of theories used in public health, which are
mainly derived from the social and behavioral sciences, allow practitioners to:

 Assess the fundamental causes of a public health problem, and

 Develop interventions to address those problems.

Note: This module has been translated into Estonian by Marie Stefanova. The translation can
be accessed at

https://www.bildeleekspert.dk/blog/2018/08/06/sotsiaalsete-normide-teooria/

Learning Objectives

After successfully reviewing these modules, students will be able to:

 List and describe the key constructs of the Health Belief Model and the theory of
planned behavior and explain how they might be applied to develop effective public
health interventions
 List and describe the elements of "perceived behavioral control"
 Describe the underlying theory and basic elements of Social Norms Theory and
marketing campaigns
 List and describe the key constructs of Social Cognitive Theory and explain how they
might be applied to develop effective public health interventions
 Summarize the criticisms that have been made regarding the major traditional models
of health behavior change and why these models do not seem adequate to account for
observed health behaviors
  Outline the major steps in the Transtheoretical Model
 List the characteristics of each step of the Transtheoretical Model
 Describe Diffusion of Innovation Theory and how it can be applied in health promotion
 Outline the basic structures of the Theory of Gender and Power and its application to
Public Health
 Explain the constructs of the Sexual Health Model and its application to public health

The Health Belief Model

The Health Belief Model (HBM) was developed in the early 1950s by social scientists at the U.S.
Public Health Service in order to understand the failure of people to adopt disease prevention
strategies or screening tests for the early detection of disease. Later uses of HBM were for
patients' responses to symptoms and compliance with medical treatments. The HBM suggests
that a person's belief in a personal threat of an illness or disease together with a person's belief
in the effectiveness of the recommended health behavior or action will predict the likelihood the
person will adopt the behavior.

The HBM derives from psychological and behavioral theory with the foundation that the two
components of health-related behavior are 1) the desire to avoid illness, or conversely get well if
already ill; and, 2) the belief that a specific health action will prevent, or cure, illness. Ultimately,
an individual's course of action often depends on the person's perceptions of the benefits and
barriers related to health behavior. There are six constructs of the HBM. The first four constructs
were developed as the original tenets of the HBM. The last two were added as research about
the HBM evolved.

1. Perceived susceptibility - This refers to a person's subjective perception of the risk of

acquiring an illness or disease. There is wide variation in a person's feelings of personal
vulnerability to an illness or disease.
2. Perceived severity - This refers to a person's feelings on the seriousness of contracting
an illness or disease (or leaving the illness or disease untreated). There is wide variation
in a person's feelings of severity, and often a person considers the medical
consequences (e.g., death, disability) and social consequences (e.g., family life, social
relationships) when evaluating the severity.
3. Perceived benefits - This refers to a person's perception of the effectiveness of various
actions available to reduce the threat of illness or disease (or to cure illness or disease).
The course of action a person takes in preventing (or curing) illness or disease relies on
consideration and evaluation of both perceived susceptibility and perceived benefit, such
that the person would accept the recommended health action if it was perceived as
beneficial.
4. Perceived barriers - This refers to a person's feelings on the obstacles to performing a
recommended health action. There is wide variation in a person's feelings of barriers, or
impediments, which lead to a cost/benefit analysis. The person weighs the effectiveness
of the actions against the perceptions that it may be expensive, dangerous (e.g., side
effects), unpleasant (e.g., painful), time-consuming, or inconvenient.
5. Cue to action - This is the stimulus needed to trigger the decision-making process to
accept a recommended health action. These cues can be internal (e.g., chest pains,
 wheezing, etc.) or external (e.g., advice from others, illness of family member,
newspaper article, etc.).
6. Self-efficacy - This refers to the level of a person's confidence in his or her ability to
successfully perform a behavior. This construct was added to the model most recently in
mid-1980. Self-efficacy is a construct in many behavioral theories as it directly relates to
whether a person performs the desired behavior.

Limitations of Health Belief Model

There are several limitations of the HBM which limit its utility in public health. Limitations of the
model include the following:

 It does not account for a person's attitudes, beliefs, or other individual determinants that
dictate a person's acceptance of a health behavior.
 It does not take into account behaviors that are habitual and thus may inform the
decision-making process to accept a recommended action (e.g., smoking).
 It does not take into account behaviors that are performed for non-health related reasons
such as social acceptability.
 It does not account for environmental or economic factors that may prohibit or promote
the recommended action.
 It assumes that everyone has access to equal amounts of information on the illness or
disease.
 It assumes that cues to action are widely prevalent in encouraging people to act and that
"health" actions are the main goal in the decision-making process.

The HBM is more descriptive than explanatory, and does not suggest a strategy for changing
health-related actions. In preventive health behaviors, early studies showed that perceived
susceptibility, benefits, and barriers were consistently associated with the desired health
behavior; perceived severity was less often associated with the desired health behavior. The
individual constructs are useful, depending on the health outcome of interest, but for the most
effective use of the model it should be integrated with other models that account for the
environmental context and suggest strategies for change.

The Theory of Planned Behavior

The Theory of Planned Behavior (TPB) started as the Theory of Reasoned Action in 1980 to
predict an individual's intention to engage in a behavior at a specific time and place. The theory
was intended to explain all behaviors over which people have the ability to exert self-control.
The key component to this model is behavioral intent; behavioral intentions are influenced by
the attitude about the likelihood that the behavior will have the expected outcome and the
subjective evaluation of the risks and benefits of that outcome.  

The TPB has been used successfully to predict and explain a wide range of health behaviors
and intentions including smoking, drinking, health services utilization, breastfeeding, and
substance use, among others. The TPB states that behavioral achievement depends on both
motivation (intention) and ability (behavioral control). It distinguishes between three types of
beliefs - behavioral, normative, and control. The TPB is comprised of six constructs that
collectively represent a person's actual control over the behavior.

1. Attitudes - This refers to the degree to which a person has a favorable or unfavorable
evaluation of the behavior of interest. It entails a consideration of the outcomes of
performing the behavior.
2. Behavioral intention - This refers to the motivational factors that influence a given
behavior where the stronger the intention to perform the behavior, the more likely the
behavior will be performed.
3. Subjective norms - This refers to the belief about whether most people approve or
disapprove of the behavior. It relates to a person's beliefs about whether peers and
people of importance to the person think he or she should engage in the behavior.  
4. Social norms - This refers to the customary codes of behavior in a group or people or
larger cultural context. Social norms are considered normative, or standard, in a group of
people.
5. Perceived power - This refers to the perceived presence of factors that may facilitate or
impede performance of a behavior. Perceived power contributes to a person's perceived
behavioral control over each of those factors.
6. Perceived behavioral control - This refers to a person's perception of the ease or
difficulty of performing the behavior of interest. Perceived behavioral control varies
across situations and actions, which results in a person having varying perceptions of
behavioral control depending on the situation. This construct of the theory was added
later, and created the shift from the Theory of Reasoned Action to the Theory of Planned
Behavior.

Limitations of the Theory of Planned Behavior

There are several limitations of the TPB, which include the following:  
  It assumes the person has acquired the opportunities and resources to be successful in
performing the desired behavior, regardless of the intention.
 It does not account for other variables that factor into behavioral intention and
motivation, such as fear, threat, mood, or past experience.
 While it does consider normative influences, it still does not take into account
environmental or economic factors that may influence a person's intention to perform a
behavior.
 It assumes that behavior is the result of a linear decision-making process, and does not
consider that it can change over time.
 While the added construct of perceived behavioral control was an important addition to
the theory, it doesn't say anything about actual control over behavior.
 The time frame between "intent" and "behavioral action" is not addressed by the theory.

The TPB has shown more utility in public health than the Health Belief Model, but it is still
limiting in its inability to consider environmental and economic influences. Over the past several
years, researchers have used some constructs of the TPB and added other components from
behavioral theory to make it a more integrated model. This has been in response to some of the
limitations of the TPB in addressing public health problems.

Diffusion of Innovation Theory

Diffusion of Innovation (DOI) Theory, developed by E.M. Rogers in 1962, is one of the oldest
social science theories. It originated in communication to explain how, over time, an idea or
product gains momentum and diffuses (or spreads) through a specific population or social
system. The end result of this diffusion is that people, as part of a social system, adopt a new
idea, behavior, or product.   Adoption means that a person does something differently than what
they had previously (i.e., purchase or use a new product, acquire and perform a new behavior,
etc.). The key to adoption is that the person must perceive the idea, behavior, or product as new
or innovative. It is through this that diffusion is possible.  

Adoption of a new idea, behavior, or product (i.e., "innovation") does not happen simultaneously
in a social system; rather it is a process whereby some people are more apt to adopt the
innovation than others.   Researchers have found that people who adopt an innovation early
have different characteristics than people who adopt an innovation later. When promoting an
innovation to a target population, it is important to understand the characteristics of the target
population that will help or hinder adoption of the innovation. There are five established
adopter categories, and while the majority of the general population tends to fall in the middle
categories, it is still necessary to understand the characteristics of the target population. When
promoting an innovation, there are different strategies used to appeal to the different adopter
categories.

1. Innovators - These are people who want to be the first to try the innovation. They are
venturesome and interested in new ideas. These people are very willing to take risks,
and are often the first to develop new ideas. Very little, if anything, needs to be done to
appeal to this population.
 2. Early Adopters - These are people who represent opinion leaders. They enjoy leadership
roles, and embrace change opportunities. They are already aware of the need to change
and so are very comfortable adopting new ideas. Strategies to appeal to this population
include how-to manuals and information sheets on implementation. They do not need
information to convince them to change.
3. Early Majority - These people are rarely leaders, but they do adopt new ideas before the
average person. That said, they typically need to see evidence that the innovation works
before they are willing to adopt it. Strategies to appeal to this population include success
stories and evidence of the innovation's effectiveness.
4. Late Majority - These people are skeptical of change, and will only adopt an innovation
after it has been tried by the majority. Strategies to appeal to this population include
information on how many other people have tried the innovation and have adopted it
successfully.
5. Laggards - These people are bound by tradition and very conservative. They are very
skeptical of change and are the hardest group to bring on board. Strategies to appeal to
this population include statistics, fear appeals, and pressure from people in the other
adopter groups.

Source: http://blog.leanmonitor.com/early-adopters-allies-launching-product/

The stages by which a person adopts an innovation, and whereby diffusion is accomplished,
include awareness of the need for an innovation, decision to adopt (or reject) the
innovation, initial use of the innovation to test it, and continued use of the innovation. There
are five main factors that influence adoption of an innovation, and each of these factors is
at play to a different extent in the five adopter categories.

1. Relative Advantage - The degree to which an innovation is seen as better than the idea,
program, or product it replaces.
2. Compatibility - How consistent the innovation is with the values, experiences, and needs
of the potential adopters.
3. Complexity - How difficult the innovation is to understand and/or use.
4. Triability - The extent to which the innovation can be tested or experimented with before
a commitment to adopt is made.
5. Observability - The extent to which the innovation provides tangible results.

Limitations of Diffusion of Innovation Theory

There are several limitations of Diffusion of Innovation Theory, which include the following:

 Much of the evidence for this theory, including the adopter categories, did not originate
in public health and it was not developed to explicitly apply to adoption of new behaviors
or health innovations.
 It does not foster a participatory approach to adoption of a public health program.
 It works better with adoption of behaviors rather than cessation or prevention of
behaviors.
 It doesn't take into account an individual's resources or social support to adopt the new
behavior (or innovation).

This theory has been used successfully in many fields including communication, agriculture,
public health, criminal justice, social work, and marketing. In public health, Diffusion of
Innovation Theory is used to accelerate the adoption of important public health programs that
typically aim to change the behavior of a social system. For example, an intervention to address
a public health problem is developed, and the intervention is promoted to people in a social
system with the goal of adoption (based on Diffusion of Innovation Theory). The most
successful adoption of a public health program results from understanding the target population
and the factors influencing their rate of adoption.

For more on diffusion of innovation theory see "On the Diffusion of Innovations: How New Ideas
Spread" by Leif Singer.

The Social Cognitive Theory

Social Cognitive Theory (SCT) started as the Social Learning Theory (SLT) in the 1960s by
Albert Bandura. It developed into the SCT in 1986 and posits that learning occurs in a social
context with a dynamic and reciprocal interaction of the person, environment, and behavior. The
unique feature of SCT is the emphasis on social influence and its emphasis on external and
internal social reinforcement.   SCT considers the unique way in which individuals acquire and
maintain behavior, while also considering the social environment in which individuals perform
the behavior. The theory takes into account a person's past experiences, which factor into
whether behavioral action will occur. These past experiences influences reinforcements,
expectations, and expectancies, all of which shape whether a person will engage in a specific
behavior and the reasons why a person engages in that behavior.

Many theories of behavior used in health promotion do not consider maintenance of behavior,
but rather focus on initiating behavior. This is unfortunate as maintenance of behavior, and not
just initiation of behavior, is the true goal in public health. The goal of SCT is to explain how
people regulate their behavior through control and reinforcement to achieve goal-directed
behavior that can be maintained over time. The first five constructs were developed as part of
the SLT; the construct of self-efficacy was added when the theory evolved into SCT.

1. Reciprocal Determinism - This is the central concept of SCT. This refers to the dynamic
and reciprocal interaction of person (individual with a set of learned experiences),
 environment (external social context), and behavior (responses to stimuli to achieve
goals).
2. Behavioral Capability - This refers to a person's actual ability to perform a behavior
through essential knowledge and skills. In order to successfully perform a behavior, a
person must know what to do and how to do it. People learn from the consequences of
their behavior, which also affects the environment in which they live.
3. Observational Learning - This asserts that people can witness and observe a behavior
conducted by others, and then reproduce those actions. This is often exhibited through
"modeling" of behaviors.   If individuals see successful demonstration of a behavior, they
can also complete the behavior successfully.
4. Reinforcements - This refers to the internal or external responses to a person's behavior
that affect the likelihood of continuing or discontinuing the behavior. Reinforcements can
be self-initiated or in the environment, and reinforcements can be positive or negative.
This is the construct of SCT that most closely ties to the reciprocal relationship between
behavior and environment.
5. Expectations - This refers to the anticipated consequences of a person's behavior.
Outcome expectations can be health-related or not health-related. People anticipate the
consequences of their actions before engaging in the behavior, and these anticipated
consequences can influence successful completion of the behavior. Expectations derive
largely from previous experience.   While expectancies also derive from previous
experience, expectancies focus on the value that is placed on the outcome and are
subjective to the individual.
6. Self-efficacy - This refers to the level of a person's confidence in his or her ability to
successfully perform a behavior. Self-efficacy is unique to SCT although other theories
have added this construct at later dates, such as the Theory of Planned Behavior. Self-
efficacy is influenced by a person's specific capabilities and other individual factors, as
well as by environmental factors (barriers and facilitators).

Limitation of Social Cognitive Theory

There are several limitations of SCT, which should be considered when using this theory in
public health. Limitations of the model include the following:

 The theory assumes that changes in the environment will automatically lead to changes
in the person, when this may not always be true.
 The theory is loosely organized, based solely on the dynamic interplay between person,
behavior, and environment. It is unclear the extent to which each of these factors into
actual behavior and if one is more influential than another.
 The theory heavily focuses on processes of learning and in doing so disregards
biological and hormonal predispositions that may influence behaviors, regardless of past
experience and expectations.
 The theory does not focus on emotion or motivation, other than through reference to
past experience. There is minimal attention on these factors.
 The theory can be broad-reaching, so can be difficult to operationalize in entirety.

Social Cognitive Theory considers many levels of the social ecological model in addressing
behavior change of individuals. SCT has been widely used in health promotion given the
emphasis on the individual and the environment, the latter of which has become a major point of
focus in recent years for health promotion activities. As with other theories, applicability of all the
constructs of SCT to one public health problem may be difficult especially in developing focused
public health programs.

The Transtheoretical Model (Stages of Change)

The Transtheoretical Model (also called the Stages of Change Model), developed by Prochaska
and DiClemente in the late 1970s, evolved through studies examining the experiences of
smokers who quit on their own with those requiring further treatment to understand why some
people were capable of quitting on their own. It was determined that people quit smoking if they
were ready to do so. Thus, the Transtheoretical Model (TTM) focuses on the decision-making of
the individual and is a model of intentional change. The TTM operates on the assumption that
people do not change behaviors quickly and decisively. Rather, change in behavior, especially
habitual behavior, occurs continuously through a cyclical process. The TTM is not a theory but a
model; different behavioral theories and constructs can be applied to various stages of the
model where they may be most effective.

The TTM posits that individuals move through six stages of change: precontemplation,
contemplation, preparation, action, maintenance, and termination. Termination was not part of
the original model and is less often used in application of stages of change for health-related
behaviors. For each stage of change, different intervention strategies are most effective at
moving the person to the next stage of change and subsequently through the model to
maintenance, the ideal stage of behavior.

1. Precontemplation - In this stage, people do not intend to take action in the foreseeable
future (defined as within the next 6 months). People are often unaware that their
behavior is problematic or produces negative consequences. People in this stage often
underestimate the pros of changing behavior and place too much emphasis on the cons
of changing behavior.
2. Contemplation - In this stage, people are intending to start the healthy behavior in the
foreseeable future (defined as within the next 6 months). People recognize that their
behavior may be problematic, and a more thoughtful and practical consideration of the
pros and cons of changing the behavior takes place, with equal emphasis placed on
both. Even with this recognition, people may still feel ambivalent toward changing their
behavior.
3. Preparation (Determination) - In this stage, people are ready to take action within the
next 30 days. People start to take small steps toward the behavior change, and they
believe changing their behavior can lead to a healthier life.
4. Action - In this stage, people have recently changed their behavior (defined as within the
last 6 months) and intend to keep moving forward with that behavior change. People
may exhibit this by modifying their problem behavior or acquiring new healthy behaviors.
5. Maintenance - In this stage, people have sustained their behavior change for a while
(defined as more than 6 months) and intend to maintain the behavior change going
forward. People in this stage work to prevent relapse to earlier stages.
 6. Termination - In this stage, people have no desire to return to their unhealthy behaviors
and are sure they will not relapse. Since this is rarely reached, and people tend to stay in
the maintenance stage, this stage is often not considered in health promotion programs.

To progress through the stages of change, people apply cognitive, affective, and evaluative
processes. Ten processes of change have been identified with some processes being more
relevant to a specific stage of change than other processes. These processes result in
strategies that help people make and maintain change.

1. Consciousness Raising - Increasing awareness about the healthy behavior.

2. Dramatic Relief - Emotional arousal about the health behavior, whether positive or
negative arousal.
3. Self-Reevaluation - Self reappraisal to realize the healthy behavior is part of who they
want to be.
4. Environmental Reevaluation - Social reappraisal to realize how their unhealthy behavior
affects others.
5. Social Liberation - Environmental opportunities that exist to show society is supportive of
the healthy behavior.
6. Self-Liberation - Commitment to change behavior based on the belief that achievement
of the healthy behavior is possible.
7. Helping Relationships - Finding supportive relationships that encourage the desired
change.
8. Counter-Conditioning - Substituting healthy behaviors and thoughts for unhealthy
behaviors and thoughts.
9. Reinforcement Management - Rewarding the positive behavior and reducing the
rewards that come from negative behavior.
 10. Stimulus Control - Re-engineering the environment to have reminders and cues that
support and encourage the healthy behavior and remove those that encourage the
unhealthy behavior.

Limitations of the Transtheoretical Model

There are several limitations of TTM, which should be considered when using this theory in
public health. Limitations of the model include the following:

 The theory ignores the social context in which change occurs, such as SES and income.
 The lines between the stages can be arbitrary with no set criteria of how to determine a
person's stage of change. The questionnaires that have been developed to assign a
person to a stage of change are not always standardized or validated.
 There is no clear sense for how much time is needed for each stage, or how long a
person can remain in a stage.  
 The model assumes that individuals make coherent and logical plans in their decision-
making process when this is not always true.

The Transtheoretical Model provides suggested strategies for public health interventions to
address people at various stages of the decision-making process. This can result in
interventions that are tailored (i.e., a message or program component has been specifically
created for a target population's level of knowledge and motivation) and effective. The TTM
encourages an assessment of an individual's current stage of change and accounts for relapse
in people's decision-making process.

Social Norms Theory

The Social Norms Theory was first used by Perkins and Berkowitz in 1986 to address student
alcohol use patterns. As a result, the theory, and subsequently the social norms approach, is
best known for its effectiveness in reducing alcohol consumption and alcohol-related injury in
college students. The approach has also been used to address a wide range of public health
topics including tobacco use, driving under the influence prevention, seat belt use, and more
recently sexual assault prevention. The target population for social norms approaches tends to
be college students, but has recently been used with younger student populations (i.e., high
school).

This theory aims to understand the environment and interpersonal influences (such as peers) in
order to change behavior, which can be more effective than a focus on the individual to change
behavior. Peer influence, and the role it plays in individual decision-making around behaviors, is
the primary focus of Social Norms Theory. Peer influences and normative beliefs are especially
important when addressing behaviors in youth. Peer influences are affected more by perceived
norms (what we view as typical or standard in a group) rather than on the actual norm (the
real beliefs and actions of the group). The gap between perceived and actual is
a misperception, and this forms the foundation for the social norms approach.  

The Social Norms Theory posits that our behavior is influenced by misperceptions of how our
peers think and act. Overestimations of problem behavior in our peers will cause us to increase
our own problem behaviors; underestimations of problem behavior in our peers will discourage
us from engaging in the problematic behavior. Accordingly, the theory states that correcting
misperceptions of perceived norms will most likely result in a decrease in the problem behavior
or an increase in the desired behavior.  

Social norms interventions aim to present correct information about peer group norms in an
effort to correct misperceptions of norms. In particular, many social norms interventions
are social norms media campaigns where misperceptions are addressed through community-
wide electronic and print media that promote accurate and healthy norms about the health
behavior. The phases of a social norms media campaign include:

 Assessment or collection of data to inform the message

 Selection of the normative message that will be distributed
 Testing the message with the target group to ensure it is well-received
 Selection of the mode in which the message will be delivered
 Amount, or dosage, of the message that will be delivered
 Evaluation of the effectiveness of the message

Social norms media campaigns are currently being funded by many federal agencies, state
agencies, foundation grants, and non-profit organizations.   Sometimes social norms media
campaigns are funded by industry. There has been a good deal of evaluations conducted on
social norms campaigns.   Case studies of effective social norms campaigns can be found here:
http://www.socialnorm.org/index.php.

There are several limitations of Social Norms Theory that need to be considered prior to using
the theory. Limitations of the theory include the following:

 Participants of an intervention focused on social norms are likely to question the initial
message being presented to them due to misperceptions they hold. Information must be
presented in a reliable way to correct those misperceptions.
 Poor data collection in the initial stages can lead to unreliable data and poor choice of
normative message. This can undermine the campaign and reinforce misperceptions.
 Unreliable sources, or sources that are not credible to the target population, can result in
an unappealing message that undermines the campaign, even if the message is
correctly chosen.
 The dose, or amount, of the message received by the target population must be enough
to make an impact, but not too much that it becomes commonplace.

Although these limitations exist, when used correctly Social Norms Theory can be very effective
in changing individual behavior by focusing on changing misperceptions at the group level.
Social norms interventions can be used alone or in conjunction with other types of intervention
strategies. The most effective social norms interventions are those that have messages targeted
to the at-risk population that are correct and influential. To target messages, a substantial
amount of research and data collection has to be invested to understand the norms that exist in
the group of interest. Social norms interventions are also most effective when presented in
interactive formats that actively engage the target audience.
 The Transtheoretical Model
The Transtheoretical Model:

 uses the Stages of Change to integrate the most

powerful principles and processes of change from leading
theories of counseling and behavior change;

 is based on principles developed from over 35 years

of scientific research, intervention development, and
scores of empirical studies;

 applies the results of research funded by over $80

million worth of grants and conducted with over 150,000
research participants; and

 is currently in use by professionals around the world.

Overview of the Model

The Transtheoretical Model (Prochaska & DiClemente, 1983;
Prochaska, DiClemente, & Norcross, 1992) is an integrative,
biopsychosocial model to conceptualize the process of intentional
behavior change. Whereas other models of behavior change focus
exclusively on certain dimensions of change (e.g. theories
focusing mainly on social or biological influences), the TTM seeks
to include and integrate key constructs from other theories into a
comprehensive theory of change that can be applied to a variety
of behaviors, populations, and settings—hence, the name
Transtheoretical.

The Stages of Change

Stages of Change lie at the heart of the TTM. Studies of change
have found that people move through a series of stages when
modifying behavior. While the time a person can stay in each
stage is variable, the tasks required to move to the next stage are
not. Certain principles and processes of change work best at each
stage to reduce resistance, facilitate progress, and prevent
relapse. Those principles include decisional balance, self-efficacy,
and processes of change. Only a minority (usually less than 20%)
of a population at risk is prepared to take action at any given
time. Thus, action-oriented guidance misserves individuals in the
early stages. Guidance based on the TTM results in increased
participation in the change process because it appeals to the
whole population rather than the minority ready to take action.

The stage construct represents a temporal dimension. Change

implies phenomena occurring over time. Surprisingly, none of the
leading theories of therapy contained a core construct
representing time. Traditionally, behavior change was often
construed as an event, such as quitting smoking, drinking, or
overeating. TTM recognizes change as a process that unfolds over
time, involving progress through a series of stages. While
progression through the Stages of Change can occur in a linear
fashion, a nonlinear progression is common. Often, individuals
recycle through the stages or regress to earlier stages from later
ones.
Precontemplation (Not Ready)
Contemplation (Getting Ready)
Preparation (Ready)
Action
Maintenance

Precontemplation (Not Ready)

People in the Precontemplation stage do not intend to take action in the

foreseeable future, usually measured as the next six months. Being
uninformed or under informed about the consequences of one’s behavior
may cause a person to be in the Precontemplation stage. Multiple
unsuccessful attempts at change can lead to demoralization about the ability
to change. Precontemplators are often characterized in other theories as
resistant, unmotivated, or unready for help. The fact is, traditional programs
were not ready for such individuals and were not designed to meet their
needs.

Contemplation (Getting Ready)

Contemplation is the stage in which people intend to change in the next six
months. They are more aware of the pros of changing, but are also acutely
aware of the cons. In a meta-analysis across 48 health risk behaviors, the
pros and cons of changing were equal (Hall & Rossi, 2008). This weighting
between the costs and benefits of changing can produce profound
ambivalence that can cause people to remain in this stage for long periods of
time. This phenomenon is often characterized as chronic contemplation or
behavioral procrastination. Individuals in the Contemplation stage are not
ready for traditional action-oriented programs that expect participants to act
immediately.

Preparation (Ready)

Preparation is the stage in which people intend to take action in the

immediate future, usually measured as the next month. Typically, they have
already taken some significant action in the past year. These individuals
have a plan of action, such as joining a gym, consulting a counselor, talking
to their physician, or relying on a self-change approach. These are the
people who should be recruited for action-oriented programs.

Action

Action is the stage in which people have made specific overt modifications in
their lifestyles within the past six months. Because action is observable, the
overall process of behavior change often has been equated with action. But
in the TTM, Action is only one of five stages. Typically, not all modifications of
behavior count as Action in this Model. In most applications, people have to
attain a criterion that scientists and professionals agree is sufficient to
reduce risk of disease. For example, reduction in the number of cigarettes or
switching to low-tar and low-nicotine cigarettes were formerly considered
acceptable actions. Now the consensus is clear—only total abstinence
counts.
Maintenance

Maintenance is the stage in which people have made specific overt

modifications in their lifestyles and are working to prevent relapse; however,
they do not apply change processes as frequently as do people in Action.
While in the Maintenance stage, people are less tempted to relapse and grow
increasingly more confident that they can continue their changes. Based on
self-efficacy data, researchers have estimated that Maintenance lasts from
six months to about five years. While this estimate may seem somewhat
pessimistic, longitudinal data in the 1990 Surgeon General’s report support
this temporal estimate. After 12 months of continuous abstinence, 43% of
individuals returned to regular smoking. It was not until 5 years of
continuous abstinence that the risk for relapse dropped to 7% (USDHHS).

Decisional Balance
Decision making was conceptualized by Janis and Mann (1977) as
a decisional “balance sheet” of comparative potential gains and
losses. Two components of decisional balance, the pros and the
cons, have become core constructs in the Transtheoretical Model.
As individuals progress through the Stages of Change, decisional
balance shifts in critical ways. When an individual is in the
Precontemplation stage, the pros in favor of behavior change are
outweighed by the relative cons for change and in favor of
maintaining the existing behavior. In the Contemplation stage,
the pros and cons tend to carry equal weight, leaving the
individual ambivalent toward change. If the decisional balance is
tipped however, such that the pros in favor of changing outweigh
the cons for maintaining the unhealthy behavior, many individuals
move to the Preparation or even Action stage. As individuals enter
the Maintenance stage, the pros in favor of maintaining the
behavior change should outweigh the cons of maintaining the
change in order to decrease the risk of relapse.

Self-Efficacy
The TTM integrates elements of Bandura’s self-efficacy theory
(Bandura, 1977, 1982). This construct reflects the degree of
confidence individuals have in maintaining their desired behavior
change in situations that often trigger relapse. It is also measured
by the degree to which individuals feel tempted to return to their
problem behavior in high-risk situations. In the Precontemplation
and Contemplation stages, temptation to engage in the problem
behavior is far greater than self-efficacy to abstain. As individuals
move from Preparation to Action, the disparity between feelings
of self-efficacy and temptation closes, and behavior change is
attained. Relapse often occurs in situations where feelings of
temptation trump individuals’ sense of self-efficacy to maintain
the desired behavior change.

Processes of Change
While the Stages of Change are useful in explaining when
changes in cognition, emotion, and behavior take place, the
processes of change help to explain how those changes occur.
These ten covert and overt processes need to be implemented to
successfully progress through the stages of change and attain the
desired behavior change. These ten processes can be divided into
two groups: cognitive and affective experiential processes and
behavioral processes.

Cognitive and Affective Experiential Processes

1. Consciousness Raising (Get the Facts)
2. Dramatic Relief (Pay Attention to Feelings)
3. Environmental Reevaluation (Notice Your Effect on Others)
4. Self-Reevaluation (Create a New Self-Image)
5. Social Liberation (Notice Public Support) Processes
Behavioral Processes
6. Self-Liberation (Make a Commitment)
7. Counter Conditioning (Use Substitutes)
8. Helping Relationships (Get Support)
9. Reinforcement Management (Use Rewards)
10. Stimulus Control (Manage Your Environment)

Critical Assumptions of the TTM

The Transtheoretical Model is also based on critical assumptions
about the nature of behavior change and population health
interventions that can best facilitate such change. The following
 set of assumptions drives Transtheoretical Model theory,
research, and practice:

 Behavior change is a process that unfolds over time

through a sequence of stages. Health population
programs need to assist people as they progress over
time.

 Stages are both stable and open to change, just as

chronic behavior risk factors are both stable and open to
change.

 Population health initiatives can motivate change by

enhancing the understanding of the pros and diminishing
the value of the cons.

 The majority of at-risk populations are not prepared

for action and will not be served by traditional action-
oriented prevention programs. Helping people set realistic
goals, like progressing to the next stage, will facilitate the
change process.

 Specific principles and processes of change need to

be emphasized at specific stages for progress through the
stages to occur.

Transtheoretical Model Research

Breakthroughs
1980s
 Discovered the Stages of Change and the dynamic
principles and processes of change related to each stage

1990s
 Developed the first computer-tailored intervention
based on the Transtheoretical Model of Behavior Change
 Demonstrated tailored interventions for smoking
cessation effective even when more than 80% were not
ready to quit

 Applied the Transtheoretical Model to a variety of

behaviors beyond smoking cessation

2000s
 Demonstrated that Transtheoretical Model-based
interventions for simultaneous multiple behavior change
are effective

 Applied the Transtheoretical Model to a wide variety

of new behavior change challenges

 Served entire populations with inclusive proactive

and home-based care

2010s
 Implemented innovative strategies 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

 Gained synergistic insights into how changing one

behavior increases the chance of changing other
behaviors (coaction)

 Improved well-being by increasing productivity and

thriving

 Increased the efficacy of our best practices by 26%

as a result of adding tailored text messages
 Developed a Clinical Dashboard to provide evidence-
based stage matched behavior change messages for
clinicians to deliver to patients.

Tailoring Matters
A recent meta-analyses, by Noar et al., of 57 studies
demonstrated greater effects in programs that are tailored on
each of the Transtheoretical Model constructs. Specifically,
programs that tailor on stage do better than those that do not;
programs that tailor on pros and cons do better than those that
do not; programs that tailor on self-efficacy do better than those
that do not, and programs that tailor on processes of change do
better than those that do not.
Noar, S.M., Benac, C.N., and Harris, M.S. (2007) Does tailoring matter? Meta-analytic
review of tailored print health behavior change interventions. Psychological Bulletin,
4, 673-693. abstract

To learn about the efficacy of our online programs, see the

citations on each of our products pages, or our program
effectiveness summary. A 2008 replication study at Oregon
Science and Health University also shows program effectiveness;
see:
Prochaska, J.O., Butterworth, S., Redding, C.A., Burden, V., Perrin, N., Lea, Michael,
Flaherty, Robb M., and Prochaska, J.M. (2008). Initial efficacy of MI, TTM tailoring,
and HRI’s in multiple behaviors for employee health promotion. Preventive
Medicine, 46, 226-231. abstract
Prochaska, J.O., DiClemente, C.C., & Norcross, J.C. (1992). In search of how people
change: Applications to the addictive behaviors. American Psychologist, 47, 1102-
1114. PMID: 1329589.
Prochaska, J.O., Redding, C.A., & Evers, K. (2002). The Transtheoretical Model and
Stages of Change. In K. Glanz, B.K. Rimer & F.M. Lewis, (Eds.) Health Behavior and
Health Education: Theory, Research, and Practice (3rd Ed.). San Francisco, CA:
Jossey-Bass, Inc.