Transtheoretical model

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Stages of change, according to the transtheoretical model.

The transtheoretical model of behavior change is an integrative theory of therapy that assesses an individual's readiness to act on a new healthier behavior, and provides strategies, or processes of change to guide the individual. The model is composed of constructs such as: stages of change, processes of change, levels of change, self-efficacy, and decisional balance.

The transtheoretical model is also known by the abbreviation "TTM" and sometimes by the term "stages of change", although this latter term is a synecdoche since the stages of change are only one part of the model along with processes of change, levels of change, etc. Several self-help books—Changing for Good (1994), Changeology (2012), and Changing to Thrive (2016)—and articles in the news media have discussed the model. In 2009, an article in the British Journal of Health Psychology called it "arguably the dominant model of health behaviour change, having received unprecedented research attention, yet it has simultaneously attracted exceptional criticism".

History and core constructs

James O. Prochaska of the University of Rhode Island, and Carlo Di Clemente and colleagues developed the transtheoretical model beginning in 1977. It is based on analysis and use of different theories of psychotherapy, hence the name "transtheoretical". Prochaska and colleagues refined the model on the basis of research that they published in peer-reviewed journals and books.

Stages of change

This construct refers to the temporal dimension of behavioural change. In the transtheoretical model, change is a "process involving progress through a series of stages":

• Precontemplation ("not ready") – "People are not intending to take action in the foreseeable future, and can be unaware that their behaviour is problematic"
• Contemplation ("getting ready") – "People are beginning to recognize that their behaviour is problematic, and start to look at the pros and cons of their continued actions"
• Preparation ("ready") – "People are intending to take action in the immediate future, and may begin taking small steps toward behaviour change"
• Action – "People have made specific overt modifications in modifying their problem behaviour or in acquiring new healthy behaviours"
• Maintenance – "People have been able to sustain action for at least six months and are working to prevent relapse"
• Termination – "Individuals have zero temptation and they are sure they will not return to their old unhealthy habit as a way of coping"

In addition, the researchers conceptualized "Relapse" (recycling) which is not a stage in itself but rather the "return from Action or Maintenance to an earlier stage".

The quantitative definition of the stages of change (see below) is perhaps the most well-known feature of the model. However it is also one of the most critiqued, even in the field of smoking cessation, where it was originally formulated. It has been said that such quantitative definition (i.e. a person is in preparation if he intends to change within a month) does not reflect the nature of behaviour change, that it does not have better predictive power than simpler questions (i.e. "do you have plans to change..."), and that it has problems regarding its classification reliability.

Communication theorist and sociologist Everett Rogers suggested that the stages of change are analogues of the stages of the innovation adoption process in Rogers' theory of diffusion of innovations.

Details of each stage

Stages of change

Stage	Precontemplation	Contemplation	Preparation	Action	Maintenance	Relapse
Standard time	more than 6 months	in the next 6 months	in the next month	now	at least 6 months	any time

Stage 1: Precontemplation (not ready)

People at this stage do not intend to start the healthy behavior in the near future (within 6 months), and may be unaware of the need to change. People here learn more about healthy behavior: they are encouraged to think about the pros of changing their behavior and to feel emotions about the effects of their negative behavior on others.

Precontemplators typically underestimate the pros of changing, overestimate the cons, and often are not aware of making such mistakes.

One of the most effective steps that others can help with at this stage is to encourage them to become more mindful of their decision making and more conscious of the multiple benefits of changing an unhealthy behavior.

Stage 2: Contemplation (getting ready)

At this stage, participants are intending to start the healthy behavior within the next 6 months. While they are usually now more aware of the pros of changing, their cons are about equal to their Pros. This ambivalence about changing can cause them to keep putting off taking action.

People here learn about the kind of person they could be if they changed their behavior and learn more from people who behave in healthy ways.

Others can influence and help effectively at this stage by encouraging them to work at reducing the cons of changing their behavior.

Stage 3: Preparation (ready)

People at this stage are ready to start taking action within the next 30 days. They take small steps that they believe can help them make the healthy behavior a part of their lives. For example, they tell their friends and family that they want to change their behavior.

People in this stage should be encouraged to seek support from friends they trust, tell people about their plan to change the way they act, and think about how they would feel if they behaved in a healthier way. Their number one concern is: when they act, will they fail? They learn that the better prepared they are, the more likely they are to keep progressing.

Stage 4: Action (current action)

People at this stage have changed their behavior within the last 6 months and need to work hard to keep moving ahead. These participants need to learn how to strengthen their commitments to change and to fight urges to slip back.

People in this stage progress by being taught techniques for keeping up their commitments such as substituting activities related to the unhealthy behavior with positive ones, rewarding themselves for taking steps toward changing, and avoiding people and situations that tempt them to behave in unhealthy ways.

Stage 5: Maintenance (monitoring)

People at this stage changed their behavior more than 6 months ago. It is important for people in this stage to be aware of situations that may tempt them to slip back into doing the unhealthy behavior—particularly stressful situations.

It is recommended that people in this stage seek support from and talk with people whom they trust, spend time with people who behave in healthy ways, and remember to engage in healthy activities (such as exercise and deep relaxation) to cope with stress instead of relying on unhealthy behavior.

Relapse (recycling)

Relapse in the TTM specifically applies to individuals who successfully quit smoking or using drugs or alcohol, only to resume these unhealthy behaviors. Individuals who attempt to quit highly addictive behaviors such as drug, alcohol, and tobacco use are at particularly high risk of a relapse. Achieving a long-term behavior change often requires ongoing support from family members, a health coach, a physician, or another motivational source. Supportive literature and other resources can also be helpful to avoid a relapse from happening.

Processes of change

Processes of change

The 10 processes of change are "covert and overt activities that people use to progress through the stages".

To progress through the early stages, people apply cognitive, affective, and evaluative processes. As people move toward Action and Maintenance, they rely more on commitments, counter conditioning, rewards, environmental controls, and support.

Prochaska and colleagues state that their research related to the transtheoretical model shows that interventions to change behavior are more effective if they are "stage-matched", that is, "matched to each individual's stage of change".

In general, for people to progress they need:

• A growing awareness that the advantages (the "pros") of changing outweigh the disadvantages (the "cons")—the TTM calls this decisional balance.
• Confidence that they can make and maintain changes in situations that tempt them to return to their old, unhealthy behavior—the TTM calls this self-efficacy.
• Strategies that can help them make and maintain change—the TTM calls these processes of change.

The ten processes of change include:

1. Consciousness-raising (Get the facts) — increasing awareness via information, education, and personal feedback about the healthy behavior.
2. Dramatic relief (Pay attention to feelings) — feeling fear, anxiety, or worry because of the unhealthy behavior, or feeling inspiration and hope when hearing about how people are able to change to healthy behaviors.
3. Self-reevaluation (Create a new self-image) — realizing that the healthy behavior is an important part of who they want to be.
4. Environmental reevaluation (Notice your effect on others) — realizing how their unhealthy behavior affects others and how they could have more positive effects by changing.
5. Social liberation (Notice public support) — realizing that society is supportive of the healthy behavior.
6. Self-liberation (Make a commitment) — believing in one's ability to change and making commitments and re-commitments to act on that belief.
7. Helping relationships (Get support) — finding people who are supportive of their change.
8. Counterconditioning (Use substitutes) — substituting healthy ways of acting and thinking for unhealthy ways.
9. Reinforcement management (Use rewards) — increasing the rewards that come from positive behavior and reducing those that come from negative behavior.
10. Stimulus control (Manage your environment) — using reminders and cues that encourage healthy behavior and avoiding places that don't.

Health researchers have extended Prochaska's and DiClemente's 10 original processes of change by an additional 21 processes. In the first edition of Planning Health Promotion Programs, Bartholomew et al. (2006) summarised the processes that they identified in a number of studies; however, their extended list of processes was removed from later editions of the text, perhaps because the list mixes techniques with processes. There are unlimited ways of applying processes. The additional strategies of Bartholomew et al. were:

1. Risk comparison (Understand the risks) – comparing risks with similar dimensional profiles: dread, control, catastrophic potential and novelty
2. Cumulative risk (Get the overall picture) – processing cumulative probabilities instead of single incident probabilities
3. Qualitative and quantitative risks (Consider different factors) – processing different expressions of risk
4. Positive framing (Think positively) – focusing on success instead of failure framing
5. Self-examination relate to risk (Be aware of your risks) – conducting an assessment of risk perception, e.g. personalisation, impact on others
6. Reevaluation of outcomes (Know the outcomes) – emphasising positive outcomes of alternative behaviours and reevaluating outcome expectancies
7. Perception of benefits (Focus on benefits) – perceiving advantages of the healthy behaviour and disadvantages of the risk behaviour
8. Self-efficacy and social support (Get help) – mobilising social support; skills training on coping with emotional disadvantages of change
9. Decision making perspective (Decide) – focusing on making the decision
10. Tailoring on time horizons (Set the time frame) – incorporating personal time horizons
11. Focus on important factors (Prioritise) – incorporating personal factors of highest importance
12. Trying out new behaviour (Try it) – changing something about oneself and gaining experience with that behaviour
13. Persuasion of positive outcomes (Persuade yourself) – promoting new positive outcome expectations and reinforcing existing ones
14. Modelling (Build scenarios) – showing models to overcome barriers effectively
15. Skill improvement (Build a supportive environment) – restructuring environments to contain important, obvious and socially supported cues for the new behaviour
16. Coping with barriers (Plan to tackle barriers) – identifying barriers and planning solutions when facing these obstacles
17. Goal setting (Set goals) – setting specific and incremental goals
18. Skills enhancement (Adapt your strategies) – restructuring cues and social support; anticipating and circumventing obstacles; modifying goals
19. Dealing with barriers (Accept setbacks) – understanding that setbacks are normal and can be overcome
20. Self-rewards for success (Reward yourself) – feeling good about progress; reiterating positive consequences
21. Coping skills (Identify difficult situations) – identifying high risk situations; selecting solutions; practicing solutions; coping with relapse

While most of these processes and strategies are associated with health interventions such as stress management, exercise, healthy eating, smoking cessation and other addictive behaviour, some of them are also used in other types of interventions such as travel interventions. Some processes are recommended in a specific stage, while others can be used in one or more stages.

Decisional balance

Main article: Decisional balance sheet

This core construct "reflects the individual's relative weighing of the pros and cons of changing". Decision making was conceptualized by Janis and Mann as a "decisional balance sheet" of comparative potential gains and losses. Decisional balance measures, the pros and the cons, have become critical constructs in the transtheoretical model. The pros and cons combine to form a decisional "balance sheet" of comparative potential gains and losses. The balance between the pros and cons varies depending on which stage of change the individual is in.

Sound decision making requires the consideration of the potential benefits (pros) and costs (cons) associated with a behavior's consequences. TTM research has found the following relationships between the pros, cons, and the stage of change across 48 behaviors and over 100 populations studied.

• The cons of changing outweigh the pros in the Precontemplation stage.
• The pros surpass the cons in the middle stages.
• The pros outweigh the cons in the Action stage.

The evaluation of pros and cons is part of the formation of decisional balance. During the change process, individuals gradually increase the pros and decrease the cons forming a more positive balance towards the target behaviour. Attitudes are one of the core constructs explaining behaviour and behaviour change in various research domains. Other behaviour models, such as the theory of planned behavior (TPB) and the stage model of self-regulated change, also emphasise attitude as an important determinant of behaviour. The progression through the different stages of change is reflected in a gradual change in attitude before the individual acts.

Due to the use of decisional balance and attitude, travel behaviour researchers have begun to combine the TTM with the TPB. Forward uses the TPB variables to better differentiate the different stages. Especially all TPB variables (attitude, perceived behaviour control, descriptive and subjective norm) are positively show a gradually increasing relationship to stage of change for bike commuting. As expected, intention or willingness to perform the behaviour increases by stage. Similarly, Bamberg uses various behavior models, including the transtheoretical model, theory of planned behavior and norm-activation model, to build the stage model of self-regulated behavior change (SSBC). Bamberg claims that his model is a solution to criticism raised towards the TTM. Some researchers in travel, dietary, and environmental research have conducted empirical studies, showing that the SSBC might be a future path for TTM-based research.

Self-efficacy

This core construct is "the situation-specific confidence people have that they can cope with high-risk situations without relapsing to their unhealthy or high risk-habit". The construct is based on Bandura's self-efficacy theory and conceptualizes a person's perceived ability to perform on a task as a mediator of performance on future tasks. In his research Bandura already established that greater levels of perceived self-efficacy leads to greater changes in behavior. Similarly, Ajzen mentions the similarity between the concepts of self-efficacy and perceived behavioral control. This underlines the integrative nature of the transtheoretical model which combines various behavior theories. A change in the level of self-efficacy can predict a lasting change in behavior if there are adequate incentives and skills. The transtheoretical model employs an overall confidence score to assess an individual's self-efficacy. Situational temptations assess how tempted people are to engage in a problem behavior in a certain situation.

Levels of change

This core construct identifies the depth or complexity of presenting problems according to five levels of increasing complexity. Different therapeutic approaches have been recommended for each level as well as for each stage of change. The levels are:

1. Symptom/situational problems: e.g., motivational interviewing, behavior therapy, exposure therapy
2. Current maladaptive cognitions: e.g., Adlerian therapy, cognitive therapy, rational emotive therapy
3. Current interpersonal conflicts: e.g., Sullivanian therapy, interpersonal therapy
4. Family/systems conflicts: e.g., strategic therapy, Bowenian therapy, structural family therapy
5. Long-term intrapersonal conflicts: e.g., psychoanalytic therapies, existential therapy, Gestalt therapy

In one empirical study of psychotherapy discontinuation published in 1999, measures of levels of change did not predict premature discontinuation of therapy. Nevertheless, in 2005 the creators of the TTM stated that it is important "that both therapists and clients agree as to which level they attribute the problem and at which level or levels they are willing to target as they work to change the problem behavior".

Psychologist Donald Fromme, in his book Systems of Psychotherapy, adopted many ideas from the TTM, but in place of the levels of change construct, Fromme proposed a construct called contextual focus, a spectrum from physiological microcontext to environmental macrocontext: "The horizontal, contextual focus dimension resembles TTM's Levels of Change, but emphasizes the breadth of an intervention, rather than the latter's focus on intervention depth."

Outcomes of programs

The outcomes of the TTM computerized tailored interventions administered to participants in pre-Action stages are outlined below.

Stress management

A national sample of pre-Action adults was provided a stress management intervention. At the 18-month follow-up, a significantly larger proportion of the treatment group (62%) was effectively managing their stress when compared to the control group. The intervention also produced statistically significant reductions in stress and depression and an increase in the use of stress management techniques when compared to the control group. Two additional clinical trials of TTM programs by Prochaska et al. and Jordan et al. also found significantly larger proportions of treatment groups effectively managing stress when compared to control groups.

Adherence to antihypertensive medication

Over 1,000 members of a New England group practice who were prescribed antihypertensive medication participated in an adherence to antihypertensive medication intervention. The vast majority (73%) of the intervention group who were previously pre-Action were adhering to their prescribed medication regimen at the 12-month follow-up when compared to the control group.

Adherence to lipid-lowering drugs

Members of a large New England health plan and various employer groups who were prescribed a cholesterol lowering medication participated in an adherence to lipid-lowering drugs intervention. More than half of the intervention group (56%) who were previously pre-Action were adhering to their prescribed medication regimen at the 18-month follow-up. Additionally, only 15% of those in the intervention group who were already in Action or Maintenance relapsed into poor medication adherence compared to 45% of the controls. Further, participants who were at risk for physical activity and unhealthy diet were given only stage-based guidance. The treatment group doubled the control group in the percentage in Action or Maintenance at 18 months for physical activity (43%) and diet (25%).

Depression prevention

Participants were 350 primary care patients experiencing at least mild depression but not involved in treatment or planning to seek treatment for depression in the next 30 days. Patients receiving the TTM intervention experienced significantly greater symptom reduction during the 9-month follow-up period. The intervention's largest effects were observed among patients with moderate or severe depression, and who were in the Precontemplation or Contemplation stage of change at baseline. For example, among patients in the Precontemplation or Contemplation stage, rates of reliable and clinically significant improvement in depression were 40% for treatment and 9% for control. Among patients with mild depression, or who were in the Action or Maintenance stage at baseline, the intervention helped prevent disease progression to Major Depression during the follow-up period.

Weight management

Five-hundred-and-seventy-seven overweight or moderately obese adults (BMI 25-39.9) were recruited nationally, primarily from large employers. Those randomly assigned to the treatment group received a stage-matched multiple behavior change guide and a series of tailored, individualized interventions for three health behaviors that are crucial to effective weight management: healthy eating (i.e., reducing calorie and dietary fat intake), moderate exercise, and managing emotional distress without eating. Up to three tailored reports (one per behavior) were delivered based on assessments conducted at four time points: baseline, 3, 6, and 9 months. All participants were followed up at 6, 12, and 24 months. Multiple Imputation was used to estimate missing data. Generalized Labor Estimating Equations (GLEE) were then used to examine differences between the treatment and comparison groups. At 24 months, those who were in a pre-Action stage for healthy eating at baseline and received treatment were significantly more likely to have reached Action or Maintenance than the comparison group (47.5% vs. 34.3%). The intervention also impacted a related, but untreated behavior: fruit and vegetable consumption. Over 48% of those in the treatment group in a pre-Action stage at baseline progressed to Action or Maintenance for eating at least 5 servings a day of fruit and vegetables as opposed to 39% of the comparison group. Individuals in the treatment group who were in a pre-Action stage for exercise at baseline were also significantly more likely to reach Action or Maintenance (44.9% vs. 38.1%). The treatment also had a significant effect on managing emotional distress without eating, with 49.7% of those in a pre-Action stage at baseline moving to Action or Maintenance versus 30.3% of the comparison group. The groups differed on weight lost at 24 months among those in a pre-Action stage for healthy eating and exercise at baseline. Among those in a pre-Action stage for both healthy eating and exercise at baseline, 30% of those randomized to the treatment group lost 5% or more of their body weight vs. 16.6% in the comparison group. Coaction of behavior change occurred and was much more pronounced in the treatment group with the treatment group losing significantly more than the comparison group. This study demonstrates the ability of TTM-based tailored feedback to improve healthy eating, exercise, managing emotional distress, and weight on a population basis. The treatment produced the highest population impact to date on multiple health risk behaviors.

The effectiveness of the use of this model in weight management interventions (including dietary or physical activity interventions, or both, and also combined with other interventions) for overweight and obese adults was assessed in a 2014 systematic review. The results revealed that there is inconclusive evidence regarding the impact of these interventions on sustainable (one year or longer) weight loss. However, this approach may produce positive effects in physical activity and dietary habits, such as increased in both exercise duration and frequency, and fruits and vegetables consumption, along with reduced dietary fat intake, based on very low quality scientific evidence.

Smoking cessation

Multiple studies have found individualized interventions tailored on the 14 TTM variables for smoking cessation to effectively recruit and retain pre-Action participants and produce long-term abstinence rates within the range of 22% – 26%. These interventions have also consistently outperformed alternative interventions including best-in-class action-oriented self-help programs, non-interactive manual-based programs, and other common interventions. Furthermore, these interventions continued to move pre-Action participants to abstinence even after the program ended. For a summary of smoking cessation clinical outcomes, see Velicer, Redding, Sun, & Prochaska, 2007 and Jordan, Evers, Spira, King & Lid, 2013.

Example for TTM application on smoke control

In the treatment of smoke control, TTM focuses on each stage to monitor and to achieve a progression to the next stage.

Stage	Precontemplation	Contemplation	Preparation	Action	Maintenance	Can Relapse to an earlier stage
Standard time	more than 6 months	in the next 6 months	in the next month	now	at least 6 months	any time
Action and intervention	not ready to quit or demoralized	ambivalent	intend to quit	take action and quit	sustained	back to smoke
Related source	Book, newspaper, friend	Book, newspaper, friend	doctor, nurse, friend...	doctor, nurse, friend...	friend, family	temptation, stress, distress

In each stage, a patient may have multiple sources that could influence their behavior. These may include: friends, books, and interactions with their healthcare providers. These factors could potentially influence how successful a patient may be in moving through the different stages. This stresses the importance to have continuous monitoring and efforts to maintain progress at each stage. TTM helps guide the treatment process at each stage, and may assist the healthcare provider in making an optimal therapeutic decision.

Travel research

The use of TTM in travel behaviour interventions is rather novel. A number of cross-sectional studies investigated the individual constructs of TTM, e.g. stage of change, decisional balance and self-efficacy, with regards to transport mode choice. The cross-sectional studies identified both motivators and barriers at the different stages regarding biking, walking and public transport. The motivators identified were e.g. liking to bike/walk, avoiding congestion and improved fitness. Perceived barriers were e.g. personal fitness, time and the weather. This knowledge was used to design interventions that would address attitudes and misconceptions to encourage an increased use of bikes and walking. These interventions aim at changing people's travel behaviour towards more sustainable and more active transport modes. In health-related studies, TTM is used to help people walk or bike more instead of using the car. Most intervention studies aim to reduce car trips for commute to achieve the minimum recommended physical activity levels of 30 minutes per day. Other intervention studies using TTM aim to encourage sustainable behaviour. By reducing single occupied motor vehicle and replacing them with so called sustainable transport (public transport, car pooling, biking or walking), greenhouse gas emissions can be reduced considerably. A reduction in the number of cars on our roads solves other problems such as congestion, traffic noise and traffic accidents. By combining health and environment related purposes, the message becomes stronger. Additionally, by emphasising personal health, physical activity or even direct economic impact, people see a direct result from their changed behaviour, while saving the environment is a more general and effects are not directly noticeable.

Different outcome measures were used to assess the effectiveness of the intervention. Health-centred intervention studies measured BMI, weight, waist circumference as well as general health. However, only one of three found a significant change in general health, while BMI and other measures had no effect. Measures that are associated with both health and sustainability were more common. Effects were reported as number of car trips, distance travelled, main mode share etc. Results varied due to greatly differing approaches. In general, car use could be reduced between 6% and 55%, while use of the alternative mode (walking, biking and/or public transport) increased between 11% and 150%. These results indicate a shift to action or maintenance stage, some researchers investigated attitude shifts such as the willingness to change. Attitudes towards using alternative modes improved with approximately 20% to 70%. Many of the intervention studies did not clearly differentiate between the five stages, but categorised participants in pre-action and action stage. This approach makes it difficult to assess the effects per stage. Also, interventions included different processes of change; in many cases these processes are not matched to the recommended stage. It highlights the need to develop a standardised approach for travel intervention design.

Criticisms

In 2009, an article in the British Journal of Health Psychology called the TTM "arguably the dominant model of health behaviour change, having received unprecedented research attention, yet it has simultaneously attracted exceptional criticism", and said "that there is still value in the transtheoretical model but that the way in which it is researched needs urgently to be addressed". Depending on the field of application (e.g. smoking cessation, substance abuse, condom use, diabetes treatment, obesity and travel) somewhat different criticisms have been raised.

In a systematic review, published in 2003, of 23 randomized controlled trials, the authors found that "stage based interventions are no more effective than non-stage based interventions or no intervention in changing smoking behaviour". However, it was also mentioned that stage based interventions are often used and implemented inadequately in practice. Thus, criticism is directed towards the use rather the effectiveness of the model itself. Looking at interventions targeting smoking cessation in pregnancy found that stage-matched interventions were more effective than non-matched interventions. One reason for this was the greater intensity of stage-matched interventions. Also, the use of stage-based interventions for smoking cessation in mental illness proved to be effective. Further studies, e.g. a randomized controlled trial published in 2009, found no evidence that a TTM based smoking cessation intervention was more effective than a control intervention not tailored to stage of change. The study claims that those not wanting to change (i.e. precontemplators) tend to be responsive to neither stage nor non-stage based interventions. Since stage-based interventions tend to be more intensive they appear to be most effective at targeting contemplators and above rather than pre-contemplators. A 2010 systematic review of smoking cessation studies under the auspices of the Cochrane Collaboration found that "stage-based self-help interventions (expert systems and/or tailored materials) and individual counselling were neither more nor less effective than their non-stage-based equivalents". A 2014 Cochrane systematic review concluded that research on the use of TTM stages of change "in weight loss interventions is limited by risk of bias and imprecision, not allowing firm conclusions to be drawn".

Main criticism is raised regarding the "arbitrary dividing lines" that are drawn between the stages. West claimed that a more coherent and distinguishable definition for the stages is needed. Especially the fact that the stages are bound to a specific time interval is perceived to be misleading. Additionally, the effectiveness of stage-based interventions differs depending on the behavior. A continuous version of the model has been proposed, where each process is first increasingly used, and then decreases in importance, as smokers make progress along some latent dimension. This proposal suggests the use of processes without reference to stages of change.

West claimed that the model "assumes that individuals typically make coherent and stable plans", when in fact they often do not. However, the model does not require that all people make a plan: for example, the SAMSHA document Enhancing Motivation for Change in Substance Use Disorder Treatment, which uses the TTM, also says: "Don't assume that all clients need a structured method to develop a change plan. Many people can make significant lifestyle changes and initiate recovery from SUDs without formal assistance".

Within research on prevention of pregnancy and sexually transmitted diseases, a systematic review from 2003 comes to the conclusion that "no strong conclusions" can be drawn about the effectiveness of interventions based on the transtheoretical model. Again this conclusion is reached due to the inconsistency of use and implementation of the model. This study also confirms that the better stage-matched the intervention the more effect it has to encourage condom use.

Within the health research domain, a 2005 systematic review of 37 randomized controlled trials claims that "there was limited evidence for the effectiveness of stage-based interventions as a basis for behavior change. Studies with which focused on increasing physical activity levels through active commute however showed that stage-matched interventions tended to have slightly more effect than non-stage matched interventions. Since many studies do not use all constructs of the TTM, additional research suggested that the effectiveness of interventions increases the better it is tailored on all core constructs of the TTM in addition to stage of change. In diabetes research the "existing data are insufficient for drawing conclusions on the benefits of the transtheoretical model" as related to dietary interventions. Again, studies with slightly different design, e.g. using different processes, proved to be effective in predicting the stage transition of intention to exercise in relation to treating patients with diabetes.

TTM has generally found a greater popularity regarding research on physical activity, due to the increasing problems associated with unhealthy diets and sedentary living, e.g. obesity, cardiovascular problems. A 2011 Cochrane Systematic Review found that there is little evidence to suggest that using the transtheoretical model stages of change (TTM SOC) method is effective in helping obese and overweight people lose weight. There were only five studies in the review, two of which were later dropped due to not being relevant since they did not measure weight. Earlier in a 2009 paper, the TTM was considered to be useful in promoting physical activity. In this study, the algorithms and questionnaires that researchers used to assign people to stages of change lacked standardisation to be compared empirically, or validated.

Similar criticism regarding the standardisation as well as consistency in the use of TTM is also raised in a 2017 review on travel interventions. With regard to travel interventions only stages of change and sometimes decisional balance constructs are included. The processes used to build the intervention are rarely stage-matched and short cuts are taken by classifying participants in a pre-action stage, which summarises the precontemplation, contemplation and preparation stage, and an action/maintenance stage. More generally, TTM has been criticised within various domains due to the limitations in the research designs. For example, many studies supporting the model have been cross-sectional, but longitudinal study data would allow for stronger causal inferences. Another point of criticism is raised in a 2002 review, where the model's stages were characterized as "not mutually exclusive". Furthermore, there was "scant evidence of sequential movement through discrete stages". While research suggests that movement through the stages of change is not always linear, a study of smoking cessation conducted in 1996 demonstrated that the probability of forward stage movement is greater than the probability of backward stage movement. Due to the variations in use, implementation and type of research designs, data confirming TTM are ambiguous. More care has to be taken in using a sufficient amount of constructs, trustworthy measures, and longitudinal data.

Behavior change (public health)

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Behavior_change_(public_health) 

Behavior change, in context of public health, refers to efforts put in place to change people's personal habits and attitudes, to prevent disease. Behavior change in public health can take place at several levels and is known as social and behavior change (SBC). More and more, efforts focus on prevention of disease to save healthcare care costs. This is particularly important in low and middle income countries, where supply side health interventions have come under increased scrutiny because of the cost.

Aims

The 3-4-50 concept outlines that there are 3 behaviors (poor diet, little to no physical activity, and smoking), that lead to four diseases (heart disease/stroke, diabetes, cancer, pulmonary disease), that account for 50% of deaths worldwide. This is why so much emphasis in public health interventions have been on changing behaviors or intervening early on to decrease the negative impacts that come with these behaviors. With successful intervention, there is the possibility of decreasing healthcare costs by a drastic amount, as well as general costs to society (morbidity and mortality). A good public health intervention is not only defined by the results they create, but also the number of levels it hits on the socioecological model (individual, interpersonal, community and/or environment). The challenge that public health interventions face is generalizability: what may work in one community may not work in others. However, there is the development of Healthy People 2020 that has national objectives aimed to accomplish in 10 years to improve the health of all Americans.

Health conditions and infections are associated with risky behaviors. Tobacco use, alcoholism, multiple sex partners, substance use, reckless driving, obesity, or unprotected sexual intercourse are some examples. Human beings have, in principle, control over their conduct. Behavior modification can contribute to the success of self-control, and health-enhancing behaviors. Risky behaviors can be eliminated including physical exercise, weight control, preventive nutrition, dental hygiene, condom use, or accident prevention. Health behavior change refers to the motivational, volitional, and action based processes of abandoning such health-compromising behaviors in favor of adopting and maintaining health-enhancing behaviors. Addiction that is associated with risky behavior may have a genetic component.

Theories

Behavior change programs tend to focus on a few behavioral change theories which gained ground in the 1980s. These theories share a major commonality in defining individual actions as the locus of change. Behavior change programs that are usually focused on activities that help a person or a community to reflect upon their risk behaviors and change them to reduce their risk and vulnerability are known as interventions. Examples include: "transtheoretical (stages of change) model of behavior change", "theory of reasoned action", "health belief model", "theory of planned behavior", diffusion of innovation", and the health action process approach. Developments in health behavior change theories since the late 1990s have focused on incorporating disparate theories of health behavior change into a single unified theory.

Individual and interpersonal

• Health belief model: It is a psychological model attempting to provide an explanation and prediction of health behaviors through a focus on the attitudes and beliefs of individuals. Based on the belief that the perception an individual has determines their success in taking on that behavior change. Factors: perceived susceptibility/severity/benefits/barriers, readiness to act, cues to action, and self-efficacy.
• Protection motivation theory: Focuses on understanding the fear appeal that mediates behavior change and describes how threat/coping appraisal is related to how adaptive or maladaptive when coping with a health threat. Factors: perceived severity, vulnerability, response efficacy.
• Transtheoretical model: This theory uses "stages of change" to create a nexus between powerful principles and processes of behavior change derived from leading theories of behavior change. Incorporates aspects of the integrative biopsychosocial model (CITE).
• Self-regulation theory: Embodies the belief that people have control over their own behavior change journey, as long as they have the resources and understanding to do so. Aims to create long-term effects for particular situations and contexts. Mainly focuses on stopping negative behaviors.
• Relapse prevention model: Focuses on immediate determinants and underhanded antecedent behaviors/factors that contribute and/or lead to relapse. Aims to identify high-risk situations and work with participants to cope with such conditions. Factors: self-efficacy, stimulus control.
• Behaviorist learning theory: Aims to understand prior context of behavior development that leads to certain consequences.
• Social cognitive theory: Explains behavior learning through observation and social contexts. Centered on the belief that behavior is a context of the environment through psychological processes. Factors: self-efficacy, knowledge, behavioral capability, goal setting, outcome expectations, observational learning, reciprocal determinism, reinforcement.
• Self-determination theory: Centers around support for natural and/or intrinsic tendencies with behavior and provides participants with healthy and effective ways to work with those. Factors: autonomy, competence, and skills.
• Theory of planned behavior: Aims to predict the specific plan of an individual to engage in a behavior (time and place), and apply to behaviors over which people have the ability to enact self-control over. Factors: behavioral intent, evaluation of risks and behavior.
• Health action process approach: HAPA suggests that the adoption, initiation, and maintenance of health behaviors should be conceived of as a structured process including a motivation phase and a volition phase. The former describes the intention formation while the latter refers to planning, and action (initiative, maintenance, recovery).

Community

• Community-based participatory research (CBPR): Utilizes community researcher partnership and collaboration. People in the designated community work with the researcher to play an active role as well as being the subjects of the study.
• Diffusion of innovations: Seeks to explain how new ideas and behaviors are communicated and spread throughout groups. Factors: relative advantage, compatibility, complexity, trial-ability, observability.

Tools

Behavior change communication (BCC)

Main article: Social and behavior change communication

Behavior change communication, or BCC, is an approach to behavior change focused on communication. It is also known as social and behavior change communication, or SBCC. The assumptions is that through communication of some kind, individuals and communities can somehow be persuaded to behave in ways that will make their lives safer and healthier. BCC was first employed in HIV and TB prevention projects. More recently, its ambit has grown to encompass any communication activity whose goal is to help individuals and communities select and practice behavior that will positively impact their health, such as immunization, cervical cancer check up, employing single-use syringes, etc.

List of behavior change strategies

• Motivational interviewing
• Goal oriented technique for eliciting and strengthening intrinsic motivation for change.
• Behavioral contract
• Intent formation, making a commitment, being ready to change. (usually written)
• Knowledge
• Educational information through behavior, consequences and benefits, getting help, acquisition of skills.
• Behavioral capabilities
• Skill development through practice, modeling, imitation, reenacting, rehearsing.
• Choices
• Building autonomy and intrinsic motivation through relevance, interests and control
• Graded tasks
• Planning ahead
• Anticipate barriers
• Problem solving
• Self-reporting
• Self-adjustment
• Rewards
• Stimulus control
• Social support

Examples

• Organizations, foundations and programs
  • Johns Hopkins Center for Communication Programs specializes in health-related BCC (behavior change communication) programs, primarily in developing countries. It includes programs in reproductive health and family planning, malaria, and HIV/AIDS.
  • Development Media International uses mass media to promote healthy behaviors in Burkina Faso, DRC and Mozambique.
  • Young 1ove provides information to youth to reduce the spread of HIV/AIDS in Botswana.
  • Science of Behavior Change (SOBC) aims to promote basic research on the initiation, personalization, and maintenance of behavior change.
  • Chocolate Moose Media, founded by Firdaus Kharas in 1995, creates animated public service announcement content for health-and-social-justice behaviour change communications.
• Physical activity and diet: Look AHEAD (Action for Health in Diabetes), Shape-up Somerville, Diabetes Prevention Program (DPP)
• Quitting smoking: The Truth Initiative, Campaign for Tobacco-Free Kids, Family Smoking Prevention and Tobacco Control 2009
• Care groups are groups of 10–15 volunteer, community-based health educators who regularly meet together.
• Barrier analysis is a rapid assessment tool used in behavior change projects to identify behavioral determinants.
• Community-led total sanitation is a behaviour change tool used in the sanitation sector for mainly rural settings in developing countries with the aim to stop open defecation. The method uses shame, disgust and to some extent peer pressure which leads to the "spontaneous" construction and long-term use of toilets after an initial triggering process has taken place.

Behavioural change theories

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Behavioural_change_theories 

Behavioural change theories are attempts to explain why human behaviours change. These theories cite environmental, personal, and behavioural characteristics as the major factors in behavioural determination. In recent years, there has been increased interest in the application of these theories in the areas of health, education, criminology, energy and international development with the hope that understanding behavioural change will improve the services offered in these areas. Some scholars have recently introduced a distinction between models of behavior and theories of change. Whereas models of behavior are more diagnostic and geared towards understanding the psychological factors that explain or predict a specific behavior, theories of change are more process-oriented and generally aimed at changing a given behavior. Thus, from this perspective, understanding and changing behavior are two separate but complementary lines of scientific investigation.

General theories and models

Each behavioural change theory or model focuses on different factors in attempting to explain behaviour change. Of the many that exist, the most prevalent are learning theories, social cognitive theory, theories of reasoned action and planned behaviour, transtheoretical model of behavior change, the health action process approach, and the BJ Fogg model of behavior change. Research has also been conducted regarding specific elements of these theories, especially elements like self-efficacy that are common to several of the theories.

Self-efficacy

Self-efficacy is an individual's impression of their own ability to perform a demanding or challenging task such as facing an exam or undergoing surgery. This impression is based upon factors like the individual's prior success in the task or in related tasks, the individual's physiological state, and outside sources of persuasion. Self-efficacy is thought to be predictive of the amount of effort an individual will expend in initiating and maintaining a behavioural change, so although self-efficacy is not a behavioural change theory per se, it is an important element of many of the theories, including the health belief model, the theory of planned behaviour and the health action process approach.

In 1977, Albert Bandura performed two experimental tests on the self-efficacy theory. The first study asked whether systematic desensitization could effect changes in avoidance behavior by improving people's expectations of their personal efficacy. The study found that "thorough extinction of anxiety arousal to visualized threats by desensitization treatment produced differential increases in self-efficacy. In accord with prediction, microanalysis of congruence between self-efficacy and performance showed self-efficacy to be a highly accurate predictor of degree of behavioral change following complete desensitization. The findings also lend support to the view that perceived self-efficacy mediates anxiety arousal." In the second experiment, Bandura examined the process of efficacy and behavioral change in individuals suffering from phobias. He found that self-efficacy was a useful predictor of the amount of behavioral improvement that phobics could gain through mastering threatening thoughts.

Learning theories and behaviour analytic theories of changes

Social learning and social cognitive theory

According to the social learning theory (more recently expanded as social cognitive theory), behavioural change is determined by environmental, personal, and behavioural elements. Each factor affects each of the others. For example, in congruence with the principles of self-efficacy, an individual's thoughts affect their behaviour and an individual's characteristics elicit certain responses from the social environment. Likewise, an individual's environment affects the development of personal characteristics as well as the person's behavior, and an individual's behaviour may change their environment as well as the way the individual thinks or feels. Social learning theory focuses on the reciprocal interactions between these factors, which are hypothesised to determine behavioral change.

Theory of reasoned action

The theory of reasoned action assumes that individuals consider a behaviour's consequences before performing the particular behaviour. As a result, intention is an important factor in determining behaviour and behavioural change. According to Icek Ajzen, intentions develop from an individual's perception of a behaviour as positive or negative together with the individual's impression of the way their society perceives the same behaviour. Thus, personal attitude and social pressure shape intention, which is essential to performance of a behaviour and consequently behavioural change.

Theory of planned behaviour

In 1985, Ajzen expanded upon the theory of reasoned action, formulating the theory of planned behaviour, which also emphasises the role of intention in behaviour performance but is intended to cover cases in which a person is not in control of all factors affecting the actual performance of a behaviour. As a result, the new theory states that the incidence of actual behaviour performance is proportional to the amount of control an individual possesses over the behaviour and the strength of the individual's intention in performing the behaviour. In his article, Further hypothesises that self-efficacy is important in determining the strength of the individual's intention to perform a behaviour. In 2010, Fishbein and Ajzen introduced the reasoned action approach, the successor of the theory of planned behaviour.

Transtheoretical or stages of change model

According to the transtheoretical model of behavior change, also known as the stages of change model, states that there are five stages towards behavior change. The five stages, between which individuals may transition before achieving complete change, are precontemplation, contemplation, preparation for action, action, and maintenance. At the precontemplation stage, an individual may or may not be aware of a problem but has no thought of changing their behavior. From precontemplation to contemplation, the individual begins thinking about changing a certain behavior. During preparation, the individual begins his plans for change, and during the action stage the individual begins to exhibit new behavior consistently. An individual finally enters the maintenance stage once they exhibit the new behavior consistently for over six months. A problem faced with the stages of change model is that it is very easy for a person to enter the maintenance stage and then fall back into earlier stages. Factors that contribute to this decline include external factors such as weather or seasonal changes, and/or personal issues a person is dealing with.

Health action process approach

The health action process approach (HAPA) is designed as a sequence of two continuous self-regulatory processes, a goal-setting phase (motivation) and a goal-pursuit phase (volition). The second phase is subdivided into a pre-action phase and an action phase. Motivational self-efficacy, outcome-expectancies and risk perceptions are assumed to be predictors of intentions. This is the motivational phase of the model. The predictive effect of motivational self-efficacy on behaviour is assumed to be mediated by recovery self-efficacy, and the effects of intentions are assumed to be mediated by planning. The latter processes refer to the volitional phase of the model.

Fogg Behavior Model

The BJ Fogg Behavior Model. The different levels of ability and motivation define whether triggers for behavior change will succeed or fail. As an example trying to trigger behavior change through something difficult to do (low ability) will only succeed with very high motivation. In contrast, trying to trigger behavior change through something easy to do (high ability) may succeed even with average motivation.

The Fogg Behavior Model (FBM) is a design behavior change model introduced by BJ Fogg. This model posits that behavior is composed of three different factors: motivation, ability and a prompt. Under the FBM, for any person (user) to succeed at behavior change needs to be motivated, have the ability to perform the behavior and needs a trigger to perform this behavior. The next are the definitions of each of the elements of the BFM:

Motivation

BJ Fogg does not provide a definition of motivation but instead defines different motivators:

• Pleasure/Pain: These motivators produce a response immediately and although powerful these are not ideal. Boosting motivation could be achieved by embodying pain or pleasure.
• Hope/fear: Both these motivators have a delayed response and are the anticipation of a future positive outcome (hope) or negative outcome (fear). As an example people joining a dating website hope to meet other people.
• Social acceptance/rejection: People are motivated by behaviors that increase or preserve their social acceptance.

Ability

This factor refers to the self-efficacy perception at performing a target behavior. Although low ability is undesirable it may be unavoidable: "We are fundamentally lazy," according to BJ Fogg. In such case behavior change is approached not through learning but instead by promoting target behaviors for which the user has a high ability. Additionally BJ Fogg listed several elements or dimensions that characterize high ability or simplicity of performing a behavior:

• Time: The user has the time to perform the target behavior or the time taken is very low.
• Money: The user has enough financial resources for pursuing the behavior. In some cases money can buy time.
• Physical effort: Target behaviors that require physical effort may not be simple enough to be performed.
• Brain cycles: Target behaviors that require high cognitive resources may not be simple hence undesirable for behavior change.
• Social deviance: These include behaviors that make the user socially deviant. These kind of behaviors are not simple.
• Non-routine: Any behavior that incurs disrupting a routine is considered not simple. Simple behaviors are usually part of routines and hence easy to follow.

Triggers

Triggers are reminders that may be explicit or implicit about the performance of a behavior. Examples of triggers can be alarms, text messages or advertisement, triggers are usually perceptual in nature but may also be intrinsic. One of the most important aspects of a trigger is timing as only certain times are best for triggering certain behaviors. As an example if a person is trying to go to the gym everyday, but only remembers about packing clothing once out of the house it is less likely that this person will head back home and pack. In contrast if an alarm sounds right before leaving the house reminding about packing clothing, this will take considerably less effort. Although the original article does not have any references for the reasoning or theories behind the model, some of its elements can be traced to social psychology theories, e.g., the motivation and ability factors and its success or failure are related to Self-efficacy.

Education

Behavioural change theories can be used as guides in developing effective teaching methods. Since the goal of much education is behavioural change, the understanding of behaviour afforded by behavioural change theories provides insight into the formulation of effective teaching methods that tap into the mechanisms of behavioural change. In an era when education programs strive to reach large audiences with varying socioeconomic statuses, the designers of such programs increasingly strive to understand the reasons behind behavioural change in order to understand universal characteristics that may be crucial to program design.

In fact, some of the theories, like the social learning theory and theory of planned behaviour, were developed as attempts to improve health education. Because these theories address the interaction between individuals and their environments, they can provide insight into the effectiveness of education programs given a specific set of predetermined conditions, like the social context in which a program will be initiated. Although health education is still the area in which behavioural change theories are most often applied, theories like the stages of change model have begun to be applied in other areas like employee training and developing systems of higher education. Education could be formal or informal depending on the target population.

Criminology

Empirical studies in criminology support behavioural change theories. At the same time, the general theories of behavioural change suggest possible explanations to criminal behaviour and methods of correcting deviant behaviour. Since deviant behaviour correction entails behavioural change, understanding of behavioural change can facilitate the adoption of effective correctional methods in policy-making. For example, the understanding that deviant behaviour like stealing may be learned behaviour resulting from reinforcers like hunger satisfaction that are unrelated to criminal behaviour can aid the development of social controls that address this underlying issue rather than merely the resultant behaviour.

Specific theories that have been applied to criminology include the social learning and differential association theories. Social learning theory's element of interaction between an individual and their environment explains the development of deviant behaviour as a function of an individual's exposure to a certain behaviour and their acquaintances, who can reinforce either socially acceptable or socially unacceptable behaviour. Differential association theory, originally formulated by Edwin Sutherland, is a popular, related theoretical explanation of criminal behaviour that applies learning theory concepts and asserts that deviant behaviour is learned behaviour.

Energy

Recent years have seen an increased interest in energy consumption reduction based on behavioural change, be it for reasons of climate change mitigation or energy security. The application of behavioural change theories in the field of energy consumption behaviour yields interesting insights. For example, it supports criticism of a too narrow focus on individual behaviour and a broadening to include social interaction, lifestyles, norms and values as well as technologies and policies—all enabling or constraining behavioural change.

Methods

Besides the models and theories of behavior change there are methods for promoting behavior change. Among them one of the most widely used is Tailoring or personalization.

Tailoring

Tailoring refers to methods for personalizing communications intended to generate higher behavior change than non personalized ones. There are two main claims for why tailoring works: Tailoring may improve preconditions for message processing and tailoring may improve impact by altering starting behavioral determinants of goal outcomes. The different message processing mechanisms can be summarized into: Attention, Effortful processing, Emotional processing and self-reference.

• Attention: Tailored messages are more likely to be read and remembered
• Effortful processing: Tailored messages elicit careful consideration of persuasive arguments and more systematic utilization of the receivers own schemas and memories. This could also turn out damaging because this careful consideration does increase counterarguing, evaluations of credibility and other processes that lessens message effects.
• Peripheral emotion/processing: tailoring could be used to create an emotional response such as fear, hope or anxiety. Since positive emotions tend to reduce effortful processing and negative emotions enhance it, emotion arousal could elicit varying cognitive processing.
• Self-reference: This mechanism promotes the comparison between actual and ideal behaviors and reflection.

Behavioral determinants of goal outcomes are the different psychological and social constructs that have a direct influence on behavior. The three most used mediators in tailoring are attitude, perception of performance and self efficacy. Although results are largely positive they are not consistent and more research on the elements that make tailoring work is necessary.

Objections

Behavioural change theories are not universally accepted. Criticisms include the theories' emphases on individual behaviour and a general disregard for the influence of environmental factors on behaviour. In addition, as some theories were formulated as guides to understanding behaviour while others were designed as frameworks for behavioural interventions, the theories' purposes are not consistent. Such criticism illuminates the strengths and weaknesses of the theories, showing that there is room for further research into behavioural change theories.

Behavioral change support system

From Wikipedia, the free encyclopedia
https://en.wikipedia.org/wiki/Behavioral_change_support_system

A Behavioral Change Support System (BCSS) is any information and communications technology (ICT) tool, web platform, or gamified environment which targets behavioral changes in its end-users. BCSS are built upon persuasive systems design techniques.

Underlying theories and models

The design of these systems and their contents are based on behavioral change theories and models for behavioral change over time. The theory of planned behavior describes the relationship between attitudes, intentions, and the desired behavior. It is considered to be one of the most influential determinant models.

A supporting model is the Fogg Behaviour Model (FBM), which states that a user must be motivated first before having the ability to perform the change in their behavior, which is triggered by either intrinsic or extrinsic factors (The term "trigger" was changed by the author in late 2017 and the term "prompt" is now being used). BCSS makes use of extrinsic (perceptual) prompts like alarms, messages with offers or calls to action, ads, requests, and more.

Other theories that aid in the design and mechanisms behind a BCSS include the social learning theory (SLT), which studies the interactions between a user and the environment, and the theory of planned behavior (initiated as the theory of reasoned action).

Techniques and elements

Applications of BCSS may include game and training elements in several market domains which can range from Health and Education and Quality of Life (QoL), to professional development and workability. Virtually any concept designed to cause a shift in a person's behavior can be considered a BCSS, even if this change is not directly observed by the users. When users are aware of this intention and choose to work within the system, the chances of favorable results from this system increase. This effect is attributed to metacognition, as most BCSS systems implement metacognitive strategies for goal attainment. These strategies help users understand the cause of their resistance to adopting the desired behavior. It requires that they monitor themselves whenever the targeted behavior can be observed to understand their progress towards the desired behavior, and record evidence (usually objective but also subjective measurements) of their behavioral changes.

There can be a positive impact on people who have difficulties in changing their behavior by considering behaviors and the distance to the desired behavior. This can be achieved by helping them develop a personalized plan for reaching the targeted behavior and learning the ways to achieve their personal goals. In most cases, the general objective can be split into more than one objective or step, before the desired behavior is adopted by the users and becomes a routine. The positive feedback introduces self-management in BCSS applications since it is particularly helpful for people to take responsibility for their own actions and do things to the best of their ability. BCSS is very often equipped with additional features like game elements to foster user engagement leading to serious game applications. Moreover, they implement machine learning techniques to predict the future behavior of users based on their past performance. The evidence of the achieved change in behavior, as well as important notifications during self-evaluation, are communicated with visual analytics tools such as performance graphs. Additional tools frequently found in BCSS include checklists and questionnaires to collect users' feedback, hardware sensing components like the Internet of things (IoT) devices (e.g., cameras), and social collaboration to help the members of a user community to support each other. Occasionally, some BCSS allow professionals (trainers, educators, medical personnel and social professionals) to participate in the BCSS activities. This can be done by giving advice and support and also by making decisions and alterations to the treatment plan according to the observed performance and the personal needs of the targeted users.

Taxonomies

Most BCSSes work on a single profile (targeted user), while some can monitor and report progress made by a group of people. There are BCSS applications purely made using software, while others include hardware components like sensors and IoT devices to introduce physical computing in a hybrid physical-digital approach. The devices used to access a BCSS are usually internet-connected mobile devices like smartphones, tablets, or smartwatches. The success in this category of BCSS applications lies in monitoring and notifying the users constantly in regards to daily activities. On the other hand, there are BCSSes which are less intrusive and rely on less frequent access to the system. Another way to distinguish BCSSes is by the knowledge domain they refer to. Theoretically, a BCSS can be built in any knowledge domain.

Knowledge domains

eHealth/mHealth

Examples of BCSS applied in eHealth domains include CAREGIVERSPRO-MMD, which is a community-based intervention to support people living with dementia and their caregivers using game elements to engage users in non-pharmacological interventions; iLift, which trains nurses in lifting and transfer techniques to prevent lower-back injuries, and We4Fit which is more like a game environment. A more extensive review of health BCSS can be found on the work of Alahäivälä & Oinas-Kukkonen (2016) and Bridle et al. (2005).

Education

As Arlinghaus and Johnston implied, “Although not sufficient, education is a necessary component for behaviour change” (2018). BCSSes are used in education less for imparting knowledge and testing knowledge gained, and more for teaching a difficult subject like "responsible sexual behaviour" in middle-school students, or for changing attitudes and beliefs about a topic of interest.

Adopting new behavioral patterns is difficult and people are not motivated to change their behavior if they do not recognize the blocking issue. Gamification is used to help recognition by providing rewards, competition, and motivational cues of a BCSS. Prochaska et al. (2007) proposed a six-stage behavioral change model (pre-contemplation, contemplation, preparation, action, maintenance, and termination) which can be applied in educational uses of a BCSS, as it appears in an ideal environment for making the first step (contemplation) after a long period of resistance (pre-contemplation). BCSSes affect the physical world and help people experiment with an alternative behavioral pattern without thinking of possible coincidences (such as social exposure). The virtual activities performed in a BCSS help in the next step (preparation) where the user makes a transition from a passive to an active state in a safe environment. The user-monitoring and reward system of a BCSS helps users complete the rest of the stages of the behavior change (action, maintenance, and termination) and avoid regression to the previous unwanted behavior. Schmied (2017) proposes a similar seven-step process: the Designing for Behaviour Change (DBC) framework. Overall, a positive behavioral change in education settings is facilitated by technology through digital intervention strategies, where a teacher or educator makes adjustments to personalize the interventions to the student's profiles and performance. Although ICT tools may not be necessary to change behavior in schools, when used in the form of serious game-assisted learning, they can provide a more in-depth perception of important concepts in a field of study despite some disadvantages.

Other Domains

BCSS has been applied in other knowledge and study areas, including workers' behaviour, consumers' brand-loyalty, and CO₂ footprints and energy consumption. Examples include applications designed to raise water-saving awareness, apps used by drivers to reduce fuel consumption by adopting an eco-friendly driving style, and educational games for simulating energy consumption in domestic environments like in Casals et al. (2017). A systematic review of the application of game elements to behavioural change in domestic energy consumption can be found in Johnson et al. (2017) An example from the Industry 4.0 domain is SATISFACTORY, which proposes a gamified social collaboration platform that is integrated into the shop-floor of industries to improve productivity, safety and workers' engagement. In the marketing context, behavioural change techniques do not aim to change the way people think, but how they consume products and services. In politics, behavioural change interventions are delivered in the form of mass-media campaigns on existing social media platforms rather than standalone applications.

Overall, there is a continually growing number of domains in which ICT tools are introduced as tools to implement and deliver behavioral change campaigns in a systematic way. Some researchers refer to persuasive technology to identify the computer-mediated communication between humans or human-computer interaction technologies used to deliver persuasive evidence. A BCSS should be treated as a more complex ICT-based construct which may use persuasive technologies, but also supports the full life-cycle of behavioral change interventions (from authoring to publishing), implements various campaigns to achieve its goals, and is adaptive to specific user profiles.

Criticism

Behavior Change Support Systems have been criticized for a lack of grounding in independent behavioral theory, as well as the lack of industry standards to measure performance or effect. Another source of criticism refers to the dominant behavioral change models as products of the theory of planned behavior. According to some researchers (Kollmus & Agyeman, 2002), there is a gap between attitude and intention, and target behavior. Thus, it is difficult to find a widely accepted model that can take all relevant behavioral parameters into account. Additionally, even if BCSSes help to effect a change in a targeted user's behavior, the user usually fails to maintain the target behavior. This could be the result of underestimating the long-term influence that environmental factors have on behavior.

There is currently an open discussion on how intrusive a BCSS should be, but this appears to be dependent upon the physical and social context of the environment in which the BCSS is being used. As BCSS makes use of personal data coming from users' profiles and the user-monitoring system, the use of BCSSes in everyday life may be legally restricted.