Tobacco use is the largest preventable cause of death and disease in Australia. It is a major cause of heart disease, stroke, several different forms of cancer, and other health problems (Quit Victoria 2005). The act of quitting smoking is not a single event, but rather a process of change within an individual. Change is often said to be a lengthy process.
Today, there are many existing models describing the process by which individuals change certain behaviours. The Transtheoretical model and stages of change is an integrative, biopsychosocial model to conceptualise the process of intentional behavioural change (Prochaska & Velicer 1997). Whereas other models of behavioural change focus exclusively on certain dimensions of change (e. g. theories focusing mainly on social or biological influences), the Transtheoretical model seeks to include and integrate key elements from other theories into a comprehensive theory of change that can be applied to a variety of behaviours, populations, and settings. It has been widely applied in the public health sector including its usage in helping people to quit smoking and improving the physical health of many. However, in recent times, it has been discovered that the Transtheoretical model is best applied in conjunction with other models of behaviour change for better results.
Dr. Prochaska originated the Transtheoretical model. His father died of alcoholism and depression and he also distrusted psychotherapy. At that time in 1975, there were over 130 different systems of psychotherapy. Dr. Prochaska analysed 18 of them and produced the Transtheoretical model. He conducted numerous case studies to produce processes of change and stages of change. (Prochaska & DiClemente 1983; Prochaska et al. 1992; Prochaska & Velicer 1997)
The Stages of Change
One of the key element of the Transtheoretical model is the stages of change. Behavioural change can be said as taking place as a progression through a series of stages. Research has measured a number of cognitive and behavioral markers that have been used to identify these stages. The Stages of Change are as follows:
* Pre-contemplation
* Contemplation
* Preparation
* Action
* Maintenance
Pre-contemplation: Individuals in the pre-contemplation stage are not thinking about or have any thoughts to correct a problem or to start a healthy behaviour in the near future (usually defined as the next six months). Pre-contemplators are usually informed about the facts of the risks associated with their behaviour such as smoking. Also, many individuals make failed change attempts, thereby becoming discouraged and revert back to their current behaviour. The inclusion of the pre-contemplation stage represents a significant contribution of the Transtheoretical model, as individuals in this stage account for a large proportion of individuals engaged in unhealthy behaviour. In comparison to more action-oriented theories of health behaviour change, which view individuals as resistant and unmotivated, the Transtheoretical model is useful in planning treatment and prevention programs by meeting the needs of these individuals, rather than ignoring them (Miller & Heather 1998).
Contemplation: An individual enters the contemplation stage when he or she becomes aware of a desire to change a particular behavior (defined as within the next six months). In this stage, individuals weigh the pros and cons of changing their behaviour, such as the benefits of quitting smoking. Contemplators represent a large proportion of individuals engaged in unhealthy behaviour, as mixed feelings between the pros and cons of change keeps many people stuck in this stage. Resolving this conflict of feelings is one way to help these individuals progress toward taking action to change their unhealthy behaviour.
Preparation: When the individuals enter the preparation stage, the pros in favour of attempting to change an unhealthy behaviour outweigh the cons, and action is intended in the near future (measured as within the next months). Many individuals in this stage have made an attempt to change their behaviour in the past year, but have been unsuccessful in maintaining that change. Preparers have a plan of action, but may not be committed to their plan. Many traditional action-oriented behaviour change programs are appropriate for individuals in this stage.
Action: This stage marks the beginning of actual change in the unhealthy behaviour (typically within the past six months). By this point, an individual is half way through the process of behavior change according to the Transtheoretical model. This is the point where relapse, and subsequently reversion to an earlier stage, is likely to occur. If an individual has not adequately prepared for the change, and committed to their chosen plan of action, relapse back to the unhealthy behaviour is a strong possibility (Miller & Heather 1998).
Maintenance: Individuals are said to be in the maintenance stage when they have successfully attained and maintained behaviour change for at least six months. While the risk for relapse is still present in this stage, it is much less, and as such individuals need to exert less effort in engaging in change processes.
Often, individuals recycle through the stages, or revert to earlier stages from later ones, rather than progress through the stages in a fixed manner.
The Processes of Change
Processes of change provide important guides for intervention programs, since the processes are the independent variables that people need to apply, to move from stage to stage. The ten processes are:
Consciousness Raising: involves increased awareness about the causes, consequences and cures for an unhealthy behaviour. Interventions that can increase awareness include feedback, education, and media campaigns about health issues such as the effects of physical inactivity or the risks of tobacco smoking.
Dramatic Relief: initially produces increased emotional experiences followed by reduced effect if the right action is taken. Role-playing, grieving, personal testimonies and media campaigns are examples of techniques that can move people emotionally about issues such as the effects of drink driving. An example would be that of RADD – Recording Artists Actors & Athletes Against Drink Driving, which features many famous names who have united their voices to deliver a staunch message against drink driving. (RADD, 2004).
Environmental Re-evaluation: combines affective and cognitive assessments of how the presence or absence of a personal habit affects one’s life. It can also include the awareness that one can serve as a positive or negative role model for others. Empathy training, documentaries and family interventions are examples.
Social Liberation: an increase in social opportunities for people who are relatively deprived. Advocacy, empowerment procedures, and appropriate policies can produce increased opportunities.
Self-reevaluation: of one’s self-image with and without a particular unhealthy habit, such as one’s image as an unhealthy person or an active person. Value clarification, healthy role models, and imagery are techniques that can move people. This works in our modern society wherein body image is important and serves as a good way to combat physical inactivity.
Stimulus Control: removes cues for unhealthy habits and adds prompts for healthier alternatives. Avoidance and self-help groups can provide the spark that supports change and reduce risks for relapse. Self-help groups could include helplines for tobacco users who think about quitting to turn to for advice.
Helping Relationships: combine trust, openness and acceptance as well as support for the healthy behaviour change. Rapport building and buddy systems are sources of social support. For example, if an individual tries to quite smoking, the family can give encouragement and support.
Counter Conditioning: involves the learning of new behaviour to replace or substitute for current or identified problem behaviour. Relaxation can counter stress, nicotine replacement can substitute for cigarettes, and fat free foods can be safer substitutes (Miller ; Heather 1998).
Contingency Management: provides consequences for taking steps in a particular direction. This can be in the form of both a reward and punishment system.
Self-liberation: is both the belief that one can change and the commitment to act on that belief. New Year’s resolutions, public testimonies can enhance self-liberation.
Application and Limitation:
Influencing Behaviour
Smoking Cessation
Smoking is the single greatest cause of death and disease in Australia. According to the 2001 National Drug Strategy Household Survey, tobacco use caused 19, 000 deaths and 142, 500 hospital episodes were attributed to tobacco smoking. By promoting smoking cessation, the number of deaths caused by tobacco use can be reduced (AIHW 2002).
The Transtheoretical model is widely applied in smoking cessation. Once smokers are identified, it is essential to determine their level of readiness to quit. Failure to do so is one of the major reasons interventions are unsuccessful (Fava et al. 1995). That is because individuals are more receptive to interventions tailored to their particular needs (Orleans and Hutchinson 1991), while ignoring those that are irrelevant (Velicer et al. 1995).
Effectiveness of interventions may be increased if the health risks of smoking can be personalised or if existing health problems can be linked to smoking (Orleans & Hutchinson 1991). Smokers feel encouraged to quite smoking if they have access to the information about the ill effects of smoking on themselves and their families (Manley et al. 1992).
An intervention closely related to establishing a quit date is a written contract between the smoker and the doctor. The contract serves as a concrete reminder of the goal of smoking cessation (Richards 1992). The doctor is now responsible for the provision of information and help to the smoker.
During the action phase, patients indicate to others of their intention to quit. Other people, even other smokers, are generally supportive of others who are trying to quit (Ferentz & Valente 1994).
In the maintenance phase, the individuals have been abstinent for more than six months. While the temptation to smoke decreases over time, it may not completely disappear until after three to five years of continual abstinence (Fava et al. 1995).
Depression
In Western Australia, mental health disorders, including depression, account for around 16% of the total burden of disease and by 2016 are expected to become the second highest cause of disease burden. In 2003-04, mental health disorders resulted in 24, 453 hospitalisations in Western Australia according to the Hospital Morbidity Data System (AIHW, 2005).
Many Australians have little knowledge about depression (Jorm 1997). These factors have important consequences for prevention, early intervention, and treatment of depression. This causes delays in seeking help. Furthermore, preventive programs for depression are only possible where there is community support. Improving depression literacy is a major goal of beyondblue: the depression initiative of Australia (Beyondblue 2008).
This serves as a great example because the initiative utilises a few models of changes including the Transtheoretical model. It also uses Health Beliefs model, which includes the individuals’ readiness to take action to avoid disease, requiring the recognition of risks and benefits of action (Becker 1974). The Elaboration Likelihood model is also used. Persuasion either by a central route, that is the consideration of the health problem; or peripheral route which is influenced by attractiveness of presenter (Petty et al. 1994).
Dieticians in promoting physical activity amongst people with diabetes have also applied the Transtheoretical model (Jackson et al 2007). As mentioned above, the Transtheoretical model is more often than not, used in conjunction with other models. No one model is perfect, thus by using several models in conjunction with each other, the effectiveness can be maximised. The Transtheoretical model of change has had its fair share of criticism. For example, it certainly is not cost effective to tailor an intervention to each individual. This would blow the health budget out of proportion. Despite its criticisms, it is proven that in cases such as smoking cessation and the management of physical inactivity, a case-by-case approach is most effective.
Therefore, the Transtheoretical model conceptualises the process of intentional behaviour change by incorporating stages of change with the processes of change, which provide important guides for intervention programs. It has been widely applied in the public health sector including its usage in helping people to quit smoking. However, it has been discovered that the Transtheoretical model is best applied in conjunction with other models of behaviour change for better results.
