Lifestyle medicine focuses on educating and motivating patients to improve the quality of their lives by changing personal habits and behaviors around the use of healthier diets which minimize ultra-processed foods such as a Mediterranean diet or whole food, plant-predominant dietary patterns. Poor lifestyle choices like dietary patterns, physical inactivity, tobacco use, alcohol addiction and dependence, drugaddiction and dependence, as well as psychosocial factors, e.g. chronic stress and lack of social support and community, contribute to chronic disease.
In the clinic, major barriers to lifestyle counseling are that
physicians feel ill-prepared and are skeptical about their patients'
receptivity. However, by encouraging healthy decisions, illnesses can be prevented or better managed in the long-term.
Characteristics
Lifestyle Medicine in Practice
Lifestyle interventions require behavior changes that may be
challenging for health professionals, communities, and patients. The
task of the LM practitioner is to motivate and support healthy behavior
changes through evidence-based approaches to prevent and manage chronic
conditions. LM emphasizes personalized care and uses patient-centered
approaches such as goal-setting, shared decision-making, and
self-management. Coaching patients how to cook healthy food at home, for example, can be part of a lifestyle-oriented medical practice. Focusing on the health needs of an individual includes looking at the person's social and economic needs, as well.
LM uses behavioral science to equip and encourage patients to
make lifestyle changes. There are many theories of behavior change; the transtheoretical model
is particularly suited to lifestyle medicine. It posits that
individuals progress through six stages of change: precontemplation,
contemplation, preparation, action, maintenance, and termination.
Stage-matched interventions are most likely to result in successful
behavior changes. LM practitioners are encouraged to adopt counseling
methods such as motivational interviewing (MI) to identify patient readiness to change and provide stage appropriate lifestyle interventions. These skills have shown to be more effective than giving advice like "Exercise more and eat healthy".
LM is similar to preventive medicine in that it also bridges the
gap between conventional medicine and public health. LM interventions
such as behavioral change counseling are used in adjunct with pharmacotherapy.
Like all of medicine, LM promotes healthy lifestyle choices to prevent
and treat diseases. Overall wellness and self-management are a crucial
components of lifestyle medicine and enforce the idea of living
healthier through behavioral change. Health promotion is the foundation
of LM and encourages individuals to participate in their own care and
well-being.
Levels of Lifestyle Medicine
LM may be practiced on three levels. The first level involves
recognition by all healthcare professionals that lifestyle choices
determine health status and are important modifiers of the response to
pharmaceutical and/or surgical treatments. All practitioners are
encouraged to include lifestyle advice along with standard treatment
protocols. The second level is specialty care (e.g., Exercise medicine and Physiatry)
in which LM interventions are the focus of treatment and pharmaceutical
and/or surgical treatments are an adjunct to be used as necessary.
The third level is population/community health programs and policies.
Lifestyle intervention advice should be included in public
health/preventive medicine guidance and policies for the prevention and
treatment of chronic diseases.
Interprofessional Education/Collaboration in Lifestyle Medicine Practice
Healthcare professionals and their future patients would benefit
if the basics of LM were incorporated into all professional training
programs. Formal training and personal experience of evidence-based
lifestyle interventions such as plant-based nutrition, stress
management, physical activity, sleep management, relationship skills,
and substance abuse mitigation would transform the American healthcare
system. LM is uniquely suited to interprofessional education
in which students from two or more healthcare professions learn
together during professional training with the objective of cultivating
collaborative practice of patient-centered care. Physicians and other healthcare providers should feel comfortable
talking with their patient about behavioral lifestyle changes and
assessing needs in determinants of health. Engaging patients in these
conversations can better help them achieve their lifestyle and
healthcare goals.
There are many educational pathways to becoming an expert in LM.
Physicians can become certified or accredited from the International
Board of Lifestyle Medicine (IBLM), American Board of Lifestyle Medicine
(ABLM), and British Society of Lifestyle Medicine (BSLM).
The Lifestyle Medicine Global Alliance (LMGA) is an organization that
connects LM professionals from nations around the world to collaborate,
share resources, and create solutions to preventing and reversing
non-communicable and chronic diseases.
From Wikipedia, the free encyclopedia
Lifestyle Medicine
The focus of Lifestyle Medicine is on these 6 pillars.
Lifestyle medicine focuses on educating and motivating patients to improve the quality of their lives by changing personal habits and behaviors around the use of healthier diets which minimize ultra-processed foods such as a Mediterranean diet or whole food, plant-predominant dietary patterns. Poor lifestyle choices like dietary patterns, physical inactivity, tobacco use, alcohol addiction and dependence, drugaddiction and dependence, as well as psychosocial factors, e.g. chronic stress and lack of social support and community, contribute to chronic disease. In the clinic, major barriers to lifestyle counseling are that
physicians feel ill-prepared and are skeptical about their patients'
receptivity.However, by encouraging healthy decisions, illnesses can be prevented or better managed in the long-term.
Characteristics
Lifestyle Medicine in Practice
Lifestyle interventions require behavior changes that may be
challenging for health professionals, communities, and patients. The
task of the LM practitioner is to motivate and support healthy behavior
changes through evidence-based approaches to prevent and manage chronic
conditions. LM emphasizes personalized care and uses patient-centered
approaches such as goal-setting, shared decision-making, and
self-management. Coaching patients how to cook healthy food at home, for example, can be part of a lifestyle-oriented medical practice. Focusing on the health needs of an individual includes looking at the person's social and economic needs, as well.
LM uses behavioral science to equip and encourage patients to
make lifestyle changes. There are many theories of behavior change; the transtheoretical model
is particularly suited to lifestyle medicine. It posits that
individuals progress through six stages of change: precontemplation,
contemplation, preparation, action, maintenance, and termination. Stage-matched interventions are most likely to result in successful
behavior changes. LM practitioners are encouraged to adopt counseling
methods such as motivational interviewing (MI) to identify patient readiness to change and provide stage appropriate lifestyle interventions. These skills have shown to be more effective than giving advice like "Exercise more and eat healthy".
LM is similar to preventive medicine in that it also bridges the
gap between conventional medicine and public health. LM interventions
such as behavioral change counseling are used in adjunct with pharmacotherapy.
Like all of medicine, LM promotes healthy lifestyle choices to prevent
and treat diseases. Overall wellness and self-management are a crucial
components of lifestyle medicine and enforce the idea of living
healthier through behavioral change. Health promotion is the foundation
of LM and encourages individuals to participate in their own care and
well-being.
Levels of Lifestyle Medicine
LM may be practiced on three levels. The first level involves
recognition by all healthcare professionals that lifestyle choices
determine health status and are important modifiers of the response to
pharmaceutical and/or surgical treatments. All practitioners are
encouraged to include lifestyle advice along with standard treatment
protocols. The second level is specialty care (e.g., Exercise medicine and Physiatry)
in which LM interventions are the focus of treatment and pharmaceutical
and/or surgical treatments are an adjunct to be used as necessary.
The third level is population/community health programs and policies.
Lifestyle intervention advice should be included in public
health/preventive medicine guidance and policies for the prevention and
treatment of chronic diseases.
Interprofessional Education/Collaboration in Lifestyle Medicine Practice
Healthcare professionals and their future patients would benefit
if the basics of LM were incorporated into all professional training
programs. Formal training and personal experience of evidence-based
lifestyle interventions such as plant-based nutrition, stress
management, physical activity, sleep management, relationship skills,
and substance abuse mitigation would transform the American healthcare
system. LM is uniquely suited to interprofessional education
in which students from two or more healthcare professions learn
together during professional training with the objective of cultivating
collaborative practice of patient-centered care.
Physicians and other healthcare providers should feel comfortable
talking with their patient about behavioral lifestyle changes and
assessing needs in determinants of health. Engaging patients in these
conversations can better help them achieve their lifestyle and
healthcare goals.
There are many educational pathways to becoming an expert in LM.
Physicians can become certified or accredited from the International
Board of Lifestyle Medicine (IBLM), American Board of Lifestyle Medicine
(ABLM), and British Society of Lifestyle Medicine (BSLM).
The Lifestyle Medicine Global Alliance (LMGA) is an organization that
connects LM professionals from nations around the world to collaborate,
share resources, and create solutions to preventing and reversing
non-communicable and chronic diseases.
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.
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:
Consciousness-raising (Get the facts) — increasing awareness via information, education, and personal feedback about the healthy behavior.
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.
Self-reevaluation (Create a new self-image) — realizing that the healthy behavior is an important part of who they want to be.
Environmental reevaluation (Notice your effect on others) —
realizing how their unhealthy behavior affects others and how they could
have more positive effects by changing.
Social liberation (Notice public support) — realizing that society is supportive of the healthy behavior.
Self-liberation (Make a commitment) — believing in one's ability to
change and making commitments and re-commitments to act on that belief.
Helping relationships (Get support) — finding people who are supportive of their change.
Counterconditioning (Use substitutes) — substituting healthy ways of acting and thinking for unhealthy ways.
Reinforcement management (Use rewards) — increasing the rewards that
come from positive behavior and reducing those that come from negative
behavior.
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:
Risk comparison (Understand the risks) – comparing risks with
similar dimensional profiles: dread, control, catastrophic potential and
novelty
Cumulative risk (Get the overall picture) – processing cumulative probabilities instead of single incident probabilities
Qualitative and quantitative risks (Consider different factors) – processing different expressions of risk
Positive framing (Think positively) – focusing on success instead of failure framing
Self-examination relate to risk (Be aware of your risks) –
conducting an assessment of risk perception, e.g. personalisation,
impact on others
Reevaluation of outcomes (Know the outcomes) – emphasising positive
outcomes of alternative behaviours and reevaluating outcome expectancies
Perception of benefits (Focus on benefits) – perceiving advantages
of the healthy behaviour and disadvantages of the risk behaviour
Self-efficacy and social support (Get help) – mobilising social
support; skills training on coping with emotional disadvantages of
change
Decision making perspective (Decide) – focusing on making the decision
Tailoring on time horizons (Set the time frame) – incorporating personal time horizons
Focus on important factors (Prioritise) – incorporating personal factors of highest importance
Trying out new behaviour (Try it) – changing something about oneself and gaining experience with that behaviour
Persuasion of positive outcomes (Persuade yourself) – promoting new positive outcome expectations and reinforcing existing ones
Modelling (Build scenarios) – showing models to overcome barriers effectively
Skill improvement (Build a supportive environment) – restructuring
environments to contain important, obvious and socially supported cues
for the new behaviour
Coping with barriers (Plan to tackle barriers) – identifying barriers and planning solutions when facing these obstacles
Goal setting (Set goals) – setting specific and incremental goals
Skills enhancement (Adapt your strategies) – restructuring cues and
social support; anticipating and circumventing obstacles; modifying
goals
Dealing with barriers (Accept setbacks) – understanding that setbacks are normal and can be overcome
Self-rewards for success (Reward yourself) – feeling good about progress; reiterating positive consequences
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.
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:
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, 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.
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.
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.
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 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.
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.
