Stage Models in Health Promotion

Underlying assumptions of TMC:
1. No single theory accounts for all behavior change.
2. Behavior change unfolds over time.
3. Stages are both stable and open to change.
4. Without planned intervention, populations will remain mired in early stages.
5. The majority of at risk population not ready for action.
6. Specific processes and principles of change need to be applied at specific stages.
7. Behavior is not random. Chronic behavior patterns are under some combo of biological, social, psychological influences.
8. Behavioral change typically consists of several attempts. Person may progress, backslide, and cycle and recycle through stages.

THE STAGES OF CHANGE; TRANSTHEORETICAL MODEL OF CHANGE
PRECONTEMPLATION (PC): People have no intention of changing (within next 6 mos). CONTEMPLATION (C): People engage in cognitive process. Decisional balance, which represents mental weighing of pros and cons assoc with changing behavior (similar to benefits and barriers). Process begins with favoring cons. Clearly implications for behavior change interventions are based on: (1) enhancing perceptions of the advantages of changing behavior. (2) minimizing perception of barriers to adopting these behavioral changes. PREPARATION (PR): People intend to adopt new behavior in immediate future (within next month). ACTION (A): People have made specific overt modifications in their lifestyles within past 6 mos. Behavioral change has often been equated with action.

However , not all changes qualify as action. Ex: promoting smoking cessation, only total abstinence counts. MAINTENANCE: (M): final stage. People still work to prevent relapse. Do not need to apply change process as frequently as do people in action stage. Specified behavior for 6 mos or longer. TMC supports the idea process of behavior change is “evolutionary, not revolutionary”. Relapse may be less important than the stage person relapses to. Health promotion efforts may include stage movement as a goal. Stage matched interventions can be deemed successful even in the absence of lasting behavior change if stage progression is achieved, so stage progression thus becomes a useful outcome in evaluating health efforts. Stage Matching:

Major premise of TMC.
Ex: Joe and Sally both smoke, would like to quit. Joe may have thought about quitting but have not made any active efforts to seek professional help: CONTEMPLATION stage. Sally has tried to quit but to no avail : PREPARATION stage. For Joe next stage is PREPARATION. For Sally, next stage is ACTION. Once we know person’s stage, diverse array of STRATEGIES will be used to promote desired behavior change. Process of Change: (poc)

Defined as essential principles that promote change. Intervention strategies that help modify a person’s thinking, feeling, or behavior constitute a change process. Processes are the actual mechanisms or drivers, propelling forward progression through the stages of change , ultimately the elimination/adoption of behaviors. 1. Conscious raising: increasing awareness about health damaging effects of particular behavior. 2. Dramatic relief: produces increased emotional awareness or anxiety followed by relief if appropriate action taken. 3. Self-reevaluation: combines both cognitive and effective assessment of one’s self image in conjunction with given health behavior. (ex: obese person seeing themselves thin). 4. Environmental reevaluation: combines both affective and cognitive assessment of how the presence or absence of a certain health behavior affects one’s social environment. (ex: effects of second hand smoke on others).

5. Self liberation: both the belief that one can change and the commitment and recommitment to act on that belief. (ex: by making a public announcement about the intent to change behavior). 6. Helping relationships: combine caring, trust, openness, and acceptance as well as support for the healthy behavior change. (ex: finding a work-out buddy). 7. Counterconditioning: substituting healthier coping strategies for unhealthy ones. Requires learning new behaviors that can serve as substitutes for unhealthy behaviors. 8. Contingency management: (also known as reinforcement management) provides consequences for taking steps in particular direction. Relying on rewards more effective. 9. Stimulus control: removes cues for unhealthy behavior and adds cues that support adoption and maintenance of healthy behaviors. (ex: not walking by bakery, having workout shoes,clothes in bag). 10. Social liberation: focuses on utilizing / increasing social opportunities that support health promoting behavior change. (ex: cont advocacy at national, state, local levels). Stage – match interventions:

Matching strategies to stages of person’s readiness.
In early stages, people apply cognitive, affective, and evaluative processes to progress through the stages, in later stages people rely more on commitments, conditioning, contingencies, environmental controls, and support for progressing toward maintained behavior change. Stage Transition: precontemplation to contemplation

Process of Change: consciousness raising, dramatic relief, self- reevaluation,environmental reevaluation. Stage Transition: contemplation to preparation
Process of Change: self-reevaluation, environmental reevaluation, self liberation, self efficacy, stimulus control. Stage Transition: preparation to action
Process of Change: self liberation, elf efficacy, stimulus control, counterconditioning, helping relationships. Stage Transition: action to maintenance
Process of Change: stimulus control, counterconditioning, helping relationships, reinforcement management. IT IS IMPORTANT NOT TO EQUATE PROCESS OF CHANGE WITH TECHNIQUES USED TO ENHANCE/PROMOTE EACH OF THE PROCESSES. Techniques are strategies, methods, or planned activities used to amplify a process of change. (table 6.4) p.118. Additional TMC Constructs:

1. Decisional balance: reflects an individual relative weighing of the pros and cons of changing his or her behavior. (ex: Joe wants to quit smoking, but to Joe smoking provides stress relief). Goal is to maximize pros of adopting new health behavior or eliminating bad behavior. STRONG PRINCIPLE OF PROGRESS: pros of health behavior change must increase about one standard deviation. WEAK PRINCIPLE: cons of health behavior change must decrease by one-half standard deviation. 2. Self-efficacy: consists of CONFIDENCE-individual’s ability to cope with high risk situations without relapsing to unhealthy behaviors. TEMPTATION: intensity of urges to engage in specific behavior when confronted with challenging situations. RESILIENT SELF-EFFICACY has been used to describe people with sufficiently high levels of self – efficacy. (p.119) THE PRECAUTION ADOPTION PROCESS MODEL

SECOND MAJOR STAGE THEORY IN FIELD OF HEALTH PROMOTION.
-The key difference between TMC and PAPM is emphasis placed on intrapsychic concepts in PAPM and more diffused emphasis on environmental factors in TMC. (p.121) see Stage theories must include. Stages in PAPM: TABLE 6-5 (p122)

Stage 1: unaware of health risk.
Stage 2: unengaged by health risk.
Stage 3: deciding about acting.
Stage 4: decided not to act.
Stage 5: deciding to act
Stage 6: acting.
Satge 7: maintenance.
According to PAPM, PRECONTAMPLATION stage can be divided into: (1). Unaware of issue. (2). Unengaged by issue. Difference between 2 stages is simply self perception. OPTIMISTIC BIAS: people do not see themselves as being vulnerable to the adverse consequences of health-risk behaviors as their peers who engage in same risk behavior. In PAPM, person who attempts and then rejects change is resolved by stage “decides not to act”. Important difference between TMC and PAPM is that PAPM does not prescribe change process. See table 6-6 (p.124) Progressing through the stages of PAPM