Stages of Change 1

8/10/2019 Stages of Change 1

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Promoting Healthy BehaviorVia Awareness of Others Change


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Behavior and Global Health

Physical good health eludes billions of people Death and disease frompreventablecauses

remain high

Behavior is a key factor in determining health

Health is a state of complete physical, psychological,

and social well-being and not simply the absence of

disease or infirmity. (World Health Organization, 1948)


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Health Promotion Means Changing

Behavior at MultipleLevelsA Individual:knowledge, attitudes, beliefs,

personality

B Interpersonal:family, friends, peers

C Community:social networks, standards,

norms

D Institutional:rules, policies, informal

structuresE Public Policy:local policies related to

healthy practices

Source: Adapted from National Cancer Institute, Theory at a Glance: A Guide for Health Promotion (2003),

available online at http://cancer.gov.


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A: Individual-Oriented Models

Individual most basic unit of health promotion

Individual-level models components of

broader-level theories and approaches Models

Stages of Change Model

Health Belief Model


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Changing ones behavior is a process, not an

event

Individuals at different levels of change Gear interventions to level of change

Source: James O. Prochaska et al., In Search of How People Change: Application to Addictive

Behaviors,American Psychologist 47, no. 9 (1992): 1102-14.


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Behavior change is rarely a discrete, single event;

the patient moves gradually from being uninterested

(precontemplation stage)

to considering a change (contemplation stage)to deciding and preparing to make a change.


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Transtheoretical Model/Stages of

Change Understanding Change

Physicians should remember that behavior change is rarely adiscrete, single event. Physicians sometimes see patients who,after experiencing a medical crisis and being advised to changethe contributing behavior, readily comply. More often, physiciansencounter patients who seem unable or unwilling to change.During the past decade, behavior change has come to beunderstood as a process of identifiable stages through whichpatients pass. Physicians can enhance those stages by taking

specific action. Understanding this process provides physicianswith additional tools to assist patients, who are often asdiscouraged as their physicians with their lack of change.

Source: Zimmerman, G. L., Olson, C. G., Bosworth, M. F. (2000). A 'Stages of Change'

Approach to Helping Patients Change Behavior. American Family Physician 61/5


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Transtheoretical Model/Stages of

Change The Stages of Change model4 shows that, for most

persons, a change in behavior occurs gradually, with

the patient moving from being uninterested, unaware

or unwilling to make a change (precontemplation), toconsidering a change (contemplation), to deciding

and preparing to make a change. Genuine,

determined action is then taken and, over time,

attempts to maintain the new behavior occur.Relapses are almost inevitable and become part of

the process of working toward life-long change




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Transtheoretical Model/Stages

of Change Prochaska and DeClemente, 1983

Developed for health risk behaviors

(especially smoking) Incorporates several theories of behavioral

change

Individuals go through 5 stages before newbehavior is adopted


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Transtheoretical Model/Stages

of Change Stage 1: Precontemplation

Unaware that a problem exists

Stage 2: Contemplation

Aware that a problem exists and thinking about making abehavioral change in the future

Stage 3: Preparation Feeling confident that making a change is possible and planning to

make such a change in the immediate future

Stage 4: Action Making a change

Stage 5: Maintenance Continuing to engage in the new, desirable behavior and avoiding

relapse


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Precontemplation Stage

During the precontemplation stage, patients

do not even consider changing. Smokers who

are "in denial" may not see that the advice

applies to them personally. Patients with high

cholesterol levels may feel "immune" to the

health problems that strike others. Obesepatients may have tried unsuccessfully so

many times to lose weight that they have

simply given up.

.




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Contemplation Stage

During the contemplation stage, patients are

ambivalent about changing. Giving up anenjoyed behavior causes them to feel a

sense of loss despite the perceived gain.

During this stage, patients assess barriers

(e.g., time, expense, hassle, fear, "I know Ineed to, doc, but ...") as well as the benefits

of change.




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Preparation Stage

During the preparation stage, patients prepare to

make a specific change. They may experiment with

small changes as their determination to changeincreases. For example, sampling low-fat foods may

be an experimentation with or a move toward greater

dietary modification. Switching to a different brand of

cigarettes or decreasing their drinking signals thatthey have decided a change is needed




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Action Stage

The action stage is the one that most

physicians are eager to see their patients

reach. Many failed New Year's resolutions

provide evidence that if the prior stages have

been glossed over, action itself is often not

enough. Any action taken by patients shouldbe praised because it demonstrates the

desire for lifestyle change.

Most people find themselves "recycling"

through the stages of change several times("relapsing") before the change becomes truly

established.




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Maintenance and Relapse Prevention

Maintenance and relapse prevention involve

incorporating the new behavior "over the longhaul." Discouragement over occasional "slips"

may halt the change process and result in the

patient giving up. However, most patients find

themselves "recycling" through the stages ofchange several times before the change

becomes truly established.




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More individuals are at the preparation and

action stages than are at the

contemplation stage Interpretation: Faculty are being pushed to make

changes before they recognize the problem?



TABLE 3


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TABLE 3Questions for Patients in the Precontemplation andContemplation Stages*

Precontemplation stageGoal: patient will begin thinking about change. "What would have to happen for you to know that this is a

problem?""What warning signs would let you know that this is a problem?""Have you tried to change in the past?"

Contemplation stageGoal: patient will examine benefits and barriers to change. "Why do you want to change at this time?"

"What were the reasons for not changing?""What would keep you from changing at this time?""What are the barriers today that keep you from change?""What might help you with that aspect?""What things (people, programs and behaviors) have helped in thepast?""What would help you at this time?""What do you think you need to learn about changing?"

*--The change can be applied to any desirable behavior (e.g.,smoking or drinking cessation, losing weight, exercise).Information from Miller WR, Rollnick S. Motivationalinterviewing: preparing people to change addictive behavior.New York: Guilford, 1991:191-202.




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Stages of Change Model (cont.)

Precontemplation

Action Decision

Maintenance Contemplation


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The Stages of Change model4 encompasses many conceptsfrom previously developed models. The Health Belief model,19the Locus of Control model20 and behavioral models fit togetherwell within this framework. During the precontemplation stage,

patients do not consider change. They may not believe that theirbehavior is a problem or that it will negatively affect them(Health Belief Model19), or they may be resigned to theirunhealthy behavior because of previous failed efforts and nolonger believe that they have control (external Locus ofControl20). During the contemplation stage, patients struggle

with ambivalence, weighing the pros and cons of their currentbehavior and the benefits of and barriers to change (HealthBelief model19).




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Health Belief Model

Perceived susceptibility and severity of ill

health

Perceived benefits and barriers to action Cues to action

Self-efficacy

Source: Irwin M. Rosenstock et al., Social Learning Theory and the Health Belief Model, Health

Education Quarterly 15, no. 2 (1988): 175-85.


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Helping the 'Stuck' Patient

The goal for patients at the precontemplation stage isto begin to think about changing a behavior. The task

for physicians is to empathetically engage patients incontemplating change (Table 2).6 During this stage,patients appear argumentative, hopeless or in"denial," and the natural tendency is for physicians totry to "convince" them, which usually engendersresistance.

Patient resistance is evidence that the physician hasmoved too far ahead of the patient in the changeprocess, and a shift back to empathy and thought-provoking questions is required. Physicians canengage patients in the contemplation process by

developing and maintaining a positive relationship,personalizing risk factors and posing questions thatprovoke thoughts about patient risk factors and theperceived "bottom line."




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The wording of questions and the patient's style of

"not thinking about changing" are also important. As

precontemplators respond to questions, rather than

jumping in and providing advice or appearingjudgmental, the task for physicians is to reflect with

empathy, instill hope and gently point out

discrepancies between goals and statements. Asking

argumentative patients, "Do you want to die fromthis?" may be perceived as a threat and can elicit

more resistance and hostility. On the other hand,

asking patients, "How will you know that it's time to

quit?" allows patients to be their "own expert" and

can help them begin a thought process that extends

beyond the examination room.




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B: Interpersonal Level:

Social Learning Theory Interaction of individual factors, social

environment, and experience

Reciprocal dynamic Observational learning

Capability of performing desired behavior

Perception of self-efficacy

Source: Albert Bandura, Social Foundations of Thought and Action (Englewood Cliffs, NJ: Prentice Hall,

1986).


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C: Community-Level Models

Analyze how social systems function

Mobilize communities, organizations, and

policymakers Use sound conceptual frameworks

Community Mobilization

Organizational Change

Diffusion of Innovations Theory


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Community Mobilization

Encompasses wider social and political

contexts

Community members assess health risks,take action

Encourages empowerment, building on

cultural strengths and involving

disenfranchised groups

Source: National Cancer Institute, Theory at a Glance: A Guide for Health Promotion: 18; Paolo Freire,

Pedagogy of the Oppressed (New York: Continuum, 1970.); Saul Alinsky, Rules for Radicals: A Pragmatic

Primer for Realistic Radicals (New York: Vintage Books, 1971; revised edition, 1989).


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For More Information

Elaine M. Murphy, Promoting Healthy

Behavior, Health Bulletin 2(Washington, DC:

Population Reference Bureau, 2005).

Available online at www.prb.org
http://www.prb.org/http://www.prb.org/

Stages of Change 1

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