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##  Promoting Health Behavior Change. ERIC Digest.                               

INTRODUCTION
Health-related habits develop early in life. The                  period during junior high school is especially important for                    developing these habits and also presents a window of vulnerability             for initiating behaviors related to smoking, drug use, and sexual               risk taking (Cohen, Brownell, & Felix, 1990; Taylor, 1999). Because             adolescent behaviors may be better predictors of disease after age              45 than adult health behaviors, interventions with children and                 adolescents are important (Taylor, 1999). Few of us emerge from                 adolescence with ideal health habits. Thus, mastering behavior                  change is critical to our quality of life. 
Several theories and               models have been developed to explain how people change their                   behavior, such as social cognitive theory, the theory of reasoned               action/planned behavior, and the health belief model. This Digest               explores the more recently developed Transtheoretical Model and                 discusses how educators can apply it in working with students. HOW            DO PEOPLE SUCCESSFULLY CHANGE THEIR OWN BEHAVIORS?Countless                 individuals have initiated behavior changes only to relapse after a             few weeks, months, or years. To be successful, behavior change must             be maintained, and this requires considerable time, effort, and                 energy. Behavior change is typically regarded primarily in terms of             getting started. The struggle to overcome inertia often seems so                great that people assume it must get easier from that point on. This            is seldom true. To accomplish permanent changes in habits, many                 tools are needed. THE TRANSTHEORETICAL MODEL OF BEHAVIOR                      CHANGEProchaska and colleagues studied the business of behavior             change for over 2 decades and developed the Transtheoretical                    Model (Prochaska, DiClemente, & Norcross, 1992; Prochaska,                      Norcross, & DiClemente, 1994; Prochaska, Redding, & Evers, 1997).               Their work revealed that behavior change evolves through different              stages: 
Stage 1--Precontemplation. Individuals in this stage do               not believe they have a problem and have often constructed defenses             that aid in denial of the problem. 
Stage 2--Contemplation.                    Individuals acknowledge having a problem and begin to deliberately              increase awareness and knowledge related to the problem. 
Stage                3--Preparation. Before initiating behavior change, individuals                  should reevaluate themselves with respect to the problem, develop               commitment to change, and construct a detailed plan for change. By              the time they reach this stage, individuals begin to perceive                   greater benefits than barriers to change. 
Stage 4--Action.                    Behavior change is initiated. Others are likely to recognize a                  person's progress toward change. After at least 6 months in the                 action stage, the person may move into the fifth stage. 
Stage                 5--Maintenance. Though change is maintained more easily now, some               vigilance is still required to avoid slips or setbacks. If and when             the change becomes so automatic that there is no possibility of                 reverting to a former behavior, the goal--"Termination"--is                     reached. 
The typical path of behavior change is not one of linear             progression, but usually involves slips backward and has been                   described as a spiral pathway (Prochaska, Norcross, & DiClemente,               1994). However, if one slips to an earlier stage, all is not lost,              because progression may occur more quickly due to insights and                  experience already gained when previously in earlier stages. 
Why              is understanding of the stages of change important for those who                will be attempting behavior change? 
1. Having a realistic view of             the work involved in behavior change may better prepare individuals             for the effort and vigilance needed to avoid setbacks. 
2.                     Individuals may better understand how progress toward change occurs             even in the absence of action. Gaining awareness about one's self,              experiencing the emotions that awareness of the problem may trigger,            and changing beliefs, attitudes, and thoughts constitute                        progress. 
3. It helps to distinguish between a lapse, that is, an             isolated mistake or temporary slip, versus a relapse, that is, a                complete setback (Brownell, Marlatt, Lichtenstein, & Wilson, 1986;              Watson & Tharp, 1997). Knowing the factors that often precipitate a             lapse or relapse, such as emotional distress, may help people                   recognize where work is needed in their lives. HOW EDUCATORS CAN              APPLY THE TRANSTHEORETICAL MODELOnly a small percentage of any              group is ready for change at a given time. For educators to reach               their audiences, they must be prepared to use a variety                         of "processes of change," that is, "any activity that you initiate              to help modify your thinking, feeling or behavior" (Prochaska,                  Norcross, & DiClemente, 1994, p. 25). 
Some of the processes that              are most helpful in the early stages of change are: 
1.                        Consciousness raising--Providing information and giving feedback to             increase awareness of a particular problem and its triggers,                    consequences, and cures. 
2. Emotional arousal--This may occur as a            result of observing a vivid case history or personal testimony of               someone who has solved a problem shared by others; role-playing can             also help. 
3. Self-reevaluation--envisioning one's self with and              without the unhealthy habit. 
4. Commitment--accepting one's                   personal responsibility for change and truly believing that one can             make the change. Self-efficacy, "the conviction that one can                    successfully execute the behavior required to produce the                       outcomes" (Bandura, 1977, 1982) relates to commitment and can be                improved in a number of ways. For example, mastery experiences can              be used to improve perceived self-efficacy (Bandura, 1986). Watson              and Tharp (1997) suggest rank-ordering situations from easiest to               most difficult and working to master behavior change in situations              of increasing difficulty. 
Some of the processes that are most                 helpful in the action stage are: 
1. Active problem                            solving--Educators can help students plan to establish cues and                 rewards for healthy behaviors and remove or minimize contact with               triggers for unhealthy behaviors. 
2.                                          Counterconditioning--substituting a healthy behavior for an                     unhealthy one. 
3. Helping relationships--Giving and receiving help            is a process that is important in every stage of change (Prochaska,             Norcross, & DiClemente, 1994). 
An appreciation of the                         Transtheoretical Model can help students avoid two common problems              of behavior change: rushing to premature action or indefinitely                 substituting thinking, talking, and learning about a problem for                acting to change a problem. Understanding the necessary tasks that              need to be completed in the stages prior to action may help in                  avoiding the rush to action. Knowing what should follow increased               knowledge and awareness of a problem behavior can help educators                guide students forward through the stages of change. Just as coaches            use planning and pacing in devising workouts for their athletes,                educators can help students plan and pace the change                            process. SKILLS FOR BEHAVIOR CHANGE"Self-monitoring" is an                essential skill for increasing self-awareness. Students can practice            keeping records of their behaviors and the antecedents and                      consequences of those behaviors. Antecedents and consequences may be            internal, such as self-talk or certain feelings, and/or external,               such as tempting cues or the presence or approval of certain                    individuals. Behavioral analysis involves studying behavior records             to discern patterns that relate to the target behavior. 
"Effective            goal" setting also can help students plan for change. Students need             practice in setting realistic and specific goals that, when                     possible, are measurable. Long-term goals should be divided into                short-term goals. Students should focus on behaviors they can change            rather than outcomes that may be outside their control. 
"Relapse              prevention skills" are critical. Because emotional distress is a                primary factor in lapses and relapses (Brownell, Marlatt,                       Lichtenstein, & Wilson, 1986), learning to cope effectively with                stress is invaluable for the individual trying to effect a major                change in behavior, which is a major stressor unto itself. Stress               management skills may minimize counterproductive negative emotions.             For example, cognitive restructuring or modifying self-talk to                  decrease negative thinking can be learned with practice (Seaward,               1997). Other relevant skills worth developing relate to time                    management, conflict resolution, assertiveness, and decision making.            An individual planning to change behavior should practice                       recognizing high-risk situations for a lapse or relapse and specific            coping skills for those situations. Plans for effectively responding            to a lapse or relapse are advisable. Mental imagery to help picture             one's self in the future with healthier habits may help maintain the            hope needed to get back on track and continue to pursue                         change. 
Developing "assertiveness skills" can be helpful in a                 number of ways. Assertiveness may help a teenager refuse peer                   demands. Skills in assertiveness may help us to ask others for                  feedback about our unhealthy habits and guidance in making changes.             As we become more aware of our strengths, weaknesses, and needs, we             can be assertive in recruiting others' support for our change                   efforts. 
"Counterconditioning, stimulus control, and reward                   skills," three processes of change that are especially important in             the action stage, can also be practiced. Finding a healthy behavior             that works well as a substitute for an unhealthy behavior may                   require some trial and error. The same is true for stimulus control             and reward; we may not immediately recognize the most powerful cues             for our behaviors or the most rewarding                                         consequences. CONCLUSIONWhile behavior change seems simple and            straightforward, rarely do people find it either. Before attempting             behavior change, it is wise to develop a realistic perspective                  regarding the time, attention, and effort that will be involved.                Knowing and having skills in the various processes of change is akin            to having, and knowing when and how to use, a full set of tools for             building a house. As we work toward behavior change, we are, in                 effect, building a new self. REFERENCESReferences identified              with an EJ or ED number have been abstracted and are in the ERIC                database. Journal articles (EJ) should be available at most research            libraries; most documents (ED) are available in microfiche                      collections at more than 900 locations. Documents can also be                   ordered through the ERIC Document Reproduction                                  Service (800-443-ERIC). 
Bandura, A. (1977). Self-efficacy: Toward             a unifying theory of behavior change. PSYCHOLOGICAL REVIEW, 84,                 191-215. 
Bandura, A. (1982). Self-efficacy mechanism in human                 agency. AMERICAN PSYCHOLOGIST, 37, 122-147. 
Bandura, A. (1986).               The explanatory and predictive scope of self-efficacy theory.                   JOURNAL OF SOCIAL AND CLINICAL PSYCHOLOGY, 4, 359-373. 
Brownell,              K. D., Marlatt, G. A., Lichtenstein, E., & Wilson, G. T. (1986).                Understanding and preventing relapse. AMERICAN PSYCHOLOGIST, 41,                765-782. 
Cohen, R. Y., Brownell, K. D., & Felix, M. R. J. (1990).             Age and sex differences in health habits and beliefs of                         schoolchildren. HEALTH PSYCHOLOGY, 9, 208-224. 
Prochaska, J. O.,              DiClemente, C. C., & Norcross, J. C. (1992). In search of how people            change: Applications to addictive behaviors. AMERICAN PSYCHOLOGIST,             47(9), 1102-1114. 
Prochaska, J. O., Norcross, J. C., & DiClemente,            C. C. (1994). CHANGING FOR GOOD: A REVOLUTIONARY SIX-STAGE PROGRAM              FOR OVERCOMING BAD HABITS AND MOVING YOUR LIFE POSITIVELY FORWARD.              New York: Avon Books. 
Prochaska, J. O., Redding, C. A., & Evers,              K. E. (1997). The transtheoretical model and stages of change. In K.            Glanz, F. M. Lewis, & B. K. Rimer (Eds.), HEALTH BEHAVIOR AND HEALTH            EDUCATION: THEORY, RESEARCH, AND PRACTICE (2nd ed.) (pp. 60-84). San            Francisco: Jossey-Bass Publishers. 
Seaward, B. L. (1997). MANAGING            STRESS: PRINCIPLES AND STRATEGIES FOR HEALTH AND WELL BEING (2nd                ed.). Sudbury, MA: Jones and Bartlett Publishers. 
Taylor,                     S. (1999). HEALTH PSYCHOLOGY (4th ed.). Boston:                                 McGraw-Hill. 
Watson, D. L., & Tharp, R. G. (1997). SELF-DIRECTED              BEHAVIOR: SELF-MODIFICATION FOR PERSONAL ADJUSTMENT (7th ed.).                  Pacific Grove, CA: Brooks/Cole Publishing                                       Company. 
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This publication was prepared with funding              from the Office of Educational Research and Improvement, U. S.                  Department of Education, under contract number RR93002015. The                  opinions expressed in this report do not necessarily reflect the                positions or policies of OERI or the Department.                             **Title:** Promoting Health Behavior Change. ERIC Digest.                               **Document Type:** Information Analyses---ERIC Information Analysis Products (IAPs) (071); Information Analyses---ERIC Digests (Selected) in Full Text (073); **Available From:** ERIC Clearinghouse on Teaching and Teacher Education, One Dupont                Circle, Suite 610, Washington, DC 20036-1186.                                **Descriptors:**  Behavior Change,  Comprehensive School Health Education, Elementary            Secondary Education,  Health Promotion, Student Behavior, Students           **Identifiers:** ERIC Digests,  Health Behavior,  Risk Reduction                              
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