Module 15: Stages of Change

As explained in previous modules, the importance of understanding your audience cannot be underestimated. For example, if the U.S. Department on Aging develops a program with the goal to increase physical activity levels among the elderly, but targets this to an elderly population that does not know that they should be exercising, there is a disconnect that will impede progress. The audience will only be receptive if the program is tailored to their degree of readiness or their “stage of change.” The Stages of Change model, also known as the Transtheoretical Model (TTM), makes it easier to determine where a population is, in terms of readiness to adopt a new behavior. TTM has been used successfully in the promotion of healthy diets, physical activity, smoking cessation as well as adoption of protective behaviors like condom use.(1)(2)  

The idea is to understand the target audience well enough (through formative research, existing literature, or experience with the population) to be able to classify them into one of the five stages of change. The program should then seek to move this population to the next stage. For instance, if the elderly population is contemplating increasing their physical activity levels, the project should seek to move them into the preparation stage. The model provides strategies to “move” the population forward.  

The five stages are:

1. Pre-contemplation

2. Contemplation

3. Preparation

4. Action

5. Maintenance (or termination depending on the desired intervention behavior)

To better illustrate this concept, each of the stages will be considered in an example based on an intervention to promote the use of skilled birth attendants (SBA) in a small rural village.

Pre-contemplation is the first stage of change, where the individual may not even be considering the change or the adoption of the new behavior.(3) At this stage, women in a rural village are using traditional birth attendants and giving birth at home. There may be limited access to health care clinics, and the tradition of home births may have caused women in the village to be unaware of other sources of pregnancy and labor assistance. An intervention to promote the use of skilled birth attendants among a pre-contemplative population would require movement from pre-contemplation to contemplation; this involves identifying the population of women and giving them information, through a trusted channel, about other forms of birth assistance, with a focus on the benefits of using skilled birth attendants.

Contemplation is the second stage of change, in which the individual is aware of the proposed behavior, through direct communication or contact with someone who has used the intervention.(4) At this stage, women in a rural village may have heard from program staff, friends, or family about using skilled birth attendants. A woman may not be pregnant yet, but she has a context for how SBAs may be beneficial for women like her. There is no guarantee that when she becomes pregnant she will choose to use an SBA. An intervention to promote the use of SBAs among a contemplative population would involve moving the population towards the preparation stage. Providing the target population with relevant and useful information (through clinics, one-on-one discussions, or lectures) allows them to make informed decisions as to whether they should continue to use traditional methods or begin preparing to use the services of SBAs.(5)

The third stage of change is preparation, during which the individual has decided to adopt the new behavior because the perceived benefits outweigh the perceived risks.(6) At this stage, a pregnant female in a rural village has gathered enough information about how skilled birth attendants can make delivery safer for both herself and her unborn child. For the individual woman, this must outweigh the potential negative effects on her family and existing support systems, as they may not approve of her decision to use an SBA. The woman is prepared to use an SBA during her delivery and may have even contacted a clinic that provides SBA services. However, there is no guarantee that the woman will end up using an SBA at the time of delivery. In order to ensure use, an intervention would seek to move this woman from preparation to the action stage by providing assistance in overcoming barriers. This can include providing access to transportation at the time of delivery, speaking to her family about why it is beneficial to use an SBA, or ensuring her that her family’s traditional birth attendant can be present to provide support during the delivery.

Action is the fourth stage of change, where the individual has performed the action or adopted the new health behavior for less than 6 months.(7) At this stage, the woman has used a skilled birth attendant for the delivery of her child. The goal for an intervention among women who have previously used SBA services is to maintain or sustain that behavior; therefore, it is important to ensure that women who use an SBA have a positive, rewarding experience, and that her perceived benefits are realized. This will reinforce her behavior change and make her more likely to use an SBA during subsequent pregnancies, and encourage her friends to do the same.

Maintenance (or termination, depending on the desired intervention behavior) is the last stage of change, where the individual is actively maintaining the desired behavior and preventing relapse. For ongoing behaviors (like smoking cessation or increased physical activity), the maintenance period typically begins 6 months after the initial action is taken.(8) With a reduced chance of relapse in this stage, there are fewer interventions targeted at “maintainers,” though an intervention for this group would involve occasional check-ins regarding knowledge absorption and behavior maintenance. Studies show that individuals in this stage perceive more pros than cons associated with performing the desired behavior, leading to maintained behavior change.(9) Having women who have successfully moved through the model speak to other individuals in the initial stages of change and act as role models for pregnant women may also help sustain their own behavior.(10)

There is risk of relapse at any phase in the process of change, especially in the initial stages of contemplation and preparation. An individual may relapse to a previous stage of stage (for example, move from action to contemplation) or relapse completely back to the original behavior.(11)

Conclusion

Conducting formative research on the topic and population of interest, program developers can classify the target population into one of these five stages. It may be necessary to create program “clusters” among the population if more than one stage is represented. By meeting the population at their current stage, instead of expecting them to conform to pre-determined program goals, the project will be more successful at achieving behavior change at a level appropriate for the target population.

Footnotes

(1) Resnicow, K., McCarty, F. and Baranowski, T. (2003). Are precontemplators less likely to change their dietary behavior? A prospective analysis. Health Education Research, 18(6):693-705.

(2) Centers for Disease Control and Prevention. (2007). Transtheoretical stage model. Divisions of HIV/AIDS Prevention.

(3) Ibid.

(4) Bousman, C.A. and Madlensky, L. (2010). Family history of lung cancer and contemplation of smoking cessation. Preventative Chronic Disease, 7(2):A29.

(5) Lach, H.W., Everard, K.M., Highstein, G., Brownson, C.A. (2004). Application of the Transtheoretical Model to health education for older adults. Health Promotion Practice, (1):88-93.

(6) UMBC. (n.d.). The transtheoretical model of behavior change. The HABITS Lab at UMBC.

(7) Sarkin, J.A., Johnson, S.S., Prochaska, J.O. and Prochaska, J.M. (2001). Applying the transtheoretical model to regular moderate exercise in an overweight population: Validation of a Stages of Change measure. Preventive Medicine, 33:462-469.

(8) Povey, R., Conner, M., Sparks, P., James, R. and Shepherd, R. (1999). A critical examination of the application of the Transtheoretical Model’s stages of change to dietary behaviors. Health Education Research, 14(5):641-651.

(9) Sarkin, J.A., Johnson, S.S., Prochaska, J.O. and Prochaska, J.M. (2001). Applying the transtheoretical model to regular moderate exercise in an overweight population: Validation of a Stages of Change measure. Preventive Medicine, 33:462-469.

(10) Pizacani, B., Laughter, D., Menagh, K., Stark, M., Drach, L. and Hermann-Franzen, C. (2011). Moving multiunit housing providers toward adoption of smoke-free policies. Preventing Chronic Disease, 8(1):A21.

(11) Velicer, W. F, Prochaska, J. O., Fava, J. L., Norman, G. J., and Redding, C. A. (1998). Smoking cessation and stress management: Applications of the Transtheoretical Model of behavior change. Homeostasis, 38:216-233.